Every finding on record at Springs at 3030 Park, The

Based on review of the clinical record, facility policy, and interviews for 3 of 3 residents (Residents # 7, 12, and 16) reviewed for dental services, the facility failed to offer routine dental services to long-term care residents, per the facility policy. The findings include: 1. Resident #7 was admitted to the facility in 9/2024 with diagnoses that included Alzheimer's Disease and protein-calorie malnutrition. The annual MDS dated [DATE] identified Resident #7 had severely impaired cognition and was not edentulous (lacking teeth). The quarterly MDS dated [DATE] identified Resident #7 did not have mouth or facial pain, discomfort or difficulty with chewing. The care plan dated 11/17/25 failed to reflect Resident #7's need for routine dental services. Review of the clinical record failed to reflect Resident #7 had been offered or had received routine dental services or that Resident #7 or Resident #7's representative had refused routine dental services from 9/2024 through 1/2026, 16 months. 2. Resident #12 was admitted to the facility in 12/2024 with diagnoses that included Parkinson's Disease and dementia. The annual MDS dated [DATE] identified Resident #12 had severely impaired cognition and was not edentulous. The care plan dated 11/20/25 failed to reflect Resident #12's need for routine dental services. Review of the clinical record failed to reflect Resident #12 had been offered or had received routine dental services or that Resident #12 or Resident #12's representative had refused routine dental services from 12/2024 through 1/2026, 13 months. 3. Resident #16 was admitted to the facility in 3/2024 with diagnoses that included Alzheimer's Disease and malignant neoplasm of the connective and soft tissues. The annual MDS dated [DATE] identified Resident #16 had severely impaired cognition and was not edentulous. The care plan dated 12/26/25 failed to reflect Resident #16's need for routine dental services. Review of the clinical record failed to reflect Resident #16 had been offered or had received routine dental services or that Resident #16 or Resident #16's representative had refused routine dental services from 3/2024 through 1/2026 22 months. Interview with the Director of Social Services (SW #1) on 1/6/26 at 12:25 PM identified that 6 long term care residents resided at the facility, 3 of the 6 (Residents #6, 14, and 23) were receiving hospice services, and she was unaware who was responsible for coordinating routine dental services for the long-term care residents (Residents #7, 12, and 16) that were not receiving hospice services. Interview with the DNS on 1/6/26 at 2:06 PM identified that she had reviewed the clinical records of Residents # 7, 12, and 16 and was unable to find documentation that routine dental services were offered/discussed or completed with the residents and/or resident representatives. During an interview with the Administrator and DNS on 1/7/26 at 8:53 AM, the DNS identified that if a resident or family member requested dental services or if a resident had a dental related issue, then dental services would be arranged. The DNS further identified that routine dental services had not been offered to long-term care residents (that were not receiving hospice services) or discussed with their resident representatives, however, moving forward the option for dental services would be discussed during the resident's care plan meetings. The Administrator indicated that she was not aware that routine dental services were not being offered to long-term care residents, but she would expect them to be offered. The Administrator further indicated that following a discussion with the Director of Social Services, it was identified that she was unaware that the facility could utilize an on-site consulting practice that offers preventative care services, including dental. The Administrator identified that the plan moving forward would be that the social worker would discuss routine dental service needs for long-term care residents during the care plan meeting, the receptionist would be responsible for arranging transportation, and the nursing supervisor would be responsible for initiating care in the event of a dental emergency. The facility's Dental Services policy directs the facility to provide or arrange for comprehensive dental services for all residents, ensuring access to preventative, routine, and emergency dental care. Maintaining oral health is essential to overall health and quality of life for residents. The policy further directs that the facility is to ensure all residents have access to dental services, either through on-site dental care or by arranging transportation and appointments with external dental providers. The provision of regular dental services includes annual dental examinations, preventative care such as cleanings, fluoride treatments, oral hygiene education, and treatments for dental conditions, including fillings, extractions, and dentures. Social Services will coordinate dental services for residents with families and are responsible for assisting with scheduling dental appointments, arranging transportation to off-site dental visits, communicating with dental providers regarding specific needs, and assisting residents/representatives with obtaining reimbursements, if eligible. The policy directs detailed records of all dental services provided to residents are maintained, including dates and outcomes of dental examinations, details of preventative care and treatments received, and documentation of any dental issues identified and the follow-up actions taken.

Based on review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #30) reviewed for staff to resident altercation, the facility failed to ensure the resident was free from abuse. The findings include:Resident #30 was admitted to the facility in July 2025 with diagnoses that included nondisplaced fracture of the fifth cervical vertebra, concussion and edema of cervical spinal cord, and cervical disc disorder at C5-C6 level.The admission MDS dated [DATE] identified Resident #30 had intact cognition and was dependent with personal hygiene. Additionally, Resident#30 had no verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others).The reportable event form dated 10/21/25 at 11:00 AM identified Resident #30 was alert and oriented. NA #3 came into Resident #30's room while the resident had a visitor and became loud speaking about personal issues. Resident #30 asked NA #3 to leave. Two other staff members came into the room and NA #3 left the room. Resident #30 did not feel comfortable with NA #3. NA #3 was removed from the schedule and sent home immediately after counseling. The physician, resident representative, and the Administrator were notified and an investigation initiated. The nurse's note by the ADNS dated 10/21/25 at 12:23 PM identified NA #3 entered Resident #30's room while the resident had a visitor present. Person #1 and Resident #30 reported that NA #3 was speaking loudly and discussing personal issues. NA #3 was asked to leave the room. NA #3 was immediately removed from the floor, counselled and was sent home. Resident #30 was reassured that NA #3 had been removed from the floor. Resident #30 stated that she felt safe and was reassured that staff were available to address any concerns. Resident #30's family visited and was made aware of the incident.The social service note dated 10/21/25 at 3:57 PM identified she met with Resident #30 regarding the incident that occurred earlier that day involving NA #3. Resident #30 reported that between 10:00 AM - 11:00 AM, NA #3 entered the resident's room and began speaking loudly and yelling about some personal situation between her spouse and the land that they live on. At the time of the incident, Resident #30 had a visitor present. Person #1 asked NA #3 to please leave the room and to stop getting loud. Two additional staff members entered the room, and NA #3, who was yelling, finally left the resident alone. The social worker assessed Resident #30 following the incident. Resident #30 stated that he/she feels safe at the facility, now that NA #3 was sent home. Resident #30 stated most of the staff are all nice and he/she does not have a problem with anyone. Resident #30 was informed that NA #3 would no longer be assigned to provide care to him/her. Resident #30 stated that he/she thought NA #3 was his/her friend and does not understand why NA #3 became so angry with him/her. Resident #30 was observed to have a supportive family and social support system. Social services will continue to monitor Resident #30 and provide 1:1 room visits as needed for emotional support and comfort.A written statement from Person #1 (visitor) dated 10/21/25 (untimed) identified Person #1 was present in Resident #30's room when NA #3 entered the room and began speaking to Resident #30 in a loud tone regarding personal issues involving peaches. Person #1 indicated that NA #3's voice was raised and that NA #3 continued speaking over Resident #30 when the resident attempted to respond. Person #1 indicated that he/she asked NA #3 to stop speaking and informed NA #3 that she was inappropriate. Person #1 indicated NA #3 continued yelling despite being asked to stop. Person #1 indicated that NA #2 entered the room and was professional and attempted to provide care to Resident #30, while NA #3 continued yelling. Person #1 indicated he/she repeatedly asked NA #3 to stop talking. Person #1 indicated NA #4 entered the room and attempted to escort NA #3 out of the room. Person #1 indicated NA #4 was professional. Person #1 indicated that he/she began recording the incident. Person #1 indicated NA #3 then directed comments towards him/her (Person #1), stating he/she was a horrible person and not a good friend and they didn't like me.A written statement from NA #2 dated 10/21/25 (untimed) identified she entered Resident #30's room to obtain the resident vital signs. NA #2 indicated she heard NA #3 and Resident #30 arguing. NA #2 indicated Person #1 was present in the room and stated (that is enough). NA #2 indicated she did not know what was said during the argument. NA #2 indicated NA #4 entered the room to get NA #3. NA #2 indicated that she left the room at that time. A written statement from NA #4 dated 10/21/25 (untimed) identified that she went to look for NA #3 and located her in Resident #30's room. NA #4 indicated that she witnessed a loud conversation between NA #3 and Resident #30. NA #4 indicated that she asked NA #3 to step out of the room. NA #4 indicated she apologized to Resident #30 regarding the incident. NA #4 indicated she reported the incident to the supervisor.A written statement from NA #3 dated 10/21/25 (untimed) identified that NA #4 informed her that Resident #30 was discussing her personal business. NA #3 indicated she went to Resident #30's room to ask the resident why she was discussing her personal business. NA #3 indicated Person #1 began yelling at her and then pulled out a phone and began recording. NA #3 indicated NA #2 and NA #4 approached the room and Person #1 started yelling at her to leave the room while she was still talking to Resident #30. NA #3 indicated she and Resident #30 began yelling at each other. NA #3 indicated NA #4 attempted to remove her out of the room. NA #3 indicated she and Resident #30 were friends and family. NA #3 indicated she was sorry for her behavior and confrontation and was aware the incident was a serious matter. The summary report dated 10/23/25 at 2:49 PM identified NA #3 entered Resident #30's room to speak with the resident regarding a statement that the resident reportedly made to another staff member. NA #3 indicated the visitor began yelling at her and recording her. NA #3 had a verbal confrontation with the visitor in the presence of Resident #30 in the room. NA #4 asked NA #3 to leave the room, and NA #3 left. NA #3 was sent home pending an investigation. After completion of the investigation, receiving and reviewing of staff statements, NA #3 will not be allowed in Resident #30's room.The care plan dated 10/27/25 identified Resident #30 had an altercation/conflict with a staff member who came into her room and confronted him/her about a personal situation. Interventions included reassure the resident as needed. Staff to encourage the resident to socialize and attend activities. Interview with NA #3 on 1/5/26 at 2:40 PM identified she has been employed by the facility since June 2025. NA #3 indicated she was not assigned to Resident #30 on 10/21/25 at the time of the incident. NA #3 indicated Resident #30 was a family friend. NA #3 indicated NA #4 informed her that Resident #30 was discussing her personal business within the facility. NA #3 indicated she entered Resident #30's room and asked the resident if it was true that the resident had been speaking about her and her family. NA #3 indicated she takes full responsibility for her behavior, for confronting Resident #30, and speaking loudly in an aggressive manner towards Resident #30. NA #3 indicated that before Resident #30 could respond, Person #1 instructed her to leave the room. NA #3 indicated she made a hand gesture towards Person #1 and stated she was not speaking to him/her, then turned towards Resident #30. NA #3 indicated Resident #30 denied making the statements and attempted to explain. NA #3 indicated she mentioned the name of Resident #30's child during the verbal altercation. NA #3 indicated Resident #30 instructed her not to mention his/her child's name and Resident #30 stated that he/she would call the police. NA #3 indicated Person #1 used foul language toward her and began recording the interaction on the phone. NA #3 indicated Person #1 started recording after she had already confronted Resident #30. NA #3 indicated NA #4 entered the room and told her she had to leave. NA #3 indicated NA #2 was in the room when she was questioning Resident #30. NA #3 indicated she was loud and arguing with Person #1 in the presence of Resident #30. NA #3 indicated she was removed from the schedule pending investigation. NA #3 indicated she was educated on abuse. NA #3 indicated since the incident she has not provided care to Resident #30.Interview with RN #3 on 1/6/26 at 11:15 AM identified she was the RN Supervisor on 10/21/25 at the time of the incident. RN #3 indicated she was notified of the incident involving NA #3, Resident #30, and Person #1 by NA #2. RN #3 indicated NA #2 informed her that she needed to go to Resident #30's room and remove NA #3 due to NA #3 arguing with Resident #30. RN #3 indicated she immediately went to Resident #30's room. RN #3 indicated she observed Resident #30 in bed and Person #1 was sitting by the bedside. RN #3 indicated no staff members were present in the room at that time. RN #3 indicated she asked Resident #30 what happened and if the resident was okay. RN #3 indicated Resident #30 stated he/she was fine. RN #3 indicated she told Resident #30 that he/she did not appear fine and appeared to have been crying. RN #3 indicated Person #1 told her, there is a rude nurse aide here who is very disrespectful, and Person #1 recorded her. RN #3 indicated she asked to review the recording. RN #3 indicated the video showed Person #1 telling NA #3 to leave the room, and the NA #3 responding no, no, and stating that she and Resident #30 were friends. RN #3 indicated the video also showed NA #4 attempting to remove NA #3 from the room. RN #3 indicated NA #3 and Person #1 were loud during the recording. RN #3 indicated after reviewing the video, she consoled Resident #30 and ensured the resident was alright. RN #3 indicated Resident #30 told her that NA #3 and their family were friends and that NA #3 was upset because she believed Resident #30 had been speaking about her to other staff members. RN #3 indicated Resident #30 denied making such statements. RN #3 indicated she assured Resident 30 that NA #3 would no longer enter the room or provide care. RN #3 indicated she immediately reported the incident to the ADNS. RN #3 indicated she and the ADNS located NA #3 and removed her from the unit to the ADNS office. RN #3 indicated the ADNS asked NA #3 to explain what happened and NA #3 provided her account of the incident. RN indicated NA #3 was instructed to leave the facility. Interview with NA #4 on 1/7/26 at 6:38 AM identified she went to look for NA #3 and found NA #3 in Resident #30's room. NA #4 indicated NA #2, NA #3, and Person #1 were present in the room. NA #4 indicated she observed NA #3 speaking to Resident #30 in a loud tone of voice. NA #4 indicated she was not present when NA #3 began arguing with Resident #30. NA #4 indicated she asked NA #3 to leave the room, and NA #3 exited the room but returned right back and continued to argue in a loud tone of voice with Resident #30 and Person #1. NA #4 indicated she was unable to understand the specific content of the conversation. NA #4 indicated NA #3 appeared upset and angry. NA #4 indicated Person #1 reported she had video-recorded the incident and was going to notify the DNS. NA #4 indicated Resident #30 appeared shocked, frazzled, and was crying about the incident. NA #4 indicated Resident #30 said he/she didn't know why NA #3 was acting that way towards him/her. NA #4 indicated she consoled Resident #30. NA #4 indicated no staff member should speak to a resident the way NA #3 was speaking to Resident #30. NA #4 indicated after leaving Resident #30's room, she spoke with NA #3 regarding the incident. NA #4 indicated while speaking with NA #3, RN #3 approached her and discussed the incident involving NA #3 and Resident #30. NA #4 indicated she had received in-service training regarding abuse.Interview with NA #2 on 1/7/26 at 7:39 AM identified she was assigned to Resident #30 on 10/21/25 at the time of the incident. NA #2 indicated she entered Resident #30's room to obtain vital signs. Upon entering the room, NA #2 indicated she observed NA #3 and Resident #30 arguing in a loud tone of voice. NA #2 indicated NA #3 appeared angry and was speaking loudly while arguing with Resident #30. NA #2 indicated NA #3 made a comment regarding Resident #30's child and Resident #30 stated to not talk about his/her child and began cursing at NA #3. NA #2 indicated the argument between NA #3 and Resident #30 escalated and became louder. NA #2 indicated she observed Person #1 take out his/her phone following the argument between NA #3 and Resident #30. NA #2 indicated NA #4 entered the room and attempted to remove NA #3 from the room. NA #2 indicated she then left the room and notified the supervisor.Interview with the ADNS on 1/7/26 at 7:47 AM identified she was notified by RN #3 that NA #3 was in Resident #30's room speaking loudly to the resident and a visitor. The ADNS indicated she went to the resident's room and observed no staff present in the room. The ADNS indicated she asked Resident #30 if he/she was okay, and the resident stated he/she was alright. The ADNS indicated Person #1 appeared upset. The ADNS indicated Person #1 showed her and RN #3 a video of the incident. The ADNS indicated Resident #30 said he/she felt safe. The ADNS indicated she notified the DNS, and NA #3 was sent home. The ADNS indicated this behavior was not the expectation of the facility and that NA #3 should have carried herself in a professional manner during work. Interview with Person #1 on 1/7/26 at 9:30 AM identified NA #3 entered Resident #30's room and approached the resident's bed. Person #1 indicated NA #3 was calm at first and talking about peaches; however, NA #3 then began ranting, raving, and rambling in a loud tone of voice. Person #1 indicated that she asked NA #3 to stop. Person #1 indicated she did not know why NA #3 was angry but indicated that NA #3 was not happy. Person #1 indicated NA #2, and NA #4 entered the room and NA #4 told NA #3 she had to leave. Person #1 indicated NA #3 continued yelling at Resident #30, saying to the resident (you are talking about me). Person #1 indicated Resident #30 was in shock, scared, and was visibly crying. Person #1 indicated Resident #30 said to Person #1 that he/she did not know what just happened, that he/she was just lying here and being attacked. Person #1 indicated Resident #30 was confused about the incident. Person #1 indicated Resident #30 spoke to his/her child regarding the incident. Person #1 indicated Resident #30 told RN #3 that he/she was laying there minding his/her own business and was being attacked. Person #1 indicated NA #4 observed Resident #30 crying and she attempted to console the resident. Person #1 indicated she showed the video of the incident to RN #3 and the ADNS and sent the video to the DNS.Review of the recording video was conducted with the Administrator and the DNS on 1/7/26 at 11:55 AM identified the recording video began after NA #3 had already confronted Resident #30. The video showed NA #4 attempting remove NA #3 from the resident's room. NA #4 was observed saying to NA #3, let's go, two times. NA #3 was observed leaning over Resident #30's bed and speaking in a loud voice, stating, you don't want to talk, you don't want to call. NA #3 exited the room and stood in the hallway, then reentered the room and approached Resident #30's bedside, stating, I heard something and I came to ask Resident #30. Resident #30 was observed stating, but if you came nicely. NA #3 was again observed leaning over the bed and speaking in a loud voice to Resident #30. Resident #30's speech was observed but was not clearly understandable on the recording. NA #3 exited the room, and NA #4 was observed closing the resident's room door. NA #4 was observed apologizing to Resident #30, stating I'm sorry okay. I'm sorry for what just happened. Resident #30 responded, who doesn't like me, what did I do. The recording ended at that time.Interview with the Administrator on 1/7/26 at 12:00 PM identified she was informed of the incident by the DNS in the afternoon. The Administrator indicated the DNS informed her NA #3 was speaking loudly to a visitor in Resident #30's room. The Administrator indicated the DNS informed her that Person #1 had recorded a video of the incident. The Administrator indicated she and the DNS had reviewed the video, which showed NA #3 speaking in a loud tone to Person #1 while NA #4 attempted to get NA #3 to leave the room. The Administrator indicated she was unaware of events that occurred prior to the video recording. The Administrator indicated during the facility's investigation, NA #3 admitted to entering Resident #30's room to confront the resident regarding the resident discussing NA #3's personal business. The Administrator indicated during the facility investigation it was not reported to her or the DNS that NA #3 had argued with Resident #30 in a loud and angry tone prior to the video recording. The Administrator indicated NA #3 was educated that confronting Resident #30 was inappropriate and unprofessional. The Administrator indicated NA #3 was sent home and provided education regarding abuse prior to returning to work and was not assigned to Resident #30. Interview with the DNS on 1/7/26 at 12:10 PM identified she was involved in the facility's Mutual Aid Program drill conducted on 10/21/25 and confirmed the facility participated in the drill. The DNS indicated she was notified of an incident by the ADNS at approximately 12:00 PM on the date of the incident. The DNS indicated that when she arrived at the facility sometime after 3:00 PM, a visitor sent her a video recording. The DNS indicated the ADNS informed her that NA #3 had been in resident room speaking loudly to the visitor. The DNS indicated NA #3 was sent home. The DNS indicated she notified the Administrator when she received the video. The DNS indicated the Administrator, and she reviewed the video, which showed NA #3 speaking in a loud tone to Person #1, while NA #4 attempted to get NA #3 to leave the room. The DNS indicated she was unaware of events that occurred prior to the video recording. The DNS indicated during the facility's investigation, NA #3 admitted to entering Resident #30's room to confront the resident regarding the resident discussing NA #3's personal business. The DNS indicated during the facility's investigation it was not reported to her, the ADNS, and the Administrator that NA #3 had argued with Resident #30 in a loud and angry tone prior to the video recording. Review of the facility abuse policy identified the facility is committed to providing a safe and nurturing environment for all residents. We uphold a zero-tolerance policy for any form of abuse or neglect. All staff members are required to adhere to this policy and take immediate action if abuse or neglect is suspected or identified. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse refers to any use of oral, written and/or gestured language that includes disparaging and/or derogatory terms to residents on their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Mental abuse - verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. Includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation. Mistreatment - inappropriate treatment or exploitation of a resident. All staff will be trained in orientation and at minimum annually regarding prevention of abuse and their responsibility to report it.Review of the facility resident rights policy identified the facility is committed to promoting and protecting the rights of each resident. Residents have the right to make informed choices, participate in decisions regarding their care, and enjoy a living environment that respects their dignity and individuality. This policy outlines the rights of residents and the facility's obligations to uphold these rights. Residents have the right to be treated with dignity, respect, and consideration by all staff members and other residents. Staff will receive training on resident's rights to ensure they understand and uphold these rights in their daily interactions. The facility will implement monitoring procedures to ensure compliance with resident's rights and address any violations promptly.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 resident (Resident #3, 28, and 32) reviewed for transmission based precautions, the facility failed ensure that appropriate signage was posted for Resident #3 who was on contact precautions, failed to ensure nursing staff adhered to appropriate infection control techniques for Resident #28, who was on droplet precautions, and failed to ensure nursing staff adhered to appropriate infection control techniques for Resident #32 who was on enhanced barrier precautions. The findings include: 1. Resident #3 was admitted to the facility in December 2025 with diagnoses that included metabolic encephalopathy, dysphagia, and urinary retention.The admission MDS dated [DATE] identified that Resident #3 had intact cognition, was frequently incontinent of bowel, required an indwelling urinary catheter, required substantial assistance from staff with bathing, and moderate assistance from staff for transfers and dressing. The admission MDS also identified that Resident #3 had a feeding tube in place upon admission to the facility.Review of the clinical record identified Resident #3 was transferred to the hospital on 1/1/26 for evaluation of shortness of breath. Resident #3 also had lab results that were positive for vancomycin resistant enterococcus (VRE) in the urine.A physician's order dated 1/2/26 directed Resident #3 required contact precautions due to VRE in the urine.The care plan 1/2/26 identified Resident #3 required enhanced barrier precautions (EBP) specifically related to the use of an indwelling urinary catheter, tube feeding care and contact precautions due to VRE in the urine. Interventions included to educate the resident, family, and staff regarding effective measures to prevent transmission.Review of facility provided transmission-based precautions line list on 1/5/26 identified that Resident #3 required EBP related to an indwelling urinary catheter and feeding tube and contact precautions for VRE.Observations on 1/5/26 at 8:45 AM and 9:40 AM identified signage posted at the right side of Resident #3's doorway identified enhanced barrier precautions (EBP) along with a PPE cart. Observation of the signage identified everyone entering the room must clean their hands when entering and when leaving the room and that providers and staff must also wear gloves and a gown for high contact resident activities. Further observation failed to identify any signage or instructions related to contact precautions.Review of the nursing care card on 1/5/26 failed to identify documentation related to enhanced barrier precautions or contact precautions for Resident #3.Interview with RN #1 (Infection Control Nurse) on 1/6/26 at 1:30 PM identified that she remembered placing signage for contact precautions outside Resident #3's doorway but was unable to provide the specific date or why the signage was not in place as of 1/5/26. RN #1 also identified that if the signage was not in place, the nurse assigned to the resident would be able to review the physician's order, but she was not sure if the need for transmission-based precautions would carry over to the nurse aide care card.The facility policy on transmission-based precautions (TBP) directed that the facility would implement transmission-based precautions when caring for residents who are known or suspected to be infected or colonized with infectious agents that required additional measures to prevent transmission. The policy further directed that contact precautions were indicated for residents or with known or suspected infections that were spread by direct or indirect contact and included VRE, and that transmission-based precautions would be initiated based on clinical assessment, laboratory confirmation, or physicians order. The policy also directed that appropriate signage indicating the type of precautions required would be placed outside of the resident's room, and all healthcare professionals, including housekeeping and ancillary staff. would be informed of the necessary precautions. 2. Review of a hospital Discharge summary dated [DATE] identified Resident #28 tested positive for influenza A on 12/28/25.Resident #28 was admitted to the facility in January 2026 with diagnoses that included influenza, atrial fibrillation, and hypothyroidism.The admission nursing assessment dated [DATE] at identified Resident #28 was alert and oriented x 3 upon admission to the facility. The nursing assessment further identified that Resident #28 was continent of bowel, incontinent of bladder, and required moderate assistance from staff with toileting, dressing, and set up by staff for eating. The nursing admission assessment also identified that Resident #28 had been placed on droplet precautions due to a diagnosis of influenza A.Review of the care plan dated 1/2/26 failed to identify interventions related to Resident #28's diagnosis of influenza A and need for droplet precautions.A physician's order dated 1/5/26 directed droplet precautions until 1/7/26 at 11:59 PM.Review of the facility provided transmission-based precautions line list on 1/5/26 identified that Resident #28 required droplet precautions due to flu.Observation on 1/5/26 at 9:00 AM identified signage posted at the right side of Resident #28's doorway which identified Droplet Precautions along with a PPE cart. Observation of the signage identified everyone stop before entering the room must clean their hands when entering and when leaving the room and make sure their eyes, nose, and mouth were fully covered before room entry. The signage also identified photos depicting use of a mask along with use of a face shield or goggles. Further observation identified that NA #1 entered Resident #28's room to provide his/her meal tray. NA #1 was observed with a surgical mask but no other PPE in place prior to entering Resident #28's room. NA #1 did not perform hand hygiene on entering the room. NA #1 was observed placing Resident #28 meal tray on the bedside table and providing setup, and then attempting to assist Resident #28 with removal of his/her surgical mask. NA #1 provided the call bell to Resident #28 and exited the room. NA #1 did not perform hand hygiene upon exiting the room and attempted to enter another resident's room but stopped upon surveyor inquiry.Interview with NA #1 immediately following the observation identified that she did not see the PPE cart or droplet precaution sign directly outside of Resident #28's room and was not aware the resident was on droplet precautions. NA #1 was unable to identify why she did not perform hand hygiene and also identified that she should have donned appropriate PPE prior to entering Resident #28's room.Observation on 1/6/26 at 12:15 PM identified NA #2 entered Resident #28's room to provide his/her meal tray. NA #2 was observed with a surgical mask in place and did not perform hand hygiene or don PPE prior to entering the room. During this observation, Resident #28 was observed sitting upright in bed with a bedside table positioned directly in front of him/her. NA #2 was observed placing the meal tray on Resident #28's bedside table. While placing the tray, Resident #28, who was not masked, was observed coughing directly towards NA #2 who was approximately 2 feet from the resident. NA #2 was observed continuing to set up Resident #28's meal tray during the coughing episode, and following setup was observed exiting Resident #28's room. NA #2 did not perform hand hygiene prior to or upon exiting the room.Interview on 1/6/26 at 12:18 PM with NA #2 identified she did not see the PPE cart or droplet precaution sign position directly outside of Resident #28's room and was not aware Resident #28 was on droplet precautions. NA #2 also identified that she did not perform hand hygiene before or after exiting Resident #28's room. NA #2 identified that she should have performed hand hygiene and used appropriate PPE.Interview with RN #1 (Infection Control Nurse) on 1/6/26 at 1:30 PM identified she was unable to provide any explanation as to why nursing staff were not donning and doffing PPE for residents who required enhanced barrier precautions (EBP) or transmission-based precautions (TBP). RN #1 identified the signage related to any resident on EBP or TBP along with the PPE carts were placed in a way that required all staff and visitors to pass by the sign and the cart before entering a resident's room. RN #1 further identified that she had recently completed in service education regarding EBP, TBP, and the use of appropriate PPE in 12/2025. RN #1 identified that she would provide additional education to all staff related to EBP, TBP, and PPE use.Observation on 1/7/26 at 9:55 AM identified LPN #3 and LPN #4 standing outside of Resident #28's room at a medication cart. LPN #3 and LPN #4 were observed wearing surgical masks and entering Resident #28's room. LPN #3 and LPN #4 did not perform hand hygiene or donning any PPE prior to entering the room. LPN #4 was observed at Resident #28's bedside. LPN #3 was observed entering Resident #28's bathroom momentarily and then stepping out and exiting the room. LPN #3 was not observed performing hand hygiene prior to leaving the room and was observed obtaining a device from the bottom of the medication cart and entering another residence room located directly across the hallway. LPN #4 continued at Resident #28's bedside and then exited the room. LPN #4 was not observed performing hand hygiene prior to exiting the room and returning to the medication cart. LPN #3 was observed returning to the medication cart. Interviews with LPN #3 and LPN #4 immediately following the observations identified LPN #3 precepting LPN #4. LPN #3 identified that she was aware Resident #28 had been on droplet precautions but had been notified in morning report that the precautions would be ending that day. LPN #3 identified that she did not review the resident's orders and believed the information she received in morning report meant that Resident #28 was no longer on precautions despite the signage and PPE cart still in place. LPN #3 and LPN #4 both identified that for droplet precautions, hand hygiene should be performed prior to entering the room and donning appropriate PPE would include a gown and surgical mask with gloves. LPN #3 did not identify any other PPE needed, while LPN #4 identified a face shield would also be needed.Interview on 1/7/26 at 10:10 AM with RN #1 related to the observations of LPN #3 and LPN #4 identified that Resident #28's orders should have been reviewed to determine when he/she was going to be taken off droplet precautions. RN #1 identified that if there was any question related to whether Resident #28 was still on droplet precautions, nursing staff should assess the resident for symptoms first and were expected to always err on the side of caution and don the appropriate PPE. RN #1 also identified that TBP signage had not been removed, and this would also be an indicator that Resident #28 continued to require droplet precautions.Review of facility education documentation identified NA #1 received infection control and prevention education on 5/6/25.Review of facility education documentation identified NA #2 and LPN #3 received EBP, TBP, respiratory infection protocols, and donning/doffing PPE in 12/2025. Review of facility education documentation identified LPN #4 received infection control and prevention education on 12/17/25.The facility policy on transmission-based precautions (TBP) directed that the facility would implement TBP when caring for residents who are known or suspected to be infected or colonized with infectious agents that required additional measures to prevent transmission. The policy further directed that Droplet precautions were indicated for residents with known or suspected infections spread by large respiratory droplets including influenza. The policy directed measures that included use of surgical masks within 6 feet of the resident, resident placement in a room with the closed door and enhanced respiratory hygiene and cough etiquette. The policy further directed that the facility would ensure appropriate PPE was readily available near the entrance of each room that required TBP, staff would be trained on proper use, donning, and doffing of PPE and supervisory staff would monitor compliance of PPE use and provide corrective action and retraining as necessary.The facility policy on personal protective equipment PPE directed that the facility was committed to ensuring the safety of residents, staff, and visitors by implementing the proper use of PPE to prevent the transmission of infections and exposure to hazardous substances. The policy also directed that types of PPE included gloves, gowns, masks, respirators, and eye protection. The policy also directed that selection of PPE should be based on the type of exposure anticipated and the recommended sequence for donning PPE to ensure maximum protection should include use of a gown, mask or N-95, goggles or face shield, and gloves. 3. Review of a hospital Discharge summary dated [DATE] identified Resident #32 was hospitalized from [DATE] to 1/2/26 due to influenza A and hyponatremia. The discharge summary further identified that Resident #32 developed acute urinary retention and required an indwelling urinary catheter. Resident #32 was admitted to the facility in January 2026 with diagnoses that included hyponatremia, hypertension, and pneumonia.The nursing admission assessment dated [DATE] identified Resident #32 was alert and oriented. The assessment also identified that Resident #32 was continent of bowel, had an indwelling urinary catheter, and required moderate assistance from staff with transfers, bathing, and dressing.The care plan dated 1/5/26 identified Resident #32 had an indwelling urinary catheter. Interventions included enhanced barrier precautions for indwelling catheter use.A physician's order dated 1/5/26 directed enhanced barrier precautions related to indwelling catheter use.Review of facility provided transmission-based precautions line list on 1/5/26 identified that Resident #32 required EBP related to an indwelling urinary catheter.Observation on 1/6/26 at 12:00 PM identified signage posted at the left side of Resident #32's doorway which identified enhanced barrier precautions (EBP) along with a PPE cart. Observation of the signage identified everyone entering the room must clean their hands when entering and when leaving the room and that providers and staff must also wear gloves and a gown for high contact resident activities which included changing linen. NA #5 was observed entering Resident #32's room and performing a linen change. NA #5 was observed with a surgical mask on but no other PPE. NA #5 began to apply a clean fitted sheet, then exited the room, utilized hand sanitizer, obtained a clean blue disposable gown from the PPE cart located outside of the room, and then placed the gown on a recliner inside of Resident #32's room. NA #5 then exited the room.Observation on 1/6/26 at 12:33 PM identified NA #5 entered Resident #32's room and closed the door. NA #5 was not observed performing hand hygiene or stopping at the PPE cart prior to entering. Observation upon entering the room identified NA #5 attempting to exit Resident #32's bathroom while donning disposable gloves. NA #5 identified she was donning PPE to provide care and complete the linen change but did it in the resident's bathroom as she had additional PPE supplies there.Interview with RN #1 (Infection Control Nurse) on 1/6/26 at 1:30 PM identified she was unable to provide an explanation as to why nursing staff were not donning and doffing PPE for residents who required enhanced barrier precautions (EBP) or transmission-based precautions (TBP). RN #1 identified the signage related to any resident on EBP or TBP along with the PPE carts were placed in a way that required all staff and visitors to pass by the sign and the cart before entering a resident's room. RN #1 further identified that she had recently completed in service education regarding EBP, TBP, and the use of appropriate PPE in 12/2025. RN #1 identified that she would provide additional education to all staff related to EBP, TBP, and PPE use.Interview on 1/6/26 at 1:44 PM with NA #5 identified she was aware that Resident #32 was on enhanced barrier precautions and also was aware that high contact activities requiring PPE included changing the residents' linens. NA #5 identified that she was in a hurry and realized after completing part of the linen change she should have donned PPE. NA #5 identified this was not typical practice for her and that she usually always made sure to read the signage and on the appropriate PPE whenever providing care for residents and that she was also aware to don PPE prior to entering and before exiting a resident's room but was unable to identify why she did not follow her typical practice in this case.Review of facility education documentation identified NA #5 received EBP, TBP, respiratory infection protocols, and donning/doffing PPE in 12/2025. The facility policy on enhanced barrier precautions directed that it was the policy of the facility that EBP would be implemented in conjunction with standard precautions during high contact resident activities when caring for residents that had an increased risk for acquiring a multi drug resistant organism (MDRO) such as a resident with indwelling medical devices, which included indwelling urinary catheters. even if the resident was not known to be infected or colonized with a MDRO. The policy further directed that use of PPE to donning of a gown and gloves during high contact resident activities would be used to reduce transmission of MDROs.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #223) reviewed for ADL's and who required assistance with toileting, the facility failed to ensure care that promoted the resident's dignity. The findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included pneumonia, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD). A physician's order dated 2/5/25 directed to administer Lasix (diuretic) 20 mg daily every other day. The nursing skilled evaluation dated 2/5/25 at 10:55 PM identified Resident #223 was alert and oriented and was continent of bladder with yellow urine. The social worker admission collection dated 2/6/25 at 2:56 PM identified Resident #223 was cognitively intact. The social worker note dated 2/6/25 at 3:20 PM identified she had called the resident representative with therapy present who indicated that Resident #223 was continent of bowel and bladder at home prior to going to the hospital and can take him/herself to and from the bathroom. The nursing skilled evaluation dated 2/6/25 at 8:57 PM identified Resident #223 was alert and oriented and was continent of bladder with yellow urine. The care plan dated 2/7/25 identified Resident #223 has mixed bladder incontinence related to weakness. Interventions included to monitor and document signs and symptoms of a urinary tract infection and clean peri area with each incontinent episode. Interview with Resident #223 on 2/9/25 at 10:15 AM indicated he/she has only been at the nursing facility since 2/5/25 and that prior to going to the hospital he/she was continent of bladder and would independently ambulate to the bathroom. Resident #223 indicated that when he/she must go to the bathroom he/she needs to go right away or will have an accident. Resident #223 indicated that this morning he/she put the call light on at about 8:00 AM and had to go to the bathroom and after a while, approximately 8:30 AM, someone came over the intercom and Resident #223 informed that person he/she had to use the bathroom, and that person replied that someone would be down there and shut the call light off. Resident #223 indicated that no one came within a few minutes, so he/she put the call light back on again but no one came into his/her room until 9:00 AM when the NA #2 came in but by that time the resident had urinated and was wet from his/her mid back to just above the knees. Resident #223 indicated that he/she was embarrassed to have wet the bed but just could not hold it that long. Interview with the DNS on 2/10/25 at 2:50 PM indicated that she had spoken to Resident #223 who was consistent in the events and was upset by the incident. The interview with the DNS on 2/11/25 at 8:15 AM indicated that approximately 4:00 PM on 2/10/25 she decided to have the social worker and herself talk to Resident #223 regarding filing a grievance from 2/9/25 about no one answering her call light for an hour resulting in resident being incontinent of urine. The DNS indicated that Resident #223 was receptive to the idea of filing a grievance. A Concern/Grievance Report dated 2/10/25 identified Resident #223 on 2/9/25 at 8:00 AM had placed call light on and no one answered it until 8:30 AM. Investigation and follow up sections were blank. The interview with the Administrator on 2/11/25 at 10:10 AM indicated that whoever answered the call from the desk should have gotten up and went to Resident #223's room and assisted him/her to the bathroom. The Administrator indicated that the call lights were to be answered timely by all staff. The Administrator indicated that the DNS must follow the grievance policy. Interview with LPN #1 on 2/11/25 at 12:25 PM indicated that she does not recall or remember Resident #223 having his/her call light on after 8:00 AM nor does she recall if the bed was soaked in urine and had to be changed when NA #2 had gone in the room about 9:00 AM. LPN #1 indicated that NA #2 was in the room when she had gone In to give Resident #223 his/her medications about 9:10 AM on 2/9/25. Review of the Skilled Nursing Resident Rights Policy identified rights of the residents are always recognized by all staff members, and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of residents. Review of the Resident Rights Policy identified the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident. A resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished and prompt efforts by the facility to resolve grievances the resident may have.

Based on review of the clinical record, facility documentation, facility policy and interviews for of 3 of 4 residents (Resident #13, 3 and 173) reviewed for advance directives, the facility failed to ensure a physician's order was obtained that reflected the resident/resident representatives wishes for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). The findings include: 1. Resident #13 had diagnoses that included atherosclerotic heart disease. An Advance Directive dated 1/23/25 identified in the event of a cardiopulmonary arrest, Resident #13 requested Do Not Resuscitate (DNR). The Advance Directive was signed by the resident representative. A review of the physician orders dated 1/23/25 to 2/9/25 failed to reflect a DNR order was written. An interview with the DNS on 2/11/25 at 11:13 AM identified she would expect the nurse to obtain a physician's order once the advance directive was signed that reflected the resident/representative wishes. A review of the facility policy for Advance Directives directs to determine if a resident has or wishes to formulate and advanced directive on admission. A DNR order form must be completed and signed by the provider and remain in effect until the resident or responsible party provides notification in writing that the DNR is no longer in effect. 2. Resident #3 had diagnoses that included a non-displaced fracture of the left malleolus bony prominence on each side of the ankle) of the left fibula (calf bone) and dementia. An Advance Directive dated 12/13/24 identified in the event of a cardiopulmonary arrest, Resident #3 requested Do Not Resuscitate (DNR). The Advance Directive was signed by the resident representative. A review of the physician orders dated 12/13/24 to 2/9/25 failed to reflect a DNR order was written. An interview with the DNS on 2/11/25 at 11:13 AM identified she would expect the nurse to obtain a physician's order once the advance directive was signed that reflected the resident/representative wishes. A review of the facility policy for Advance Directives directs to determine if a resident has or wishes to formulate and advance directive on admission. A DNR order form must be completed and signed by the provider and remain in effect until the resident or responsible party provides notification in writing that the DNR is no longer in effect. 3. Resident #173 had diagnoses that included covid 19 and pneumonia. An Advance Directive dated 2/4/25 identified in the event of a cardiopulmonary arrest, the resident requested Do Not Resuscitate (DNR). The Advance Directive was signed by Resident #173. A review of the physician orders dated 1/4/25 to 2/9/25 failed to reflect a DNR order was written. An interview with the DNS on 2/11/25 at 11:13 AM identified she would expect nurse to obtain a physician's order once the advanced directive was signed that reflected the resident wishes. A review of the facility policy for Advance Directives directs to determine if a resident has or wishes to formulate and advanced directive on admission. A DNR order form must be completed and signed by the provider and remain in effect until the resident or responsible party provides notification in writing that the DNR is no longer in effect.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #223) reviewed for medication administration, the facility failed to notify the physician when medications and creams were not available/provided according to the physician's order. The findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included pneumonia, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD). A physician's order dated 2/5/25 directed to administer Mucinex 1200 mg twice a day, Coenzyme Q10 200 mg tablet once a day, Triamcinolone Acetonide external cream 0.1% apply to abdominal folds and under left breast daily, and Anusol external cream 2.5% apply to hemorrhoids twice a day. Review of the nursing notes dated 2/5/25 to 2/10/25 failed to reflect the physician was notified that the Mucinex, Coenzyme Q10, Triamcinolone Acetonide external cream and Anusol had not been administered/applied per the physician's order. The social worker admission collection dated 2/6/25 at 2:56 PM identified Resident #223 was cognitively intact. Review of the MAR dated 2/6/25 to 2/10/25 identified: Mucinex 1200 mg twice a day was not administered 10 out of 10 opportunities. Coenzyme Q10 give a 200 mg tablet once a day was not administered 5 out of 5 opportunities. Triamcinolone Acetonide external cream 0.1% apply to abdominal folds and under left breast daily was not applied 4 out of 5 opportunities. Anusol external cream 2.5% apply to hemorrhoids twice a day was not applied 4 out of 4 opportunities. A physician's order dated 2/7/25 directed to change Anusol external cream 2.5% to once daily. The care plan dated 2/7/25 identified Resident #223 has altered respiratory status related to pneumonia, pulmonary hypertension, and COPD. Interventions included administering medications as ordered. Interview with Resident #223 on 2/9/25 at 9:15 AM indicated that the facility has not been giving him/her all the physician ordered medications and creams. Resident #223 indicated that the nurses just say they don't have it available, so he/she was not sure if it was a pharmacy issue or something else because he/she could have his/her resident representative bring in medications from home. Medication observation on 2/10/25 at 8:45 AM identified LPN #1 did not have the Mucinex 1200mg tablet or the CQ10 tablet available. Interview with LPN #1 on 2/10/25 at 9:30 AM indicated that she doesn't have CQ10 or the Mucinex to give to Resident #223. LPN #1 indicated that she would have to notify the pharmacy. LPN #1 indicated that she was only notifying the pharmacy and did not need to notify the physician. The interview with the DNS on 2/11/25 at 8:03 AM indicated that when medications are not available the charge nurse must notify the supervisor or the DNS. The DNS indicated that she was notified prior to surveyor medication observation yesterday. The DNS indicated that if she was aware prior she would have contacted the pharmacy right away and signed the form stating the facility would pay for the over-the-counter medications and creams Resident #223 needed. The DNS indicated that the nurse should have notified the pharmacy right away when the first dose was not available. The DNS indicated that the nurses do not have to notify the physician when a resident misses a medication dose, but sometimes the nurses will notify the physician but not all the time. The DNS indicated that if the nurse notifies the physician, it would be documented in the resident's clinical record. The interview with the Administrator on 2/11/25 at 10:15 AM indicated that if a resident does not receive a medication or treatment the physician had ordered that the nurse or supervisor were responsible to call the pharmacy and notify the physician right away after every missed dose. The Administrator indicated that if the physician was notified of the medication not being given her expectation it would be documented in the clinical record. The interview with MD #1 on 2/11/25 at 11:47 AM indicated that when a new admission comes in, he reviews and approves the medications and treatments from the hospital discharge w-10. MD #1 indicated that he would expect a resident to have all their physician ordered medications from the pharmacy within 24 hours. MD #1 indicated that if a resident does not have a medication after 24 hours, he would have expected the nurse to call him and let him know, because it is good for him to know and determine if a resident needs that medication or if the resident would need something else in its place or if resident would need to be sent back to the hospital. MD #1 indicated that MD #1 indicated that if a resident missed a dose he would expect to be notified. MD #1 indicated that the Mucinex was for Resident #223's cough and would assist with breaking down the mucus so resident cough bring it up. MD #1 indicated that it would be important for Resident #223 to have since he/she was in the hospital for pneumonia. Review of the Medication Administration Policy identified medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only the person legally authorized to do so. Medications are administered in accordance with written orders from the prescriber. If a dose of regularly scheduled medication is withheld or refused an explanatory note is entered in the medical record and if 2 consecutive doses of a medication are withheld or refused the physician is notified.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #223) reviewed for medication administration, the facility failed to administer medications and creams according to the physician's order. The findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included pneumonia, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD). A physician's order dated 2/5/25 directed to administer Mucinex 1200 mg twice a day, Coenzyme Q10 200 mg tablet once a day, Triamcinolone Acetonide external cream 0.1% apply to abdominal folds and under left breast daily, and Anusol external cream 2.5% apply to hemorrhoids twice a day. Review of the nursing notes dated 2/5/25 to 2/10/25 failed to reflect the physician was notified that the Mucinex, Coenzyme Q10, Triamcinolone Acetonide external cream and Anusol had not been administered/applied per the physician's order. The social worker admission collection dated 2/6/25 at 2:56 PM identified Resident #223 was cognitively intact. Review of the MAR dated 2/6/25 to 2/10/25 identified: Mucinex 1200 mg twice a day was not administered 10 out of 10 opportunities. Coenzyme Q10 give a 200 mg tablet once a day was not administered 5 out of 5 opportunities. Triamcinolone Acetonide external cream 0.1% apply to abdominal folds and under left breast daily was not applied 4 out of 5 opportunities. Anusol external cream 2.5% apply to hemorrhoids twice a day was not applied 4 out of 4 opportunities. A physician's order dated 2/7/25 directed to change Anusol external cream 2.5% to once daily. The care plan dated 2/7/25 identified Resident #223 has altered respiratory status related to pneumonia, pulmonary hypertension, and COPD. Interventions included administering medications as ordered. Interview with Resident #223 on 2/9/25 at 9:15 AM indicated that the facility has not been giving him/her all the physician ordered medications and creams. Resident #223 indicated that the nurses just say they don't have it available, so he/she was not sure if it was a pharmacy issue or something else because he/she could have his/her resident representative bring in medications from home. Medication observation on 2/10/25 at 8:45 AM identified LPN #1 did not have the Mucinex 1200mg tablet or the CQ10 tablet available. Interview with LPN #1 on 2/10/25 at 9:30 AM indicated that she doesn't have CQ10 or the Mucinex to give to Resident #223. LPN #1 indicated that she would have to notify the pharmacy. LPN #1 indicated that she was only notifying the pharmacy and did not need to notify the physician. The interview with the DNS on 2/11/25 at 8:03 AM indicated that when medications are not available the charge nurse must notify the supervisor or the DNS. The DNS indicated that she was notified prior to surveyor medication observation yesterday. The DNS indicated that if she was aware prior she would have contacted the pharmacy right away and signed the form stating the facility would pay for the over-the-counter medications and creams Resident #223 needed. The DNS indicated that the nurse should have notified the pharmacy right away when the first dose was not available. The DNS indicated that the nurses do not have to notify the physician when a resident misses a medication dose, but sometimes the nurses will notify the physician but not all the time. The DNS indicated that if the nurse notifies the physician, it would be documented in the resident's clinical record. The interview with the Administrator on 2/11/25 at 10:15 AM indicated that if a resident does not receive a medication or treatment the physician had ordered that the nurse or supervisor were responsible to call the pharmacy and notify the physician right away after every missed dose. The Administrator indicated that if the physician was notified of the medication not being given her expectation it would be documented in the clinical record. The Administrator indicated that it was the facility's responsibility to give the resident his/her medications per the physician's orders whether it is from the emergency medication box, the facility over the counter house stock, or the pharmacy. The interview with MD #1 on 2/11/25 at 11:47 AM indicated that when a new admission comes in, he reviews and approves the medications and treatments from the hospital discharge w-10. MD #1 indicated that he would expect a resident to have all their physician ordered medications from the pharmacy within 24 hours. MD #1 indicated that if a resident does not have a medication after 24 hours, he would have expected the nurse to call him and let him know, because it is good for him to know and determine if a resident needs that medication or if the resident would need something else in its place or if resident would need to be sent back to the hospital. MD #1 indicated that MD #1 indicated that if a resident missed a dose he would expect to be notified. MD #1 indicated that the Mucinex was for Resident #223's cough and would assist with breaking down the mucus so resident cough bring it up. MD #1 indicated that it would be important for Resident #223 to have since he/she was in the hospital for pneumonia. Review of the Medication Administration Policy identified medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only the person legally authorized to do so. Medications are administered in accordance with written orders from the prescriber. If a dose of regularly scheduled medication is withheld or refused an explanatory note is entered in the medical record and if 2 consecutive doses of a medication are withheld or refused the physician is notified.

Based on clinical record reviews, facility documentation, facility policy and interviews for of 3 of 3 residents (Resident # 7, 3 and 16) reviewed for pressure ulcers, for Resident #7 the facility failed to conduct comprehensive skin assessments by a registered nurse following the identification of a pressure injury consistent with professional standards, for Resident #3, the facility failed to complete a required nutritional assessment related to the presence of a newly identified pressure injury and for Resident #16 the facility failed to ensure the air mattress was set by the residents' weight per the physician order. The findings include: 1. Resident #7 had diagnoses that included fracture of the left femur and difficulty walking. The Hospital Discharge Summary dated 12/16/24 identified wound care for the left femur surgical site with no documented pressure injuries. The Baseline Care Plan dated 12/16/24 identified Resident #7 was at risk for skin breakdown. Interventions included the application of pressure reduction devices and regular repositioning. The Admission RN assessment dated [DATE] at 7:40 PM identified a Stage 1(non-blanchable erythema) pressure injury to the left heel measuring 5.0cm x 0.1 cm. Physician's orders dated 12/16/24 directed skin prep to the bilateral heels every morning and every evening and to float heels while in bed. The Admission MDS dated [DATE] identified Resident #7 was cognitively intact, required one-person partial moderate assist with bed mobility, one to two person assist with dressing, two person assist with transfers and had one unhealed stage 1 pressure injury. Subsequent weekly skin assessments dated 12/23/24 through 1/11/25 identified the continued presence of a non-blanchable pressure injury to the left heel with consistent measurements and no noted changes, however, these wound assessments were not completed by an RN. An RN assessment dated [DATE] at 4:02 PM identified the left heel pressure injury was purple in discoloration, and measured 3.2 cm x 1.8 cm. Orders were obtained for betadine application to maintain dryness and a referral to the wound specialist was made. An Initial Wound Evaluation and management Summary dated 1/16/25 identified an unstageable DTI to the left heel of undetermined thickness measuring 3.2cm x 2.0cm and had been present more than 32 days. Recommendations included offloading the wound, elevating/floating the heels and applying betadine twice daily. An interview with the ADNS on 2/09/25 at 3:05 PM identified she was responsible for the monitoring and tracking of all wounds at the facility. The ADNS identified Resident #7 had been admitted to the facility with a pressure injury but due to an oversight she failed to track the wounds progression until a change was reported on 1/12/25. Following the discovery, the ADNS completed a comprehensive skin assessment of the skin injury, obtained physician orders and referred Resident #7 to the wound specialist. An interview with the Administrator on 2/10/25 at 12:14 PM identified the ADNS should conduct a comprehensive weekly wound assessment for any resident with a wound including a detailed description and measurements. An interview with the Wound Specialist on 2/10/25 at 2:29 PM identified the progression of Resident #7's pressure injury was unavoidable due to limited mobility and existing comorbidities, despite appropriate interventions being in place. However, the Wound Specialist would expect a comprehensive nursing assessment on admission and thereafter. A review of the facility policy for Pressure Injuries and Surgical Sites for Licensed Nurses directs for newly admitted and existing residents, a licensed nurse will complete an evaluation from the head to most distal extremity within 24 hours of admission that includes any skin issues related to a pressure injury, surgical site, laceration or other skin anomaly identified during the evaluation. A licensed nurse is to document a weekly evaluation of pressure injuries to include the measurement, appearance, color and drainage. The LPN Practice Act Declaratory Ruling allows the LPN to contribute to the nursing assessment by collecting, reporting, and recording subjective and objective patient-related data in an accurate and timely manner. But an LPN cannot perform the assessment independently. 2. Resident #3 had diagnoses that included a non-displaced fracture of the left malleolus bony prominence on each side of the ankle) of the left fibula (calf bone) and dementia. A Nutritional assessment dated [DATE] identified Resident #3 was malnourished and had a stage 1 pressure ulcer on the coccyx that was present on admission. Recommendations included to provide Ensure supplement daily. The Admission MDS dated [DATE] identified Resident #3 was severely cognitively impaired, required two person assist with bed mobility/transfers, was at risk for the development of pressure ulcers and had one unhealed pressure ulcer. The Care Plan dated 12/30/24 identified Resident #3 had limited physical mobility and actual skin impairment of non-blanchable redness to the sacral area related to fragile skin/bony prominence. Interventions included pressure reducing devices, keep skin clean/dry and reposition every two hours to take pressure off the sacral area. A Nursing progress note dated 1/21/25 at 9:44 PM identified Resident #3 had a splint in place on the left lower extremity since admission for a fracture of left ankle and upon removal of splint observed skin to be red and noted callous to the left lateral (outside) foot and redness to the left dorsal (top) foot. Initial Wound Evaluation and management Summary dated 1/23/25 identified a stage II pressure wound of the left, lateral foot and an unstageable deep tissue injury of the left, dorsal foot secondary to a medical device. Recommendations included offloading heels and betadine twice daily. Recommendations also included a dietary consultation to evaluate Resident #3's abnormal body mass index (measurement of a person's leanness based on height and weight). A Nutrition progress note dated 1/27/25 identified Resident #3 was stable since admission with meal intake between 75 - 100% and taking 50 - 100% Ensure supplements. Recommendations included to continue the plan of care. A Nutrition progress notes dated 1/29/25 identified Resident #3 no longer wanted Ensure supplementation reporting it was too sweet. Ensure was discontinued upon request. Review of the nutrition assessments and progress notes failed to reflect the newly identified skin injury. An interview with the Dietitian on 2/10/25 at 5:57 AM identified she would complete an assessment and document any newly identified pressure injuries. She would also consider the need for additional supplementation or increased protein intake. The Dietitian further identified she could not recall being made aware of any new skin integrity concerns for Resident #3 but would have documented any new skin injuries in the clinical record. An interview with the Administrator on 2/10/25 at 11:59 AM identified any new injuries were discussed in morning report and risk meetings. The Administrator identified she would expect the dietitian to assess any new skin injury and make any recommendations accordingly. The Administrator further identified, subsequent to surveyor inquiry, she discussed the case with the Dietitian who indicated she was not aware Resident #3 had a pressure injury. An interview with the DNS on 2/11/25 at 11:14 AM identified she would expect the dietitian to document the presence of any newly identified injury and any recommendations. Although requested a policy for the dietitian role and responsibility in wound management was not provided. Performance Expectations of the Dietitian identified they must utilize existing support structures and create new ones to ensure practices and standards are present and contributing to success. 3. Resident #16 was admitted to the facility on [DATE] with diagnoses that included unstageable sacral pressure ulcer, protein-calorie malnutrition, and diabetes. A physician's order dated 12/13/24 directed the use of an air mattress. Check air mattress settings as per weight or manufacturers settings every shift and check for placement and function every shift. The care plan dated 12/16/24 identified Resident #16 was admitted with pressure ulcers to the sacrum, and bilateral heels. Interventions included encouraging Resident #16 to frequently shift weight, educate Resident #16 about proper skin care to prevent skin breakdown, and heel lift boots while in bed. The admission MDS dated [DATE] identified Resident #16 had moderately impaired cognition was always incontinent of bowel and had a catheter for urine. Resident #16 required total assistance for toileting, dressing, transfers, and personal hygiene. Resident #16 had 1 community acquired pressure ulcer that was unstageable and 2 pressure ulcers that were deep tissue injuries (DTI). Additionally, Resident #16 was at risk for developing pressure ulcers and had a pressure reducing device for the chair and bed. The care plan dated 1/22/25 identified Resident #16 has a new pressure ulcer to the left lateral heel on 1/16/25 and a new deep tissue injury to the right lateral plantar foot on 1/22/25. Interventions were to apply betadine to the areas. Review of the weight record identified the following weights: 12/14/24 Resident #16 weighed 142.5 lbs. 12/16/24 Resident #16 weighed 147.2 lbs. 12/24/24 Resident #16 weighed 148.2 lbs. 12/30/24 Resident #16 weighed 147.2 lbs. 1/11/25 Resident #16 weighed 136.0 lbs. 1/27/25 Resident #16 weighed 134.0 lbs. 2/3/25 Resident #16 weighed 134.5 lbs. Observation on 2/9/25 at 10:16 AM and 2:15 PM identified Resident #16 was lying on bed in supine position on the air mattress that was set at 75 lbs. Observation on 2/10/25 at 6:13 AM identified Resident #16 was lying on bed in supine position on the air mattress that was set at 75 lbs. Interview with RN #1 (11:00 PM to 7:00 AM charge nurse/supervisor) on 2/10/25 at 8:35 AM indicated that the charge nurse was responsible to check the placement and function of the air mattress every shift and sign off in the EMR that the air mattress had air and was set to the resident's weight. RN #1 indicated that she had looked at Resident #16's air mattress about 1:00 AM and signed off after she had looked at the control box of the air mattress and it was set at 75 lbs. RN #1 indicted that she works every weekend and when she came yesterday Resident #16's air mattress was set at 75 lbs. so she thought it was the right setting so this morning about 1:00 AM she made sure that it was still set at 75 lbs. and signed it off in the EMR. Review of the clinical record, RN #1 indicated that Resident #16's last weight on 2/3/25 was 134.5 lbs. RN #1 indicates that Resident #16 was not able to verbalize if the air mattress was too hard or too soft and that was why the physician order stated to set the air mattress by Resident #16's weight. RN #1 indicated that the purpose of the air mattress was to prevent wounds or to prevent wounds from getting worse if it was at the proper setting. The interview with ADNS (wound nurse) on 2/10/25 at 11:00 AM indicated that Resident #16 was on an air mattress due to the coccyx wound. ADNS indicated that the air mattress was to prevent wounds from getting worse and to alleviate pressure to the coccyx area. ADNS indicated that there is a physician order to check placement and function every shift by the charge nurse and the air mattress was to be set based on the resident's weight. Observation of Resident #16 with ADNS on 2/10/25 at 11:05 AM identified Resident #16 was lying in bed and ADNS indicated that the setting for the air mattress dial was set between 75 to 80 lbs. the ADNS indicated that Resident 16 weighs more than 80 lbs. After clinical record review, ADNS indicated that Resident #16 weight was 134.5 lbs. so the setting was not at the correct setting, and she would change it. Interview with ADNS on 2/10/25 at 11:16 AM indicated that she had spoken to maintenance, and they informed her the air mattresses were to be set based on the resident's weight. ADNS indicated that Resident #16's air mattress was set at 80 lbs. would be too soft, and Resident #16 could bottom out resulting in his/her buttocks being on the bed frame applying pressure. ADNS indicated that she and maintenance could not find a manufacture booklet for the air mattress used. Interview with the DNS on 2/11/25 at 7:52 AM indicated that the air mattress was set to the resident's weight. The DNS indicated that the nurse's aides were responsible for making sure it was at the correct setting when they went into a resident's room. The DNS indicated that there was not a policy for the air mattresses nor was there a manufacture booklet. Interview with the Administrator on 2/11/25 at 12:00 PM identified there was not a policy for air mattresses and they could not find the manufacturers' booklet for Resident #16's air mattress. Although requested, a facility policy for air mattresses and the manufacturer booklet for air mattresses was not provided. 42117

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #17) reviewed for accidents, the facility failed to implement interventions and supervision to prevent falls. The findings include: Resident #17 had diagnoses that included dementia and history of fracture. A Fall Risk assessment dated [DATE] identified Resident #17 was at risk for falls. The Admission MDS dated [DATE] identified Resident #17 was severely cognitively impaired, required two person assist with bed mobility/transfers and had a history of falls since admission without injury. The Care Plan dated 9/18/24 identified Resident #17 had impaired cognition and was at risk for falls related to dementia. Interventions included anticipating resident needs, ensuring the call bell is within reach and if restless, relocating the resident to a common area for closer supervision instead of assisting them to bed. Physician orders dated 9/19/24 directed assist of one with ADL's. Assist of two with mechanical lift transfer. a. A Nursing progress note dated 10/6/24 at 12:16 PM identified RN #3 witnessed Resident #17 sliding off the wheelchair and mechanical lift pad landing on the footrest while in front of the nurse's station. An assessment identified Resident #17 was unable to verbalize what lead to the incident, had no complaints or discomfort, and was safely transferred back to the wheelchair. The resident representative was notified. The post fall investigation dated 10/6/24 identified Resident #17 was observed to have slid out of his/her wheelchair and mechanical lift pad and onto the floor. The investigation further identified Resident #17 was previously observed to be constantly sliding down in the chair trying to get up and needed constant reminders to scoot back in the chair. The care plan was revised to maintain resident in a common area for close observation. An interview and clinical record review with the Administrator on 2/10/25 at 1:12 PM identified Resident #17's wheelchair and mechanical lift pad should have been evaluated to address repeated incidents of sliding down in the chair. The Administrator further identified simply reminding a resident to scoot back in the chair was not an appropriate intervention for a resident who was cognitively impaired. An interview with the Director of Rehabilitation on 2/11/25 at 10:19 AM identified Resident #17 had poor safety awareness and was often kept in staff sight for safety. The Director of Rehabilitation identified she did not receive a request to evaluate Resident #17 related to repeatedly sliding out of their chair to determine if there was general weakness versus behavior. The Director of Rehabilitation further identified Resident #17 would not be able to consistently respond to reminders to self-scoot back in the chair due to his/her behaviors and cognition. An interview with the DNS on 2/11/25 at 10:56 AM identified a referral to evaluate Resident #17's chair and mechanical lift pad should have been completed after he/she was repeatedly observed sliding in the chair. Attempts to interview RN #3 were unsuccessful. A review of the facility policy for Fall Reduction directs all falls to be analyzed at the time of occurrence and root cause identified that lead to the potential breakdown with resident specific interventions put in place pertaining to the individual conditions following the fall. b. A nursing progress note dated 1/12/25 at 8:00 PM Resident #17 was observed on the floor at the nurse's station with the wheelchair on top of him/her. A body assessment was completed with no visible injuries and neurological assessments were initiated. The APRN and resident representative were notified. The post fall investigation dated 1/12/25 identified [NAME] #1 observed Resident #17 standing up from his/her wheelchair in front of the nurse's station holding onto the railing while calling for help. [NAME] #1 went to get a nurse, and upon return, Resident #17 had fallen. The care plan was revised to evaluate for anti-tippers for the wheelchair or obtain reclining wheelchair. An interview and clinical record review with the Administrator on 2/10/25 at 1:12 PM identified Resident #17 was known to have a history of falls and would have required periodic documented supervision checks as determined by the interdisciplinary team. Resident #17 would also be placed in front of the nurse's station or other common area where staff were aware not to leave the area if another staff member was not nearby. The Administrator further identified [NAME] #1 should not have left Resident 17 after identifying a safety concern. An interview with the Director of Housekeeping on 2/10/25 at 3:09 PM identified facility policies direct that housekeeping staff may not touch or provide direct care to a resident. However, for any safety concern, they are required to remain with the resident and call for help. An interview with [NAME] #1 on 2/10/25 at 3:14 PM identified he was in a nearby dining area when he heard Resident #17 call for help. [NAME] #1 then observed Resident #17 alone in front of the nurse's station standing up out of her wheelchair. [NAME] #1 identified that while not permitted to physically intervene with residents, he would normally ask the resident to sit back in the chair, remain with the resident and call for help for any identified safety concern. [NAME] #1 identified instead, in a state of panic, he left the area to find a nurse. Upon return, Resident #17 was on the floor with the wheelchair on top of him/her. An interview with the Director of Rehabilitation on 2/11/25 at 10:19 AM identified she did not receive a request to evaluate Resident #17's wheelchair following the fall on 1/12/25. An interview with the DNS on 2/11/25 at 10:56 AM identified [NAME] #1 should have remained with Resident #17 and called for help. The DNS was unable to provide any documented supervision checks for Resident #17. A review of the facility policy for Fall Reduction directs all falls to be analyzed at the time of occurrence and root cause identified that lead to the potential breakdown with resident specific interventions put in place pertaining to the individual conditions following the fall. Although requested, a policy for housekeeping staff interactions and residents regarding safety was not provided.

Based on review of facility documentation and interviews, the facility failed to maintain a complete and accurate record of residents identified with Multidrug-resistant organisms (MDRO) in accordance with infection control standards. The findings include: A review of the facility infection control program identified no documented surveillance of long term residents with current or a history of MDRO's. An interview and facility documentation review with the ADNS on 2/10/25 at 9:44 AM identified she was the assigned infection preventionist (IP) for the facility for the preceding five months and was responsible for implementing and monitoring infection control activities in the facility. The ADNS identified that although she tracked the MDRO status for short term residents, she had not completed surveillance or tracking on any long-term residents. The ADNS had not observed any long-term resident on enhanced barrier precautions indicating an MDRO when she was first employed at the facility and had not verified their status. The ADNS was unable to provide any documented MDRO tracking from the previous IP. An interview with the Administrator on 2/10/25 at 12:24 PM identified she would expect surveillance for all residents with MDRO's to be maintained with complete and accurate record keeping including appropriate precautions put in place. An interview with the DNS on 2/11/25 at 11:17 AM identified she would expect an MDRO log to be maintained for all residents at the facility. Although requested, a policy for MDRO surveillance was not provided. Centers for Disease Control and Prevention (CDC) provide infection control standards for long-term care facilities that require the implementation of an MDRO surveillance program that includes the tracking and trending of those with MDRO's and infection, communication of MDRO status during transfers and strategies for transmission-based precautions.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #1) who required staff assistance with getting in and out of the bed and chair, via a mechanical lift, the facility failed to ensure a proper transfer to prevent a fall that resulted in Resident #1 sustaining bilateral femur fractures. The findings include: Resident #1's diagnoses included dementia, cervical spine spondylopathy, depression, respiratory failure, and aphasia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required assistance of two (2) staff members with getting in and out of the bed and chair, and was incontinent of bowel and bladder. The Resident Care Plan dated [DATE] identified activities of daily living self-care performance deficit related to dementia and limited mobility. Interventions directed to provide assistance of two (2) staff members for turning and repositioning when in bed, and assistance of two (2) staff members for transfers via a mechanical lift (Hoyer lift). A physician's order dated [DATE] directed to provide assistance of two (2) staff members for transfers via the Hoyer lift. The nurse's note dated [DATE] at 2:30 PM identified the 7AM-3PM Nursing Supervisor was notified by the 7AM-3PM charge nurse at 1:20 PM that Resident #1 slid out from the Hoyer lift during a transfer from the wheelchair to the bed and fell to the floor. The note identified the Nursing Supervisor immediately went into Resident #1's room, found Resident #1 on the floor in a sitting position at the bedside adjacent to the Hoyer lift with wheelchair in front. The note indicated upon assessment Resident #1 was alert, verbally responsive, verbalized pain to the right side, and denied pain to any other parts of the body. The note identified the Advanced Practice Registered Nurse (APRN) was contacted and an order was obtained to send Resident #1 to the Emergency Department (ED). The nurse's note dated [DATE] at 6:10 PM identified a call was made to the ED for an update on Resident #1's status and it was reported Resident #1 had bilateral femur fractures and further results were pending. The nurse's note dated [DATE] at 8:30 PM identified the facility received a call from the ED physician who reported Resident #1 had sustained bilateral femur fractures and expired after beginning to decompensate and due to Resident #1's Do Not Resuscitate status, no resuscitation was performed. The facility's summary report of the [DATE] incident dated [DATE] identified the nurse aides had Resident #1 in the Hoyer pad, moved the wheelchair towards the bed, and during the turn to place Resident #1 over the bed the bottom hook of the pad dislodged, and Resident #1 slid to the floor and landed on his/her bottom. The report indicated the Hoyer pad was intact and there was no area that was ripped before or after the incident. An interview was conducted on [DATE] at 1:54 PM with the 7AM-3PM nurse aide, Nurse Aide (NA) #4. NA #4 stated on [DATE], another nurse aide, NA #3, asked her for assistance to transfer Resident #1 into bed and when she went into Resident #1's room to assist with the transfer, Resident #1 was already hooked up to the Hoyer lift. NA #4 stated NA #3 began to move Resident #1 and when Resident #1 was being moved, Resident #1 fell out of the pad. NA #4 stated after Resident #1 fell , she noticed that one (1) of the pad straps was not attached to the Hoyer lift and did not notice if it was strapped prior to the transfer and fall. An interview was conducted on [DATE] at 2:11 PM with the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #2. RN #2 stated on [DATE], when Resident #1 sustained the fall, he went to Resident #1's room to assess the resident and was told by NA #3 and NA #4 that one (1) of the straps on the Hoyer lift pad came undone, and Resident #1 fell . RN #2 stated he assessed Resident #1 who initially had no complaints of pain and was transferred back to bed by staff, however, once Resident #1 was back in bed, he/she had complaints of pain to the knee, the APRN was notified and an order was given to send Resident #1 to the ED, 911 was called and Resident #1 was transported to the ED. An interview was conducted on [DATE] at 2:20 PM with NA #3. NA #3 stated that on [DATE] Resident #1 was being put back to bed for incontinence care. She stated she had hooked the Hoyer pad to the Hoyer lift and NA #4 was assisting with the transfer. NA #3 stated during the transfer the strap on the bottom hook came off and Resident #1 slipped out of the Hoyer lift, falling to the floor. An interview was conducted on [DATE] at 2:36 PM with the Director of Nursing (DON), Administrator and Executive Director. The DON stated it was reported that during the Hoyer lift transfer on [DATE], the strap from the pad came off and Resident #1 fell to the floor landing in a sitting position. The interview identified during the investigation, staff interviews and a mock re-enactment was done which showed placement of the Hoyer pad, where it was positioned, and where the resident slid from the pad. The DON and Executive Director stated the conclusion of the investigation, the bottom strap of the Hoyer lift pad dislodged which caused Resident #1 to slip out and fall to the floor. The DON, Administrator and Executive Director explained the Hoyer lift pad being used was a three (3) point pad and it was connected at each of the top two (2) points and the third strap should be strapped through the resident's legs and it could not be determined if the strap was not connected properly or if it became dislodged during the transfer somehow. The DON, Administrator and Executive Director stated the nurse aides should have ensured the Hoyer lift pad was secured prior to the transfer. Review of the facility policy titled Lifts and Transfers of Residents by Clinical Associates directed, in part, all clinical associates shall attend Direct Care Orientation, which includes training on how to lift and transfer residents, once this training has been completed and a qualified instructor has deemed the associate has successfully demonstrated the skill, the associate will be marked as having acquired this skill in Watermark's Learning Center. The policy directed, when a resident requires the use of a mechanical lift for lifting and/or transfers, two (2) associates trained to use the mechanical lift are to assist with the lift or transfer.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #1) who were reviewed for a mechanical lift (Hoyer) transfer, the facility failed to provide documentation that staff education and competencies were conducted to ensure safe transfer techniques. The findings include: Resident #1's diagnoses included dementia, cervical spine spondylopathy, respiratory failure, aphasia, and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required assistance of two (2) staff members with getting in and out of the bed and chair, and was incontinent of bowel and bladder. A physician's order dated 1/30/24 directed to provide assistance of two (2) staff members for transfers via the Hoyer lift. The nurse's note dated 3/2/24 at 2:30 PM identified the 7AM-3PM Nursing Supervisor was notified by the 7AM-3PM charge nurse at 1:20 PM that Resident #1 slid out from the Hoyer lift during a transfer from the wheelchair to the bed and fell to the floor. The note identified the Nursing Supervisor immediately went into Resident #1's room, found Resident #1 on the floor in a sitting position at the bedside adjacent to the Hoyer lift with wheelchair in front. The note indicated upon assessment Resident #1 was alert, verbally responsive, verbalized pain to the right side, and denied pain to any other parts of the body. The note identified the Advanced Practice Registered Nurse (APRN) was contacted and an order was obtained to send Resident #1 to the Emergency Department (ED). Interview with the 7AM-3PM nurse aide, Nurse Aide (NA) #4, on 3/21/24 at 1:54 PM identified on 3/2/24, another nurse aide, NA #3, asked her for assistance to transfer Resident #1 into bed. NA #4 identified when she went into Resident #1's room to assist with the transfer, Resident #1 was already hooked up to the Hoyer lift. NA #4 identified NA #3 began to move Resident #1 and when Resident #1 was being moved, Resident #1 fell out of the pad. NA #4 identified after Resident #1 fell , she noticed that one (1) of the pad straps was not attached to the Hoyer lift and did not notice if it was strapped prior to the transfer and fall. NA #4 identified training regarding Hoyer lift transfers was given during the orientation period while shadowing a trained nurse aide. Interview with NA #3 on 3/21/24 at 2:20 PM identified on 3/2/24, Resident #1 was being put back to bed to be provided incontinent care. NA #3 identified she had hooked the straps of the Hoyer pad to the Hoyer lift, NA #4 was assisting with the transfer and during the transfer the strap on the bottom hook came off, Resident #1 slid out of the Hoyer lift and fell to the floor. NA #3 identified training on Hoyer lift transfers was given yearly during in-service training. Interview with the Director of Nursing (DON), Administrator and Executive Director on 3/21/24 at 2:36 PM identified it was reported that during the Hoyer lift transfer on 3/2/24, the strap from the pad came off and Resident #1 fell to the floor landing in a sitting position. The DON, Executive Director and the Administrator identified staff are trained upon hire and yearly competencies are conducted. The DON identified she could not provide documented competencies for NA #3 and NA #4. The DON identified upon hiring staff are paired with a senior nurse aide to get training on Hoyer lift transfers and then observed by the unit nurses to ensure they are performing the transfer correctly. The DON identified there was no documentation regarding NA #3 and NA #4 having had their competencies done on a Hoyer lift transfer. The DON identified NA #3 had a skills checklist from years ago but was unable to provide an updated checklist and NA #4 had been at the facility for a short period of time and she could not provide documentation of completion of a skills checklist/competency. Review of the facility policy titled Lifts and Transfers of Residents by Clinical Associates, last revised 12/18/17, directed, in part, all clinical associates shall attend Direct Care Orientation, which includes training on how to lift and transfer residents, once this training has been completed and a qualified instructor has deemed the associate has successfully demonstrated the skill, the associate will be marked as having acquired this skill in Watermark's Learning Center. The policy further directed, in part, no associate shall engage in lifting or transferring a resident independently until trained by a qualified instructed and deemed by the instructor to have properly demonstrated lifting and transferring techniques and prior to performing any lift or transfer. Additionally, the policy directed, in part, when a resident requires the use of a mechanical lift for lifting and/or transfers, 2 associates trained to use the mechanical lift are to assist with the lift or transfer.

Based on review of facility documentation, observations of the kitchen and interviews, the facility failed to ensure that food temperatures were taken and documented daily at each meal and failed to ensure proper infection control practices for hand washing were maintained while plating food at mealtime. The findings included: 1. Interview and review of facility documentation on 2/22/2023 at 12:25 PM with Cook #1 identified that he did not know why the cook scheduled on 2/22/2023 did not document the temperatures of foods served on 2/4/2023 for( 3 meals). Cook #1 indicated that when he came in to work his next scheduled day that is when he started to write on the 2/4/2023 blank form realizing it was the wrong day went to the correct sheet to document on and further indicated that he did not work on 2/4/2023. Cook #1 further indicated that the food is provided by the assisted living facility kitchen, and it is delivered to the skilled nursing facility via satellite kitchen, the food is kept warm, skilled nursing completes some of prep and cooking, plates and serves meals to the skilled nursing facility residents. On 2/27/23 at 10:00 AM during facility documentation review and interview the Associate Executive Director of dietary subsequent to inquiry on 2/22/23 identified the cook that was working on 2/4/23 in the kitchen was spoken to by him/her and Human Resource (HR) regarding the lack of documentation of food temperatures for all meals on 2/4/2023. The Associate Executive Director of dietary further indicated the cook working 2/4/23 stated that he had taken the temperatures but had not written them down and that the temperatures should have been documented. Although the Associate Executive Director was able to provide evidence of food temperatures for the food that was prepared and delivered to the satellite kitchen, he was unable to provide documentation of food temperatures taken on 2/4/2023 for the satellite kitchen that serves the Skilled Nursing facility. 2. On 2/27/2023 at 12:15 PM observation of Cook #1 identified Cook #1 wearing a mask that was moving down past his nose while preparing and plating food with gloved hands, Cook #1 was noted to repeatedly touch the mask and then return to plating food, the Associate Executive Director observing in the dining area was immediately made aware of the observation. Subsequent to inquiry, the Associate Executive Director of dietary consulted with the supervising chef in attendance, assisted Cook #1 by obtaining a new mask, removed gloves, completed hand washing and new gloves applied. No concerns were noted during observation for the remainder of plating through 12:40 PM. On 12/27/2023 at 12:25 PM interview with the Dietary Supervisor identified he would have expected Cook #1 to remove the gloves, washed his hands and apply new gloves after touching his mask before resuming plating of the food. The facility policy for dining services labeled Handwashing revised on 10/16/2020 indicated in part the facility policy ensures that standard precautions including proper and effective handwashing techniques are followed at all times to prevent the spread of disease, germs, and cross contamination. The policy further indicated in part that anyone preparing, handling, or serving food will wash their hands frequently and that gloves or alcohol-based sanitizers will not be used in place of hand washing and hands will be washed when changing food preparation tasks and after touching the face, hair, or body.

Based on clinical record review, facility policy review, and interviews for 1 sampled resident (Resident # 171) reviewed for edema, the facility failed to ensure that a baseline care plan was completed within 48 hours of resident admission to address the resident's needs. The findings include : Resident # 171's diagnoses included Chronic Congestive Heart Failure (CHF), sick sinus syndrome and atrial fibrillation. Resident #171 was admitted on [DATE] and was in the facility less than 10 days. Completion of admission Minimum Data Set ( MDS) assessment was not required during this time. The Resident Care Plan (RCP)with Care Plan initiation dates of 2/20/23 and 2/21/2023(72 and 96 hours after admission). The Resident Care Plan (RCP) meeting attendance sheet dated 2/23/2023 at 11:30 AM identified as the Initial 72-hour Care Plan meeting indicated that an initial care plan meeting was held and noted that interdisciplinary staff, resident, and family signed as being in attendance. On 2/27/2023 at 1:25 PM an interview with the Assistant Director of Nursing (ADNS) indicated that the baseline care plan, which is a paper care plan, is the responsibility of the interdisciplinary team and indicated the baseline care plan should be completed within 48 hours of admission. The ADNS further indicated that agency staff do not complete the baseline care plan but would have expected the staff nurses on duty the following shifts complete the 48 hours care plan. The facility policy labeled, Skilled Nursing Care Planning Protocol revised 3/3/2015 notes in part, the facility would provide an interdisciplinary plan of care that meets the resident's individual needs and preferences. The policy and procedure further indicated that all residents would have a care plan started on admission and that the admission nurse is responsible for the baseline care plan.

Based on clinical record review, facility policy review and interviews for 1 sample resident (Resident #10) reviewed for hospitalization , the facility failed to ensure the resident was assessed comprehensively after significant change of condition in accordance to the professional standard and facility practice. The findings include: Resident #10's diagnoses included left femur fracture, rheumatoid arthritis, Peripheral Vascular Disease (PVD) and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #10 had intact cognition and required extensive assist of 1 to 2 person with transfer, toileting, hygiene and non-ambulatory. The nurse's note dated 2/6/23 at 2:02 PM identified Resident #10 had been vomiting, noted with lethargy and left the facility for nephrology appointment. Further review of the nurse's note dated 2/6/23 at 3:32 PM identified Resident #10 had an episode of unresponsiveness and vomiting at his/her nephrology appointment and the resident was transferred to hospital for an evaluation. A review of the clinical record nurses notes for 2/6/23 failed to reflect that a comprehensive assessment had been conducted by a Registered Nurse (RN) when Resident # 10 experienced vomiting and lethargy prior to his/her nephrology appointment. Interview with Assistant Director of Nursing Services (ADNS) on 2/23/23 at 10:30 AM identified a RN was responsible for assessing Resident # 10 when there was significant change of condition. She also indicated that she would check the resident's vital sign, check mini mental cognitive status, check resident abdomen and update the physician of the resident condition. The ADNS also indicated she would document the resident's clinical condition in the resident's medical chart. Interview with Director of Nursing Services (DNS) on 2/23/23 at 12:10 PM identified a RN was responsible for assessing a resident's condition after a significant change of condition. She further indicated the physician and the resident's representative would be notified, and the RN assessment would be documented in the clinical record. The facility failed to ensure that a RN conducted a comprehensive assessed after Resident # 10 experienced a change in condition. A review of facility nursing policy dated 1/27/15 title Change in Resident Condition notes in part the charge nurse/nurse supervisor will notify the physician, resident's representative when there was a significant change in a resident's condition.

Based on clinical record review, facility policy and interviews for 1 sampled resident ( Resident # 171) reviewed for edema, the facility failed to ensure body weights were obtained as ordered by the physician. The finding include: Resident # 171's was admitted to the facility on [DATE] with diagnoses that included Chronic Congestive Heart Failure (CHF), sinus syndrome and atrial fibrillation. A physician's order dated 2/18/2023 directed to obtain Resident #171's weight on admission, daily for 3 days, weekly for four weeks, then monthly. On 2/21/23 at 12:30 PM observation identified Resident # 171 noted with bilateral ankle swelling. When questioned about the swelling Resident #171 was unsure if the swelling was new or old. On 2/22/2023 at 1:45 PM and interview with Licensed Practical Nurse (LPN#1) indicated Resident #171 had a weight obtained on admission, (2/17/2023), then again on 2/20/2023 in the electronic health medical record. LPN #1 further indicated that more weights could be found in the weight book. LPN #1 found a weight completed on 2/19/2023 189 pounds but only noted a yellow highlighted blank space for 2/18/2023. LPN#1 indicated that the day 2/18/23 was a Saturday and she did not know why the weight was not obtained. The Resident Care Plan ( RCP) dated 2/23/2023 indicated in part Resident # 171 had a potential nutritional problem related to recent hospitalization and CHF. Intervention included: to obtain weights as ordered by the physician. The Care Plan further indicated that Resident #171 had CHF. Interventions included: to monitor the resident's weight and to monitor, document, report signs or symptoms of CHF which included weight gain unrelated to intake. On 2/23/2023 at 2:27 PM an interview with LPN #3 indicated if there was a refusal of the weight the refusal would be indicated in the progress note where the weight is signed off on in the electronic medical record and indicated he could not remember what was written without seeing the medical record. LPN #3 further indicated that he was not assigned to Resident #171 during the morning when the weight would have been obtained by staff and indicated he took over the assignment at noon time as scheduled. LPN # 3 also indicated when he took over the assignment he did not check to see if weights were completed or not. On 2/23/2023 at 2:45 PM an interview with RN #2 indicated she could not recall reviewing the weight assignment sheets on the units to be sure they were completed. RN#2 further indicated that if the weight was refused it would be documented as such by the LPN charge nurse. RN #2 also indicated she would have expected the weight to be obtained. On 2/23/2023 at 3:00PM interview with the ADNS indicated that there was no weight obtained on 2/18/2023 and indicated LPN #3 was responsible for ensuring the weight was completed, documented on the weight sheet in the weight book and in the electronic medical record. The DNS further indicated during review of the electronic Medication Administration Record (MAR) LPN #3 signed off the order to obtain the weight on 2/18/2023 but there was no note entered regarding the result of the weight or if it was refused. The DNS further indicated the Nurse Aides (NA) are responsible for obtaining weights, the licensed nurse is responsible for documenting the weights in the computer and signing off the weight in the Medication Administration Record (MAR). Review of the facility policy labeled Skilled Nursing Weights Policy dated 10/30/2015 notes in part, Resident's weights are kept within acceptable parameters of nutritional status taking into account their clinical condition. The policy further indicated that the resident's weights will be obtained as ordered by the physician, federal/state regulations or standards of practice.

Based on observation, facility policy review and interviews, the facility failed to ensure that staff was wearing a N-95 mask and face shield/goggles prior to going in a positive COVID-19 room in accordance to facility practice. The findings include: Observation on 2/23/23 at 9:10 AM identified License Practical Nurse (LPN #2) was preparing to administered medication outside a positive COVID-19 room. LPN#2 was noted wearing a gown, surgical mask and gloves and proceeded to go inside the positive Covid 19 resident's room to administer a medication. Further observation with LPN #2 having close contact with the positive COVID-19 resident during the medication administration. Interview with LPN #2 on 1/23/23 at 9:25 AM identified she was aware that room she went in was a positive COVID-19 room and on the resident was on strict precaution. She also indicated that staff are required to wear a gown, N-95 mask, face shield/goggles and gloves prior to entering a positive COVID-19 room. She also indicated she should wear a N-95 mask and face shield/goggles while administering a medication. Interview with Director of Nursing Services (DNS) on 1/23/23 at 11:00 AM identified staff is required to wear a N-95 mask, gown, face shield/goggles and gloves prior to entering a positive COVID-19 room. She would expect her staffs to wear proper Personal Protective Equipment (PPE) when providing care to a positive COVID-19 room and also during medication administration. A review of facility nursing policy dated 6/15/22 title COVID-19 Infection and Outbreak Policy notes when confirmed positive COVID-19 is identified to place a signage of Isolation In Use on door and to use isolation gown, gloves, face mask and eye protection.

Based on clinical record review, facility documentation, facility policy review and interviews for 1 of 5 residents (Resident #9) reviewed for vaccinations, the facility failed to administer pneumovax vaccine following a request to receive the vaccinations. The findings include: Resident #9 's diagnoses included dementia, atrial fibrillation, heart failure, depression, and hypertension. A review of facility documentation of Resident # 9's medical consent and acknowledgement dated 9/30/22 immunization record identified Resident # 9's responsible party signed the consent to administer vaccines according to the recommended schedule on 10/7/22. The immunization record identified that the consent for pneumovax dose 1 was refused. Interview with Director of Nursing Services (DNS) on 2/22/23 at 2:00 PM identified RN #1 (Infection Control Nurse) was responsible for obtaining and ensuring the resident's vaccine was administered after the consent was obtained. She also indicated that typically RN #1 had a separate consent form that allowed the facility to administer the pneumovax vaccine. She could not provide a reason on why the pneumovax vaccine was not given and flu vaccine was given using the medical consent and acknowledgement. Subsequent to inquiry, the pneumovax vaccine was ordered on 2/24/23. RN #1 was not available for interview during the survey. Review of facility nursing policy dated 10/22/19 title Influenza and Pneumovax Vaccination Policy notes vaccination will be offered to all residents. Each resident will be offered a pneumococcal immunization unless contraindicated or the resident has already been immunized.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #20) who was reviewed for an accident with an injury, the facility failed to ensure the proper transfer technique was utilized when the resident was transferred via a mechanical (Hoyer) lift from the bed to the wheelchair. The findings include: Resident #20's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 had memory deficits, severe cognitive impairments, required total two (2) person assistance with transfers in and/or out of the bed and chair, and utilized a wheelchair for mobility. The resident care plan revised on 4/27/18 identified Resident #20 had a self-care performance deficit. Interventions directed to Hoyer transfer assist of two (2) staff using an Invacare-Medium-Blue pad. The nurse's note dated 5/4/18 indicated the 7AM-3PM Nursing Supervisor, Registered Nurse (RN) #1, was called to Resident #20's room and upon entering the resident was observed laying on the floor. The note identified Resident #20's right ankle and foot were noted to be externally rotated, the attending physician was on the unit and after the resident was examined, Resident #20 was lifted back to bed with the assist of six (6) staff members and additional support was provided to the right lower extremity. The note identified Resident #20 was transferred to the hospital at 11:40 AM. The Reportable Event Form dated 5/4/18 identified Resident #20 was observed laying on the floor, two (2) nurse aides witnessed the incident, the resident was transferred to the hospital and [DIAGNOSES REDACTED]. The report identified Resident #20 returned to the facility with the plan for an orthopedic consult in one (1) week, question casting and bedrest. Subsequent to the incident NA #1 and NA #2 were suspended pending a full investigation. The facility's investigation noted in a written statement, NA #1, identified during the transfer Resident #20 began screaming and stiffing up, so she held onto the resident's two (2) feet for protection and it was at that time she noticed Resident #20 sliding out of the Hoyer pad. The investigation indicated upon a re-enactment of the Hoyer transfer even though two (2) nurse aides, Nurse Aide (NA) #1 and NA #2, assisted Resident #20 with the transfer, it was noted that the Hoyer pad was not placed at the base of the resident's neck and the wheelchair was placed at the foot of the bed on an angle near the wall and the leg rests were attached. The investigation identified as Resident #20 was lifted off the bed and being maneuvered toward the wheelchair, NA #1 observed that the pad was bunched up under the resident and Resident #20 began to slide down and onto the floor. The report indicated the Hoyer pad remained attached to the Hoyer lift. Interview and review of the facility's investigation with the Director of Nursing (DON) on 3/6/19 at 2:00 PM identified that at the time of the accident the staff placed the Hoyer pad above the resident's head in error. The DON stated the Hoyer pad should have been placed at the base of the resident's neck. The DON identified the investigation indicated that the Hoyer pad was bunched up when the staff attempted the transfer and the nurse aides should have ensured the Hoyer pad was smooth and without wrinkles prior to moving Resident #20. The DON indicated that the wheelchair should have been at the foot of the bed close to the bed and the footrests should have been removed to create more space for a safer transfer. The DON stated that she had provided Hoyer transfer education to the staff 4/17/18 (less than a month prior to the accident). The DON indicated the proper placement of the pad and chair were discussed in the in-service. The DON stated NA #1 and NA #2 were terminated as a result of the investigation and subsequent to the incident all staff were observed for proper Hoyer transfer techniques. Attempts to interview NA #1 and NA #2 were unsuccessful.

Based on clinical record review and staff interviews for 2 of 2 sampled residents reviewed for hospitalization (Residents #14 and Resident #22), the facility failed to notify the office of the state long-term care Ombudsman of transfers out of the facility. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified Resident #14 had no cognitive impairment and required the assistance of 2 people for activities of daily living. Nurses note dated 12/15/18 at 8:37 AM identified Resident #14 called the nurse and complained of left sided chest pain. The physician was notified, 911 was called, and Resident #14 was transferred to hospital. A nursing note dated 12/15/18 at 9:31 PM identified Resident # 14 was admitted to the hospital. 2. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] identified Resident #22 had no cognitive impairment, and required extensive assistance of two people for bed mobility, and transfers. Nurses note dated 2/5/19 at 2:29 PM identified Resident #22 had a facial droop and slurred speech. The physician was notified and Resident #22 was sent to the hospital. Nurses note dated 2/5/19 at 9:25 PM identified Resident #22 was admitted to the hospital. Interview with Social Worker #1 (SW) on 3/7/19 at 11:40 AM identified that he/she did not notify the Ombudsman of Resident #14 and #22's transfer/admission to the hospital. Further interview with SW #1 identified he/she was unaware of the regulation to notify the Ombudsman until last week and notifications were not being sent out. SW #1 identified that he/she spoke with the Ombudsman last week to clarify what was needed and would subsequently begin sending monthly notifications of residents being transferred/admitted to the hospital. The facility did not provide a policy regarding notification of the Ombudsman regarding the transfer of residents out of the building.

Based on observation, review of the clinical record, facility policy, manufacturer recommendations and interviews for one of two sampled residents (Resident #29) reviewed for accidents, the facility failed to ensure equipment was used according to manufacturer recommendations to prevent a fall with an injury. The findings include: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified Resident #29 had intact cognition, required total dependence of two staff for transfers and bathing, did not walk, and was without falls since the prior assessment. physician's orders [REDACTED]. The care plan dated 8/1/16 identified Resident #29 was at risk for falls related to [DIAGNOSES REDACTED] and impaired vision. Resident #29 also was identified with a self-care deficit. Interventions included to transfer Resident #29 with the hoyer lift and assistance of two staff, and to provide total assistance with bathing. A weight record dated 8/23/16 identified Resident #29 weighed 158.8 lbs., and was 58 inches tall (4 foot 8 inches). physician's orders [REDACTED]. Accident/incident report dated 8/30/16 at 8:30 AM identified Resident #29 slid out of the hoyer pad (sling) while being transferred from the shower chair to the bed by LPN #1 and NA #1. A written statement from LPN #1 dated 8/30/16 identified Resident #29 was about 2 feet from the ground and quickly slid out of the Hoyer pad during the transfer. Resident #29 hit his/her buttocks and back of the head. Subsequent to the fall, Resident #29 complained that his/her head hurt and after physician notification, Resident #29 was transferred to the emergency room for evaluation. The hospital discharge summary dated 9/9/16 identified Resident #29 was hospitalized between 8/30/16 - 9/9/16 due to a head injury. Upon arrival to the emergency department, a CT-scan noted bilateral frontal lobe subarachnoid hemorrhages and subdural hematomas with minimal mass effect. Kcentra (a medication) was administered to reverse the Coumadin effects and Resident #29 was admitted to the SICU for neurological monitoring. On 8/31/16 a repeat CT-scan showed no increase in the size of the intracranial hemorrhages, the neurological exam was stable and a feeding tube was placed and verified with X-ray. On 9/8/16 Resident #29 tolerated breakfast and the feeding tube was removed. On 9/9/16 the discharge summary identified Resident #29 was at normal baseline mentation and deemed medically stable for discharge back to the facility. Follow up recommendations included a repeat head CT-scan and cardiology appointment within 2 weeks. Interview with Resident #29 on 4/12/17 at 10:15 AM identified that he/she does not remember how the fall occurred, is visually impaired and could not see what happened. However, Resident #29 indicated that he/she had terrible headaches after the fall and was in the hospital for a while. Resident #29 indicated that something must have gone wrong because he/she has been transferred with the use of the hoyer many times without a fall. Interview and re-enactment with LPN #1 on 4/12/16 at 11:00 AM identified that he/she assisted NA #1 to position the hoyer pad under Resident #29 and connected it to the lift. Resident #29 was lifted, and upon removing the shower chair from underneath the resident, Resident #29 slid through the toileting hole in the hoyer pad and onto the floor. Resident #29 banged the back of his/her head. LPN #1 indicated the fall happened very fast and he/she was unable to prevent the resident from falling. Observation of the hoyer pad that was used at the time of the fall identified it was a Joerns size large Hoyer sling. The mechanical hoyer lift used at the time of the fall was noted to be manufactured by Linak. Observation of the sling and the mechanical lift identified both were intact and in working order. Interview with The National Director of Safe Patient Handling, (manufacturer of the Hoyer pad/sling) on 4/12/17 at 1:00 PM identified that several factors may have contributed to Resident #29's fall, however, if the sling was connected appropriately to the lift, according to the manufacturer guidelines, the resident would not be able to slide out of the toileting hole and fall. The National Director of Safe Patient Handling indicated that hoyer slings have been around for [AGE] years and they are not designed to allow a resident to slide out. The National Director of Safe Patient Handling indicated that the sling used at the time of the fall was a large universal sling with a weight range between (250 lbs. - 350 lbs.). If Resident #29 was smaller than the weight recommendation, he/she may have been too small for that hoyer sling and that may have contributed the fall. Additionally, The National Director of Safe Patient Handling indicated that manufacturer recommendations include to use the Joerns Hoyer sling with a Joerns Hoyer lift. If the lift used was not a Joerns, The National Director of Safe Patient Handling indicated he/she would be unable to determine how the cradle connected to the Joerns brand Hoyer sling. That may or may not have been a contributing factor to the fall. Further, based on the weight of the resident, The National Director of Safe Patient Handling indicated that it was likely the Hoyer sling was one size too big. Interview with the DNS on 4/12/17 at 1:10 PM identified that Resident #29 had been using the same hoyer sling for many years however, he/she was unable to provide documentation of what size sling was being used, or how Resident #29 was assessed to be appropriate for that sling. The DNS could not provide any information or documentation on how facility staff assess residents for hoyer sling size. He/she indicated that the nurse who admits the resident, if they require a mechanical lift transfer, will just judge what sling would be best for use. The DNS did not have the manufacturer guidelines for Resident #29's Hoyer sling. Although attempts to contact NA #1 for an interview were made, an interview was not obtained. Review of the facility lift/transfer policy identified that nursing associates will be trained on the use and care of the mechanical lift/transfer device utilized in their department. Training will be consistent with the instructions provided by the manufacturer of the device. If multiple types of lifts are used, slings will be labeled accordingly for the lift in which they are to be used to ensure equipment and slings are not miss matched which could create an unsafe condition. The Joerns manufacturer recommendations dated 2015 identified the following; Joerns recommends the use of genuine Hoyer slings. Hoyer brand slings are approved by Joerns for use on Joerns brand lifts. Slings used on Joerns brand lifts, including Hoyer lifts, must be approved by Joerns. For the safety of the residents and caregiver; before using a sling, a full risk assessment must be conducted to ensure that the correct sling choice, method of positioning in the sling and procedure for transfer has been determined for the patient.

Based on resident interview, staff interview, clinical record review, and facility record review for the only resident in the survey sample reviewed with an allegation of mistreatment (R# 96), the facility failed to ensure a resident was not treated roughly and/or received care when requested, and/or for eleven sampled residents (R# 8, 18, 21, 26, 33, 36, 40, 64, 76, 83, 84), the facility neglected to provide necessary care, interventions and/or treatments as directed by the physician and/or assessments and/or care plans, and/or failed to act on complaints of care issues resulting in ongoing lack of treatment/medications and/or care. The findings below resulted in a finding of immediate jeopardy. The findings include: 1. Resident # 96 (R # 96) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with a BIMS score of 15 (,[DATE] = cognitively intact), requiring extensive assist with bed mobility, personal hygiene, and bathing, and had frequent pain. A resident care plan dated [DATE] identified a problem with pain. Interventions included assess for pain and medicate. Additionally, a behavior problem was identified with interventions that included that the social worker would be available for support and comfort. A nurse's note dated [DATE] at 12:30 PM noted the writer and the ombudsman met with the resident. Subsequent to the meeting, licensed staff were to make frequent checks through the weekend to ensure the resident was satisfied with care. A grievance dated [DATE] indicated R # 96 had general complaints about lack of care. The report indicated that the 3PM -11PM nurse aides were educated on timely answering of call lights on all three wings and the resident would have frequent checks by licensed personnel. An interview on [DATE] at 9:00AM with R #96 indicated that when he/she was first admitted , NA#1 was giving him/her a bed bath. During the bath, the nurse aide was rough and disregarded his/her request not to wash certain areas due to pain. R #96 indicated he/she was experiencing severe pain and that the nurse aide would not stop washing him/her until he/she yelled to stop. R#96 further indicated that NA #1 had left him/her on the bedpan for 20 minutes ignoring his/her requests to have the bedpan removed. R #96 indicated he/she was so fearful he/she called the state ombudsman. An interview on [DATE] at 12:45 PM with the ADNS indicated she attended a meeting with R #96 and the state ombudsman on [DATE]. She indicated she was not able to recall the entire meeting and had not documented the meeting. She did note that she recalled R#96 had complained about the way NA #1 provided care, but did not investigate the allegation because there was a lot of dialogue with the resident and every ,[DATE] hour checks were initiated. An interview on [DATE] at 1:15 PM with the Administrator/DNS indicated she was not aware that R #96 had alleged that NA #1 was rough and/or did not provide care as requested by the resident. She indicated she thought the complaint was related to staff complaining to the resident that they did not have enough staff. She indicated the resident was placed on every ,[DATE] hour checks to relieve any fears he/she might have about not having enough staff in the building. The administrator/DNS further indicated if she was aware of the complaint regarding roughness and/or neglect she would have initiated an abuse investigation. An Interview on [DATE] at 3:00 PM with NA #1 indicated R # 96 did complain she was being too rough while giving a bedbath. She stated she continued with the bed bath because she had to get the resident clean. NA #1 indicated she stopped when the resident grabbed the washcloth from her hand and started to yell. She reported the incident to RN #3 who completed the bedbath and dressed the resident. An interview on [DATE] at 1:45 PM with RN #3 indicated she recalled when R#96 reported to her that NA#1 was rough with care. She indicated she did not report the allegation to the DNS because the resident and NA #1 had made peace by the end of the shift. Review of a facility policy and procedure on abuse and neglect, in part, indicated an investigation would be conducted on reports of abuse and/or neglect. 2. Resident #36 was admitted to the facility on [DATE] after hospitalization for a compression fracture of T12 and pain. Kyphoplasty was performed percutaneously with 2 sutured incisions remaining. The initial MDS dated [DATE] identified the resident was without cognitive impairment, required extensive assistance with mobility, had no infections, and had moderate pain less than daily. The admission nursing notes indicated the presence of two incisions of the back both measuring approximately 0.5 cm with the one on the right side having a suture in place. There were no physician orders obtained to remove the suture. The admission physician orders directed cleansing the wound and applying a new dressing daily. The admission nursing assessment form for skin assessment was blank and unsigned. The care plan dated [DATE] identified the risk for skin breakdown related to a surgical wound. Interventions included to turn and position every two hours, inspect skin completely from head to toe every week and document results, and to inspect skin daily with care and bathing and report changes to the charge nurse. Review of nursing notes from admission through [DATE], failed to document any assessment of the incisions and/or removal of the suture. The treatment kardex for [DATE] failed to have any treatments transcribed on it or evidence that the treatment to the incisions had been done as ordered by the physician. On [DATE], the physician assessed the resident and noted the suture still in place to the right incision with a large amount of purulent drainage. He removed the suture and sent the resident to the ED for evaluation. An emergency department visit dated [DATE] identified the resident was seen for [MEDICAL CONDITION] of the back and an abscess of the incision which was opened, drained and packed. Orders included removing the packing in 2 days and administer antibiotics. The resident was sent back to the hospital on [DATE] with increased redness of the area and admitted . Interview and clinical record review with the ADNS on [DATE] at 2 PM failed to provide documentation that the surgical incision had received the daily treatment ordered by the physician, that the physician or surgeon had been notified of the presence of a suture/need for removal, that the resident had been sent to the surgeon within one week as directed in the discharge summary and/or that the incisions had been assessed daily for signs of infection. 3. Resident #33's [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] noted the resident was on day 20 of 42 of [MEDICATION NAME] and [MEDICATION NAME] intravenously (IV) for endocarditis. Nurse's notes on [DATE] noted the resident was very lethargic. Labs done that day indicated a rising BUN and creatinine which were communicated to the attending physician. The resident was sent to the hospital for evaluation. The hospital discharge summary dated [DATE] noted that the resident had been started on [MEDICATION NAME] a few days earlier to stimulate appetite. The creatinine on admission was 2.1 with a prior baseline of 1.3. The [MEDICATION NAME] was discontinued due to acute [MEDICAL CONDITION]. The resident was sent back to the facility on [DATE] with orders to continue [MEDICATION NAME] IV every 12 hours until [DATE] and then switch to antibiotics by mouth indefinitely. The type of antibiotics by mouth was not specified in the discharge summary. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review noted that the antibiotics by mouth were not begun until [DATE] leaving the resident without antibiotic coverage for 5 days. Interview with the ADNS and review of the clinical record on [DATE] at 8:20 AM noted that the resident's medication list from the hospital identified that [MEDICATION NAME] 2 grams intravenously was to be administered every 12 hours, but was transcribed inappropriately and administered every 8 hours. Further review noted that the resident should have received antibiotics by mouth immediately upon completing the IV antibiotics on [DATE]. The physician was not notified for antibiotic orders until [DATE]. 4. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was moderately impaired for decision-making skills, required assistance from staff for activities of daily living (ADL) and was receiving care for a skin ulcer related to [MEDICAL CONDITION] of the lower extremities. a. A wound/skin assessment obtained on admission to the facility dated [DATE] noted measurements to several necrotic areas of the posterior lower extremities (right and left calves). Five necrotic areas were noted to the left calf measuring 1.5 centimeters (cm) x .5cm (linear), 1cm x .3cm (linear), and circular wounds measuring .8cm, .3cm, and .5cm. The right calf was noted as having 3 necrotic areas measuring 1 cm x .2cm (linear), 1.5 cm x .2cm (linear), and a circular wound measuring .3cm. No further assessments were documented. On [DATE] at 9:05 AM, interview and review of the clinical record with the ADNS identified that although the resident was discharged from the facility with the wounds still present on [DATE], the facility was to have assessed the resident's wounds on a weekly basis and documented the assessments. b. Resident #26's admission orders [REDACTED]. No frequency of application was documented. The treatment kardex identified that the treatment was transcribed that the resident was to receive [MEDICATION NAME] application daily, without clarification of the treatment with the physician. Also noted was a lack of documentation that the treatment had been done from [DATE] through [DATE]. On [DATE] at 10:21 AM interview and review of the clinical record with the ADNS indicated in part, that prior to the administration of a treatment, the physician order was to have been clarified in regards to the frequency of the treatment and further noted that this was a transcription error. 5. Resident #8's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R#8 was alert and oriented, and required limited to extensive assistance from staff with ADL's. physician progress notes [REDACTED]. The physician questioned an allergic reaction. Physician orders dated [DATE] directed to apply [MEDICATION NAME] cream 1% to back and leg rash daily for 5 days; if no improvement, will consider a dermatology consult. Review of the [DATE] treatment kardex identified that R#8 did not receive the topical cream as ordered for 2 of the 5 days. Review of the nurse's treatment notes dated [DATE] identified pinpoint rash noted on trunk, feet and right hip. Treatment notes dated [DATE], and [DATE] identified the rash was improving, anti- itch cream applied to rash area with great relief. Although the physician order for [REDACTED]. Treatment notes dated [DATE] at 10:00 AM identified that the rash persisted. A Dermatologist Consult dated [DATE] identified pruritis, and non-specific [MEDICAL CONDITION]. New orders were obtained to apply [MEDICATION NAME] Cream twice a day for 3 weeks; follow up in 3 weeks if rash not better. Review of the [DATE] treatment kardexes identified out of 63 shifts, on 8 eight occasions, R#8 did not receive the treatment as ordered. Further review identified that after the order for the cream expired on [DATE], the resident continued to receive the cream without a physician order for [REDACTED]. Interview with R#8 on [DATE] at 9:40 AM noted that he/she frequently had to ask staff to put the cream on the rash, or it did not get done. Additionally, R#8 stated that although the rash was better, it continued to get itchy, and he/she would ask for cream to be applied. Interview with RN#1 on [DATE] at 11:00 AM noted when R#8 gets a rash on his/her back, legs and feet, they apply [MEDICATION NAME], although the resident does not have an order for [REDACTED]. 6. Resident #18's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R #18 was alert and oriented, required limited to extensive assistance with ADL's, and had [MEDICAL CONDITION]. The admission medication orders dated [DATE] directed the administration of [MEDICATION NAME] 100 mcg inhaler twice a day. Physician orders dated [DATE] identified a clarification in the [MEDICATION NAME] order to [MEDICATION NAME] Diskus 100 mcg inhaler twice a day. Nurse's notes dated [DATE] (date of admission) identified the medication list had been verified with the resident's physician and orders were faxed to the pharmacy. Nurse's notes dated [DATE] at 11:00 AM identified the pharmacy called for order clarification on the [MEDICATION NAME] inhaler. A new order was faxed to the pharmacy. Nurse's notes dated [DATE] identified a STAT order was sent to the pharmacy for R#18 to receive the [MEDICATION NAME] inhaler. The pharmacist notified the facility to alert them that they did not have the medication in stock but were ordering it. Review of the medication kardex for [DATE] identified that although [MEDICATION NAME] 100mcg inhaler twice daily was ordered on admission ([DATE]), the order was not transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, the MAR indicated [REDACTED]. Review of the clinical record and interview with the ADNS on [DATE] at 10:00 AM failed to identify that the physician was made aware that the [MEDICATION NAME] was not available nor did the resident receive it. Additionally, the ADNS stated that when a new admission enters the facility, all medication orders are to verified by the physician, the pharmacy notified and the medication transcribed onto the kardex. She was unable to explain why the [MEDICATION NAME] was not transcribed/ordered for 3 days or why the resident did not receive the steroid inhaler for 8 days. 7. Resident #40's [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] identified 19 staples to the right hip. Nurse's notes dated [DATE] on the 7:00 PM to 7:00 AM shift identified that the staples were to be removed in the morning. No further documentation was present in the nurse's notes until [DATE] at 8:00 AM at which time the nurse identified that he/she attempted to remove the staples, stopped due to discomfort, and was awaiting a staple removal kit. The note further identified the resident was having complaints of the staple site being tender. Nurse's notes dated [DATE] on the day shift identified the staples were removed, and steri-strips applied. Review of R# 40's clinical record and interview with RN#1 on [DATE] at 3:00 PM identified that there were no staple removal kits in house and that they were waiting to receive them from their supply company. Further interview noted that another nurse attempted on [DATE] to remove the staples with a suture removal kit unsuccessfully. RN#1 stated she reported this to the ADNS. Interview with the ADNS on [DATE] at 3:15 PM noted that although she was aware that the facility had no staple removal kits, she did not do anything to obtain one. 8. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] at 6:00 PM identified the presence of 31 staples to the lower spine. a. The physician history and physical dated [DATE] identified the incision site was healing well, follow up with the hematologist in 1 week and follow up with [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record from the time of admission on [DATE] through [DATE], failed to provide any documentation identifying an assessment of the incision to the lower spine or presence/absence of staples. Interview with RN #6 on [DATE] at 10:15 AM identified that on [DATE], R# 76's family had asked when the staples were going to be removed. The family then called the physician and RN #6 spoke to the MD and noted that the physician said they should have been removed a week after the resident was admitted . RN# 6 stated she wrote the order to remove the staples and proceeded to do so. RN# 6 stated that there was dry skin around the staples, and that she had not assessed the area until the staples were removed. Interview with RN #1 on [DATE] at 10:37 AM noted that although she completed the admission for R#76 and noted that there were 31 staples present on the spine, she could not recall what the area looked like. RN# 1 further noted that when an admission occurs, it is the responsibility of that nurse to transcribe the orders from the admission paperwork onto the physician order sheets, notify the physician of the admission, review the medications and treatment orders, notify the pharmacy and if follow up appointments were needed, to make sure that they were done. Review of the clinical record at that time with RN #1 failed to provide any documentation that the incision line on the lower spine had been assessed from the time of admission on [DATE], until the staples were removed on [DATE]. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to review all the paperwork from the hospital, transcribe all the orders to physician order sheets, notify the physician and review orders, and notify the pharmacy. She further noted that a complete body assessment is to be done at the time of admission and if the resident has an incision line, the area should be assessed and documented in the clinical record e.g. what the area looks like including size, if staples, how many, drainage, etc. The ADNS noted that when a resident comes into the facility and has a suture line with staples, the area is to be assessed every shift and documented. Additionally, ADNS stated that if the resident has staples and there is no order for removal of them, they are to alert the physician so a date can be determined, and that she was unaware R # 76 had no order to remove staples. b. The hospital discharge summary dated [DATE] directed follow up appointments that needed to be made for R # 76 as follows: The surgeon in one week. The hematologist/ oncologist in 1 week. The GI physician in ,[DATE] weeks. [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record identified that R #76's follow up appointment with the surgeon was not done until [DATE] (24 days after admission). The record lacked documentation of visits with the Hematologist, GI physician and/or the [MEDICAL CONDITION] therapist. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to make any appointments identified on the admission paperwork. Review of the clinical record at that time with the ADNS failed to identify that R # 76's follow up appointments were made with 4 physicians. The ADNS stated that there is no system in place for assuring that after a resident is admitted that everything was completed. Additionally, she stated that she does not audit a resident's chart after admission to see if completed. There was no policy for the care and assessment of surgical incisions. 9. Resident #76's [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident as scoring a 5 on the Brief Interview for Mental Status (severe cognition impairment), requiring extensive assistance of one staff member for activities of daily living, and receiving nutrition via a feeding tube (pe[DEVICE]). A hospital discharge summary dated [DATE] identified the resident was being transferred to an extended care facility with a pe[DEVICE] and a stage two pressure ulcer to the coccyx. a. Admission nurse's notes and a Skilled Nursing admission assessment dated [DATE] at 6:00PM identified the resident had a stage two open area to the coccyx, but failed to identify a description of the area ( measurement, appearance of the wound base and edges, appearance of wound edges, etc). Review of the physician orders identified that a treatment to the area was not obtained from admission on [DATE] until [DATE]. A physician order dated [DATE] directed to cleanse the open area on the coccyx with Normal Saline and apply [MEDICATION NAME] every other day. Review of the facility pressure ulcer policy for Stage two pressure ulcers identified in part, to complete a comprehensive assessment of the wound and include the length, width and depth in centimeters, appearance of the wound base and wound edges. Interview with the admitting registered nurse, RN#1, on [DATE] at 11:15 AM identified that she was not aware that she was to have described the pressure ulcer according to the facility policy. She further noted that she did not obtain a treatment order on admission ([DATE]) because the wound nurse was to have evaluated the area to recommend a treatment, and that she applied a dry protective dressing, pending the wound nurse evaluation. Interview with the Wound Nurse/ADNS on [DATE] at 1:30 PM identified that she was not able to evaluate the resident's wound until [DATE] and recommended a treatment of [REDACTED]. b. The facility pressure ulcer monitoring policy identified, in part, to complete a wound assessment at least weekly. Review of the weekly wound assessment sheet identified the wound was only assessed on [DATE]. No further assessment of the wound was documented from [DATE] to [DATE]. Review of the resident's Inter-Disciplinary Discharge summary dated [DATE] identified the resident was discharged home from the facility but failed to identify the presence and/or treatment of [REDACTED]. Interview with the Wound Nurse/Assistant Director of Nurses (ADNS) on [DATE] at 1:30 PM identified that she is expected to assess the wounds weekly, but is not always able to complete the weekly monitoring because of other duties. She further identified that it is the responsibility of the Charge Nurse to complete the weekly assessments if she is unable to complete them. She further noted that the Nurse Aides complete weekly body audits after the resident's shower/bath and the nurse records it on the Treatment Administration Record. Review of the resident's weekly body audits (Treatment Administration Record) with the ADNS at that time failed to identify skin checks were completed on [DATE], [DATE], [DATE] and [DATE]. 10. Resident #84's [DIAGNOSES REDACTED]. The nursing admission note dated [DATE] identified the presence of a stage 2 pressure sore that measured 2 cm by 2 cm. No other description of the wound was present. Physician orders dated [DATE] directed to cleanse the coccyx with normal saline, pat dry, followed by a protective dressing every 3rd day. On [DATE], an air mattress was ordered along with skin prep to heels every shift, and to turn and reposition every two hours. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on [DATE] failed to document any assessments of the pressure sore although the resident's discharge summary indicated the wound was still present. Interview with the ADNS on [DATE] at 8:25 AM failed to provide documentation that the resident's pressure sore was appropriately assessed on admission, or that any subsequent assessments had been done to assess the pressure sore as per facility policy. 11. Resident #33 was readmitted from the hospital on [DATE] with an open blister of the right heel. No treatment orders were present until [DATE] when a dry protective dressing was ordered to be applied daily. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on [DATE] failed to document any assessments of the pressure sore. Interview and review of the clinical record with the ADNS on [DATE] at 8:20 AM failed to provide documentation that the resident's pressure sore was accurately and thoroughly assessed upon admission and at least weekly, that appropriate treatment orders to maintain a moist healing environment were initiated, and/or that a care plan had been developed that addressed needs related to healing the pressure sore. 12. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated the resident had short and long-term memory problems, required extensive assistance with bed mobility and transfers, did not walk, was incontinent of bowel, and had one stage II pressure ulcer. A wound skin assessment dated [DATE] identified a stage II pressure ulcer on the right buttock measuring 3cm x 1.5cm x 0.1cm An initial care plan dated [DATE] identified a stage II pressure ulcer on the right buttock. Interventions included treatment as ordered and turn and position every two hours. Review of physician orders dated [DATE], [DATE], [DATE], and [DATE] failed to include a treatment for [REDACTED]. Review of a treatment record dated [DATE] indicated to cleanse the stage II on the right buttock with normal saline followed by a clean protective dressing and to change every 3 days. Review of the clinical record and interview on [DATE] at 1:00 PM with the ADNS indicated a treatment order should have been obtained when the resident was admitted on [DATE]. She further indicated the clean protective dressing initiated on [DATE] without a physician order, was not appropriate for a stage II open area. 13. Resident # 64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had moderate cognitive impairment, required extensive assistance with bed mobility and transfers and limited assist with walking in the room, and had one stage three pressure ulcer. A physician order dated [DATE] directed Santyl to the left heel and a heel boot when in bed. A subsequent physician order dated [DATE] directed the resident to be seen by the wound clinic. An initial care plan dated [DATE] identified a problem with skin integrity and a pressure ulcer to the "right heel". Interventions included to remind the resident to reposition self and treatment as ordered. A noted dated [DATE] indicated the " right " heel ulcer was worsening with an increase in slough. A pressure ulcer assessment dated [DATE] identified a stage II pressure ulcer on the left heel measuring 3 cm x 2 cm and pink in color. On [DATE], the left heel pressure ulcer was a stage III measuring 2 cm round with a 0.4 cm depth and on [DATE], the left heel pressure ulcer was a stage III which had declined to 2.5 cm x 4 cm with a 1.3 cm depth with slough and minimum to moderate serosanguinous drainage. An assessment dated [DATE] identified the left heel pressure ulcer was unstageable measuring 7 cm with 4 cm of necrosis. A wound specialist consult sheet dated [DATE] identified a 7.5 cm x 4.7 cm x 0.6 cm pressure ulcer on the left heel. The consult indicated the resident needed a vascular PVR and a podus boot to the left lower extremity as soon as possible. An arterial PVR report dated [DATE] indicated, in part, adequate perfusion bilaterally of the lower extremities. A lab report dated [DATE] identified [MEDICAL CONDITION] in the left heel. An interview and review of the clinical record on [DATE] at 1:30 PM with the ADNS failed to provide documentation that the resident care plan was reviewed and revised on [DATE] and/or on [DATE] when the left heel increased in size and stage with the development of slough and serosanguinous drainage. She indicated she wanted to give the Santyl treatment time to work and not until [DATE] was a physician order obtained for the resident to see the wound doctor. The ADNS indicated the care plan documentation that the pressure ulcer was on the right heel was an error and she would change it to the left heel. She indicated the nurse aide care card documentation did not need to be corrected because they currently were not using them and the nurse aides got their information from morning report. The record lacked documentation of pressure relief interventions initiated to the left heel. At the time of the interview, a review of the weekly pressure ulcer assessment noted the pressure ulcer was not assessed from [DATE] until [DATE]. The ADNS at that time indicated the wound assessments are done weekly. R#64's assessments were being done by the wound clinic but he/she missed the [DATE] visit due to inclement whether. The resident was not seen in the wound clinic until [DATE] and facility staff failed to assess the wound during the interim. 14. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 14 day assessment identified the resident was independent for cognitive skills, and required limited and/or extensive assistance of staff for most activities of daily living (ADL). The resident care plan updated on [DATE] identified the risk for falls. Interventions included having a bed alarm in place and strict fall preventions. a. Review of R#83's nursing notes and facility documentation dated [DATE] between 5:55 AM to 6:00 AM identified that the resident was found on the floor with a swollen head. On [DATE] at 2:00 PM and on [DATE] at 10:20 AM interviews with RN#1 and NA #3 indicated that during last rounds while RN #1 was completing her med pass, Resident #83 was found sitting on the floor in his/her room with a swollen head. RN #1 and NA#3 further indicated that although the bed alarm was present, it was disconnected and the staff didn't know when the bed alarm was checked last and/or didn't believe that they were required to check the bed alarm routinely throughout the shift. On [DATE] at 10:45 A.M. interview and review of the clinical record with the ADNS indicated that although there were no nurse's aides care cards and/or documentation on the treatment kardex prompting the staff to check the bed alarm at the time of the fall, the bed alarm was part of the fall precautions and was to have been checked routinely every two hours and/or when providing care. Subsequent to the resident's fall the resident was transferred to an acute care facility via 911 emergency and was admitted with an hematoma to the right scalp. b. R#83 was re-admitted to the facility on [DATE] following the fall sustained on [DATE]. The resident care plan dated on [DATE] iden

Based on clinical record reviews and staff interviews for 7 sampled residents (R# 8, R # 18, R# 26, R# 33, R# 36, R# 40 and R# 76), identified with transcription errors, surgical wounds, other wounds, orders for medical follow up appointments, and/or receiving antibiotic therapy, the facility failed to follow and/or obtain necessary physician orders. The findings below resulted in a finding of immediate jeopardy. The findings include: 1. Resident #36 was admitted to the facility on [DATE] after hospitalization for a compression fracture of T12 and pain. Kyphoplasty was performed percutaneously with 2 sutured incisions remaining. The initial MDS dated [DATE] identified the resident was without cognitive impairment, required extensive assistance with mobility, had no infections, and had moderate pain less than daily. The admission nursing notes indicated the presence of two incisions of the back both measuring approximately 0.5 cm with the one on the right side having a suture in place. There were no physician orders obtained to remove the suture. The admission physician orders directed cleansing the wound and applying a new dressing daily. The admission nursing assessment form for skin assessment was blank and unsigned. The care plan dated [DATE] identified the risk for skin breakdown related to a surgical wound. Interventions included to turn and position every two hours, inspect skin completely from head to toe every week and document results, and to inspect skin daily with care and bathing and report changes to the charge nurse. Review of nursing notes from admission through [DATE], failed to document any assessment of the incisions and/or removal of the suture. The treatment kardex for [DATE] failed to have any treatments transcribed on it or evidence that the treatment to the incisions had been done as ordered by the physician. On [DATE], the physician assessed the resident and noted the suture still in place to the right incision with a large amount of purulent drainage. He removed the suture and sent the resident to the ED for evaluation. An emergency department visit dated [DATE] identified the resident was seen for [MEDICAL CONDITION] of the back and an abscess of the incision which was opened, drained and packed. Orders included removing the packing in 2 days and administer antibiotics. The resident was sent back to the hospital on [DATE] with increased redness of the area and admitted . Interview and clinical record review with the ADNS on [DATE] at 2 PM failed to provide documentation that the surgical incision had received the daily treatment ordered by the physician, that the physician or surgeon had been notified of the presence of a suture/need for removal, that the resident had been sent to the surgeon within one week as directed in the discharge summary and/or that the incisions had been assessed daily for signs of infection. 2. Resident #33's [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] noted the resident was on day 20 of 42 of [MEDICATION NAME] and [MEDICATION NAME] intravenously (IV) for endocarditis. Nurse's notes on [DATE] noted the resident was very lethargic. Labs done that day indicated a rising BUN and creatinine which were communicated to the attending physician. The resident was sent to the hospital for evaluation. The hospital discharge summary dated [DATE] noted that the resident had been started on [MEDICATION NAME] a few days earlier to stimulate appetite. The creatinine on admission was 2.1 with a prior baseline of 1.3. The [MEDICATION NAME] was discontinued due to acute [MEDICAL CONDITION]. The resident was sent back to the facility on [DATE] with orders to continue [MEDICATION NAME] IV every 12 hours until [DATE] and then switch to antibiotics by mouth indefinitely. The type of antibiotics by mouth was not specified in the discharge summary. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review noted that the antibiotics by mouth were not begun until [DATE] leaving the resident without antibiotic coverage for 5 days. Interview with the ADNS and review of the clinical record on [DATE] at 8:20 AM noted that the resident's medication list from the hospital identified that [MEDICATION NAME] 2 grams intravenously was to be administered every 12 hours, but was transcribed inappropriately and administered every 8 hours. Further review noted that the resident should have received antibiotics by mouth immediately upon completing the IV antibiotics on [DATE]. The physician was not notified for antibiotic orders until [DATE]. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was moderately impaired for decision-making skills, required assistance from staff for activities of daily living (ADL) and was receiving care for a skin ulcer related to [MEDICAL CONDITION] of the lower extremities. a. A wound/skin assessment obtained on admission to the facility dated [DATE] noted measurements to several necrotic areas of the posterior lower extremities (right and left calves). Five necrotic areas were noted to the left calf measuring 1.5 centimeters (cm) x .5cm (linear), 1cm x .3cm (linear), and circular wounds measuring .8cm, .3cm, and .5cm. The right calf was noted as having 3 necrotic areas measuring 1 cm x .2cm (linear), 1.5 cm x .2cm (linear), and a circular wound measuring .3cm. No further assessments were documented. On [DATE] at 9:05 AM, interview and review of the clinical record with the ADNS identified that although the resident was discharged from the facility with the wounds still present on [DATE], the facility was to have assessed the resident's wounds on a weekly basis and documented the assessments. b. Resident #26's admission orders [REDACTED]. No frequency of application was documented. The treatment kardex identified that the treatment was transcribed that the resident was to receive [MEDICATION NAME] application daily, without clarification of the treatment with the physician. Also noted was a lack of documentation that the treatment had been done from [DATE] through [DATE]. On [DATE] at 10:21 AM interview and review of the clinical record with the ADNS indicated in part, that prior to the administration of a treatment, the physician order was to have been clarified in regards to the frequency of the treatment and further noted that this was a transcription error. 4. Resident #8's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R#8 was alert and oriented, and required limited to extensive assistance from staff with ADL's. physician progress notes [REDACTED]. The physician questioned an allergic reaction. Physician orders dated [DATE] directed to apply [MEDICATION NAME] cream 1% to back and leg rash daily for 5 days; if no improvement, will consider a dermatology consult. Review of the [DATE] treatment kardex identified that R#8 did not receive the topical cream as ordered for 2 of the 5 days. Review of the nurse's treatment notes dated [DATE] identified pinpoint rash noted on trunk, feet and right hip. Treatment notes dated [DATE], and [DATE] identified the rash was improving, anti- itch cream applied to rash area with great relief. Although the physician order for [REDACTED]. Treatment notes dated [DATE] at 10:00 AM identified that the rash persisted. A Dermatologist Consult dated [DATE] identified pruritis, and non-specific [MEDICAL CONDITION]. New orders were obtained to apply [MEDICATION NAME] Cream twice a day for 3 weeks; follow up in 3 weeks if rash not better. Review of the [DATE] treatment kardexes identified out of 63 shifts, on 8 eight occasions, R#8 did not receive the treatment as ordered. Further review identified that after the order for the cream expired on [DATE], the resident continued to receive the cream without a physician order for [REDACTED]. Interview with R#8 on [DATE] at 9:40 AM noted that he/she frequently had to ask staff to put the cream on the rash, or it did not get done. Additionally, R#8 stated that although the rash was better, it continued to get itchy, and he/she would ask for cream to be applied. Interview with RN#1 on [DATE] at 11:00 AM noted when R#8 gets a rash on his/her back, legs and feet, they apply [MEDICATION NAME], although the resident does not have an order for [REDACTED]. 5. Resident #18's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R #18 was alert and oriented, required limited to extensive assistance with ADL's, and had [MEDICAL CONDITION]. The admission medication orders dated [DATE] directed the administration of [MEDICATION NAME] 100 mcg inhaler twice a day. Physician orders dated [DATE] identified a clarification in the [MEDICATION NAME] order to [MEDICATION NAME] Diskus 100 mcg inhaler twice a day. Nurse's notes dated [DATE] (date of admission) identified the medication list had been verified with the resident's physician and orders were faxed to the pharmacy. Nurse's notes dated [DATE] at 11:00 AM identified the pharmacy called for order clarification on the [MEDICATION NAME] inhaler. A new order was faxed to the pharmacy. Nurse's notes dated [DATE] identified a STAT order was sent to the pharmacy for R#18 to receive the [MEDICATION NAME] inhaler. The pharmacist notified the facility to alert them that they did not have the medication in stock but were ordering it. Review of the medication kardex for [DATE] identified that although [MEDICATION NAME] 100mcg inhaler twice daily was ordered on admission ([DATE]), the order was not transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, the MAR indicated [REDACTED]. Review of the clinical record and interview with the ADNS on [DATE] at 10:00 AM failed to identify that the physician was made aware that the [MEDICATION NAME] was not available nor did the resident receive it. Additionally, the ADNS stated that when a new admission enters the facility, all medication orders are to verified by the physician, the pharmacy notified and the medication transcribed onto the kardex. She was unable to explain why the [MEDICATION NAME] was not transcribed/ordered for 3 days or why the resident did not receive the steroid inhaler for 8 days. 6. Resident #40's [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] identified 19 staples to the right hip. Nurse's notes dated [DATE] on the 7:00 PM to 7:00 AM shift identified that the staples were to be removed in the morning. No further documentation was present in the nurse's notes until [DATE] at 8:00 AM at which time the nurse identified that he/she attempted to remove the staples, stopped due to discomfort, and was awaiting a staple removal kit. The note further identified the resident was having complaints of the staple site being tender. Nurse's notes dated [DATE] on the day shift identified the staples were removed, and steri-strips applied. Review of R# 40's clinical record and interview with RN#1 on [DATE] at 3:00 PM identified that there were no staple removal kits in house and that they were waiting to receive them from their supply company. Further interview noted that another nurse attempted on [DATE] to remove the staples with a suture removal kit unsuccessfully. RN#1 stated she reported this to the ADNS. Interview with the ADNS on [DATE] at 3:15 PM noted that although she was aware that the facility had no staple removal kits, she did not do anything to obtain one. 7. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] at 6:00 PM identified the presence of 31 staples to the lower spine. a. The physician history and physical dated [DATE] identified the incision site was healing well, follow up with the hematologist in 1 week and follow up with [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record from the time of admission on [DATE] through [DATE], failed to provide any documentation identifying an assessment of the incision to the lower spine or presence/absence of staples. Interview with RN #6 on [DATE] at 10:15 AM identified that on [DATE], R# 76's family had asked when the staples were going to be removed. The family then called the physician and RN #6 spoke to the MD and noted that the physician said they should have been removed a week after the resident was admitted . RN# 6 stated she wrote the order to remove the staples and proceeded to do so. RN# 6 stated that there was dry skin around the staples, and that she had not assessed the area until the staples were removed. Interview with RN #1 on [DATE] at 10:37 AM noted that although she completed the admission for R#76 and noted that there were 31 staples present on the spine, she could not recall what the area looked like. RN# 1 further noted that when an admission occurs, it is the responsibility of that nurse to transcribe the orders from the admission paperwork onto the physician order sheets, notify the physician of the admission, review the medications and treatment orders, notify the pharmacy and if follow up appointments were needed, to make sure that they were done. Review of the clinical record at that time with RN #1 failed to provide any documentation that the incision line on the lower spine had been assessed from the time of admission on [DATE], until the staples were removed on [DATE]. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to review all the paperwork from the hospital, transcribe all the orders to physician order sheets, notify the physician and review orders, and notify the pharmacy. She further noted that a complete body assessment is to be done at the time of admission and if the resident has an incision line, the area should be assessed and documented in the clinical record e.g. what the area looks like including size, if staples, how many, drainage, etc. The ADNS noted that when a resident comes into the facility and has a suture line with staples, the area is to be assessed every shift and documented. Additionally, ADNS stated that if the resident has staples and there is no order for removal of them, they are to alert the physician so a date can be determined, and that she was unaware R # 76 had no order to remove staples. b. The hospital discharge summary dated [DATE] directed follow up appointments that needed to be made for R # 76 as follows: The surgeon in one week. The hematologist/ oncologist in 1 week. The GI physician in ,[DATE] weeks. [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record identified that R #76's follow up appointment with the surgeon was not done until [DATE] (24 days after admission). The record lacked documentation of visits with the Hematologist, GI physician and/or the [MEDICAL CONDITION] therapist. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to make any appointments identified on the admission paperwork. Review of the clinical record at that time with the ADNS failed to identify that R # 76's follow up appointments were made with 4 physicians. The ADNS stated that there is no system in place for assuring that after a resident is admitted that everything was completed. Additionally, she stated that she does not audit a resident's chart after admission to see if completed. There was no policy for the care and assessment of surgical incisions.

Based on clinical record reviews, observations, review of facility policies/procedures and interviews, the facility management failed to identify, assess, and intervene regarding significant issues related to medication administration, physician order [REDACTED]. The findings include: The survey conducted on February 15, 16, 17, 18, and 22, 2011, found that the Administrator/facility management failed to identify significant issues listed below, related to quality of care and/or neglect that resulted in findings of immediate jeopardy. Those findings included: 1. The Director of Nursing/Administrator on 2/22/11 at 11 AM noted that she had been busy overseeing the functions of the assisted living facility upstairs and had not devoted time to the administration of the skilled nursing facility. The Connecticut State Public Health Code requires that the Director of Nursing work full time at the facility no matter how many beds the facility has. 2. The survey resulted in findings of neglect related to the failure to administer medications, and/or treatments in accordance with physician orders [REDACTED]. Please refer to deficiencies F224, 281, 309 and 314. 3. The survey found that the facility management failed to have the necessary supplies to provide medications and treatments to Residents #18, 21, 36, 40, and 76. Please refer to deficiencies F281, 309, and 328. 4. The survey found that the facility management failed to obtain physician orders [REDACTED]. Please refer to deficiencies F281, 309, and 314. 5. The facility failed to communicate and/or notify the attending physician and/or medical director of the need for treatment orders, clarification of medication orders, need for antibiotic orders, unavailablility of supplies/medications, and/or lack of tube feeding supplies. Please refer to deficiency F157. 6. The facility management failed to ensure adequate nursing supervision and oversight of inexperienced nurses and nurse aides. Although the Administrator was aware of complaints regarding care or lack there of being provided by inexperienced nurses, they failed to act on that information, and/or provide necessary education and oversight. 7. The facility management failed to ensure written nurse aide assignments to guide care provided to residents were available to staff. When asked on 2/22/11 at 11AM why the nurse aides lacked assignments, the ADNS replied that they "went by the wayside". 8. The facility management failed to have a system in place to audit admission records, check for errors, and/or communicate resident needs to the nursing staff. 9. The facility failed to implement fall prevention measures resulting in a fall with injuries. Please refer to Deficiency F323. Interview with the Administrator on 2/22/11 at 11AM identified that the focus since she had arrived 6 month prior, was to resolve issues on the Assisted Living Unit upstairs. She further noted that the ADNS was out of work for a couple of months.

Based on clinical record review and staff interview for 6 of 6 sampled residents (R#18, R# 25, R# 33, R# 36, R# 40, and R # 76), identified with a change in condition/treatment needed, the facility failed to notify the physician in a timely manner regarding staple removal, medications errors/omissions, surgical sites assessment, bruises, and/or IV/oral antibiotic medication order clarification. The findings include: 1. Resident #36 was admitted to the facility on [DATE] after hospitalization for a compression fracture of T12 and pain. Kyphoplasty was performed percutaneously with 2 sutured incisions remaining. The initial MDS dated [DATE] identified the resident was without cognitive impairment, required extensive assistance with mobility, had no infections, and had moderate pain less than daily. The admission nursing notes indicated the presence of two incisions of the back both measuring approximately 0.5 cm with the one on the right side having a suture in place. There were no physician orders obtained to remove the suture. The admission physician orders directed cleansing the wound and applying a new dressing daily. The admission nursing assessment form for skin assessment was blank and unsigned. The care plan dated 9/17/10 identified the risk for skin breakdown related to a surgical wound. Interventions included to turn and position every two hours, inspect skin completely from head to toe every week and document results, and to inspect skin daily with care and bathing and report changes to the charge nurse. Review of nursing notes from admission through 9/25/10 failed identify any documentation of an assessment of the incisions and/or removal of the suture. The treatment kardex for September failed to have any treatments transcribed on it or evidence the treatment ordered by the physician to the incisions had been done. On 9/26/10, the physician assessed the resident and noted the suture still in place to the right incision with large amount of purulent drainage. He removed the suture and sent the resident to the ED for evaluation. An emergency department visit dated 9/26/10 identified the resident was seen for [MEDICAL CONDITION] of the back and a wound abscess. Orders included to remove the packing in 2 days and administer antibiotics. Interview and review of the clinical record with the ADNS on 2/17/11 at 2 PM failed to provide documentation that the physician had been notified of the presence of a suture. 2. Resident #33's [DIAGNOSES REDACTED]. The hospital discharge summary dated 12/21/10 noted the resident was on day 20 of 42 of [MEDICATION NAME] and [MEDICATION NAME] intravenously (IV) for endocarditis. Nurse's notes on 12/16/10 noted the resident was very lethargic. Labs done that day indicated a rising BUN and creatinine which were communicated to the attending physician. The resident was sent to the hospital for evaluation. The hospital discharge summary noted that the resident had been started on [MEDICATION NAME] a few days earlier to stimulate appetite. The creatinine on admission was 2.1 with a prior baseline of 1.3. The [MEDICATION NAME] was discontinued due to acute [MEDICAL CONDITION]. The resident was sent back to the facility on [DATE] with orders to continue [MEDICATION NAME] IV every 12 hours until 1/3/11 and then switch to antibiotics by mouth indefinitely. The type of antibiotics by mouth was not specified in the discharge summary. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review noted that the antibiotics by mouth were not begun until 1/8/11 leaving the resident without antibiotic coverage for 5 days. Interview with the ADNS and review of the clinical record on 2/17/11 at 8:20 AM noted that the resident's medication list from the hospital identified that [MEDICATION NAME] 2 grams intravenously was to be administered every 12 hours, but was transcribed inappropriately and administered every 8 hours. Further review noted that the resident should have received antibiotics by mouth immediately upon completing the IV antibiotics on 1/4/11. The physician was not notified for antibiotic orders until 1/8/11. 3. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident as scoring a 5 on the Brief Interview for Mental Status (severe cognition impairment), requiring extensive assistance of one staff member for activities of daily living and received nutrition via a feeding tube (pe[DEVICE]). A hospital discharge summary dated 10/5/10 identified the resident was being transferred to an extended care facility with a pe[DEVICE] that was inserted on 10/4/10 for difficulty swallowing and having increased secretions. The resident was to have nothing my mouth (NPO). The Dietician notes dated 10/5/10 recommended pe[DEVICE] feedings of Diabetisource AC 75 milliliters (ml) per hour for 20 hours per day and water flushes of 160ml four times daily via pe[DEVICE]. Review of a nurse's note dated 10/5/10 at 6:00 PM identified the resident was admitted to the facility with a pe[DEVICE] in place but tube feedings were unable to be initiated because a feeding pump and formula were inaccessible. Interview with RN#1 on 2/17/11 at 11:15 AM identified that she was unsuccessful in procuring a feeding pump and Diabetisource formula from the facility vendor. She further noted that she called the physician and obtained an order for [REDACTED]. She further identified that a pump was present but the tubing in stock was incompatible with it. Interview with RN #5 on 2/17/11 at 1:55 PM identified that on 10/6/10 she worked 7:00AM to 3:00PM and identified the resident had not receive a tube feeding since admission. She further identified that Fibersource formula and a feeding pump were available in the supply closet so she notified the physician because the resident's lips were starting to look dry. On 10/6/10 the physician directed to start Fibersource at 75ml/hour until Diabetisource arrived. Further review noted physician admission orders [REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 2/17/11 at 2:30PM with the resident's physician identified that he was not notified that an alternative formula was available in the facility (Fibersource) and he would have ordered the alternative formula be administered until Diabetisource was procured. 4. Resident #18's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R #18 was alert and oriented, required limited to extensive assistance with ADL's, and had [MEDICAL CONDITION]. The admission medication orders dated 1/10/11 directed the administration of [MEDICATION NAME] 100 mcg inhaler twice a day. Physician orders dated 1/14/11 identified a clarification in the [MEDICATION NAME] order to [MEDICATION NAME] Diskus 100 mcg inhaler twice a day. Nurse's notes dated 1/10/11 (date of admission) identified the medication list had been verified with the resident ' s physician and orders were faxed to the pharmacy. Nurse's notes dated 1/14/11 at 11:00 AM identified the pharmacy called for order clarification on the [MEDICATION NAME] inhaler. A new order was faxed to the pharmacy. Nurse's notes dated 1/17/11 identified a STAT order was sent to the pharmacy for R#18 to receive the [MEDICATION NAME] inhaler. The pharmacist notified the facility to alert them that they did not have the medication in stock but where ordering it. Review of the medication kardex for January 2011 identified that although [MEDICATION NAME] 100mcg inhaler twice daily was ordered on admission (1/10/11), the order was not transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, the MAR indicated [REDACTED]. Review of the clinical record and interview with the ADNS on 2/22/11 at 10:00 AM failed provide documentation that the physician was made aware that the [MEDICATION NAME] was not available or that the resident did not receive the [MEDICATION NAME] from admission through 1/18/11. Interview with MD #1 on 2/17/11 at 2:00 PM identified he could not recall if he had been notified, but if he was aware of the medication not being available he would have ordered a different inhaler for that resident. 5. Resident #40's [DIAGNOSES REDACTED]. The nurse's admission note dated 1/19/11 identified 19 staples to the right hip. Nurse's notes dated 1/30/11 on the 7:00 PM to 7:00 AM shift identified that the staples are to be removed in the morning. No further documentation was present in the nurse ' s notes until 2/8/11 at 8:00 AM at which time the nurse identified that he/she attempted to remove the staples, stopped due to discomfort, and awaiting a staple removal kit. The note further identified the resident was having complaints of the staple site being tender. Nurse's notes dated 2/9/11 on day shift identified the staples were removed, and steri-strips applied Review of R# 40's clinical record and interview with RN#1 on 2/16/11 at 3:00 PM failed to provide documentation that the physician was notified when the staple removal kit was not available. Interview and review of R # 40's clinical record with the ADNS on 2/16/11 at 3:15 PM failed to identify that the physician had been made aware of R # 40's staples not being removed until 2/9/11, 10 days after the staples were to be removed. Interview with MD#1 on 2/17/11 at 2:00pm identified he was not made aware that the staple removal kit was not available for 10 days. Interviews were unable to determine why staple removers were not available in the facility or why one was not obtained upon the resident ' s admission. 6. Resident #25's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident was alert and oriented, and required extensive assistance with bed mobility and transfers. Nurse's notes dated 11/4/10 at 9:30 AM identified the physician visited, and was notified about a large purple area behind the left knee that had been noted on 11/3/10. The physician ordered a left lower extremity ultrasound. Bilateral lower leg [MEDICAL CONDITION] was noted. Nurse's notes dated 11/4/10 at 7 PM identified ultrasound results noted a [MEDICAL CONDITION] in the posterior left leg. The covering physician was called and R #25 was placed on bedrest the primary physician was available in the morning. Nurse's notes 11/5/10 at 9:50 AM noted that the purple area behind the left knee persisted, the resident denied pain, bilateral lower extremity [MEDICAL CONDITION] was noted, the skin was cool to touch, and a decrease in circulation and sensation had been noted. The physician was notified and R #25 was admitted to the hospital with [REDACTED]. Interview with RN #5 on 2/17/11 at 1:30 PM noted that the bruise behind R# 25's knee was reported to her from the previous shift, and they had not notified the physician. Interview with the ADNS on 2/17/11 at 2:20 PM noted that when a bruise is identified, the charge nurse is to assess the area, report the findings to the MD and document the assessment and notification in the clinical record. Review of R#25's clinical record and 24 hour report sheets at that time with the ADNS failed to provide documentation that the physician was notified when the bruise was first identified.

Based on observations, clinical record reviews and staff interviews 11 sampled residents (R# 8, 18, 21, 25, 26, 33, 36, 40, 64, 76, 84), the facility failed to follow professional standards of practice related to assessment and treatment of [REDACTED]. The findings include: 1. Resident #36 was admitted to the facility on [DATE] after hospitalization for a compression fracture of T12 and pain. Kyphoplasty was performed percutaneously with 2 sutured incisions remaining. The initial MDS dated [DATE] identified the resident was without cognitive impairment, required extensive assistance with mobility, had no infections, and had moderate pain less than daily. The admission nursing notes indicated the presence of two incisions of the back both measuring approximately 0.5 cm with the one on the right side having a suture in place. There were no physician orders obtained to remove the suture. The admission physician orders directed cleansing the wound and applying a new dressing daily. The admission nursing assessment form for skin assessment was blank and unsigned. The care plan dated [DATE] identified the risk for skin breakdown related to a surgical wound. Interventions included to turn and position every two hours, inspect skin completely from head to toe every week and document results, and to inspect skin daily with care and bathing and report changes to the charge nurse. Review of nursing notes from admission through [DATE], failed to document any assessment of the incisions and/or removal of the suture. The treatment kardex for September failed to have any treatments transcribed on it or evidence the treatment to the incisions had been done as ordered by the physician. On [DATE], the physician assessed the resident and noted the suture still in place to the right incision with large amount of purulent drainage. He removed the suture and sent the resident to the ED for evaluation. An emergency department visit dated [DATE] identified the resident was seen for [MEDICAL CONDITION] of the back and an abscess of the incision which was opened, drained and packed. Orders included removing the packing in 2 days and administer antibiotics. The resident was sent back to the hospital on [DATE] with increased redness of the area and admitted . Interview and clinical record review with the ADNS on [DATE] at 2 PM failed to provide documentation that the surgical incision had received the daily treatment ordered by the physician, that the physician or surgeon had been notified of the presence of a suture/need for removal, that the resident had been sent to the surgeon within one week as directed in the discharge summary and/or that the incisions had been assessed daily for signs of infection. According to Fundamentals of Nursing, 7th Edition, Potter-Perry 2009, the health care provider will assess the wound at least daily. Assessment for abnormal healing includes: incision line poorly approximated, drainage present more than 3 days after closure, (lack of ) inflammation decreased in first ,[DATE] days after injury, no [MEDICATION NAME] of wound edges by day 4, and/or no healing ridge by day 9. 2. Resident #33's [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] noted the resident was on day 20 of 42 of [MEDICATION NAME] and [MEDICATION NAME] intravenously (IV) for endocarditis. Nurse's notes on [DATE] noted the resident was very lethargic. Labs done that day indicated a rising BUN and creatinine which were communicated to the attending physician. The resident was sent to the hospital for evaluation. The hospital discharge summary noted that the resident had been started on [MEDICATION NAME] a few days earlier to stimulate appetite. The creatinine on admission was 2.1 with a prior baseline of 1.3. The [MEDICATION NAME] was discontinued due to acute [MEDICAL CONDITION]. The resident was sent back to the facility on [DATE] with orders to continue [MEDICATION NAME] IV every 12 hours until [DATE] and then switch to antibiotics by mouth indefinitely. The type of antibiotics by mouth was not specified in the discharge summary. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review noted that the antibiotics by mouth were not begun until [DATE] leaving the resident without antibiotic coverage for 5 days. Interview with the ADNS and review of the clinical record on [DATE] at 8:20 AM noted that the resident's medication list from the hospital identified that [MEDICATION NAME] 2 grams intravenously was to be administered every 12 hours, but was transcribed inappropriately and administered every 8 hours. Further review noted that the resident should have received antibiotics by mouth immediately upon completing the IV antibiotics on [DATE]. The physician was not notified for antibiotic orders until [DATE]. According to Basic Nursing, Mosby, Third Edition, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was moderately impaired for decision-making skills, required assistance from staff for activities of daily living (ADL) and was receiving care for a skin ulcer related to [MEDICAL CONDITION] of the lower extremities. a. A wound/skin assessment obtained on admission to the facility dated [DATE] noted measurements to several necrotic areas of the posterior lower extremities (right and left calves). Five necrotic areas were noted to the left calf measuring 1.5 centimeters (cm) x .5cm (linear), 1cm x .3cm (linear), and circular wounds measuring .8cm, .3cm, and .5cm. The right calf was noted as having 3 necrotic areas measuring 1 cm x .2cm (linear), 1.5 cm x .2cm (linear), and a circular wound measuring .3cm. No further assessments were documented. On [DATE] at 9:05 AM, interview and review of the clinical record with the ADON identified that although the resident was discharged from the facility with the wounds still present on [DATE], the facility was to have assessed the resident's wounds on a weekly basis and documented the assessments. b. Resident #26 ' s admission orders [REDACTED]. No frequency of application was documented. The treatment kardex identified that the treatment was transcribed that the resident was to receive [MEDICATION NAME] application daily without clarification of the treatment with the physician. Also noted was a lack of documentation that the treatment had been done from [DATE] through [DATE]. On [DATE] at 10:21 AM interview and review of the clinical record with the ADON indicated in part, that prior to the administration of a treatment, the physician order was to have been clarified in regards to the frequency of the treatment and further noted that this was a transcription error. 4. Resident #8's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R#8 was alert and oriented, and required limited to extensive assistance from staff with ADL's. physician progress notes [REDACTED]. The physician questioned an allergic reaction. Physician orders dated [DATE] directed to apply [MEDICATION NAME] cream 1% to back and leg rash daily for 5 days. If no improvement, will consider a dermatology consult. Review of the [DATE] treatment kardex identified that R#8 did not receive the topical cream as ordered for 2 of the 5 days. Review of the nurse's treatment notes dated [DATE] identified pinpoint rash noted on trunk, feet and right hip. Treatment notes dated [DATE], and [DATE] identified the rash was improving, anti- itch cream applied to rash area with great relief. Although the physician order for [REDACTED]. Treatment notes dated [DATE] at 10:00 AM identified that the rash persisted. A Dermatologist Consult dated [DATE] identified pruritis, and non-specific [MEDICAL CONDITION]. New orders were obtained to apply [MEDICATION NAME] Cream twice a day for 3 weeks. Follow up in 3 weeks if rash not better. Review of the [DATE] treatment kardexes identified out of 63 shifts, on 8 eight occasions, R#8 did not receive the treatment as ordered. Further review identified that after the order for the cream expired on [DATE], the resident continued to receive the cream without a physician order for [REDACTED]. Interview with R#8 on [DATE] at 9:40 AM noted that he/she frequently had to ask staff to put the cream on the rash, or it did not get done. Additionally, R#8 stated that although the rash is better, it continues to get itchy, and he/she will ask for cream to be applied. Interview with RN#1 on [DATE] at 11:00 AM noted when R#8 gets a rash on his/her back, legs and feet they apply [MEDICATION NAME], although the resident does not have an order for [REDACTED]. 5. Resident #18's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified R #18 was alert and oriented, required limited to extensive assistance with ADL's, and had [MEDICAL CONDITION]. The admission medication orders dated [DATE] directed the administration of [MEDICATION NAME] 100 mcg inhaler twice a day. Physician orders dated [DATE] identified a clarification in the [MEDICATION NAME] order to [MEDICATION NAME] Diskus 100 mcg inhaler twice a day. Nurse's notes dated [DATE] (date of admission) identified the medication list had been verified with the resident ' s physician and orders were faxed to the pharmacy. Nurse's notes dated [DATE] at 11:00 AM identified the pharmacy called for order clarification on the [MEDICATION NAME] inhaler. A new order was faxed to the pharmacy. Nurse's notes dated [DATE] identified a STAT order was sent to the pharmacy for R#18 to receive the [MEDICATION NAME] inhaler. The pharmacist notified the facility to alert them that they did not have the medication in stock but where ordering it. Review of the medication kardex for [DATE] identified that although [MEDICATION NAME] 100mcg inhaler twice daily was ordered on admission ([DATE]), the order was not transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, the MAR indicated [REDACTED]. Review of the clinical record and interview with the ADNS on [DATE] at 10:00AM failed to identify that the physician was made aware that the [MEDICATION NAME] was not available nor did the resident receive it. Additionally, the ADNS stated that when a new admission enters the facility, all medication orders are to verified by the physician, the pharmacy notified and the medication transcribed onto the kardex. She was unable to explain why the [MEDICATION NAME] was not transcribed/ordered for 3 days or why the resident did not receive the steroid inhaler for 8 days. According to the Nurse Practice Act Section ,[DATE]a, definition of nursing, the practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaboration in the implementation of the total health care regime and executing the medical regimen under the direction of a licensed physician. 6. Resident #40's [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] identified 19 staples to the right hip. Nurse's notes dated [DATE] on the 7:00 PM to 7:00 AM shift identified that the staples are to be removed in the morning. No further documentation was present in the nurse ' s notes until [DATE] at 8:00 AM at which time the nurse identified that he/she attempted to remove the staples, stopped due to discomfort, and awaiting a staple removal kit. The note further identified the resident was having complaints of the staple site being tender. Nurse's notes dated [DATE] on day shift identified the staples were removed, and steri-strips applied Review of R# 40's clinical record and interview with RN#1 on [DATE] at 3:00 PM identified that there were no staple removal kits in house and that they were waiting to receive them from their supply company. Further interview noted that another nurse attempted on [DATE] to remove the staples with a suture removal kit unsuccessfully. RN#1 stated she reported this to the ADNS. Interview with the ADNS on [DATE] at 3:15 PM noted that although she was aware that the facility had no staple removal kits, she did not do anything to obtain one. 7. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's admission note dated [DATE] at 6:00 PM identified the presence of 31 staples to the lower spine. a. The physician history and physical dated [DATE] identified the incision site was healing well. Follow up with hematologist in 1 week and follow up with [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record from time of admission [DATE] through [DATE] failed to provide any documentation identifying an assessment of the incision to the lower spine or presence/absence of staples. Interview with RN #6 on [DATE] at 10:15 AM identified that on [DATE], R# 76's family had asked about when the staples were going to be removed. The family then called the physician and RN #6 spoke to the MD and noted that the physician said they should have been removed a week after the resident was admitted . RN# 6 stated she wrote the order to remove the staples and proceeded to do so. RN# 6 stated that there was dry skin around the staples, and that she had not assessed the area until the staples were removed. Interview with RN #1 on [DATE] at 10:37 AM noted that although she completed the admission for R#76 and noted that there were 31 staples present on the spine, she could not recall what the area looked like. RN# 1 further noted that when an admission occurs, it is the responsibility of that nurse to transcribe the orders from the admission paperwork onto the physician order sheets, notify the physician of the admission, review the medications and treatment orders, notify the pharmacy and if follow up appointments were needed, to make sure that they are done. Review of the clinical record at that time with RN #1 failed to provide any documentation that the incision line on the lower spine had been assessed from the time of admission on [DATE], until the staples were removed on [DATE]. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to review all the paperwork from the hospital, transcribe all the orders to physician order sheets, notify the physician and review orders, and notify the pharmacy. She further noted that a complete body assessment is to be done at the time of admission and if resident has a incision line, the area should be assessed and documented in the clinical record what the area looks like including size, if staples, how many, drainage, etc. The ADNS noted that when a resident comes into the facility and has a suture line with staples, the area is to be assessed every shift and documented. Additionally, ADNS stated that if the resident has staples and there is no order for removal of them, they are to alert the physician so a date can be determined. ADNS further stated that she was unaware R # 76 had no order to remove staples. b. The hospital discharge summary dated [DATE] directed follow up appointments that needed to be made for R # 76 as follows: The surgeon in one week The hematologist/ oncologist in in 1 week The GI physician in ,[DATE] weeks [MEDICAL CONDITION] therapy in ,[DATE] weeks. Review of the clinical record identified that R #76's follow up appointment with the surgeon was not done until [DATE] (24 days after admission). The record lacked documentation of visits with the Hematologist, GI physician and/or the [MEDICAL CONDITION] therapist. Interview with the ADNS on [DATE] at 11:05 AM identified that when a resident is admitted to the facility, the nurse who does the admission is to make any appointments identified on the admission paperwork. Review of the clinical record at that time with the ADNS failed to identify that R # 76's follow up appointments were made with 4 physicians. The ADNS stated that there is no system in place for assuring that after a resident is admitted that everything was completed. Additionally, she stated that she does not audit a resident ' s chart after admission to see if completed. There is no policy for the care and assessment of surgical incisions. According to Fundamentals of Nursing, 7th Edition, Potter-Perry 2009, the health care provider will assess the wound at least daily. Assessment for abnormal healing includes: incision line poorly approximated, drainage present more than 3 days after closure, (lack of ) inflammation decreased in first ,[DATE] days after injury, no [MEDICATION NAME] of wound edges by day 4, and/or no healing ridge by day 9. 8. Resident #25's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident was alert and oriented, and required extensive assistance with bed mobility and transfers. Nurse's notes dated [DATE] at 9:30 AM identified the physician visited, and was notified about a large purple area behind the left knee that had been noted on [DATE]. The physician ordered a left lower extremity ultrasound. Bilateral lower leg [MEDICAL CONDITION] was noted. Nurse's notes dated [DATE] at 7 PM identified ultrasound results noted a [MEDICAL CONDITION] in the posterior left leg. The covering physician was called and R #25 was placed on bedrest the primary physician was available in the morning. Nurse's notes [DATE] at 9:50 AM noted that the purple area behind the left knee persisted, the resident denied pain, bilateral lower extremity [MEDICAL CONDITION] was noted, the skin was cool to touch, and a decrease in circulation and sensation had been noted. The physician was notified and R #25 was admitted to the hospital with [REDACTED]. Interview with RN #5 on [DATE] at 1:30 PM noted that the bruise behind R# 25's knee was reported to her from the previous shift, and they had not notified the physician. Interview with the ADNS on [DATE] at 2:20 PM noted that when a bruise is identified, the charge nurse is to assess the area, report the findings to the MD and document the assessment and notification in the clinical record. Review of R#25's clinical record and 24 hour report sheets at that time with the ADNS failed to provide documentation that the physician was notified when the bruise was first identified. According to the Nurse Practice Act Section ,[DATE]a, definition of nursing, the practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaboration in the implementation of the total health care regime and executing the medical regimen under the direction of a licensed physician. 9. Resident #84's [DIAGNOSES REDACTED]. The nursing admission note dated [DATE] identified the presence of a stage 2 pressure sore that measured 2 cm by 2 cm. No other description of the wound was present. Physician orders dated [DATE] directed to cleanse the coccyx with normal saline, pat dry, followed by a protective dressing every 3rd day. On [DATE] an air mattress was ordered along with skin prep to heels every shift, and to turn and reposition every two hours. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on [DATE] failed to document any assessments of the pressure sore although the resident's discharge summary indicated the wound was still present. Interview with the ADNS on [DATE] at 8:25 AM failed to provide documentation that the resident's pressure sore was appropriately assessed on admission, or that any subsequent assessments had been done to assess the pressure sore. 10. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] indicated the resident had short and long-term memory problems, required extensive assistance with bed mobility and transfers, did not walk, was incontinent of bowel, and had one stage II pressure ulcer. A wound skin assessment dated [DATE] identified a stage II pressure ulcer on the right buttock measuring 3cm x 1.5cm x 0.1cm An initial care plan dated [DATE] identified a stage II pressure ulcer on the right buttock. Interventions included treatment as ordered and turn and position every two hours. Review of physician orders dated [DATE], [DATE], [DATE], and [DATE] failed to include a treatment for [REDACTED]. Review of a treatment record dated [DATE] indicated to cleanse stage II on right buttock with normal saline followed by a clean protective dressing and change every 3 days. Review of the clinical record and interview on [DATE] at 1:00 PM with the ADON indicated a treatment order should have been obtained when the resident was admitted on [DATE]. She further indicated the clean protective dressing initiated on [DATE] without a physician order was not appropriate for a stage II open area. 11. Resident #76's [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident as scoring a 5 on the Brief Interview for Mental Status (severe cognition impairment), requiring extensive assistance of one staff member for activities of daily living, and receiving nutrition via a feeding tube (pe[DEVICE]). A hospital discharge summary dated [DATE] identified the resident was being transferred to an extended care facility with a pe[DEVICE] and a stage two pressure ulcer to the coccyx. a. Admission nurse's notes and a Skilled Nursing admission assessment dated [DATE] at 6:00PM identified the resident had a stage two open area to the coccyx, but failed to identify a description of the area ( measurement, appearance of the wound base and edges, appearance of wound edges, etc). Review of the physician orders identified that a treatment to the area was not obtained from admission on [DATE] until [DATE]. A physician order dated [DATE] directed to cleanse the open area on the coccyx with Normal Saline and apply [MEDICATION NAME] every other day. Review of the facility pressure ulcer policy for Stage two pressure ulcers identified in part, to complete a comprehensive assessment of the wound and include the length, width and depth in centimeters, appearance of the wound base and wound edges. Interview with the admitting registered nurse, RN#1, on [DATE] at 11:15 AM identified that she was not aware that she was to have described the pressure ulcer according to the facility policy. She further noted that she did not obtain a treatment order on admission ([DATE]) because the wound nurse was to have evaluated the area to recommend a treatment, and that she applied a dry protective dressing, pending the wound nurse evaluation. Interview with the Wound Nurse/ADNS on [DATE] at 1:30 PM identified that she was not able to evaluate the resident's wound until [DATE] and recommended a treatment of [REDACTED]. b. The facility pressure ulcer monitoring policy identified, in part, to complete a wound assessment at least weekly. Review of the weekly wound assessment sheet identified the wound was only assessed on [DATE]. No further assessment of the wound was documented from [DATE] to [DATE]. Review of the resident's Inter-Disciplinary Discharge summary dated [DATE] identified the resident was discharged home from the facility but failed to identify the presence and/or treatment of [REDACTED]. Interview with the Wound Nurse/Assistant Director of Nurses (ADNS) on [DATE] at 1:30 PM identified that she is expected to assess the wounds weekly, but is not always able to complete the weekly monitoring because of other duties. She further identified that it is the responsibility of the Charge Nurse to complete the weekly assessments if she is unable to complete them. She further noted that the Nurse Aides complete weekly body audits after the resident's shower/bath and the nurse records it on the Treatment Administration Record. Review of the resident's weekly body audits (Treatment Administration Record) with the ADNS at that time failed to identify skin checks were completed on [DATE], [DATE], [DATE] and [DATE]. 12. Resident #33 was readmitted from the hospital on [DATE] with an open blister of the right heel. No treatment orders were present until [DATE] when a dry protective dressing was ordered to be applied daily. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on [DATE] failed to document any assessments of the pressure sore. Interview and review of the clinical record with the ADNS on [DATE] at 8:20 AM failed to provide documentation that the resident's pressure sore was accurately and thoroughly assessed upon admission and at least weekly, that appropriate treatment orders to maintain a moist healing environment were initiated, and/or that a care plan had been developed that addressed needs related to healing the pressure sore. 13. Resident # 64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had moderate cognitive impairment, required extensive assistance with bed mobility and transfers and limited assist with walking in the room, and had one stage three pressure ulcer. A physician order dated [DATE] directed Santyl to the left heel and a heel boot when in bed. A subsequent physician order dated [DATE] directed the resident to be seen by the wound clinic. An initial care plan dated [DATE] identified a problem with skin integrity and a pressure ulcer to the "right heel". Interventions included to remind the resident to reposition self and treatment as ordered. A noted dated [DATE] indicated the " right " heel ulcer was worsening with an increase in slough. A pressure ulcer assessment dated [DATE] identified a stage II pressure ulcer on the left heel measuring 3 cm x 2 cm and pink in color. On [DATE], the left heel pressure ulcer was a stage III measuring 2 cm round with a 0.4 cm depth and on [DATE], the left heel pressure ulcer was a stage III which had declined to 2.5 cm x 4 cm with a 1.3 cm depth with slough and minimum to moderate serosanguinous drainage. An assessment dated [DATE] identified the left heel pressure ulcer was unstageable measuring 7 cm with 4 cm of necrosis. A wound specialist consult sheet dated [DATE] identified a 7.5 cm x 4.7 cm x 0.6 cm pressure ulcer on the left heel. The consult indicated the resident needed a vascular PVR and a podus boot to the left lower extremity as soon as possible. An arterial PVR report dated [DATE] indicated, in part, adequate perfusion bilaterally of the lower extremities. A lab report dated [DATE] identified [MEDICAL CONDITION] in the left heel. An interview and review of the clinical record on [DATE] at 1:30 PM with the ADNS failed to provide documentation that the resident care plan was reviewed and revised on [DATE] and/or on [DATE] when the left heel increased in size and stage with the development of slough and serosanguinous drainage. She indicated she wanted to give the Santyl treatment time to work and not until [DATE] was a physician order obtained for the resident to see the wound doctor. The ADNS indicated the care plan documentation that the pressure ulcer was on the right heel was an error and she would change it to the left heel. She indicated the nurse aide care card documentation did not need to be corrected because they currently were not using them and the nurse aides got their information from morning report. The record lacked documentation of pressure relief interventions initiated to the left heel. At the time of the interview, a review of the weekly pressure ulcer assessment noted the pressure ulcer was not assessed from [DATE] until [DATE]. The ADNS at that time indicated the wound assessments are done weekly. R#64's assessments were being done by the wound clinic but he/she missed the [DATE] visit due to inclement whether. The resident was not seen in the wound clinic until [DATE] and facility staff failed to assess the wound during the interim. According to the Merck Manual, 2008, Objectives (in the treatment of [REDACTED]. Transparent films are sufficient for ulcers with limited exudate; they should not be used over cavities and must be changed every 3 to 7 days. Hydrogels which are cross-linked polymer dressings that come in sheets or gels, are indicated for very shallow wounds, such as re-[MEDICATION NAME] wounds with minimal exudate. According to the Government's Pressure Ulcers Treatment Guide, http://www.woundheal.com/healing/clinicalPrintVersion.htm, re-assess pressure ulcers at least weekly. If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted. 14. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] indicated the resident had short and long-term memory problems, required extensive assistance with eating, and utilized a feeding tube. A physician order dated [DATE] directed Fibersource HN at 80cc/hour with 110cc flush every shift until the dietitian assesses. A subsequent order directed to hold the feeding due to no connector (available) to (attach) feeding bottle, continue to flush. A resident care plan dated [DATE] identified the potential for dehydration and/or overhydration. Interventions included to adjust feeding volume and water flushes per physician and dietician recommendations. A review of R#21's clinical record and interview on [DATE] at 1:10 PM with the ADNS failed to provide documentation that the resident's fluid intake and output were monitored during the resident's stay in the facility. A review of the dietician assessment and interview on [DATE] at 11:00 AM with the dietician indicated the resident was drinking clear liquids along with supplemental tube feedings and that she would have expected the i

Based on record review and staff interview for five of five sampled residents reviewed for pressure ulcers (R # 76, 33, 84, 21, 64), the facility failed to obtain physician treatment orders on admission, document and/or initiate pressure relief interventions, use appropriate treatments to maintain a healing environment and/or prevent infections, revise the plan of care when the wound declined, and/or failed to assess the wounds at least weekly. The findings below resulted in a finding of immediate jeopardy. The findings include: 1. Resident #76's [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] identified the resident as scoring a 5 on the Brief Interview for Mental Status (severe cognition impairment), requiring extensive assistance of one staff member for activities of daily living, and receiving nutrition via a feeding tube (pe[DEVICE]). A hospital discharge summary dated 10/5/10 identified the resident was being transferred to an extended care facility with a pe[DEVICE] and a stage two pressure ulcer to the coccyx. a. Admission nurse's notes and a Skilled Nursing admission assessment dated [DATE] at 6:00PM identified the resident had a stage two open area to the coccyx, but failed to identify a description of the area ( measurement, appearance of the wound base and edges, appearance of wound edges, etc). Review of the physician orders [REDACTED]. A physician order [REDACTED]. Review of the facility pressure ulcer policy for Stage two pressure ulcers identified in part, to complete a comprehensive assessment of the wound and include the length, width and depth in centimeters, appearance of the wound base and wound edges. Interview with the admitting registered nurse, RN#1, on 2/17/11 at 11:15 AM identified that she was not aware that she was to have described the pressure ulcer according to the facility policy. She further noted that she did not obtain a treatment order on admission (10/5/10) because the wound nurse was to have evaluated the area to recommend a treatment, and that she applied a dry protective dressing, pending the wound nurse evaluation. Interview with the Wound Nurse/ADNS on 2/17/11 at 1:30 PM identified that she was not able to evaluate the resident's wound until 10/7/10 and recommended a treatment of [REDACTED]. b. The facility pressure ulcer monitoring policy identified, in part, to complete a wound assessment at least weekly. Review of the weekly wound assessment sheet identified the wound was only assessed on 10/7/10. No further assessment of the wound was documented from 10/7/10 to 11/19/10. Review of the resident's Inter-Disciplinary Discharge summary dated 11/19/10 identified the resident was discharged home from the facility but failed to identify the presence and/or treatment of [REDACTED]. Interview with the Wound Nurse/Assistant Director of Nurses (ADNS) on 2/17/11 at 1:30 PM identified that she is expected to assess the wounds weekly, but is not always able to complete the weekly monitoring because of other duties. She further identified that it is the responsibility of the Charge Nurse to complete the weekly assessments if she is unable to complete them. She further noted that the Nurse Aides complete weekly body audits after the resident's shower/bath and the nurse records it on the Treatment Administration Record. Review of the resident's weekly body audits (Treatment Administration Record) with the ADNS at that time failed to identify skin checks were completed on 10/6/10, 10/11/10, 10/18/10 and 10/25/10. 2. Resident #84's [DIAGNOSES REDACTED]. The nursing admission note dated 12/21/10 identified the presence of a stage 2 pressure sore that measured 2 cm by 2 cm. No other description of the wound was present. Physician orders [REDACTED]. On 12/7/10, an air mattress was ordered along with skin prep to heels every shift, and to turn and reposition every two hours. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on 1/20/11 failed to document any assessments of the pressure sore although the resident's discharge summary indicated the wound was still present. Interview with the ADNS on 2/17/11 at 8:25 AM failed to provide documentation that the resident's pressure sore was appropriately assessed on admission, or that any subsequent assessments had been done to assess the pressure sore as per facility policy. 3. Resident #33 was readmitted from the hospital on [DATE] with an open blister of the right heel. No treatment orders were present until 12/22/10 when a dry protective dressing was ordered to be applied daily. Review of the pressure sore assessment forms noted they were completely blank. Review of all nursing notes from admission to discharge on 1/13/11 failed to document any assessments of the pressure sore. Interview and review of the clinical record with the ADNS on 2/17/11 at 8:20 AM failed to provide documentation that the resident's pressure sore was accurately and thoroughly assessed upon admission and at least weekly, that appropriate treatment orders to maintain a moist healing environment were initiated, and/or that a care plan had been developed that addressed needs related to healing the pressure sore. 4. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated the resident had short and long-term memory problems, required extensive assistance with bed mobility and transfers, did not walk, was incontinent of bowel, and had one stage II pressure ulcer. A wound skin assessment dated [DATE] identified a stage II pressure ulcer on the right buttock measuring 3cm x 1.5cm x 0.1cm An initial care plan dated 12/17/10 identified a stage II pressure ulcer on the right buttock. Interventions included treatment as ordered and turn and position every two hours. Review of physician orders [REDACTED]. Review of a treatment record dated 12/19/10 indicated to cleanse the stage II on the right buttock with normal saline followed by a clean protective dressing and to change every 3 days. Review of the clinical record and interview on 2/18/10 at 1:00 PM with the ADNS indicated a treatment order should have been obtained when the resident was admitted on [DATE]. She further indicated the clean protective dressing initiated on 12/19/10 without a physician order, was not appropriate for a stage II open area. 5. Resident # 64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had moderate cognitive impairment, required extensive assistance with bed mobility and transfers and limited assist with walking in the room, and had one stage three pressure ulcer. A physician order [REDACTED]. A subsequent physician order [REDACTED]. An initial care plan dated 12/21/10 identified a problem with skin integrity and a pressure ulcer to the "right heel". Interventions included to remind the resident to reposition self and treatment as ordered. A noted dated 1/7/11 indicated the " right " heel ulcer was worsening with an increase in slough. A pressure ulcer assessment dated [DATE] identified a stage II pressure ulcer on the left heel measuring 3 cm x 2 cm and pink in color. On 12/28/11, the left heel pressure ulcer was a stage III measuring 2 cm round with a 0.4 cm depth and on 12/31/10, the left heel pressure ulcer was a stage III which had declined to 2.5 cm x 4 cm with a 1.3 cm depth with slough and minimum to moderate serosanguinous drainage. An assessment dated [DATE] identified the left heel pressure ulcer was unstageable measuring 7 cm with 4 cm of necrosis. A wound specialist consult sheet dated 1/10/11 identified a 7.5 cm x 4.7 cm x 0.6 cm pressure ulcer on the left heel. The consult indicated the resident needed a vascular PVR and a podus boot to the left lower extremity as soon as possible. An arterial PVR report dated 1/11/11 indicated, in part, adequate perfusion bilaterally of the lower extremities. A lab report dated 1/17/11 identified [MEDICAL CONDITION] in the left heel. An interview and review of the clinical record on 2/16/11 at 1:30 PM with the ADNS failed to provide documentation that the resident care plan was reviewed and revised on 12/28/10 and/or on 12/31/10 when the left heel increased in size and stage with the development of slough and serosanguinous drainage. She indicated she wanted to give the Santyl treatment time to work and not until 1/7/11 was a physician order [REDACTED]. The ADNS indicated the care plan documentation that the pressure ulcer was on the right heel was an error and she would change it to the left heel. She indicated the nurse aide care card documentation did not need to be corrected because they currently were not using them and the nurse aides got their information from morning report. The record lacked documentation of pressure relief interventions initiated to the left heel. At the time of the interview, a review of the weekly pressure ulcer assessment noted the pressure ulcer was not assessed from 1/21/11 until 2/1/11. The ADNS at that time indicated the wound assessments are done weekly. R#64's assessments were being done by the wound clinic but he/she missed the 1/31/11 visit due to inclement whether. The resident was not seen in the wound clinic until 2/7/11 and facility staff failed to assess the wound during the interim.