Every finding on record at St Ann's Home

Based on interview and record review the facility failed to develop a person-centered care plan related to hospice services for 1 (Resident #10) of 12 residents reviewed for person-centered care planning resulting in the potential for unmet care needs.Findings include:Resident #10Review of an admission Record revealed Resident #10 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease and dementia.Review of Order Summary for Resident #10 revealed .ADMIT to (Name Omitted) hospice dx: (diagnosis) Alzheimer's disease. with a start date of 10/31/25Review of Care Plan for Resident #10 revealed no noted care plan related to collaboration of care between the facility and (Name Omitted) hospice services.In an interview on 1/22/26 at 2:13 PM, Hospice Registered Nurse (H/RN) DD reported Resident #10 had been on services for a few months this time, he had previously had services as well. H/RN DD reported Resident #10 had a separate care plan that was completed by hospice and provided to the facility. H/RN DD reported she did not have access to Resident #10's care plan for the facility and could not update any information in the care plan. In an interview on 1/23/26 at 1:20 PM, Director of Nursing (DON) B reported Social Services Coordinator (SSC) M created the initial care plan for hospice services. DON B reported the care plan provided to the facility by hospice was reviewed and incorporated into the facility's care plan. DON B reported there was no separate care plan that indicated a resident received hospice services. In an interview on 1/23/26 at 1:23 PM, SSC M reported she assisted with the hospice start of care for a resident, but she did not make any changes in the care plan to reflect the start of hospice care. SSC M reported hospice provides a care plan and it is located the resident's record.

Based on observation, interview, and record review the facility failed to maintain infection control practices and implement enhanced barrier precautions (EBP) related to wound care for 1 (Resident #9) of 3 resident reviewed for wound care resulting in the potential for cross contamination, disease transmission, and the introduction of infection.Findings include:Resident #9Review of an admission Record revealed Resident #9 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease (progressive mental deterioration), dementia (loss of cognitive functioning), and anxiety disorder.Review of Centers for Disease Control and Prevention (CDC) dated March 20, 2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 .On 1/23/26 at 11:49 AM, Certified Nurse Assistant (CNA) CC was observed providing incontinent care, a brief change, and transferring Resident #9 from bed to wheelchair. CNA CC did not wear a gown during the care she provided. When queried, CNA CC reported Resident #9 did not have a wound and she was not in enhanced barrier precautions. Review of Order Summary for Resident #9 revealed .Right lateral ankle wound: cleanse with saline and gauze. Monitor for signs of infection with a start date of 8/12/25.No order was noted for enhanced barrier precautions.No signage was observed outside Resident #9's room indicating she was in enhanced barrier precautions.Review of Care Plan for Resident #9 revealed no noted care plan related to a wound, wound care, nor enhanced barrier precautions.On 1/23/26 at 12:02 PM, Licensed Practical Nurse (LPN) W was observed providing wound care to Resident #9 right lateral ankle wound. LPN W was not wearing a gown during wound care. LPN W reported Resident #9 was not in enhanced barrier precautions.In an interview on 1/23/26 at 12:13 PM, Director of Nursing (DON) B reported enhanced barrier precautions were implemented for a resident with a wound only if the wound had drainage. DON B reported she was unaware that Resident #9 had a wound with a dressing. DON B reported the facility had followed the guidance of 'if there was no drainage, there was no need for EBP. DON B reviewed Resident #9's record and reported she was not started on EBP when the wound was noted on 8/10/25 and she had not been placed on EBP at all.Review of Encounter for Resident #9 dated 8/12/25 at 01:00 (1:00 am) revealed .wound care.wound on right ankle.Wound 1 Type: pressure, Location: right lateral ankle (outer ankle).unstageable.exudate (a mass of cells and fluid that has seeped out of the body): scant (traces, minimal amount) serous (clear to yellow in color and watery consistency drainage).In an interview on 1/23/26 at 1:13 PM, Assistant Director of Nursing (ADON) Q reported Resident #9's wound had no drainage and the dressing remained intact, without becoming dislodged. ADON Q reported there was no need for Resident #9 to be in EBP.Review of facility policy Enhanced Barrier Precautions with a revision date of 7/1/25 revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Enhanced barrier precautions refers to the use of gown and gloves for use during high-contact resident care activates.clear signage will be posted on the door or wall outside of the reside room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure wounds.).High contact care activities include:.transferring.providing hygiene.changing briefs.wound care: any skin opening requiring a dressing.Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer in 1 (Resident #9) of 2 reviewed for pressure ulcers, resulting in the development of a pressure wound on Resident #9's right ankle.Findings include:Resident #9Review of an admission Record revealed Resident #9 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease (progressive mental deterioration), dementia (loss of cognitive function), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 8/4/25 revealed a Self-Care Assessment - Mobility- roll left to right- Substantial/maximal assistance, sit to laying substantial/maximal assistance, and laying to sitting on bed side dependent.Review of Care Plan for Resident #9 revealed .has an ADL (activities of daily living) self-care performance deficient r/t (related to) Alzheimer's, dementia.intervention: bed mobility; one person min assist initiated on 6/12/25.has potential impairment of skin integrity of the r/t fragile skin.will maintain.intact skin.revised on 11/19/25.Interventions: keep skin clean and dry.pressure relieving/reducing cushion to protect the skin while in bed.has pressure relieving/reducing mattress, and pillows for comfort.Revised on 6/12/25.Review of Braden Scale- for Predicting Pressure Ulcer Risk Evaluation for Resident #9 dated 8/4/25 at 10:31 AM, revealed .sensory perception: very limited, moisture: very moist, Activity: chairfast, Resident is slightly limited: makes frequent though slight changes in body or extremity position independently, nutrition adequate, friction and shear: problem: Braden score 13.0 (moderate risk for developing pressure ulcers).Review of Alert Note for Resident #9 dated 8/10/25 at 15:21 (3:21 pm) revealed . Resident has an open area on right ankle that measures 0.5 cm. The open area has a white base. Areas cleaned with NS (normal saline) and a 3x3 adhesive dressing applied.Review of encounter for Resident #9 dated 8/12/25 at 01:00 (1:00 am) revealed .wound care.wound on right ankle.is seen today to evaluation wound on her right ankle.Wound 1 Type: pressure, Location: right lateral ankle (outer ankle) size (cm) (centimeters) 0.4 x 0.4 cm, There is a depth of 0.1 cm though this is not a true depth due to the presence of slough (dead tissue that accumulates on the wound surface).unstageable.exudate: scant serous (minimal clear to yellow in color and watery consistency drainage).Plan.small unstageable pressure injury to the right lateral ankle, will have staff cleanse the wound with saline and gauze, apply MediHoney gel to the wound base and cover with a 3x3 silicone foam border dressing. Change every other day and prn (as needed) if disrupted. She does have pressure relieving boots in her room, recommend she have them on whenever she is in bed. On 1/22/26 at 2:23 PM, Resident #9 was observed in bed positioned on her right side with the wound on her right ankle positioned directly on the mattress, pressure relieving boots observed on the dresser.Review of Order Summary for Resident #9 revealed .Right lateral ankle wound: cleanse with saline and gauze, apply MediHoney gel to the wound base and cover with a 3x3 silicone foam border dressing, change every other day and prn if disrupted. Monitor for signs of infection with a start date of 8/12/25 .Please avoid putting the tight black stocking on her RLE (right lower extremity) until her ankle wound is healed.every shift for pressure relief.with a start date of 8/26/25.Pressure relieving boots to BLE (bilateral lower extremities) when in bed.every shift for pressure injury right ankle. with a start date of 8/14/25.with position changes do not position on her right ankle. Has open blister. Area measures 0.5 cm. every shift with a start date of 8/11/25.In an interview on 1/23/26 at 12:30 PM, Certified Nurse Assistant (CNA) CC reported she would review the care plan for Resident #9 to determine specific needs related to positioning, mobility, transfers, and personal care. When queried, CNA CC reported she applied Resident #9's pressure relieving boots to her feet when she laid Resident #9 down because she saw them in her room and assumed she needed them on. CNA CC accessed Resident #9's care plan and Kardex (a summary of the care plan used for easy access to information), and CNA CC reported there was nothing on the care plan or Kardex regarding Resident #9 wearing pressure relieving boots. When CNA CC was further queried regarding Resident #9's ankle wound, CNA CC reported Resident #9 did not have a wound, and there was no information in her care plan indicating she had a wound.In an interview on 1/23/26 at 12:40 PM, Licensed Practical Nurse (LPN) W reported she was unable to locate a care plan or interventions related to Resident #9's ankle wound. LPN W reported there were orders in Resident #9's record related to positioning and pressure relieving boots. LPN W reported the CNAs cannot access a resident's orders. When queried, how the CNAs knew to complete Resident #9's orders related to positioning and applying pressure relieving boots when in bed, LPN W stated that's a good question, unless the nurse tells them, they do not know. In an interview on 1/23/26 at 12:54 PM, Assistant Director of Nursing (ADON) Q reviewed Resident #9's record and confirmed there was not a care plan related to her ankle wound. ADON Q reported, if an intervention was not listed on the care plan and in the task section of the Kardex the CNAs could not access the information. ADON Q confirmed there were orders in place for Resident #9's positioning and the application of her pressure relieving boots. CNAs carried out the tasks, but the nurse assigned was responsible for the task. ADON Q reported Resident #9's pressure relieving boots were implemented after the wound was discovered on her right ankle which ADON Q reported was a boney prominence.In an interview on 1/23/26 at 12:59 PM, Director of Nursing (DON) B reported Resident #9 should have a care plan in place with interventions related to the wound on her right lateral ankle. DON B confirmed positioning and pressure relieving boots were not addressed in Resident #9's care plan for skin integrity.

Based on interview, observation, and record review, the facility failed to adhere to profession standards of infection prevention for 1. the proper personal protective equipment use for enhanced barrier precautions for 1 of 1 resident (Resident #6) and 2. hand hygiene during dining and meal service, resulting in the increased potential for cross-contamination, bacterial harborage, and placing a vulnerable population at high risk for the transmission/transfer of pathogenic organisms and cross contamination between residents. Findings include: 1. Enhanced barrier precautions Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Resident #6: Review of the Admission Record for Resident #6 revealed he admitted to the facility on [DATE] with pertinent diagnoses of peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), cellulitis of right lower limb (potentially serious bacterial infection in the deeper layers of the skin), chronic ulcer of right lower leg with necrosis (death of cells or tissue) of the muscle, chronic ulcer of right lower leg with necrosis of bone, non pressure ulcer of right heel and mid foot, and non pressure ulcer of right ankle. During an observation on 11/21/24 at 03:00 PM, Resident #6 was woken up in his room and was removed from the room so Housekeeper RR could clean his room. Resident #6 was under enhanced barrier precautions due to his leg wounds and pressure ulcers. Housekeeper RR entered the room and began stripping down the resident's bed and placed the linens in a large plastic bag. Housekeeper RR was observed to not don personal protective equipment of a gown or gloves. Review of sign, Enhanced Barrier Precautions indicated Everyone must: Clean their hands, including before entering and when leaving the room .Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities Changing linens . In an interview on 11/22/24 at 01:29 PM, Director of Environmental Services Q reported the staff would don PPE (personal protective equipment) when cleaning a room when a resident who was under enhanced barrier precautions and COVID (with additional PPE for that) was discharged or moved rooms. In an interview on 11/22/24 at 10:04 AM, Director of Nursing (DON) B reported the facility did perform education for hand hygiene and enhanced barrier precautions, as well as verbal education when a break down was noticed. DON B reported audits were conducted for enhanced barrier precautions (EBP) and when to don and dof personal protective equipment. DON B reported EBP has been the the most challenging and the facility still struggled between the differences of precautions requirements, there was continual re-education provided to staff. 2. Hand Hygiene During an observation on 11/21/24 at 12:08 PM, Certified Nursing Assistant (CNA) II was observed passing out lunch trays to residents in the small dining room area. CNA II performed set up for a resident and then proceeded to the meal cart to retrieve a lunch tray for another resident without performing hand hygiene. Performed set up for the resident, went and retrieved another tray for a female resident asked if she needed set up assistance, went to the meal cart and retrieved a meal tray for another female resident seated at the table with the other where she grabbed the female residents coffee cup lid removed it, obtained a refill for the coffee and returned it back to the table without performing hand hygiene. CNA II retrieved a meal tray for another female resident and performed set up for the resident utilizing her silverware to cut up the barbeque chicken on the resident's plate. In an interview on 11/21/24 at 12:43 PM, Certified Nursing Assistant (CNA) I reported she would performance hand sanitization between the delivery of each residents meal for infection control process so she was not spreading germs. In an interview on 11/22/24 at 10:04 AM, Director of Nursing (DON) B reported for hand hygiene there were we several avenues of hand hygiene education and audits we do, skills fair once a year and expectations for staff to complete hand hygiene - hand sanitization and hand washing (when indicated). DON B reported random CNA audits were conducted which covered hand hygiene/hand washing. DON B reported the facility would do weekly and monthly audits and try to cover every staff member and nursing staff. DON B reported staff should be performing hand hygiene prior to entering and when exiting a resident room, before and after care, when a resident was in isolation, hands become soiled, during meal service between delivery and set up assistance between residents. Typically there was hand sanitizer on the meal deliver carts for staff to utilize. 46999 During an observation on 11/21/24 at 12:06pm, Certified Nursing Assistant (CNA) X sat between 2 residents at the dining table in the memory care area of the facility. Each resident had a meal, and beverages set up in front of them. CNA X brought a loaded fork to the mouth of a resident who sat to her left, then turned to the right, picked up a fork loaded with food and brought the utensil to the mouth of a resident who sat to her right. No hand hygiene was observed between CNA X assisting residents with eating. During an observation on 11/21/24 at 12:09pm, CNA X used a napkin to wipe the face of the resident who sat to her left, then turned to her right, picked up a cup and assisted the resident to her right with drinking. CNA X then walked over to another resident, loaded that resident's fork and handed the utensil to that resident. No hand hygiene was completed between resident care as CNA X assisted 3 residents with eating. During an observation on 11/21/24 at 12:12pm, Registered Nurse (RN) M sat between 2 residents at the dining table in the memory care area. RN M loaded a spoon with food and assisted a resident who sat to her right with eating, then turned to a resident on her left and placed a cup in that resident's hand. RN M did not complete hand hygiene after assisting the first resident/before assisting the next resident. During an observation on 11/21/24 at 12:24pm, CNA X gathered dirty dishes on a tray, then walked over to a resident who was still eating and assisted that resident was pouring root beer into a cup, placing a lid on the cup, placing a straw in the lid and removing the paper covering on the straw. No hand hygiene was completed between CNA X touching dirty dishes with bare hands and then assisting a resident with her drink. In an interview on 11/21/24 at 12:58pm, RN M reported the facility normally had 3 staff to assist the memory care residents with eating, but on this date only 2 staff assisted. When further queried, RN M reported other staff were available to assist but she had not asked for support. RN M reported she did not sanitize her hands between assisting each resident because several resident's needed physical assistance to eat and hand sanitizing between residents was not possible. In an interview on 11/21/24 at 1:04pm, CNA X reported staff expected to complete hand hygiene between each resident they assisted with eating. When further queried, CNA X reported she did not complete hand hygiene between residents as she assisted them with eating lunch on 11/21/24 because she was busy. 47955 During an observation on 11/20/24 at 12:10 PM, Certified Nurse Assistant (CNA) II was observed in the main dining room serving meal plates to residents. CNA II was observed serving a resident at the middle table in the dining room, returning to the food service area and retrieving another plate and serving that plate to another resident. CNA II was observed serving lunch to 5 different residents who were at different tables in the main dining room and CNA II did not perform hand hygiene at any time. At 12:16 PM, CNA II was observed delivering a meal plate to a resident seated at a table on the left side in the dining room, CNA II used the resident's silverware to cut the food on the plate, then CNA II went to the drink station and prepared a drink for a different resident. CNA II poured juice into a cup, added thickener (a substance that thickens liquid for special diets) to the cup, used the palm of her hand to apply a lid to the cup and delivered that drink to the resident. CNA II was then observed removing her mask, touching her nose, and readjusting her mask into place on her face and CNA II returned to meal service area to retrieve an empty cup. Again, CNA II did not perform hand hygiene at any time. CNA II was further observed adjusting a wheelchair of a resident, adjusting the clothing protector of different resident, and then returned to meal service to retrieve a plate that CNA II delivered to a resident seated at the far end of the middle table. At no time did CNA II perform hand hygiene during this observation. A bottle of hand sanitizer was noted on the window ledge near the meal service area and other staff members present in the dining room were noted sanitizing their hands multiple times during meal service. In an interview on 11/21/24 at 2:06 PM, CNA F reported that hands should be washed with soap and water when meal service begins and ends, and hand sanitizer could be used between residents. CNA F reported that staff should not assist more than one resident to eat at a time. CNA F reported there are more residents that need assistance than there was staff available to assist with meals, and staff did have to assist more than one resident with a meal. CNA F reported that hand hygiene should be done between every bite if staff had to assist more than one resident during a meal. In an interview on 11/21/24 at 2:10 PM, CNA R reported that staff could wear gloves when assisting a resident with a meal. CNA R reported that hand hygiene should be done at the beginning of meal service and between each resident.

Based on observation, interview and record review, the facility failed to ensure 1. as needed (PRN) medications did not extend greater than 14 days, 2. continued indication for use of psychotropic and antipsychotic medications, and 3. obtain informed consents for medications, for 2 (R23 and R27) of 5 residents reviewed for unnecessary medications, resulting in the risk of serious side effects and adverse reactions from potentially unnecessary medications. Findings include: According to https://www.aafp.org/afp/2000/0301/p1437.html, in an article titled, Appropriate Use of Psychotropic Drugs in Nursing Homes, revealed, Because treatment with psychotropic medications is indicated only to maintain or improve functional status, diagnoses and specific target symptoms or behaviors must be documented, and the effectiveness of drug therapy must be monitored. Resident #23: (R23) Review of a Face Sheet for R23 revealed she was admitted to the facility on [DATE] with pertinent diagnoses of dementia, adjustment disorder, depression, anxiety, stroke, chronic pain, and disorientation. A review of R23's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/14/24, revealed .Section E: Behaviors: Hallucinations and delusions .B. Symptoms: Physical, Verbal, and Other .Not exhibited . 1. Review of Order dated 6/24/24, revealed, .PRN .Lorazepam Tablet 0.5 MG .Give 1 tablet by mouth every 6 hours as needed for Anxiety, agitation, restlessness, delusions .D/C Date: 8/10/24 . Review of Medication Administration Record (MAR) for June revealed, no administration of PRN Lorazepam Tablet 0.5 MG . Review of Medication Administration Record (MAR) for August revealed R23 received the ordered Lorazepam on .8/1/24 at 6:09 PM, 8/4/24 at 1:18 PM . Review of medical record revealed no behaviors or agitation noted for administered date to indicate use of PRN medication. Review of Order dated 8/10/24, revealed, .PRN .Lorazepam Tablet 0.5 MG .Give 1 tablet by mouth every 6 hours as needed for Anxiety, agitation, restlessness, delusions for 30 days . Review of Medication Administration Record (MAR) for August revealed R23 received the ordered Lorazepam .8/10/24 at 11:47 PM, 8/22/24 at 7:05 PM, and 8/26/24 at 3:50 PM . Review of medical record revealed no behaviors or agitation noted for administered date to indicate use of PRN medication. Review of Pharmacy Medication Reviews dated 8/12/24, revealed, .Patient continues with Ativan PRN. Medication last used 8/11/24, dose was effective . 2. Review of Order Note dated 6/24/24, revealed, .Haloperidol Lactate Concentrate 2 MG//ML .Give 0.5 milliliter by mouth every 4 hours a needed for agitation, restlessness, paranoia, hallucinations, delusions for 30 days . Review of Medication Administration Record (MAR) for August revealed R23 received the ordered Haloperidol on, .8/26/24 at 7:33 PM, 8/27/24 at 4:20 PM, and 8/30/24 at 3:39 PM . Review of medical record revealed no behaviors or agitation noted for administered date to indicate use of PRN medication. Review of Order dated 9/25/24 revealed, .Haloperidol Lactate Oral Concentrate 2 MG/ML (Haloperidol Lactate) .Give 0.5 ml by mouth every 4 hours as needed for agitation, restlessness, paranoia, hallucinations for 30 Days .D/C Date10/16/2024 1038 . Review of Medication Administration Record (MAR) for September revealed R23 received the ordered Haloperidol on, 9/27/24 at 11:04 AM . Review of record revealed no behaviors or agitation noted for administered date to indicate use of PRN medication. Review of Medication Administration Record (MAR) for October revealed, no PRN administered in October 24. Review of Pharmacy Medication Reviews dated 10/15/24, revealed, .Medications reviewed and are appropriate to needs based on function and diagnoses. (Resident #23) is now on hospice. Patient continues with Ativan PRN. Medication last used 10/14/24, dose was effective. Medication remains appropriate for hospice/end of life comfort care. Haloperidol PRN started, last used 9/27, dose was ineffective. Will continue to monitor PRNS for use and effectiveness . 3. Review of Order dated 7/25/24 revealed, .PRN (As Needed) ABH (Ativan, Bandryl, Haldol) .Apply to carotid topically every 4 hours as needed for Agitation, restlessness, psychosis symptoms for 15 days .1mg/25mg/1mg cream .Apply 1 ML topically to skin over carotid artery Note: No discontinue date. Review of Medication Administration Record (MAR) for August 24 revealed .PRN (As Needed) ABH (Ativan, Bandryl, Haldol) .on 8/4/24 and 8/5/24 medication was dispensed at 1:27 PM and 7:27 PM . Review of medical record revealed no behaviors or agitation noted for administered dates to indicate use of PRN medication. Review of Pharmacy Medication Reviews dated 8/12/24, revealed, .(Resident #23) continues on scheduled ABH gel, PRN dosing not renewed .No recommendation at this time . Review of Order dated 8/13/24 revealed, .PRN (As Needed) ABH (Ativan, Bandryl, Haldol) .Apply to carotid topically every 4 hours as needed for Agitation, restlessness, delusions Apply 1 ML Per (Nurse Practitioner NN) .DC dated: 8/29/24 . Review of Medication Administration Record (MAR) for August revealed no administration of PRN ABH gel for R23 following new order dated 8/13/24 until discontinued on 8/29/24. Review of N Adv -Long Term Care Evaluation (MDS Quarterly Evaluation Assessment) dated 8/28/24 at 12:54 PM, revealed, .Mood and Behavior: Mood is pleasant, no unwanted behaviors witnessed . Review of medical record revealed no behaviors or agitation noted for administered dates to indicate use of PRN medication. Review of Order dated 8/29/24, revealed, .PRN (As Needed) ABH (Ativan, Bandryl, Haldol) .Apply to carotid topically every 4 hours as needed for Agitation, restlessness, delusions Apply 1 ML Per (Nurse Practitioner NN) .D/C Date-11/20/2024 1148 . Review of MAR's for August, September, October, and November 2024 revealed the PRN ABH cream was applied on 9/8, 9/13, 9/14, 10/20, 10/29, 11/14, and 11/19/24. Review of medical record revealed no behaviors or agitation noted for administered dates to indicate use of PRN medication. 4. Review of Order dated 9/25/24, revealed, .Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety, agitation for 30 days . Review of Order Note 9/25/2024 at 1:42 PM, revealed, .The system has identified a black box warning for the following order: Ativan Oral Tablet 0.5 MG (Lorazepam)*Controlled Drug* .Give 1 tablet by mouth every 6 hours as needed for anxiety, agitation for 30 Days .Black Box Warning: Warning: <i>Risks from concomitant use with opioids</i>Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs for patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required . Review of Medication Administration Record (MAR) for September revealed R23 received the ordered Ativan on .9/25/24 at 1:30 PM and 09/27/24 at 11:45 AM . Review of Medication Administration Record (MAR) for October revealed R23 received the ordered Ativan on, 10/4 at 3:57 PM, 10/10 at 1:12 PM, and 10/14 at 7:12 PM . Review of record revealed no behaviors or agitation noted for administered dated to indicate use of PRN medication. Review of Hospice Visit Note dated 9/26/2024 at 10:15 AM, .94y/o admitted with cerebrovascular disease .Staff report an increase in her sleep and report her speech is more nonsensical this cert period .Spoke with facility nurse who reports patient has been lethargic today and has not taken her morning medications yet. She reports she is planning to try again soon .Patient sitting up in wheelchair in common area. RN brought patient back to her room for assessment. She was initially lethargic and difficult to arouse but throughout visit she became more alert and was staying awake. Patient is unable to answer most questions but she was able to state her birth month. Her speech is delayed, slurred and slow .RN brought patient back to the common area where staff are doing an activity .Declines: increased lethargy, decreased appetite, 4lb weight loss, requires frequent cueing at meals and activities .Interventions: collaboration with facility staff regarding care needs .Goals: maintain safety and comfort .Frequency: once weekly and PRN . Review of Hospice Visit Note dated 10/9/2024 at 2:48 PM, revealed, .Spoke with facility nurse (LPN Y) prior to visit, she declines immediate needs .Upon arrival to patient room she is alert and laying in bed, she appears calm and comfortable. Patient is mostly cooperative with assessment, she does tense her arm while this RN is applying BP cuff but does allow RN to check BP. Patient spoke a few words, often not appropriate to the context of the conversation and her speech is slurred and delayed .Patient remains alert throughout visit, she declines getting out of bed when asked. No additional needs noted . Requested behavior documentation and rational for continued use of PRN medications for R23. No documentation to support continued use was received prior to exit. Review of N Adv - Long Term Care Evaluation (MDS Quarterly review) dated, 11/11/2024 at 11:09 AM, revealed, .Lookback: Reason for evaluation: Other .Mood and Behavior: Mood is pleasant, no unwanted behaviors witnessed . Review of Behavior documentation retrieved on 11/20/24 for the previous 30 days revealed, no documented behaviors or agitation for R23. Resident #23 was observed from 11/20/24 to 11/22/24 with no behaviors or agitation noted. In an interview on 11/22/24 at 11:21 AM, Social Service Coordinator (SSC) K reported she was questioning why the facility, pharmacist, and hospice had decided to keep the ABH cream for the resident and she was informed the medication met the therapeutic effects to address R23's behaviors and other medications had been tried in the past prior to her appointment at the facility. This writer attempted to interview the facility pharmacist on 11/22/24 but was unable to speak with them prior to exit. In an interview on 11/22/24 at 12:04 PM, Hospice RN P reported hospice had done a lot of trail or error for R23. Hospice RN P reported she took over her case in August 24 and prior they had tried many doses and frequencies, different medications, such as the ABH gel and Haldol. Hospice RN P reported she had psychosis, delusions, and agitation noted on the nursing note and that was why the decision was made to start the routine ABH gel. Hospice RN P reported the hospice communicated with the providers at the facility and the providers at the facility would write the orders for the medications. Hospice RN P reported it is up to the discretion of the provider who renewed the prescription and if it is utilized and the provider/facility were the ones who drove the continued use of the medications. Hospice RN P reported the consents were driven by starting new or change the dose. She reported the hospice agency would obtain verbal consent from family for the medication consents. Hospice RN P reviewed the hospice records for R23 and noted there were no consents given for the lorazepam and Haldol that she could find. Review of the medical record revealed no documentation of a consent, informed consent or a signed consent for Resident #23's PRN Lorazepam orders, PRN ABH cream orders, PRN Ativan order, or PRN Haldol order. In an interview on 11/22/24 at 01:34 PM, Director of Nursing (DON) B reported the facility would write the orders per the recommendations from hospice. Review of policy, Use of Psychotropic Drugs revised on 5/8/24, revealed, .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) .9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) .12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's- monthly medication regimen review, c. During MDS review (quarterly, annually, significant change), and d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care .13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . Review of PRN Medications revised on 5/8/24, revealed, .PRN medication refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness .Indications for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or current evidence-based practices or standards. Policy Explanation and Compliance Guidelines: 1. Documentation will be provided in the resident's medical record to show adequate indications for a medication's use and the diagnosed condition for which it was prescribed .3. When administering a PRN medication: a. Verify physician's order for the medication .b. Document the reason voiced by the resident and/or assessment findings that show why the resident needs the medication. Verify the reason is for the prescribed indication for the medication . 48637 Resident #27(R27) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R27 admitted to the facility on [DATE] with diagnoses including dementia, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R27 was moderately cognitively impaired (8-12 is moderate cognitive impairment). R27 signed onto Hospice on 9/7/2022. Review of R27's Physician Orders revealed the following: Lorazepam Tablet 0.5 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for anxiety, agitation, restlessness or combative behaviors for 30 Days. It was started on 7/5/2024 and was completed on 8/3/2024. Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 4 hours as needed for anxiety, agitation, restlessness or combative behaviors for 30 Days. It was started on 6/13/2024 and was completed on 7/5/2024. Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for anxiety, agitation or restlessness for 30 Days. It was started on 4/23/2024 and was completed on 5/23/2024. Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for anxiety, agitation or combative behaviors for 30 Days. It was started on 3/12/2024 and was completed on 4/11/2024. Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for anxiety, agitation and combative behaviors with bathing cares until 2/18/2024. It was started on 1/18/2024 and was completed on 2/18/2024. Review of R27's Medication Administration Record (MAR) from January 2024 to April 2024 revealed that R27 took PRN (as needed) lorazepam 9 times. Review of R27's MAR from May 2024 to November 2024 revealed R22 took PRN lorazepam 1 time. Review of the Pharmacist Note to Attending Physician/Prescriber dated 1/12/2024 revealed (resident name omitted- R27) is currently receiving a PRN order for the psychotropic medication Ativan. This medication is required by facility policy to be written for a 14 day supply when ordered for PRN use. Orders for this medication may be extended beyond the 14 days if the attending physician or prescribing practitioner believes it to be appropriate. The attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration on the prescription (F757/F758). Resident is currently on Hospice. Ativan PRN started on 1/5/2024 . The Physician/Prescriber Response was not filled out and signed by the provider. Review of R27's chart from January 2024 to July 2024 revealed that there was no documentation for the rationale for continued use of PRN lorazepam for greater than 14 days. During an interview on 11/22/2024 at 8:41 AM, Licensed Practical Nurse (LPN) Y reported that R27 has been on PRN lorazepam for a while and it was just discontinued on 11/21/2024 since R27 wasn't using it often. LPN Y stated that the Hospice nurse or facility Physician monitors PRN psychotropic medications. During an interview on 11/22/2024 at 10:43 AM, Director of Nursing (DON) B reported that a Psychoactive Medication Consent is given in the admission packet to each resident to consent or not consent to the use of psychotropic drugs. DON B stated that when a resident is on Hospice, Hospice obtains consents for new psychotropic medications and talks to the family. During an interview on 11/22/2024 at 11:58 AM, Hospice Registered Nurse (RN) P reported that the facility oversees resident medications. RN P stated that Hospice gets verbal consents from family for new psychotropic medications and a progress note should be put in the resident chart. She was unable to locate a consent or progress note regarding PRN lorazepam. Hospice RN P said that Hospice gets orders from the facility providers. During an interview on 11/22/2024 at 10:49 AM, Pharmacist O stated that PRN psychotropics duration should not be longer than 14 days. Pharmacist O reported that lorazepam PRN should only be written for 14 days but this can be extended with a rationale for the extension and must be documented by the provider with a new order. Pharmacist O stated that he has to remind Hospice and facility Providers that PRN psychotropics can't be written for more than 14 days at a time per regulations.

Based on observation, interview and record review, the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 resident (Resident #22) of 1 resident reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Resident #22 (R22) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R22 admitted to the facility on [DATE] with diagnoses including PTSD, depression, bipolar disorder (mood swings ranging from depressive lows to manic highs, chronic respiratory failure and Takotsubo Syndrome (sudden temporary weakening of the muscular portion of the heart which appears after a significant stressor, either physical or emotional). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R22 was cognitively intact (13 to 15 cognitively intact). During an observation and interview on [DATE] in the afternoon, R22 was walking with her walker down the hall and appeared agitated (heavy breathing, fidgeting and uneasiness) after riding the exercise bike in the therapy room. R22 went into her room and reported that she was worried about getting COVID since she already had respiratory issues. R22 continued to discuss how many of her family members had passed away over the years. Review of R22's psychiatric periodic evaluation dated [DATE] revealed Family history father deceased at age 38 secondary to pedestrian hit by a train. Mother deceased at age 63 of facial cancer with metastasis. One sister living and with history of lung cancer history. Hx (history) of addiction in the family heavy alcohol and tobacco use. Review of R22's chart revealed there was not an assessment for PTSD that identified specific triggers of her PTSD or any mention of trauma or trauma triggers with interventions on the care plan. Review of R22's chart revealed no task for mood/behavior with interventions related to triggers. During an interview on [DATE] at 1:47 PM, Certified Nursing Assistant (CNA) II stated that R22 told her a little bit of her past but she didn't know too many details about triggers that can cause her distress. During an interview on [DATE] at 8:39 AM, Licensed Practical Nurse (LPN) Y stated that R22 doesn't like anything out of her normal routine since it makes her anxious. LPN Y stated that she knows some of R22's past but as far as triggers, she isn't aware of triggers that can cause her distress. During an interview on [DATE] at 2:06 PM, Assistant Director of Nursing (ADON) C stated that she wasn't sure about a PTSD assessment or care plan related to PTSD for R22. During an interview on [DATE] at 3:36 PM, Nursing Home Administrator A reported that the Social Worker acknowledged that a PTSD care plan was missing for R22. According to, National Alliance on Mental Illness (NAMI) Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur after someone experiences a traumatic event that caused intense fear, helplessness, or horror. PTSD can result from personally experienced traumas (e.g., rape, war, natural disasters, abuse, serious accidents, and captivity) or from the witnessing or learning of a violent or tragic event .While it is common to experience a brief state of anxiety or depression after such occurrences, people with PTSD continually re-experience the traumatic event; avoid individuals, thoughts, or situations associated with the event; and have symptoms of excessive emotions. People with this disorder have these symptoms for longer than one month and cannot function as well as they did before the traumatic event. PTSD symptoms usually appear within three months of the traumatic experience; however, they sometimes occur months or even years later . https://namimi.org/mental-illness/ptsd

Based on interview and record review, the facility failed to offer and provide the pneumococcal vaccine for 5 (Resident #6, #11, #14, #41, and #44) of 5 residents reviewed for immunizations, resulting in a delay in the residents to be given the opportunity to receive or decline the pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults [AGE] years and Older dated 02/09/23, revealed, .Routine vaccination: Adults [AGE] years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-PCV20-508.pdf Resident #6: Review of an Admission Record revealed Resident #6 was a female with pertinent diagnoses which included pressure ulcer of sacral region (above the tailbone), adult failure to thrive, anemia, dementia, kidney failure, severe sepsis (life threatening complication of infection), dysphagia (damage to the brain responsible for production and comprehension of speech), encephalopathy (brain disease that alters brain function or structure), heart failure, and C-diff (inflammation in the colon caused by bacteria). Review of Immunization report dated 1/11/24, revealed, PPSV23 .Date Given: 9/5/2017 .PCV13 .Date Given: 10/24/2016 . No documentation of the PCV20 offered or provided to this resident. Review of Immunization Informed Consent Record updated on 10/6/23 and signed on 11/15/23, revealed, the resident was not offered the PCV20 vaccine as it had been over 5 years since the last pneumonia vaccine. Resident #11: Review of an Admission Record revealed Resident #11 was a female with pertinent diagnoses which included heart failure, muscular dystrophy (genetic condition that causes progressive muscle weakness and wasting), cardiac pacemaker, diabetes, mild cognitive impairment (person has more memory or thinking problems that other people of their age), cellulitis (potentially serious bacterial infection in the deeper layers of the skin), and heart attack. Review of Immunization report dated 1/11/24, revealed, PPSV23 .Date Given: 10/14/2014 .PCV13 .Date Given: 10/8/2017 . No documentation of the PCV20 offered or provided to this resident. Review of Immunization Informed Consent Record updated on 10/6/23 and signed on 10/4/23, revealed, the resident was not offered the PCV20 vaccine as it had been over 5 years since the last pneumonia vaccine. Resident #14: Review of an Admission Record revealed Resident #14 was a female with pertinent diagnoses which included heart disease, Alzheimer's disease diabetes, vascular disease, kidney disease, cardiac pacemaker, sick sinus syndrome (heart rhythm disorder), and COPD. Review of Immunization report dated 1/11/24, revealed, PPSV23 .Date Given: 6/27/12 .PCV13 .Date Given: 3/15/2017 . No documentation of the PCV20 offered or provided to this resident. Review of Immunization Informed Consent Record updated on 10/6/23 and signed on 10/4/23, revealed, the resident was not offered the PCV20 vaccine as it had been over 5 years since the last pneumonia vaccine. Resident #41: Review of an Admission Record revealed Resident #41 was a female with pertinent diagnoses which included Parkinson's disease, endometrial cancer with metastasis to right hip and femur, dementia, and high blood pressure. Review of Immunization report dated 1/11/24, revealed, PPSV23 .Date Given: 2/5/2019 .PCV13 .Date Given: 8/24/2017 . No documentation of the PCV20 offered or provided to this resident. Review of Immunization Informed Consent Record updated on 10/6/23 and signed on 10/23/23, revealed, the resident was not offered the PCV20 vaccine as it had been over 5 years since the last pneumonia vaccine. Resident #44: Review of an Admission Record revealed Resident #44 was a female with pertinent diagnoses which included Alzheimer's disease, dementia, rheumatoid arthritis (chronic inflammatory disorder affecting many joints and organs), adult failure to thrive, prediabetes, and spinal stenosis. Review of Immunization report dated 1/11/24, revealed, PPSV23 .Date Given: 3/21/2014 .PCV13 .Date Given: 10/4/2016 . No documentation of the PCV20 offered or provided to this resident. Review of Immunization Informed Consent Record updated on 10/6/23 and signed on 10/15/23, revealed, the resident was not offered the PCV20 vaccine as it had been over 5 years since the last pneumonia vaccine. In an interview on 01/11/24 at 10:44 AM, Infection Preventionist (IFP) S reported she had been in the position since November 23. IFP S reported she had done an audit to see who needed the COVID, Flu and RSV vaccines and the facility reached out to residents and DPOAs to obtain consent, obtained physician orders and provided those vaccinations over a few days period of time to those residents who needed them. When queried on the pneumonia vaccinations, IFP S reported the additional pneumonia vaccinations was something she was working on with the physician for those residents who were eligible and would require the vaccine. Review of the policy, Pneumococcal Vaccine (Series) revised on 1/9/24, revealed, .6. The type of pneumococcal vaccine (PCV 15, PCV20, or PPSV23) offered will depend upon the resident's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations .8. Pneumococcal vaccines are recommended for adults aged >[AGE] years and based on presence or absences of underlying conditions .

Based on observation, interview, and record review the facility failed to implement infection control standards for storage of respiratory care equipment for 2 of 8 residents (Resident #36, #198), reviewed for infection control practice, resulting in the potential for the spread of disease, increase the risk of infection and bacterial harborage. Findings include: Resident #36: Review of an Admission Record revealed Resident #36 was a female with pertinent diagnoses which included dementia, anxiety, respiratory failure, impaired coordination, neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), arthritis, aspiration pneumonia, achalasia of cardia (rare swallowing disorder), abnormal movements, and sleep apnea. Review of current Care Plan for Resident #36, revised on 10/19/23, revealed the focus, .(Resident #36) has oxygen therapy r/t (related to) CHF (congestive heart failure) . with the intervention .OXYGEN SETTINGS: O2 via nasal prongs/mask @ 2-4L PRN (as needed) . Review of Orders dated 10/22/23, revealed, .Oxygen Tubing - change weekly and date q (every) sunday every night shift every Sun for oxygen use . During an observation on 01/09/24 at 01:27 PM, Resident #36 was observed in her room seated in her wheelchair with her tray table in front of her as she was reading a book. There was an oxygen tank on the back of her wheelchair. Observed curled up oxygen tubing and oxygen mask on the night stand next to her bed. The oxygen mask was not on a protective barrier, bin, or plastic bag. Upon inspection of the oxygen tubing, it was dated 10/23/23. Resident #36 reported she uses the oxygen when she needs it. During an observation on 01/10/24 at 09:37 AM, Resident #36 was observed seated in her wheelchair with her table in front of her. The oxygen tubing and mask directly on the nightstand curled up with no protective barrier, bin, or plastic bag and dated 10/23/23. During an observation on 01/10/23 at 11:53 AM, Resident #36 was seated in her recliner and the oxygen tubing and mask were curled up on the nightstand with the mask and oxygen tubing directly on the night stand next to the head of her bed with no protective barrier, bin or plastic bag. The oxygen tubing was dated 10/23/23. During an observation on 01/10/24 at 01:07 PM, CNA EE was exiting Resident #36's room, and the oxygen tubing and mask were in the same place as previous observations undisturbed. During an observation on 01/11/24 at 11:53 AM, Resident #36's oxygen tubing and mask were observed on her night stand next to her bed, it was dated 10/23/23 and there was not on a protective barrier, bin, or placed in a plastic bag for infection control. Resident #198: Review of an Admission Record revealed Resident #198 was a female with pertinent diagnoses which included fracture of femoral neck right femur, hemiplegia (paralysis) and hemiparesis (weakness) of left side following stroke, diabetes, history of falling. impairment of right upper extremity, and use of blood thinners. Review of Care Plan revised on 1/7/24, revealed the focus, .CPAP / BiPAP Therapy Obstructive Sleep Apnea with the intervention .Encourage Resident's use of CPAP/BiPAP . Review of Orders dated 1/2/24, revealed, .CI-Pap: Assist and Apply ci-pap with home setting; on HS (at night) and off in am every shift . Note: No order to clean or how to store equipment. During an observation on 01/09/24 at 11:44 AM, Resident #198 was observed seated in her wheelchair at the foot of her bed on the left side. On the nightstand on the right side of the bed, R#198's CPAP mask was observed placed on top of the CPAP machine without a protective barrier, bin, or in a plastic bag for infection control. During an observation on 01/10/24 at 10:09 AM, Resident #198's CPAP machine was on the nightstand with the mask placed on top of it without a protective barrier, plastic bag or bin for infection control. During an observation on 01/11/24 at 11:54 AM, Resident #198's CPAP machine was observed on the windowsill in her new room with the CPAP mask placed behind it next to the window without a protective barrier, bin, or placed in a plastic bag for infection control. In an interview on 01/10/24 at 01:01 PM, Licensed Practical Nurse (LPN) CCC reported for the CPAP machines and masks, the nurses would take them apart and place them on a barrier to dry, once dry put them back together, place in a plastic bag and let them hang on the hook on the nightstand. In an interview on 01/11/24 at 11:00 AM, Infection Preventionist R reported there would be a task order for the nurses to care for the CPAP, such as to clean and ensure it was dried. Infection Preventionist R reported she was unsure if the nurses were performing cleaning of the CPAP machines and equipment, and she would need to check and see if it had taken place.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 2 of 13 residents (Resident #14 & #36) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Oxygen Administration, dated 12/1/23, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . Resident #14 Review of an Admission Record revealed Resident #14 was a female, with pertinent diagnoses which included obstructive lung disease, diabetes, shortness of breath, and chronic bronchitis. Review of an Order Summary Report for Resident #14 revealed the active physician order .Res (Resident) on continuous 2L (2 Liter) oxygen flow via nasal cannula . with a start date of 7/2/23. Review of an Order Summary Report for Resident #14 revealed the active physician order to .Change (oxygen) tubing once weekly every Sunday at bedtime .change and date tubing . with a start date of 7/2/23. Review of a current Care Plan for Resident #14 revealed the focus .(Resident #14) has diagnoses of COPD (Chronic Obstructive Lung Disease), chronic bronchitis, ischemic cardiomyopathy, personal history of nicotine dependence (former smoker), CAD (Coronary Artery Disease) . with interventions which included .Oxygen therapy as ordered; including changing tubing once weekly on Sunday and prn (as needed) . both initiated 7/2/23. In an observation on 1/10/24 at 9:52 AM, observed Resident #14 in bed in her room, with oxygen tubing in place administered via nasal cannula. Noted the tubing, and the bag hanging from the concentrator (to store the tubing when not in use), were both dated 12/11/23 (more than four weeks ago). Review of the Treatment Administration Record (TAR) for Resident #14, dated December 2023, revealed the order .Change (oxygen) tubing once weekly every Sunday at bedtime .change and date tubing . was initialed as completed on 12/17/23, 12/24/23, and 12/31/23. Note the tubing observed in Resident #14's room was dated 12/11/23. Review of the TAR for Resident #14, dated January 2024, revealed the order .Change (oxygen) tubing once weekly every Sunday at bedtime .change and date tubing . was initialed as completed on 1/7/24. Note the tubing observed in Resident #14's room was dated 12/11/23. In an interview on 1/11/24 at 3:29 PM, Director of Nursing (DON) B reported oxygen tubing should be changed once a week and documented in the treatment record. 41424 Resident #36: Review of an Admission Record revealed Resident #36 was a female with pertinent diagnoses which included dementia, anxiety, respiratory failure, impaired coordination, neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), arthritis, aspiration pneumonia, achalasia of cardia (rare swallowing disorder), abnormal movements, and sleep apnea. Review of current Care Plan for Resident #36, revised on 10/19/23, revealed the focus, .(Resident #36) has oxygen therapy r/t (related to) CHF (congestive heart failure) . with the intervention .OXYGEN SETTINGS: O2 via nasal prongs/mask @ 2-4L PRN (as needed) . Review of Orders dated 10/22/23, revealed, .Oxygen Tubing - change weekly and date q (every)sunday every night shift every Sun for oxygen use . Review of Treatment Administration Record (TAR) for November 2023, revealed, .Oxygen Tubing - change weekly and date q sunday every night shift every Sun for oxygen use .Start Date: 10/22/23 at 6:00 PM . was initialed as completed on 11/5/23, 11/12/23, 11/19/23, and 11/26/23. Note the tubing observed in Resident #36's room was dated 10/23/23. Review of Treatment Administration Record (TAR) for December 2023, revealed, .Oxygen Tubing - change weekly and date q sunday every night shift every Sun for oxygen use .Start Date: 10/22/23 at 6:00 PM . was initialed as completed on 12/3/23, 12/10/23, 12/17/23, 12/24/23, and 12/31/23. Note the tubing observed in Resident #36's room was dated 10/23/23. Review of Treatment Administration Record (TAR) for January 2024, revealed, .Oxygen Tubing - change weekly and date q sunday every night shift every Sun for oxygen use .Start Date: 10/22/23 at 6:00 PM . was initialed as completed on 1/7/24. Note the tubing observed in Resident #36's room was dated 10/23/23. During an observation on 01/09/24 at 01:27 PM, Resident #36 was observed in her room seated in her wheelchair with her tray table in front of her as she was reading a book. There was an oxygen tank on the back of her wheelchair. Observed curled up oxygen tubing and oxygen mask on the night stand next to her bed. The oxygen mask was not on a protective barrier, bin, or plastic bag. Upon inspection of the oxygen tubing, it was dated 10/23/23. Resident #36 reported she uses the oxygen when she needs it. During an observation on 01/10/24 at 09:37 AM, Resident #36 was observed seated in her wheelchair with her table in front of her. The oxygen tubing and mask directly on the night stand curled up with no protective barrier, bin, or plastic bag and dated 10/23/23. During an observation on 01/10/23 at 11:53 AM, Resident #36 was seated in her recliner and the oxygen tubing and mask were curled up on the night stand with the mask and oxygen tubing directly on the night stand next to the head of her bed with no protective barrier, bin or plastic bag. The oxygen tubing was dated 10/23/23. During an observation on 01/10/24 at 01:07 PM, CNA EE was exiting Resident #36's room and the oxygen tubing and mask were in the same place as previous observations undisturbed. During an observation on 01/11/24 at 11:53 AM, Resident #36's oxygen tubing and mask were observed on her night stand next to her bed, it was dated 10/23/23 and was not on a protective barrier, bin, or placed in a plastic bag for infection control. In an interview on 01/11/24 at 11:01 AM, Infection Preventionist (IFP) R reported there was a reminder on the tasks list for the nurses to change the tubing weekly and this was documented in the administration record. IFP R reported there would be an order for this task to be completed.

Based on observation, interview, and record review the facility failed to develop and implement person centered dementia care interventions to address wandering, disorientation, and reassurance for 1 of 13 residents (Resident #8) reviewed for dementia care, resulting in Resident #8 experiencing worsening wandering, disorientation to his room, verbal aggression from another resident, and emotional distress. Findings include: Review of an Admission Record dated 6/29/23 revealed Resident #8 was admitted to the facility with the following pertinent diagnoses: dementia (a condition characterized by progressive or persistent loss of intellectual functioning), posterior subcapsular cataract (eye condition causing difficulty reading and reduced vision in brightly light areas), and depression. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored 5/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Section GG of the MDS revealed Resident #8 ambulated 150' with a wheeled walker and required supervision or touching assistance to do so safely. Review of a Care Plan for Resident #8 dated 1/3/24 revealed focus/goal/interventions as follows: Focus: (Resident #8) is an elopement risk d/t history of wandering and expressing desire to leave the facility unattended, Goal: (Resident #8's) safety will be maintained through next review date. Interventions: distract (Resident #8) from wandering by offering pleasant diversions, structured activities, food, conversation, television. Identify pattern of wandering, is it purposeful, aimless, or escapist? Intervene as appropriate. No focus/goal/interventions related to wandering were present prior to 1/3/24. The care plan did not reflect the importance of maintaining the familiar arrangement of his room, his need for large print/his visual deficits, triggers for wandering, or techniques for reassurance and redirection, or his use of a wander guard bracelet for safety. During an observation on 1/9/24 a 1:29pm, Resident #8's room was brightly light with daylight coming from a large window opposite the door. The room had few personal belongings visible from the hallway, only 2 small family pictures were present, and due to the size of the pictures and the back light from the window, were difficult to see. A large print welcome sign with Resident's name on it was posted on the door at a height greater than 5', and Resident #8's name was on a placard to the right of door with a print size of about 1/4 . During an observation on 1/9/24 at 1:33pm, Resident #8 ambulated around his room without his wheeled walker and walked into his bathroom. During an observation on 1/9/24 at 2:17pm, Resident #8 walked out of his room alone without his wheeled walker, approached the surveyor and reported he was looking for his wife. Resident #8 appeared tearful and stated, I think my wife left me and I love her so much. Resident #8 stood in the hallway unattended for several minutes. During an observation on 1/10/24 at 1:01pm, Resident #8 donned a coat then walked from his room into the hallway using 1 hand on his wheeled walker, his posture flexed, which caused a 24 gap between his body and the frame of the walker. Resident #8 stood in the hallway for 30 seconds, turned around, still with only 1 hand on the walker, posture flexed with the walker away from his body, and returned to his room. During an interview on 1/10/24 at 12:57pm, Family Member (FM) AA reported Resident #8 was a very quiet man who relied on her for day-to-day direction prior to him being admitted to the facility. FM AA reported she visited Resident #8 every day in the afternoon, and he was always very happy to see her. FM AA reported the Resident #8 had a vision impairment that limited his ability to read. In an interview on 1/10/24 at 1:12pm, Certified Nursing Assistant (CENA) G reported Resident #8 regularly went into other resident's rooms when unsupervised and at times became upset when staff arrived and attempted to redirect him. CENA G reported Resident #8's care plan did not provide interventions for staff to follow related to Resident #8 going into other resident's rooms, and only a few interventions regarding his wandering that were recently added. CENA G reported she had learned a lot about Resident #8 by talking with him and that he often worried about his wife, but his anxiety was reduced when he was reassured about his wife's location and their marriage. In an interview on 1/11/23 at 12:44pm, Activity Assistant (AA) E reported Resident #8 enjoyed physical games, large print word search puzzles, music activities, watching football and visiting. In an interview on 1/10/24 at 3:14pm, Social Services Coordinator (SSC) S reported Resident #8 had been walking unsupervised and going into other resident's rooms, and the frequency of him doing so had had recently increased. When queried about interventions for these behaviors, SSC S initially responded by saying he (Resident #8) is on two medications. SSC S reported Resident #8 had more difficulty recognizing his room after his furniture was rearranged and that the staff recently put the furniture back in its original location. SSC was also trialing the use of an emotional support robotic cat in his room to reduce Resident #8's wandering. SSC reported Resident #8 frequently worried that about his wife and forget that his wife and other family members visited him. SSC S reported she was aware of at least one occasion when another resident yelled at Resident #8 and shook an object in his face in effort to get him out of their room. When queried if another resident yelling at Resident #8 might cause him to respond aggressively, SSC S stated He's a pretty [NAME] guy, but everyone has their breaking point. In an interview on 1/11/24 at 10:5am Certified Nursing Assistant (CENA) J reported she had witnessed Resident #8 repeatedly going into other resident's rooms and lying in their beds. CENA J reported Resident #8 was a very kind person but frequently said he was missing his wife and seemed to be looking for her, especially later in the day. CENA J reported at least 1 resident was upset that Resident #8 came into her room and that resident yelled at him. Review of a Behavior Note for Resident #8 dated 9/12/23 revealed a statement: Resident observed by this nurse using the bathroom facilities in another resident room. Review of a Behavior Note for Resident #8 dated 10/23/23 revealed a statement: Resident observed walking down the hallway with walker, shoes on wrong feet, jacket on and looking for his wife. He states that he seen (sic) her care outside his window and needed to go get her. Review of a Behavior Note for Resident #8 dated 10/29/23 revealed a statement: Resident observed using poor safety awareness, walking around hallways with no walker or staff assist. Physician and ADON (Assisted Director of Nursing) notified. Review of a Behavior Note for Resident #8 dated 12/10/23 revealed a statement: Resident out wondering (sic) the hallway near his room, observed poor safety awareness . Review of a Behavior Note for Resident #8 dated 12/29/23 revealed a statement: Resident observed using strong toned voice towards another resident's family member .resident also observed frequently wandering up and down the halls looking for his wife .physician assistant aware. Review of a Behavior Note for Resident #8 dated 12/29/23 revealed a statement: Pt (patient) voicing that another patient is his wife and kept going into room. Behavior: agitation, anxiety, screaming. Review of a Behavior Note for Resident #8 dated 12/29/23 revealed a statement: Resident observed at 1900 (7:00pm) intruding into the room of another male resident. Resident refused to leave the room for any reason . Review of a facility policy titled Dementia Care dated 12/1/23, revealed the following statements: The care plan interventions will be related to each resident's individual symptomology and rate of dementia progression .interventions will be monitored on an ongoing basis .and revised for effectiveness .the environment will be modified to accommodate individual resident care needs . Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .the resident's care plan must be reviewed after each assessment .and revised based on changing goals, preferences and needs of the resident and in response to current interventions .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan .

Based on observation, interview, and record review, the facility failed to maintain and change oxygen tubing per physician order in 2 of 3 residents (Resident #14 & #36) reviewed for respiratory care, resulting in the potential for the development and spread of respiratory illness. Findings include: Review of the policy/procedure Oxygen Administration, dated 12/1/23, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . Resident #14 Review of an Admission Record revealed Resident #14 was a female, with pertinent diagnoses which included obstructive lung disease, diabetes, shortness of breath, and chronic bronchitis. Review of an Order Summary Report for Resident #14 revealed the active physician order .Res (Resident) on continuous 2L (2 Liter) oxygen flow via nasal cannula . with a start date of 7/2/23. Review of an Order Summary Report for Resident #14 revealed the active physician order to .Change (oxygen) tubing once weekly every Sunday at bedtime .change and date tubing . with a start date of 7/2/23. Review of a current Care Plan for Resident #14 revealed the focus .(Resident #14) has diagnoses of COPD (Chronic Obstructive Lung Disease), chronic bronchitis, ischemic cardiomyopathy, personal history of nicotine dependence (former smoker), CAD (Coronary Artery Disease) . with interventions which included .Oxygen therapy as ordered; including changing tubing once weekly on Sunday and prn (as needed) . both initiated 7/2/23. In an observation on 1/10/24 at 9:52 AM, observed Resident #14 in bed in her room, with oxygen tubing in place administered via nasal cannula. Noted the tubing, and the bag hanging from the concentrator (to store the tubing when not in use), were both dated 12/11/23 (more than four weeks ago). In an interview on 1/11/24 at 3:29 PM, Director of Nursing (DON) B reported oxygen tubing should be changed once a week and documented in the treatment record. 41424 Resident #36: Review of an Admission Record revealed Resident #36 was a female with pertinent diagnoses which included dementia, anxiety, respiratory failure, impaired coordination, neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), arthritis, aspiration pneumonia, achalasia of cardia (rare swallowing disorder), abnormal movements, and sleep apnea. Review of current Care Plan for Resident #36, revised on 10/19/23, revealed the focus, .(Resident #36) has oxygen therapy r/t (related to) CHF (congestive heart failure) . with the intervention .OXYGEN SETTINGS: O2 via nasal prongs/mask @ 2-4L PRN (as needed) . Review of Orders dated 10/22/23, revealed, .Oxygen Tubing - change weekly and date q (every)sunday every night shift every Sun for oxygen use . During an observation on 01/09/24 at 01:27 PM, Resident #36 was observed in her room seated in her wheelchair with her tray table in front of her as she was reading a book. There was an oxygen tank on the back of her wheelchair. Observed curled up oxygen tubing and oxygen mask on the night stand next to her bed. The oxygen mask was not on a protective barrier, bin, or plastic bag. Upon inspection of the oxygen tubing, it was dated 10/23/23. Resident #36 reported she uses the oxygen when she needs it. During an observation on 01/10/24 at 09:37 AM, Resident #36 was observed seated in her wheelchair with her table in front of her. The oxygen tubing and mask directly on the night stand curled up with no protective barrier, bin, or plastic bag and dated 10/23/23. During an observation on 01/10/23 at 11:53 AM, Resident #36 was seated in her recliner and the oxygen tubing and mask were curled up on the night stand with the mask and oxygen tubing directly on the night stand next to the head of her bed with no protective barrier, bin or plastic bag. The oxygen tubing was dated 10/23/23. During an observation on 01/10/24 at 01:07 PM, CNA EE was exiting Resident #36's room and the oxygen tubing and mask were in the same place as previous observations undisturbed. During an observation on 01/11/24 at 11:53 AM, Resident #36's oxygen tubing and mask were observed on her night stand next to her bed, it was dated 10/23/23 and was not on a protective barrier, bin, or placed in a plastic bag for infection control. In an interview on 01/11/24 at 11:01 AM, Infection Preventionist (IFP) R reported there was a reminder on the tasks list for the nurses to change the tubing weekly and this was documented in the administration record. IFP R reported there would be an order for this task to be completed.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision and safety interventions for 2 of 13 residents (Resident #8 and Resident #12) reviewed for accident hazards/supervision, resulting in Resident #8 wandering into other resident's rooms as well as off the unit, and Resident #12 being transported in a wheelchair without the use of footrests. Findings include: Resident #8 Review of a Admission Record dated 6/29/23 revealed Resident #8 was admitted to the facility with the following pertinent diagnoses: dementia (a condition characterized by progressive or persistent loss of intellectual functioning), posterior subcapsular cataract (eye condition causing difficulty reading and reduced vision in brightly light areas), and depression. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored 5/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Section E of the MDS revealed Resident #8 exhibited verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) during 1 to 3 days of the 14-day assessment period. Section GG of the MDS revealed Resident #8 ambulated 150' with a wheeled walker and required supervision or touching assistance to do so safely. Review of a Care Plan for Resident #8 dated 1/3/24 revealed focus/goal/interventions as follows: Focus: (Resident #8) is an elopement risk d/t history of wandering and expressing desire to leave the facility unattended, Goal: (Resident #8's) safety will be maintained through next review date. Interventions: distract (Resident #8) from wandering by offering pleasant diversions, structured activities, food, conversation, television. Identify pattern of wandering, is it purposeful, aimless, or escapist? Intervene as appropriate. During an observation on 1/9/24 at 1:33pm, Resident #8 ambulated around his room without his wheeled walker and walked into his bathroom. During an observation on 1/9/24 at 2:17pm, Resident #8 walked out of his room alone without his wheeled walker, approached the surveyor and reported he was looking for his wife. Resident #8 stood in the hallway unattended for several minutes. During an observation on 1/10/24 at 1:01pm, Resident #8 donned a coat then walked from his room into the hallway using 1 hand on his wheeled walker, his posture flexed, which caused a 24 gap between his body and the frame of the walker. Resident #8 stood in the hallway for 30 seconds, turned around, still with only 1 hand on the walker, posture flexed with the walker away from his body, and returned to his room. In an interview on 1/10/24 at 1:12pm, Certified Nursing Assistant (CENA) G reported Resident #8 regularly went into other resident's rooms when unsupervised and at times became upset when staff arrived and attempted to redirect him. CENA G reported Resident #8's care plan did not provide interventions for staff to follow related to Resident #8 going into other resident's rooms, and only a few interventions regarding his wandering. CENA G reported Resident #8 required supervision assistance for safety while walking. In an interview on 1/10/24 at 3:14pm, Social Services Coordinator (SSC) S reported Resident #8 had been walking unsupervised and going into other resident's rooms, and the frequency of him doing so had had recently increased. When queried about interventions for these behaviors, SSC S reported he (Resident #8) is on two medications. SSC S reported Resident #8 had more difficulty recognizing his room after his furniture was rearranged and that the staff recently put the furniture back in its original location. SSC was also trialing the use of an emotional support robotic cat in his room to reduce Resident #8's wandering. SSC S reported she was aware of at least one occasion when another resident yelled at Resident #8 and shook an object in his face in effort to get him out of their room. When queried if another resident yelling at Resident #8 might cause him to respond aggressively, SSC S stated everyone has their breaking point. In an interview on 1/11/24 at 10:5am Certified Nursing Assistant (CENA) J reported she had witnessed Resident #8 repeatedly going into other resident's rooms and lying in their beds. CENA J reported at least 1 resident was upset that Resident #8 came into her room. In an interview on 1/11/24 at 9:32am, Registered Nurse (RN) Q reported on 1/2/24 Resident #8 was unsupervised walked out of the skilled nursing unit, into another area of the building. RN Q reported staff from the assisted living area of the building called and reported Resident #8 was in the dining room of that unit. RN Q reported a CENA was sent to get Resident #8, but when the CENA arrived in the assisted living dining room, Resident #8 was gone. An unknown staff member found him and brought him back to the skilled nursing area. RN Q reported she did not know when Resident #8 left the skilled nursing unit or what time he returned. RN Q reported it was not unusual for Resident #8 to wander prior to 1/11/24, but he had not previously left the unit. In an interview on 1/11/24 at 1:42pm, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B reported they were aware that Resident #8 had wandered into other resident's rooms on the skilled nursing unit and that he required supervision for safety when walking. NHA A confirmed that Resident #8 wandered more than 300'unsupervised on 1/2/24 when he left the skilled nursing unit. NHA A confirmed this was a safety concern and reported as a result, a wander guard bracelet was placed on Resident #8. Review of a Behavior Note for Resident #8 dated 9/12/23 revealed a statement: Resident observed by this nurse using the bathroom facilities in another resident room. Review of a Behavior Note for Resident #8 dated 10/23/23 revealed a statement: Resident observed walking down the hallway with walker, shoes on wrong feet, jacket on and looking for his wife. He states that he seen (sic) her care outside his window and needed to go get her. 41424 Review of Mosby's Textbook for Long-Term Care Nursing Assistants - E-Book by [NAME] A. [NAME], 6th Edition 2013 titled 'Wheelchair Safety revealed .Make sure the person's feet are on the footplates (foot pedals/rests) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving . Resident #12: Review of an Admission Record revealed Resident #12 was a male with pertinent diagnoses which included dementia, lack of coordination, diabetes, Alzheimer's disease, hearing loss, unsteadiness on feet, abnormalities of gait and mobility, and cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language). Review of current Care Plan for Resident #12, revised on 8/29/23, revealed the focus, .(Resident #12) is at risk for falls r/t (related to) hx of falls, age related debility, impulsiveness, poor safety awareness, and other comorbidities . with the intervention .ensure that (Resident #12) is wearing appropriate footwear; nonskid socks when transferring, ambulating or mobilizing in w/c (wheelchair) .Wheelchair mobility: Wheels 50-150 feet with SBA/CGA . A Minimum Data Set (MDS assessment completed on 10/16/23, revealed, Resident #12 was a walker and manual wheelchair as mobility devices, .sit to stand with partial/moderate assistance - helper does LESS THAN HALF the effort .Able to wheel 250 feet independently . During an observation on 01/10/24 at 12:53 PM, Resident #12 was observed in the hallway across from the nurse's station and he needed to go to his room as he had spilled something on his pants, Certified Nursing Assistant (CNA) BB came up behind him and told him they were going to take him to his room which was down the short hallway. Staff proceeded to push the resident down and around the hallway to his room without foot pedals on his wheelchair. In an interview on 01/10/24 at 01:01 PM, Licensed Practical Nurse (LPN) CC reported a resident would not be propelled in a wheelchair without foot pedals as they could go flying out of the chair, place the foot down and propel them out. In an interview on 01/11/24 at 11:05 AM, Infection Preventionist R reported the residents who were cognitively impaired to ensure to have the bags on the back of the chair to hold the foot pedals and this was something new the facility was implementing for the foot pedals to be there for the resident's chair. In an interview on 01/10/24 at 01:29 PM, Director of Nursing (DON) B reported it was a huge safety concern to push a resident without foot pedals as it could pull them out and cause of injury to the resident and/or their feet.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for documentation of medication administration in 2 of 10 residents (Resident #45 & #18) reviewed for medication administration, resulting in the potential for medication errors. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Medication Administration, dated 12/1/23, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Administer medication as ordered in accordance with manufacturer specifications .Sign MAR (Medication Administration Record) after administered . Resident #45 Review of an Admission Record revealed Resident #45 was a male, with pertinent diagnoses which included stroke, dysphagia (difficulty swallowing), anemia, and irritable bowel syndrome. Review of an Order Summary Report for Resident #45, revealed active physician orders for .Dicyclomine HCl Tablet 20 MG Give 1 tablet via (G-Tube) four times a day for treatment of functional/irritable bowel syndrome . with a start date of 12/29/23, .Ondansetron HCl Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet via PEG-Tube every 6 hours for Nausea . with a start date of 12/15/23, and .Simethicone Oral Tablet 80 MG (Simethicone) Give 1 tablet via G-Tube four times a day for gas . with a start date of 1/3/24. In an observation on 1/11/24 at 11:20 AM, Registered Nurse (RN) Q prepared scheduled medications for Resident #45. Observed RN Q prepare Dicyclomine HCl Tablet 20 MG, Ondansetron HCl Oral Tablet 4 MG, and Simethicone Oral Tablet 80 MG for Resident #45. RN Q crushed the medications and placed them in a medication cup for administration via G-Tube. RN Q then documented the medications as given (signed the MAR) prior to administration to Resident #45. Resident #18 Review of an Admission Record revealed Resident #18 was a female, with pertinent diagnoses which included Alzheimer's disease, arthritis, muscle contracture, right ankle pressure ulcer, and pain in the left wrist and right knee. Review of an Order Summary Report for Resident #18, revealed an active physician order for .Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 milliliter by mouth every 6 hours for pain management . with a start date of 1/5/24. In an observation and interview on 1/11/24 at 11:28 AM, RN Q prepared scheduled medication for Resident #18. Observed RN Q prepare Morphine Sulfate (Concentrate) Solution 20 MG/ML 0.25 ML for Resident #18. RN Q then documented the medication as given (signed the MAR) prior to administration to Resident #18. RN Q stated in regard to medication administration documentation .I try to wait until they actually take (the medication) . In an interview on 1/11/24 at 12:17 PM, Licensed Practical Nurse (LPN) K reported medications should not be documented as administered/signed until after they are given. In an interview on 1/11/24 at 12:22 PM, LPN C reported medications should not be documented as given/signed until after administration. In an interview on 1/11/24 at 3:29 PM, Director of Nursing (DON) B reported the expectation for the nursing staff would be to document medications as given after administration. DON B stated .If they do it before they can't indicate if there is something refused or spit out .

Based on observation, interview, and record review, the facility failed to ensure access to a call light in 1 of 12 sampled residents (Resident #198) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs. Findings include: According to https://www.ncbi.nlm.nih.gov, .Call light technology serve as a means of communication for patients to their care providers that are outside of the patient's room. This technology is a direct link to getting their needs met and the care provided by nurses . Resident #198: Review of an Admission Record revealed Resident #198 was a female with pertinent diagnoses which included fracture of femoral neck right femur, hemiplegia (paralysis) and hemiparesis (weakness) of left side following stroke, diabetes, history of falling and use of blood thinners. Review of Care Plan revised on 12/29/23, revealed the focus, .(Resident #198) at risk for falls r/t (related to); falls in community, fracture of right femur, hemiplegia and hemiparesis r/t CVA (cerebral vascular accident) and other comorbidities . with the intervention .Be sure [NAME]'s call light is within reach and encourage her to use it for assistance as needed. [NAME] needs prompt response to all requests for assistance . During an observation on 01/09/24 at 11:44 AM, Resident #198 was observed seated in her wheelchair at the left side of the bed towards the foot of the bed and she reported she was unable to self-propel herself in her wheelchair. Resident #198's call light was observed placed on her bed, behind her towards the head of the bed out of R#198's reach. R#198 reported she was very thirsty and was unable to self-propel to the water which was placed on her night stand behind her at the head of the bed as well as the water which was placed on the built-in dresser top under the television set. Neither water had been drunk as they were full, and no ice was present. During an observation on 01/09/24 at 11:46 AM, Certified Nursing Assistant (CNA) Z entered the room and went to obtain some fresh water for R #198 when she returned R#198 took two big sips from the straw and drank 2/3 of the cup of water. R#198 repeatedly kept saying I needed that so badly .Sure needed that .I was so thirsty .it was so nice to have some cold water . In an interview on 01/11/24 at 11:59 AM, CNA X reported prior to exiting a room it was important to place the call light in the resident's reach prior to exiting the room. The resident's water would need to be placed in reach whether it would be to place water on the nightstand while lying in bed or on the tray table in their reach if they're up in their wheelchair or chair. In an interview on 01/11/24 at 12:01 PM, CNA Y reported it was important for the resident to have the call light in reach when you leave the room so they would be able to call for assistance if needed. In an interview on 01/11/23 at 12:03 PM, Assistant Director of Nursing (ADON) C reported it was very important to ensure the resident had water or to keep hydrated because it could cause low blood pressure and other issues. ADON C reported when leaving a resident's room, the staff should ensure that all the things that the resident would need were in place, such as, water, remote to the tv, and other frequently used resident items. Review of policy, Call Lights: Accessibility and Timely Response revised on 12/1/23, revealed, .5. Staff will ensure the call light is within reach of resident and secured, as needed .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident ' s room .

Based on observation, interview, and record review, the facility failed to: (1) Effectively label and monitor the expiration dates and condition of canned goods; (2) Keep food and non-food contact surfaces clean to sight and touch; (3) Maintain general cleanliness in the freezer; and (4) Properly store food product. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness that affected all residents that consumed food from the kitchen. Findings include: 1. On 1/23/2023 at 9:30 AM, an initial tour of the food service was conducted with Dietary Manager (DM) U and Registered Dietary Technician V. The following items were noted in the dry food storage area: Three 46 ounce cans of pineapple juice were observed with a best use date of December 2022. DM U removed these from stock to prevent them from being used. One dented 6 pound 11 ounce can of sliced pineapples was observed. DM U removed this from stock. DM U reported that dented cans should be caught prior to stocking and are sent back to the supplier. DM U and Registered Dietary Technician V were unable to identify the expiration dates of several stocked cans including a can of apple sauce, a can of stewed tomatoes, and a can of chocolate syrup. DM U reported that all cans should be marked with the date that they are stocked and are removed from stock in either one year or the product's expiration date, whichever comes first. Many cans of food were observed in stock without a date marking. Registered Dietary Technician V reported that this is a process that needs to be reviewed by the facility. 38905 According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 2. During a tour of the 1st walk in freezer, at 9:20 AM on 1/24/23, it was observed that a white powdery substance was coating a portion of the floor and accumulation of paper and packaging trash was found on the floor. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . 3. During a follow up tour of the kitchen, at 9:41 AM on 1/24/23, an interview with DM U found that mechanical scoops are stored in the clean utensil drawer. Observation of the drawer found an accumulation of crumb debris on the inside and back of the drawer. DM U observed the drawer and asked a staff member to clean it. During a tour of the JP dining room, at 10:45 AM on 1/24/23, observation of the juice machine found an accumulation of sticky debris on the underside of the spouts and corners of the machine. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4. During a tour of the main walk in freezer, at 9:45 AM on 1/24/23, a box of hot dogs was found opened and unpackaged, leaving product open and exposed. When asked if this is how product would normally be stored, DM C stated No and discarded the product.

Based on observation, interview, and record review the facility failed follow maintain a sanitary environment, resulting in the potential for increased infections, cross-contamination and bacterial harborage. Findings include: In an observation on 1/23/23 at 10:43 AM., noted a sit to stand (lift to assist residents to stand and transfer) parked next to room [ROOM NUMBER]. The handle gripes visibly soiled with a crusted substance, and grime. In an observation on 1/23/23 at 11:58 AM., noted the shared bathroom for rooms 513/515. The toilet was visibly soiled with feces on toilet seat, floor in front of the toilet, the underside of the toilet seat and the base of the toilet. In an observation on 1/23/23 at 12:04 PM., noted on the toilet in the shared bathroom for rooms 503/505 the toilet base was soiled with feces smeared on the front area of the toilet bowel (outside rim). In an observation on 1/23/23 at 12:08 PM., noted in room [ROOM NUMBER] the call light (cord with button to push for assistance) was heavily soiled with a buildup of a crusted substances and grime in room [ROOM NUMBER] In an observation on 1/23/23 at 12:09 PM., noted in room [ROOM NUMBER] the call light was heavily soiled with a buildup of a crusted substances and grime. During an interview on 1/23/23 at 12:33 PM., Housekeeper (Hsk) O reported resident rooms are cleaned by housekeeping staff once a day and as needed. Hsk O reported resident shared equipment such as lifts, vital machines and wheelchairs are cleaned by the Certified Nurse Aides (CNA's). Hsk O reported all high touch surfaces in resident rooms such as call lights, bedside tables, night stands are to be cleaned by housekeeping, and any staff that notices something that is visibly soiled. In an observation on 1/23/23 at 2:04 PM., noted the toilet seat in room [ROOM NUMBER] was soiled on the under seat with what appeared to be feces. In an observation on 1/23/23 at 2:10 PM., noted a hoyer lift in an alcove near the nursing station. On the side of the lift, it was noted a reddish-brown smudge with what appeared to be dried blood or feces. Noted no cleaning wipes near or attached to the lift. In an observation on 1/23/23 at 2:18 PM., noted a vitals machine (measures resident vital signs) near room [ROOM NUMBER] the machines finger probe (measures oxygen in the blood) was heavily soiled with grime in the crevasses. In an observation on 1/23/23 at 2:25 PM., CNA G reported CNA's are suppose to sanitize resident shared equipment between uses, and when anything is visibly soiled, any staff should be cleaning the soiled item, or ask for assistance from housekeeping or maintenance. In an observation on 1/24/23 at 12:06 PM., noted a hoyer lift on the 500 hall. On the side of the lift, it was noted a reddish-brown smudge with what appeared to be dried blood or feces. Noted no cleaning wipes near or attached to the lift. In an observation on 1/24/23 at 12:55 PM., noted a vitals machine near room [ROOM NUMBER] the machines finger probe was heavily soiled with grime in the crevasses. During an interview on 1/25/23 at 11:15 AM., Infection Control Preventionist-Director of Nursing (ICP/DON) B reported any staff that notices items, shared equipment, commonly touched surfaces should be cleaned right away. ICP/DON B reported staff are not required to not wipe down resident shared equipment such as lifts, and vital machines unless they are visibly soiled.

Based on observation, interview, and record review, the facility failed to clean and store CPAP (continuous positive airway pressure) equipment (a treatment used for sleep apnea - pressurized air is provided through a mask to prevent collapse of the airway) according to facility policy for 1 resident (Resident #6), of 2 residents reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Resident #6 Review of an Admission Record revealed Resident #6 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's Disease and Obstructive Sleep Apnea. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 12/26/2022 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #6 was moderately cognitively impaired. In an observation on 1/23/2023 at 1:54 PM, Resident #6's CPAP mask was resting on her bedside table open to the air, not in a case or protective bag. In an observation on 1/24/2023 at 8:15 AM, Resident #6's CPAP mask was resting on her bedside table open to the air, not in a case or protective bag. In an observation on 1/24/2023 at 12:02 PM, Resident #6's CPAP mask was resting on her bedside table open to the air, not in a case or protective bag. In an observation on 1/24/2023 at 2:58 PM, Resident #6's CPAP mask was resting on her bed open to the air, not in a case or protective bag. Review of Resident #6's active Physician Orders on 1/24/2023 revealed an order to assist resident with placement of CPAP but no order regarding the cleaning or storage of the CPAP. Review of Resident #6's active Treatment Administration Record on 1/24/2023 revealed no documentation regarding the cleaning and storage of the CPAP. In an interview on 1/24/2023 at 3:06 PM, CNA (Certified Nursing Assistant) Z reported that nurses were responsible for the cleaning and maintenance of CPAP machines. In an interview on 1/24/2023 at 3:47 PM, RN (Registered Nurse) Y reported that CPAP masks should be cleaned with soap and water because they can build up mildew and mold. RN Y reported that she was not aware who was responsible for cleaning CPAP supplies at the facility and was not aware of the facility's policy or process. In an interview on 1/25/2023 at 10:00 AM, DON (Director of Nursing) B reported that she could not provide documentation and could not confirm whether Resident #6's CPAP had been cleaned by the facility since her admission. DON B reported that the facility policy states that the CPAP mask should be cleaned daily. Review of facility policy/procedure CPAP/BiPAP Cleaning, revised 1/24/2023, revealed .Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use . Weekly cleaning activities . wash headgear/straps in warm, soapy water and air dry . wash tubing with warm, soapy water and air dry .

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) detailing estimated charges for continued services in 2 of 3 residents (Resident #42 & #4) reviewed for timely provision of notifications, resulting in the potential for residents/resident representatives to be unaware of changes regarding financial liability. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) information related to Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms, page last updated 12/1/21, revealed .Skilled Nursing Facilities (SNFs) must issue a notice to Original Medicare (fee for service - FFS) beneficiaries in order to transfer potential financial liability before the SNF provides .an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or .custodial care .For Part A items and services: SNFs use the SNF ABN as the liability notice . Obtained from: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN- Resident #42 Review of a Face Sheet revealed Resident #42 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), syncope (loss of consciousness) and collapse, muscle weakness, repeated falls, and unspecified abnormalities of gait and mobility. Review of the SNF Beneficiary Protection Notification Review FORM CMS-20052 for Resident #42, completed by facility staff, revealed .Last covered day of Part A Service .9/23/22 .the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Under the section .Was an SNF ABN, Form CMS-10055 provided to the resident? The box No - If no, explain why the form was not provided was checked. The box Other Explain was checked but no explanation was provided. Resident 4 Review of a Face Sheet revealed Resident #4 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness. Review of the SNF Beneficiary Protection Notification Review FORM CMS-20052 for Resident #4, completed by facility staff, revealed .Last covered day of Part A Service .12/9/22 .the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . Under the section .Was an SNF ABN, Form CMS-10055 provided to the resident? The box No - If no, explain why the form was not provided was checked. The box Other Explain was checked but no explanation was provided. In an interview on 1/24/23 at 11:16 AM, Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Finance Representative (FR) W were queried as to why the box No - If no, explain why the form was not provided was checked and the box Other Explain was checked but no explanation was provided on Resident #42 and Resident #4's completed SNF Beneficiary Protection Notification Review FORM CMS-20052 forms. NHA A reported had identified an error when State Agency (SA) requested the SNF Beneficiary Protection Notification Review FORM CMS-20052 forms to be completed for Resident #42 and Resident #4. NHA A and FR W reported Resident #42 and Resident #4 should have received an SNF ABN. NHA A reported there had been turnover with the facility social worker in March of 2022 and the social worker had been the one who completed the SNF ABN forms when required. NHA A reported the new social worker had not been trained on their responsibility to complete the SNF ABN forms, so the SNF ABN forms had not been done since the previous social worker departed in March, 2022.

This citation pertains to intake MI 451. Based on observation, interview, and record review the facility failed to: 1.) ensure timely treatment and assessment of a hot liquid spill for 1 of 4 residents (Resident #1) reviewed for accidents and hazards, resulting in a second-degree burn and pain and 2.) ensure one of one kitchenette's steam table was not accessible to residents, resulting in the potential for additional [CONDITION(S)] or scalding from an unattended steam table. Findings include: During an observation and interview on 5/24/22 at 10:45 AM, the kitchenette located just down the hall from rooms 529 and 531 was unattended, no staff were present in the area, the steam table was on and functioning. The steam table well lids were lifted, and hot steam poured out. The sign off to the side of the entrance to behind the kitchenette had a sign that stated, The kitchenette area is for **STAFF ONLY** If you need assistance, please see a staff member. PLEASE KEEP GATE CLOSED. There was no gate in the area, and therefore no gate was closed. The steam table well lids were very hot to the touch. Dietary Staff N was observed coming down the hall approaching the kitchenette and reported she had been away from the kitchenette for approximately eight minutes. Dietary Staff N confirmed there was no gate and reported staff put the two metal poled signs in the entry way. The two poles in the entry way did not fully obstruct entrance to behind the kitchenette where the very hot steam table was operating per direct observation. (A steam table is intended to keep hot food hot, and hot food holding temperatures should be above 135 degrees Fahrenheit to give reference to temperature). During an observation and interview on 5/24/22 at 11:08 AM, the kitchenette area was once again unattended with no staff in the area and the steam table was fully operating. The entry to the kitchenette was unobstructed; there were no signs or gates in the way. All three steam table well covers were hot to the touch with instant feeling of hot/pain. The left well was set at seven out of ten (heat setting), the middle well was set at seven, and the right well was set at eight on the steam table. At 11:11 AM, Registered Nurse L arrived at the kitchenette, confirmed there was no gate and reported she had never seen one before, and left the area at 11:13 AM and the kitchenette area was once again unsupervised. At 11:18 AM, Director of Nursing B arrived at the kitchenette. At 11:31 AM, Dietary Staff N arrived back at the kitchenette. During an observation and interview on 5/24/22 at 11:18 AM, at the kitchenette down the hall from rooms 529 and 531, Director of Nursing (DON) B confirmed there was nothing blocking the entrance to the kitchenette while the steam tables were operating at that time and reported there used to be something they kept to block off behind the kitchenette area. There were no other staff present in the area who would have been supervising the kitchenette/steam table area. During an observation and interview on 5/24/22 at 11:32 AM, Resident #1 was seated in her wheelchair in her room and reported she couldn't remember when the hot coffee spill occurred, but reported a bandage was being changed everyday on her right upper/inner thigh area and as she spoke of it she kept rubbing the area gently with her hand. Resident #1 stated, It (the burned area) just doesn't want to heal all the way up and reported the pain was not as much now as it did at first (4/25/22). Resident #1 reported she was given a new tray table after the coffee spill/burn because the old one would always wobble when you moved it and stated, It (the tray table) did it (wobble) for a long time. During an observation and interview on 5/25/22 at 11:34 AM, with Director of Nursing (DON) B present, Resident #1 had her pant leg pulled up and the area on her right upper inner thigh was observed to be reddened around the edges and scabbed in various areas. Resident #1 reported the area was painful with bathing, touching of the area, or when putting clothes on or taking clothes off. DON B measured the area and it was 3.8 by 3.5 centimeters. During an interview on 5/24/22 at 8:57 AM, Director of Nursing (DON) B confirmed Resident #1's burn occurred on 4/25/22, but wasn't recognized as a burn until 4/28/22. DON B confirmed no skin assessment/treatment of Resident #1's right thigh occurred immediately after the hot coffee spill on 4/25/22 at approximately 12:00 PM and was assessed that night on a routine weekly skin check at approximately 8 PM. DON B reported the nurse who did the 4/25/22 8 PM skin assessment didn't know the impaired skin was from a burn. DON B confirmed the wheels of Resident #1's tray table were stuck and the tray table fell leading to the spill. DON B confirmed no one changed Resident #1's pants or assessed the skin immediately after the incident/spill and reported Registered Nurse (RN) H (who was first staff to respond to Resident #1 post hot coffee spill) assumed the floor nurse would find out from Certified Nurse Aide P so RN H didn't proceed any further with any skin assessment. DON B reported after a hot liquid spill staff was supposed to take resident's pants off, put a cool cloth on the burned area, assess the area, make notifications, take the temperature of the hot liquid if available, and get a treatment for the area. DON B reported Resident #1's right thigh burn from the hot coffee spill was a second-degree burn as it was a blister that was open. DON B confirmed three days later the facility recognized the area found on Resident #1's right thigh was from a hot liquid spill burn. DON B reported the first treatment put into place, the [calamine and zinc paste product], probably wasn't the best treatment and that the Nurse who completed the 4/25/22 skin assessment thought it was excoriation, not a burn, and used that product instead of other products better suited for a burn, such as A and D (vitamin A and D ointment). DON B confirmed the [calamine and zinc past product] would be used for excoriation, but not a burn. During an interview on 5/24/22 at 9:46 AM, Dietary Manager (DM) E reported when the coffee is brewed it comes out at 180 degrees Fahrenheit. DM E confirmed prior to the 4/25/22 burn there were no coffee temperature logs being done and stated, not to my knowledge. DM E confirmed he didn't know what the temperature of the coffee was that was served to Resident #1 on 4/25/22 and there was no coffee brewing temperature log that day. DM E reported after the incident he tested it and it took 45 minutes for the coffee to reach 140 degrees after dispensing from the coffee machine into a carafe. (Water temperature of 140 degrees Fahrenheit can cause a third degree burn to occur in five seconds under circumstances dependent on an individual's condition.) During an interview on 5/24/22 at 10:07 AM, Director of Nursing B confirmed the facility didn't do a facility wide audit/sweep/assessment to check for other non-functioning tray tables in resident rooms and that they just did one today, 5/24/22, and found some that needed lubrication. During an interview on 5/24/22 at 5:17 PM, Certified Nurse Aide (CNA) P reported she did not change Resident #1's pants after the hot coffee spill on 4/25/22, but instead changed the Resident in room 514 as she was asked by Licensed Practical Nurse (LPN) R to do so. CNA P reported she must have misheard LPN R. CNA P confirmed she didn't recall Registered Nurse H having told her to clean up/change Resident #1 after the hot coffee spill. During an interview on 5/25/22 at 10:34 AM, Director of Nursing B confirmed the right thigh burn area's wound treatment that included a dressing change was discontinued on 5/22/22. During an interview on 5/25/22 at 11:15 AM, Registered Nurse (RN) H reported on 4/25/22 she didn't hear Resident #1's tray table fall, she was just passing through the area, and wasn't working Resident #1's unit. RN H reported a hospice certified nurse aide (CNA) reported to her that Resident #1 spilled her tray and needed help, RN H entered Resident #1's room and saw the meal tray turned over with food and drink on the floor, Resident #1 was back from her tray a little bit, and Resident #1 reported to RN H that she had got a little bit (of coffee) on her leg. RN H reported a CNA, who she couldn't remember their name, was present and helping clean up the tray. RN H reported she got Resident #1 a new meal/tray, set up her meal for her, left Resident #1's room, and then told the assigned certified nurse aide for Resident #1 that shift, CNA P, Resident #1 needed her pants changed. RN H confirmed she did not assess Resident #1's right thigh where the hot liquid spill was and had thought CNA P would have notified the nurse working the unit if she had found any burn areas. RN H confirmed she had not inspected the tray table and reported Resident #1 had told her that all she did was pull the tray table towards her and it spilled/tipped over. During an interview on 5/25/2022 at 11:28 AM, with Environmental Services Director (ESD) F reported 9/11/2018 was the last work order addressing the gate to the kitchenette (the one located between rooms 529 and 531) and it was pertaining to the gate chain being ripped out of the wall. ESD F reported no gate/barricade had been put back up after that work order was submitted. ESD F reported staff would put two metal poled signs in the area of the entrance. ESD F confirmed the kitchenette previously, before the work order was submitted, was barricaded with the chain. ESD F reported Resident #1's tray table was replaced after the hot spill incident (4/25/22) and reported tray tables are replaced fairly often. ESD F confirmed a full facility tray table inspection was completed yesterday, 5/24/22, but one was not done immediately following the 4/25/22 hot spill incident with Resident #1. During an interview on 5/25/22 at 2:09 PM, Director of Nursing (DON) B and Nursing Home Administrator A reported we don't know what the outcome would have been had staff followed the facility post hot spill interventions for Resident #1 and DON B stated, Maybe it would have prevented some of it. Review of Resident #1's Incident Report, dated 4/28/22, stated, Cognitive Status: Moderately Impaired .BIMS Score (brief interview for mental status score) 11 (reflecting moderately impaired cognition) .At 12:00 pm on 4/28/22, it was reported to the DON (Director of Nursing B) and Administrator (Nursing Home Administrator A) that (Resident #1) had redness to her right thigh that had been identified on Monday evening 4/25/22 as a possible result of spilled coffee that occurred at 12:00 pm. This incident was not immediately reported to DON .(Resident #1) was eating lunch in her room and had moved her tray table away and when she pulled it back towards her, her food and drinks fell on the floor. Some of her coffee fell on her as well. A staff member (Registered Nurse H) had asked the CNA (Certified Nurse Aide P) to change her pants .A skin assessment was done that evening and excoriation was noted to (Resident #1's) leg and [Brand of calamine zinc paste; skin protectant] was applied for treatment. On 4/28/22, when the redness was observed by (Certified Nurse Aide S), C.N.A. (Certified Nurse Aide) .Treatment was altered by ADON (Assistant Director of Nursing; ADON (Assistant Director of Nursing D) as a result of learning that this area of redness may have been a result of a coffee spill on 4/25/22. A new tray table replaced the original table on 4/28/22 as the previous tray table was evaluated and the wheels were found to be sticking .Nursing staff will be educated on the proper steps following a hot liquid spill. Review of Resident #1's Hot Liquid Spill incident report, dated 4/25/2022, stated, On 4/28/22 at 12:04 PM, it was reported to the DON (Director of Nursing B) and Administrator (Nursing Home Administrator A) that (Resident #1) had redness to her right thigh, which was a possible result of spilled coffee. The spilled coffee occurred on 4/25/22 at 12:00 pm ., Injury Type Burn .Injury Location Right thigh (front), and Other Info (information) Tray table wheels were sticking and did not move smoothly when she pulled the tray back towards her with the food and liquids on it. Review of Resident #1's Skin Only Evaluation form, dated 4/25/22, stated, Does Resident have current skin issues? .Yes, Skin Issue #1 .Excoriation, Location right thigh, Abnormalities .Skin: Excoriation .Treatment remains in place for excoriation of right thigh area., and the Length (cm) and Width (cm) measurement sections were left blank and no measurements were anywhere else on the form. Review of Resident #1's Skin Only Evaluation form, dated 4/29/22, stated, Does Resident have current skin issues? .Yes, Skin Issue #1 .Excoriation, Location right thigh, Abnormalities .Skin: Excoriation .redness and excoriation noted to right thigh, tx (treatment) put in ., and the Length (cm) and Width (cm) measurement sections were left blank and no measurements were anywhere else on the form. Review of Resident #1's Skin Only Evaluation form, dated 5/5/22, stated, Other skin issue blister, Location right thigh, and the Length (cm) and Width (cm) measurement sections were left blank and no measurements were anywhere else on the form. Review of Resident #1's progress notes, dated 4/25/22 - 5/25/22, stated the following: -4/25/22 Nurses note, Resident (Resident #1) has current skin issues. Skin Issue: Excoriation. Skin Issue Location: right thigh redness and excoriation noted to right thigh, tx (treatment) put in for [calamine and zinc paste product] q shift (every shift) until resolved. -4/28/22 Nurses note, Resident currently has a open blister, redden area, to right inner thigh size of 4.5cmx4cm. Slight painful with touch . she stated her tray fell on her and floor Monday afternoon. Tray table is currently unsteady at the time of assessment. Notified maintenance to get a new table at this time, table was switch out and dycem applied to help prevent tray table from moving. Notified (Nurse Practitioner C) of new order cleanse with ns (normal saline) pat dry, cover area with [MEDICATION(S)] non-adhering dressing and apply border gauze daily until resolve. -5/2/22 Nurses note, Dressing to right inner thigh changed as per orders .Some serous drainage noted on dressing when removed. -5/3/22 Nurses note, The resident continues to be monitored for red area inner thigh. -5/6/12 Nutrition progress note, Blister to (R) (right) inner thigh is monitored by nursing. -5/12/22 Skin progress note, Other Skin Issue: Blister Skin Issue Location: Right thigh Wound Bed: Slough (dead tissue, usually cream or yellow in colour). Wound Exudate: Serous (fluid). PeriWound (tissue surrounding a wound) Condition: [CONDITION(S)] (reddening of the skin) .Dressing Saturation: Minimal (<25%) . -5/19/22 Skin progress note, .open area r/t (related to) healing burn site Skin Issue Location: right inner thigh Length: 4 cm (centimeters) Width (cm): 4 cm . -5/23/22 Nurse Practitioner note, .Wound of thigh from a hot liquid. It appears to be healing .Continue to monitor for now. - 5/23/22 Nurses note, Monitoring redness and scabbing around dressing site on right thigh. It appears that either skin was irritated or injured with island dressing removal .(Resident #1) indicated she does have some discomfort in area where thigh wound is present, but that it only occurs when that area is 'being messed with.'. - 5/25/22 Nurses note, .Continued monitoring of excoriation on Right thigh. Review of Resident #1's discontinued physician orders, included Cleanse redden area to right inner thigh with NS (normal saline) pat dry, apply [MEDICATION(S)] non adhering dressing to wound and cover with border gauze daily until resolved., dated 4/28/22 - 5/23/22 and apply [calamine and zinc paste product] to right thigh d/t (due to) excoriation/redness qshift (every shift) x (for) 14 days, dated 4/25/22-4/28/22. Review of Resident #1's diagnosis list, stated, unspecified dementia without behavioral symptoms, dated 10/1/2021. Review of Resident #1's activities of daily living care plan, included an intervention of Eating: Independent after set up, revised 2/17/2020, and HOT LIQUIDS: Hot liquids to be drank at table only with clothing protector Dycem to Tray Table, revised 4/28/22. Review of Resident #1's order details, order date 4/28/22, stated, Cleanse redden area to right inner thigh with NS (normal saline) pat dry, apply [MEDICATION(S)] non adhering dressing to wound and cover with border gauze daily until resolved. Review of Resident #1's Kardex, dated 4/28/22, stated, Safety .HOT LIQUIDS: Hot liquids to be drank at table only with clothing protector Dycem to Tray Table. Review of the facility's work order, dated 9/11/2018, stated, Gate for behind serving area chain cant (can't) hook to other side ring gone. Review of Resident #1's physician orders, dated 5/22/22, stated, Monitor excoriation on right thigh every shift for improvement until resolved. Review of the facility's Hot Liquid Safety policy, revised 4/28/22, stated, Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions .Hot liquids can cause scalding and [CONDITION(S)]. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure .Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for [CONDITION(S)]. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids. Monitor resident for at least 24 hours following exposure to hot liquids, as redness or blisters may not appear initially. Review of the facility's Hot Liquid Interventions form, undated, stated, 1st: Cool water on skin - if there is only water at dining table, take some of that water and place it on the skin (not pour), 2nd notify the nurse immediately, 3rd: Bring resident to a private place, 4th: Remove clothing, 5th: Place a cool cloth on the area, not ice, 6th: Asses area, notify physician, 7th: Notify DON immediately, 8th: Check coffee temperature from the cup. If not available, then from the coffee it was served from, 9th: Incident Report, 10th: Statements from all staff.

Based on observation, interview, and record review the facility failed to: 1. Properly date mark and discard potentially hazardous foods; 2. Fully air-dry pots and pans before being stacked and stored; 3. Thoroughly clean food contact surfaces; and 4. Properly cool potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 38 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, at 9:36 AM on 9/27/21, inside main cooler one, an interview with dietary technician H, found that potentially hazardous foods are held for 7 days. At this time, it was observed that a container of hard-boiled eggs, cut cucumbers, cut tomatoes, and cut strawberries were found with a discard date of 10/4. During the initial tour of the kitchen, at 9:43 AM on 9/27/21, it was observed that an open package of sliced turkey dated with a best buy date of 9/17, an open packaged of salami with a best buy date of 9/9, and an open package of sliced ham dated 9/22 to 9/30, were all found on the shelf of walk-in cooler two. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) . 2. During the initial tour of the kitchen, at 9:55 AM on 9/27/21, an interview with Certified Dietary Manager (CDM) P found that pots and pans should be stored and stacked after they are fully dried. Review of the clean pots and pans storage rack found two 1/8th pans and two 1/4 pans that were stacked and stored wet. According to the 2013 FDA Food Code 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; . 3. During the initial tour of the kitchen, at 10:00 AM on 9/27/21, an interview with CDM P found that the plastic bag covering the standup mixer means that its clean. When asked how often the standup mixer is used, CDM P stated, we use it every day. Review of the standup mixer found dried white splatter debris on the under arm of the unit as well as on the legs and under portion of the table next to the standup mixer. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4. During a revisit to the kitchen, at 11:51 AM on 9/27/21, a review of the facilities August and September Cooling Charts, found items that had improperly cooled with no indication of being discarded. The August Cooling Chart shows that Turkey, cooked on 8/20, was found to be 140°F at 3:00 PM and 77°F after the first two hours of cooling. The September Cooling Chart shows Short Ribs, cooked on 9/25, were found to be 140°F at 4:00 PM and 87°F after the first two hours of cooling. According to the Critical Limits section of the facilities Cooling Chart, Cooked foods must be cooled from 140°F to 70°F within 2 hours . It was also noted that the Corrective Action Taken section on each Cooling Chart, was left blank for both the August and September Cooling Charts. During an interview with CDM P, at 3:45 PM on 9/27/21, it was found that the expectation for staff is to use ice [NAME], the freezer, and shallow pans to spread out food product, when cooling potentially hazardous foods in the facility. According to the 2013 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less.

Based on observation, interview and record review the facility failed to prevent, identify, stage, assess and determine the root cause of re-occurring pressure ulcers for 4 of 8 residents reviewed for pressures (#1, #6, #8, #10) out of a total sample of 15, resulting in harm for the reoccuring open areas localized at the coccyx area for Resident #8, non healing pressure ulcers for Resident #1 and #10, and failed to prevent pressure ulcers for Resident #6. Findings include: Resident #8's undated face sheet reflected she was an [AGE] year old female who had resided in the facility since 8/24/11. The Annual Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating Resident #8 was cognitively intact. The Annual MDS dated [DATE] also reflected Resident #8 had active [DIAGNOSES REDACTED]. The facility identified the all following placing Resident #8 at risk: The facility's electronic "Medical Treatment" or interventions reflected on 11/23/14 Resident #8 had problems related to pressure ulcers: "Impaired skin integrity, [MEDICAL CONDITION] w/autonomic dysfunction, Hx (history) of rotator cuff tear w/ chronic adhesive capulitus ... decreased functional mobility, Pain, hx of moisture dermatitus/maceration". Facility wound noted dated 5/4/12 reflected a late entry for 5/3/12 that Resident #8 had "Moisture [MEDICAL CONDITION] - perspiration, occasion urinary dribbling..." This was the only documentation found for why Resident #8 had such frequent excoriation of the buttocks. The most recent documentation the facility found where Resident #8 refused a ROHO cushion was 4/2012, and then the note stated to encourage the use of the ROHO cushion. There was no documentation that the Resident was educated on the risks of refusing the cushion in the development of skin breakdown, A physician's telephone order dated 5/10/14 reflected, " to apply "4 X 4 in [MEDICATION NAME] dressing to open areas then apply 6 X 6 in dressing to keep in place qd (everyday) gd". The quarterly "Dietary Comments" dated 7/17/14 reflected Resident #8 continues to be "offered regular diet with calorie dense foods related to decreased appetite and BMI 17.6. Resident's appetite fluctuates and when resident (#8) accepts 100% it is small portions and very seldom foods from all food groups offered. Wt (weight) fluctuations r/t (related to) 1 - 2+ Le (Lower extremity) [MEDICAL CONDITION] but have remained within resident's usual wt (95 to 100). Wt. (weight) has been in this range less than 1 year. Resident 8# has been offered nutritional supplements in the past but does not accept for extended period of time. Resident #8 remains at risk for dehydration related to limited fluid intake ... skin is free from pressure ulcers. Chronic maceration to buttock and coccyx has remained healed since 5/2/14. Resident (#8) is continent of bowel and bladder with a Braden score of 18, mild risk for breakdown... no recent lab values ... no changes to routine". However, the following problems were found: On 9/15/14 Resident #8's electronic clinical record was reviewed. It was discovered that Resident #8, according to the nursing progress notes from 5/30/14 to 8/29/14, documented that Resident #8 was excoriated 8 times, and Resident #8 had open areas to the coccyx 10 times. Late in the afternoon of 9/15/14 the DON, was asked why Resident #8 was not identified as a resident who had pressure ulcers. The DON replied, "Because LPN "C" was not calling it a pressure ulcer instead LPN "C" called Resident #8's skin condition a maceration". On the afternoon of 9/15/14 a note with a list of requests for Resident #8 was given to the DON. One of the requests was for wound measurements and the DON returned with measurements from 2012; there was none during the annual survey window from the 2013 to 2014 survey year. On 9/17/14 an RN surveyor observed the coccyx and found a large dark purple area that was not blanchable and no measurements had been taken of the area. On 9/18/14 at 8:30 am the Physician's Assistant "I" stated she was not (un) aware of any open areas or discolored areas Resident #8 had on her coccyx. Physician assistant "H" acknowledged she observed Resident #8 within the last month but had not looked at her coccyx nor was aware she had any open areas. Physician Assistant "H" stated she had not seen Resident #8's coccyx in months. On 8/17/14 at 4:00 pm during an interview with Resident #8's daughter and Resident #8 she stated she was not aware of the current condition of her mother's coccyx. Resident #8's daughter stated she last saw her mother's coccyx about 1 1/2 weeks ago when her dressing needed changing, and she did not have a large dark purple area covering her entire coccyx area at that time. Furthermore, On 9/17/14 at about 4:00 pm, during an interview with Resident #8 and her daughter, it was revealed that neither were aware that the prior cushion she refused was better for prevention of pressure ulcers than her current gel cushion. Resident #8 nor her daughter remembered refusing the air over lay to the mattress. Furthermore, Resident #8 stated she did not understand the seriousness of the wound on her coccyx and would allow staff to lay down on the bed for a couple of hours to alleviate pressure from her coccyx area. Interventions dated 11/23/13 reflected there were discontinued interventions which stated, "Interventions will minimize risk for skin impairment Three months" on 1/29/14 and 4/23/14. However, on 7/22/14, when the updated interventions were in place, it was the same exact wording, "Interventions will minimize risk for of further skin impairment. Three months". On 11/23/13 the Magic Butt cream to coccyx and peri area BID (twice daily) with cares was discontinued; the intervention that replaced it was cushion in wheelchair and recliner. Resident #8 preferred rolled blanket behind low back when reclined in chair, the use of the pressure reducing cushion was discontinued. The only current intervention left was, "Encourage to use satin draw sheets to assist with bed mobility for decreased friction". Additionally, on 1/29/14, and 4/23/14 and 7/22/14 it was documented that "the facility goals were not met continues with recurring maceration, will continue to treat as ordered". However, there were no new or updated interventions in place from 1/29/14 through 7/22/14. On 9/17/14 (date of the survey), Resident #8 was asked, "Retry ROHO cushion, notify Physician and DON of any non compliance with interventions, as well as providing teaching and encouragement". The interventions stated, "Goal was not met, care plan reviewed and amended. Area on buttocks currently open, new tx (treatment) orders received". On 9/17/14 at about 4:00 pm, during an interview with Resident #8 and her daughter, her daughter explained how difficult it was to find a satin draw sheet for a twin size bed, indicating, the one intervention that was kept was made possible because of Resident #8's daughter's intervention. On 9/18/14 Assistant Physician "H" and Physician "I" observed Resident #8's coccyx area, however no documentation on Resident #8's wound was received as of 9/18/14. ( ) Resident #8 was observed in her room on 9-16-14 at 10:45 a.m. while LPN "J" was changing the dressing on Resident #8's buttock. LPN "J" removed a 4" x 4" foam dressing from Resident #8's buttock. The dressing covered Resident #8 coccyx and entire sacrum. This Surveyor observed that Resident #8's entire sacrum area was dark purple and the skin over the coccyx was loose. There was no drainage on the old dressing. LPN "J" did not have a 4" x 4" dressing to replace the 4" x 4" dressing she removed. LPN "J" had a 2.5" x 2.5" dressing which did not cover the entire sacrum. The facility wound nurse LPN "C" came in with a 4" x 4" foam dressing and completed the treatment. This Surveyor asked LPN "C" about Resident #8's sacrum being purple and LPN "C" said Resident #8 had chronic discoloration of her buttock and maceration. LPN "C" said she did not measure or monitor the area of discoloration. During a telephone interview with the Medical Director (MD) "I" this Surveyor asked MD "I" if he had been consulted or treated Resident #8 for her chronic reoccurring pressure ulcers on her coccyx and observed her sacrum area which was dark purple. MD "I" said he could not recall seeing Resident #8 and he would need to see Resident #8's medical record to determine if he had consulted on Resident #8's wound care or observed Resident #8's purple sacrum. During an interview with Nurse Practitioner (NP) "H" on 9-17-14 at 3:00 p.m. NP "H" said she had seen Resident #8 earlier that day and Resident #8 had an open area on her left buttock and an excoriated area on the right buttock. This Surveyor asked if NP "H" had observed that Resident #8 had a a dark purple sacrum and NP "H" said Resident #8's sacrum was darker than it normally was. She had seen this chronic discoloration in chronically ill people and it was not a pressure ulcer. This Surveyor asked why NP "H" did not comment about the purple sacrum in her note for that day, NP "H" stated it was not a pressure ulcer and the nurses measure and document that type of skin problem. ( ) Review of Resident #1's undated face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and was not his own responsible party. Review of Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required extensive assistance of 2 people for transfers and was unable to walk. Resident #1's Brief Interview for Mental Status score dated 8-18-14 was 6/15 (severely impaired cognition). Review of Resident #1's electronic medical record revealed a note dated 9-12-14 at 1:39 p.m. that documented Resident #1 had an unstageble wound on his left lateral foot that measured 1.3 cm (centimeters). Resident #1 was observed in his room on 9-16-14 at 10:00 a.m. When the Surveyor and Certified Nurses Aide (CNA) "B" entered the room Resident #1's feet were off the wedge cushion and on his bed, his left lateral foot was on the mattress (the left lateral foot had a non stageable pressure ulcer). CNA "B" put Resident #1's legs up on the wedge cushion and Resident #1 complained of pain when his legs were put up. CNA "B" stated Resident #1 never kept his feet on the wedge cushion. During an interview with the facility wound nurse License Practical Nurse (LPN) "C" on 9-16-25 at 10:25 a.m., in the nursing office, this Surveyor asked LPN "C" if she was aware Resident #1 did not keep his feet on the foam wedge in his room and Resident #1 appeared uncomfortable with his feet up on the wedge cushion. LPN "C" stated hospice supplied the wedge cushion but he also had a blue positioning pillow. LPN "C" went to Resident #1's room with this Surveyor and observed Resident #1's feet up on the wedge cushion. Resident #1's right foot was pressing into the cushion on the tendon just above his heel and the rest of Resident #1's right leg was not in contact with the cushion. Resident #1's left leg was supported by the cushion and his heel was off the cushion. Resident #1 complained of leg pain. LPN "C" removed the wedge cushion and placed a blue positioning pillow under Resident #1's legs. Resident #1's legs were both supported by the blue positioning pillow and Resident #1 did not complain of pain while on the blue postioning pillow. This Surveyor asked LPN "C" which positioning aide should be provided for Resident #1. LPN "C" stated she would update Resident #1's care plan to use the blue pillow and proceeded to remove two wedge cushions from Resident #1's room. This Surveyor asked LPN "C" for documentation of assessments provided for positioning devices and LPN "C" was unable to locate any assessment/s for Resident #1's positioning devices. LPN "C" provided an updated care plan that documented Resident #1 had a wedge cushion in bed for pressure relief and it was discontinued on 9-16-14 (date of survey) and the blue positioning pillow was added to the care plan on 9-16-14 (after the observation on 9-16-14 at 10:25 a.m.). During an interview with the facility wound nurse LPN "C" on 9-17-14 at 2:30 p.m., LPN "C" reviewed the wound documentation for Resident #1. LPN "C" stated the wound on Resident #1's left lateral foot started on 8-13-14 and the wedge cushion was care planned as in place as of 11-26-13. No new intervention for pressure relief were started after the wound was found on 8-13-14. LPN "C" stated Resident #1 had a pressure ulcer on his right heel that started on 5-25-13 and the pressure ulcer on the right heel was documented as healed on 8-11-14. Review of Resident #10's undated face sheet revealed he was an [AGE] year old male admitted to the facility on [DATE] and was not his own responsible party. Review of Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's Minimum Data Set ((MDS) dated [DATE] revealed he required extensive assistance of 2 people for transfers, he was not able to walk, and his Brief Interview for Mental Status (BIMS) was 9/15 (moderate cognitive impairment). Resident #10's was observed in bed on 9-17-14 9:30 a.m. Resident #10's right foot was twisted in a blue boot, his right great toe was touching the side of the blue boot and his right heel was not in the heel of the boot. CNA "U" was observed to enter Resident #10's room to provide care and repositioned both of Resident #10's feet in his boots so that the heel of both feet were back in the heel of the blue boots. Resident #10 complained of leg pain when CNA "U" repositioned his feet. CNA "U" stated she checked on Resident #10 every 2 hours and his feet were always partially out of his boots. This Surveyor asked if CNA "U" had ever reported Resident #10's inability to keep his feet in his pressure relieving boots. CNA "U" stated she had not reported any problem/s with Resident #10's pressure relieving boots. During an interview with the facility wound nurse (LPN) "C" on 9-17-14 at 2:30 p.m., LPN "C" stated Resident #10 had the sore on his right great toe since 7-11-14. LPN "C" stated she did not know what caused the sore on Resident #10's right great toe and there were no incident or accident reports for the sore on Resident #10's right great toe. This Surveyor asked LPN "C" if she was aware Resident #10 did not keep his feet in place in the pressure relieving boot and was observed that day with his right great toe pushing into the side of the blue pressure relieving boot. LPN "C:" stated she was not aware of any problem with Resident #10's pressure relieving boots and was not aware that the pressure relieving boot was touching the wound on Resident #10's great toe. ( ) According to the 9/2/14 annual MDS (minimum data set- an assessment tool), Resident #6 was a [AGE] year old female resident who was admitted to the facility 2/29/12. [DIAGNOSES REDACTED]. Resident #6's BIMS (brief interview for mental status) was a 3 of 15, which indicated severely cognitively impaired. and was identified with having difficulty with understanding and being understood. Her Braden skin assessment for 3/3/14, 6/2/14 and 8/26/14 all indicated she was at a moderate risk for breakdown with an assessment score of 14 (13-14 = moderate risk). A review of Resident #6's annual MDS (9/2/14) reflected she had one (1) stage I pressure ulcer and 2 stage II pressure ulcers. The electronic nurse's notes (NN's) reflected the following entries, which were not all inclusive. Under the heading, "General Skin Condition": On 7/13/14, at 2: 15 a.m., "no problems noted.. At 9:34 a.m., skin intact no new problems noted... At 4:53 p.m., skin issues noted redness to both heels noted ... At 11:24 p.m., redness to heels noted". On 7/15/14, the NN's reflected: At 10:24 a.m., "Trx (treatment) performed as ordered, no new skin problems noted to area... At 10:51 a.m., under the Weekly Skin Assessment section: ...Buttocks and Sacrum continue to be red.. Feet and heels: both heels cont (continue) to be red.. and also at 5:43 p.m., redness to coccyx, no s/s (signs or symptoms) of infection noted... Under Procedure Done: Skin tx (treatment) done per order.. At 5:44 p.m. redness noted to heels ..." On 7/20/14, at 4:44 a.m., "no new skin issues noted.. At 4:45 a.m., skin intact". On 7/25/14, at 5:50 p.m., "redness noted to coccyx area, some excoriation noted". On 8/11/14, at 9:11 p.m., "Trx performed as ordered, no skin problem noted to area, no redness noted to area". This phrase was repeated 4 times with the additional phrase specific to the buttocks and heels skin intact i.e. "Trx performed as ordered, no skin problem noted to area, skin intact to buttocks". Then on 8/12/14, at 9:04 a.m., the Weekly Skin Assessment reflected the following, "...Buttocks and Sacrum: Continue to small open area less then (sic) 1 cm (centimeter) to coccyx, trx continue to buttock... feet and heels: both heels lateral of them has pressure points, skin intact but poor circulation noted, orange, black underneath skin discoloration, skin prep applied, continue to wear blue boots to bed... At 10:14 a.m., Trx performed as ordered..Buttocks is not improving to area, continue trx, not open skin intact". On 8/13/14, at 4:17 p.m., the following was recorded regarding the heel ulcers (by the wound nurse, LPN - Licensed Practical Nurse "C") Pressure Ulcer: "Assessment type: Initial assessment on 09/13/14 Pressure Ulcer: Has area of intact skin with non-blanchable redness (Pressure stg I). Site: Left heel inner aspect of bottom of heel. Stage I, 2 cm red blanches slowly surrounding skin is normal skin tone, blanchable Pressure Ulcer: Unstageable - Wound bed covered by slough and/or eschar Site: Right heel outer aspect of bottom of heel unable to stage 1.5 cm x 2 cm area tan hard skin callus like. Surrounding skin is normal skin tone, blanches easily". At 5:43 p.m., under "General Skin Condition: redness noted to heels, tx (treatment) performed as ordered". And again, the same nurse (LPN "M") recorded at 5:43 p.m., "no new problems noted". Nurse "M" mentioned nothing about the unstageable pressure ulcer on Resident #6's heel and the description by the wound nurse, mentioned nothing about a red left heel which contradicted LPN ("C"). On 8/17/14, at 1:25 p.m., under "General Skin Condition," LPN "Y" recorded, "Pt (patient) heels has a thick layer of skin that can peel of (sic) heel and will cause heel pressure ulcers to be open". At 9:31 p.m., LPN "M" documented, "redness and soreness noted to bilateral heels. no s/s of infection. dressing dry and intact bilateral heels reddened and sore, tx performed as ordered". On 8/18/14, at 7:56 p.m. LPN "Y" recorded, "dressings to both heels are clean, dry and intact". On 8/19/14, at 10:56 a.m., LPN "Z" recorded in the Weekly Skin Assessment: (under) Feet and heels: dressings are clean, dry and intact to bilateral heels". On 8/22/14, at 12:02 p.m., Wound Nurse "C" recorded the left heel was a stage I. Under "Ulcer Status: improving. outer aspect of heel has 4 cm x 2 cm area of red tissue paper like skin that blanches very slowly... Right heel, Stage II, improving - inner aspect of heel with 2.5 cm x 3 cm open area- with [MEDICATION NAME] resurfacing occurring. Surrounding skin is light res (sic), tissue paper like skin that is blanchable". On 8/26/14, at 12:06 p.m., Nurse "C" in the Weekly Skin Assessment, recorded under "Buttocks and sacrum: continue to be to coccyx, trx in place.. (under) Feet and heels: both heels are open". On 9/8/14, at 12:29 p.m., Nurse "Y" recorded under "General Skin Condition: Heels has improved, heels no longer open. Skin intact. No s/s of infection. Trx d/c (discontinue) MBC (Magic Butt Cream), skin prep heel initiated". There were no entries in which Resident #6 was non-compliant with turning, repositioning or elevating heels. An entry in the nursing notes on 8/13/14, at 4:17 p.m., reflected that Hospice had provided a wedge cushion to float Resident #6's heels, as heel lift boots had been ineffective. A review of Resident #6's Care Plans, specific to skin integrity reflected, under the "Problem section, potential for impaired skin integrity, moderate risk for skin breakdown," dated 2/28/14. The "Approaches included: Skin assessments, weekly per policy. Administer medications and treatments as ordered and evaluate effectiveness. Involve Hospice providers with skin care and management, report changes in skin to DON (Director Of Nursing), dietary and physician or Nurse Practitioner. On 3/19/14, a mat to the wall at bedside was added". Floating of heels while in bed, was not added until 8/13/14 when the heels began to open up from being red (after the fact, not before) even though Resident #6 was identified as being at risk. There was no turning, repositioning in bed, or while up in her wheelchair all day. On 9/18/14, at approximately 11 a.m., the DON stated that Resident #6's previous Care Plans included preventive measures, approaches for her heels and bottom while in bed and up in her wheelchair. However, these were not carried over with the addition to the Care Plan on 8/13/14 and the current care plan during the time of the survey. Additionally, a request for those approaches was made at that time, but were not provided prior to the exit on 9/18/14. ( )