Every finding on record at St. Ann's Skilled Nursing and Therapy

Based on observation, record review, and interview, the facility failed to ensure the common area and resident rooms were clean for 3 (#9,10, and #11) of 4 sampled residents reviewed for homelike environment. The DON identified 106 residents resided in the facility. Findings:On 07/15/26 at 9:40 a.m., trash was observed under Resident #11's bed that included a tissue and a plastic cup.On 07/15/26 at 1:28 p.m., a dead black/light grey bug with black stripes on the back was observed in a corner of the baseboards in the common area by the central nursing station. A spider web with small trapped insects was also observed.On 07/15/26 at 1:32 p.m., another spider web was observed in another corner further down along the same baseboards in the common area by the central nursing station.On 07/15/26 at 1:33 p.m., a dead brown bug was observed in the common area by the bookshelves near the central nursing station.A facility policy titled Housekeeping Policies & Procedures, dated 06/29/12, read in part, Failing to mop separately along the baseboards will cause a dirt build up near the baseboard. The floor may be clean, but it won't clean if the baseboards are dirty . it is the duty of both Housekeeping and Nursing to clean the resident unit - the bed, night stand, over bed table, dresser, and any spills.On 07/14/26 at 11:05 a.m., Resident #10 stated staff did not clean their room because the facility fired everyone.On 07/14/26 at 11:13 a.m., Resident #9 stated staff had not cleaned their room in approximately two weeks, and they had to clean the dressers themselves.On 07/15/26 at 9:40 a.m., Certified Nursing Assistant #1 stated the facility was low on housekeeping staff, and they had to clean the facility.On 07/15/26 at 9:46 a.m., Resident #11 stated they had bugs in their room frequently and their room was not as clean as they would like it. They stated their room had not been cleaned in two or three weeks.On 07/16/26 at 4:31 p.m., the DON stated housekeeping staff looked into rooms, the entrance, and common areas for trash and bugs. They stated their expectation for housekeeping staff was to clean up bugs in common areas.On 07/16/26 at 5:03 p.m., the laundry/housekeeping manager stated they informed staff to move furniture and then sweep and mop. They stated they informed their floor tech to keep an eye on the corners of the common areas for bugs. The laundry/housekeeping manager stated they expected staff to clean up dead bugs found in the common area. The laundry/housekeeping manager identified spider webs and dead insects on ground in the common area by the central nursing station. They stated it was not a homelike environment.

Based on record review and interview, the facility failed to ensure coordination of care with hospice services for 1 (#1) of 3 residents sampled for services per physician orders.The corporate nurse consultant identified 10 residents who received hospice services.Findings:A Hospice-Nursing Facility Contract, dated 07/08/25, read in part, Hospice and facility shall communicate with one another regularly and as needed for each particular hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day.An undated diagnosis report showed Res #1 had diagnoses which included Alzheimer's disease and dementia.A quarterly assessment, dated 10/25/25, showed Res #1 was severely cognitively impaired with a BIMS score of 00. The assessment showed Res #1 had no swallowing disorders and received hospice services.A nurse note, dated 11/04/25, showed Res #1 was declining in health with difficulty chewing and swallowing food and medications. The note showed hospice was contacted for reassessment.An undated hospice communication form showed Res #1 had been assessed by Hospice RN #1. Hospice RN #1 documented the physician would be contacted for a liquid antibiotic and pureed diet orders for Res #1. The form showed RN #2 had acknowledged receipt of the communication form.A hospice physician order fax form, dated 11/05/25, showed to administer cephalexin (an antibiotic) 500 mg every eight hours for seven days. The order form showed the facility received the fax on 11/11/25.A hospice physician order fax form, dated 11/10/25, showed to start a mechanical soft diet and may crush medications. The order form showed the facility received the fax on 11/11/25.A nurse note, dated 11/10/25, showed Res #1's family was upset due to the delay in antibiotic administration. The note showed hospice attempted to fax the physician orders multiple times unsuccessfully. The note showed verbal orders were received from hospice and initiated.An electronic physician order, dated 11/10/25, showed to start a pureed diet and crush medications.An electronic physician order, dated 11/11/25, showed to administer cephalexin 500 mg every eight hours for seven days for infection.A hospice communication form, dated 11/11/25, showed Res #1 had been assessed by Hospice RN #1. Hospice RN #1 documented Res #1's lung sounds and heart rate were improved and no signs/symptoms of pain were observed. The form showed RN #2 had acknowledged receipt of the communication form. A grievance form, dated 11/11/25, showed Res #1's family member voiced concerns regarding timeliness of diet change, medications being crushed, and receipt of hospice orders via fax.A QAPI form, dated 11/11/25, showed hospice orders implemented timely was identified as a problem. The form showed the immediate plan of correction was review of internal communication daily, staff in-service, and compliance rounds daily for 5 days, weekly for 4 weeks, and monthly for 2 months until compliance reached.A grievance resolution form, dated 11/14/25, showed the following interventions to prevent recurrence: hospice provider was contacted to change process of receiving orders. Hospice staff were to bring verbal orders sheets to place in residents' hospice binders instead of faxing orders to the facility,education provided to nurses regarding follow-up for changes made by hospice and/or physicians,in-service completed with staff,ombudsman notified, andreview of internal hospice communication daily.A Hospice in-service form, dated 11/14/25, showed staff were educated on follow-up, coordination of care, and ensuring family communication.A Sentinel Event Compliance Round Tracking form showed compliance rounds regarding hospice orders had been completed on 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/17/25, 11/24/25, 12/01/25, and 12/08/25.On 12/08/25 at 2:35 p.m., RN #2 stated they received a communication form from the hospice nurse on 11/04/25 regarding Res #1. They stated the hospice nurse had communicated they would contact the physician and obtain orders for an antibiotic. RN #2 stated they had not realized the orders were not received until Monday 11/10/25 when Res #1's family member voiced concern regarding the delay in the initiation of the antibiotic. RN #2 stated they should have followed up with the hospice agency to ensure the orders had been received and initiated. RN #2 stated they had received education regarding the importance of follow-up for changes made by hospice and/or physicians. On 12/08/25 at 2:40 p.m., the ADON stated the staff noted a decline in Res #1 on 11/04/25 and notified hospice. They stated the hospice nurse assessed Res #1 and wrote on the communication form the physician would be contacted regarding a change in diet and an antibiotic for possible infection. The ADON stated the facility had not received the orders until 11/10/25 and 11/11/25. They stated RN #2 should have followed up with the hospice nurse within a few hours after the visit or reported to the oncoming nurse to follow up with the hospice nurse regarding the order changes for Res #1 that had been discussed earlier that day. The ADON stated RN #2 was counseled following the incident. They stated hospice was contacted and changes in the receipt of orders were made to prevent recurrence. The ADON stated facility staff were in-serviced, hospice communication forms were being reviewed daily, and compliance rounds continued at this time. On 12/08/25 at 3:00 p.m., hospice RN #1 stated they assessed Res #1 on 11/04/25 and thought the resident may have an infection. They stated the physician was contacted and orders for an antibiotic were received. Hospice RN #1 stated they asked their office to fax the orders to the facility and had not realized the orders were not received. They stated the staff at the facility had not followed up with them to ensure the orders were received until 11/10/25. Hospice RN #1 stated verbal order sheets will be placed in residents' hospice binders instead of faxing physician orders going forward. On 12/09/25 at 1:00 p.m., hospice office staff #1 stated the physician orders for Res #1 were faxed to the facility on [DATE] and again on 11/11/25. They stated no record of the orders having been faxed to the facility prior to these dates.

Based on observation, record review, and interview, the facility failed to update a care plan for 1 (#14) of 22 sampled residents observed for accurate care plans. The DON identified 105 residents resided in the facility. Findings: On 06/12/25 at 1:37 p.m., Resident #14 was observed sitting up in bed at approximately a 75 degree angle and slowly feeding themselves. Most of their food was still on their plate. They stated, It would be nice if I had help. On 06/12/25 at 2:00 p.m., CNA #10 went in and asked if Resident #14 was done and then left the tray with them, but did not assist. A care plan, initiated on 10/06/21, showed Resident #14 required supervision or limited staff participation to eat. The care plan had not been revised. On 06/12/25 at 2:12 at p.m., CNA #10 stated, I don't know why [Resident #14] is in [their] room, I take care of the opposite side of the hall. I already went in there twice and [Resident #14] said [they were] fine. [Resident #14] is not a feeder as far as I know. We have a feeding table in the dining room for those that require assistance. [Resident #14] didn't get [their] tray until almost one o'clock. I'm not just going to leave [Resident #14] there, I am going to ask if [they] need help. I am the one that passed the trays, so it is my responsibility to make sure the residents on the hall get assistance if they need it, while CMA #3 is assisting in the dining room. On 06/12/25 at 2:18 p.m., CMA #3 stated, I believe [Resident #14] requires queuing and supervision. [Resident #14] did not want to go to the dining room for lunch today. We can look at the care plan to find out what kind of assistance they require if we don't know. On 06/12/25 at 2:25 p.m., the MDS coordinator stated, [Resident #14] had a significant change assessment done on 04/04/25 because their functional status had declined and they were picked up by hospice. The significant change assessment shows that [Resident #14] required substantial/maximal assistance with eating. The care plan shows [Resident #14] requires supervision or limited staff participation to eat. That part of the care plan was initiated on 10/06/21, and has not been revised since then. I am supposed to update care plans every time I complete a comprehensive assessment. I must have missed it. On 06/12/25 at 2:53 p.m., the administrator stated, Yes, care plans should be current and the expectation is that staff should assist when a resident requires assistance with eating.

Based on observation, record review, and interview, the facility failed to provide eating assistance for 1 (#14) of 1 sampled resident observed for eating assistance. The DON identified 105 residents resided in the facility and eight residents required feeding assistance. Findings: On 06/12/25 at 1:37 p.m., Resident #14 was observed sitting up in bed at approximately a 75 degree angle and slowly feeding themselves. Most of their food was still on their plate. They stated, It would be nice if I had help. On 06/12/25 at 2:00 p.m., CNA #10 went in and asked if Resident #14 was done and then left the tray with them, but did not assist. A Nursing Skills Guideline, revised 03/2025, read in part, Our facility is committed to providing care that respects the dignity, preferences, and unique needs of each resident. Assistance with activities of daily living will be provided in a manner that prioritizes the resident's comfort, safety, and personal preferences .To ensure care aligns with the principles of person-centered care, enhancing the quality of life and satisfaction of our residents. A significant change assessment, dated 04/04/25, showed Resident #14 required substantial/maximal assistance with eating and had a BIMS score of 10 indicating moderate cognitive impairment. On 06/12/25 at 2:12 at p.m., CNA #10 stated, I don't know why [they are] in [their] room, I take care of the opposite side of the hall. I already went in their twice and [they] said [they were] fine. [They are] not a feeder as far as I know. We have a feeding table. [They] didn't get [their] tray until almost one o'clock. I'm not just going to leave [them] there I am going to ask if [they] need help. I am the one that passed the trays, so it is my responsibility. On 06/12/25 at 2:53 p.m., the administrator stated, The expectation is that staff should assist when a resident requires assistance with eating.

Based on record review and interview, the facility failed to ensure the 5 rights of medication administration to prevent medication errors for 1 (#257) of 22 residents reviewed for medication administration. The DON identified 105 residents resided in the facility. Findings: A policy titled Preparation for Medication Administration, revised 12/01/12, read in part, Medications are administered at the time they are prepared .Residents are identified before medication is administered. The medication nurse or certified medication aide will turn to that resident's medication sheet, compare photo with resident and positively identify the resident. An incident note, dated 06/02/25 at 10:45 p.m., read in part, Medication aide stated to nurse that [they] had made a mistake while attempting to administer medication. [They] state[d] that [they] had two patients who take their medication with applesauce. [They] prepared one cup of medication, applied applesauce and placed it in the cart to give a potassium tablet time to dissolve due to patient being unable to take it whole. [They] then prepared another patients medication and applied applesauce to it as well [they] then pushed [their] cart to [Resident #257's room] and gave the medication in the cup along with applesauce and when [they] returned to [their] cart [they] realized that the appropriate medication cup containing the potassium tablet was still in the cart dissolving. [They] immediately reported [their] findings to the nurse and the patients vitals were assessed right away. provider, family and management were all notified and medication aide was educated on the 5 rights on medication administration. Interventions to monitor vitals q [every] 2 are in place. On 06/10/25 at 11:06 a.m., LPN #6 stated, My med aide [CMA #6] reported that [they] had two different meds for residents in applesauce. One was potassium dissolving, I believe baclofen was the other that was inappropriately given. I educated [them] about the 5 rights of medication administration, notified the essential people, and initiated every two hour vital sign checks. I was noticing lower oxygen levels, I think it was [Resident #257's] baseline. There were no others symptoms. During my monitoring [Resident #257] was fine. Resident [#257] was on B hall at that time. The med aide [#6]worked down there quite often. On 06/10/25 at 3:15 p.m., CMA #6 stated, I was letting a resident's med melt in applesauce. I had another resident that also had to be crushed and added to applesauce.I usually use the PIG [punch, initial, give] method, and I check it three times. While the potassium was dissolving, I got [Resident #101's] baclofen because [they] asked for it while I was letting the potassium dissolve. I accidentally took the baclofen to [Resident #257] because I was getting [their] meds ready before I was asked to get [Resident #101's] medication. On 06/10/25 at 3:38 p.m., the DON stated, The nurse called me and let me know about the situation, I asked how [Resident #257] was, and if they had called the physician. I provided education to [LPN #6 and CMA #6] on the five rights of medication administration. The next day is when we started our in-service for the rest of the staff. We are scheduled to have our QA [quality assurance] meeting at the end of the month and the medication error will be addressed. We did already start monitoring medication administration with compliance rounds for five days, and then it will be weekly.

Based on record review and interview, the facility failed to accurately complete a resident assessment for one (#50) of 22 sampled residents reviewed for accurate assessments. The Administrator identified 106 residents resided in the facility. The Corp Nurse Consultant identified 28 residents who received anticoagulant medications. Findings: Resident #50 had diagnoses which included, heart disease, chronic obstructive pulmonary disease, and high cholesterol. A physician's order, dated 04/26/24, documented the resident was to be administered Aspirin 81 milligrams one tablet one time a day in the evening. A physician's order, dated 04/27/24, documented the resident was to be administered Plavix 75 milligrams one time a day. An Admission Assessment, dated 05/02/24 documented Resident #50 received anticoagulant medications. On 05/13/24 at 12:26 p.m., Resident #50 was asked what all the bruising was on their arms. They stated My skin was thin and I take Plavix and Aspirin. On 05/16/24 at 11:40 a.m., MDS Coordinator #1 was shown the admission assessment and Resident #50's physician orders. They were asked what medication Resident #50 had been on that was an anticoagulant. They stated they had coded the Plavix as an anticoagulant. They were asked if Plavix was an anticoagulant. They stated, Yes and ASA was an antiplatelet. On 05/16/24 at 11:55 a.m., MDS Coordinator #1 stated, Plavix is not an anticoagulant, I coded it wrong. On 05/16/24 1:59 p.m., the DON was asked if they were aware Plavix had been coded as an anticoagulant been coded as an anticoagulant. They stated Yes.

Based on record review, observation and interview, the facility failed to ensure a resident experiencing pain received treatment for pain for one sampled resident (#51) of 35 residents who receive pain medications and treatment. The DON stated 106 residents resided in the facility. Findings: A Pain policy revised, 09/10/07, read in part .1. The leadership of the long-term care facility must ensure that a commitment to resident comfort permeates all aspects of the facility's operation .2. Appoint a pain management coordinator with the responsibility for ensuring that all residents are properly assessed for pain and that all residents who have pain receive effective treatment. 4. Proper communication between teams members must be in place to ensure that information about the resident's pain is routinely conveyed and acted upon. Documentation should meet the same standards regardless of the nursing shift involved and communication between shift changes is vital . Resident (#51) had a diagnosis which included Syncope and Collapse. A Pain Care Assessment, last reviewed 05/11/24, documented Resident (#51) had pain now. Resident (#51) had pain in the past few months. How often does it occur? Resident #51 reported daily and sometimes worse. Resident(#51) reported it is continuous. A Nursing/Progress Note, documented on 05/14/24 for Resident (#51) daughter called stating they have been having pain in their foot and they believe it's gout. They stated they are unable to sleep at night. On 05/14/24 at 11:01a.m., there was no further documentation for pain or pain medication administered in Resident(#51) progress notes. A Care-plan, last reviewed 04/02/24, documented resident (#51) Evaluate the effective of pain interventions. Review for compliance , alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. On 05/14/24 at 10:43a.m., LPN#3 stated Resident (#51) does not have PRN pain medication. On 05/14/24 at 10:44a.m., LPN#3 reported On 05/14/24 at 10:45a.m., LPN#3 stated Resident #51 was not reported to the Physician when Resident #51 reported pain. On 05/16/24 at 11:25a.m., the DON reported that Resident #51 was not administered pain medication after Pain Assessment on 05/11/24. On 05/16/24 at 11:26a.m., the DON reported that Resident #51 was not administered pain medication after daughter reported pain for Resident #51, documented in Progress Notes on 05/14/24.35 residents recieve pain medications

Based on observation, record review, and interview, the facility failed to ensure a medication was available to administer for one (#209) of three sampled residents reviewed during medication observation. The administrator identified 106 residents resided in the facility. The Corp nurse consultant identified 106 residents received medications. Findings: A Medication Ordering and Receiving From Pharmacy policy, dated January 2022, read in part, .Medications and related products are received from the dispensing pharmacy on a timely basis . Resident #209's MAR documented 9 on 05/14/24 at 8:00 p.m., and 05/15/24 at 8:00 a.m. An Orders Administration Note, dated 05/15/24 at 8:14 a.m., read in part .Buprenorphine HCL Sublingual Tablet 2 MG .Ordered yesterday still haven't received order . An Orders Administration Note, dated 05/14/24 at 8:18 p.m., read in part .Buprenorphine HCL Sublingual Tablet 2 MG .waiting on pharmacy to deliver medication . On 05/15/24 at 9:18 a.m., the DON was asked why Resident #209's medication was not available to administer. They stated it was not in the facility. They were asked when the last time the medication had been administered. They reviewed the May 2024 MAR and stated yesterday morning. Resident #209 had missed two doses.

Based on observation, record review, and interview, the facility failed to ensure staff implemented infection control measures (sanitized their hands) while passing medications. The Administrator identified 106 residents resided in the facility. The Corp Nurse Consultant identified 106 residents received medications. Findings: A Hand Hygiene policy, dated 10/07/03, read in part, .Hand hygiene the simple and effective method of preventing the spread of pathogens which cause infections .Failure to properly clean hands can result in the spread of these pathogens to residents .The singe most important step in the prevention of infection is hand hygiene . On 05/15/24 at 7:55 a.m., CMA #1 was observed to pop a tablet of Eliquis that fell in the open med cart drawer. CMA #1 then popped another pill that fell on the floor. CMA #1 was observed to pick the pill up off the floor and throw it in the trash on the end of the cart. They were not observed to sanitize their hands then continued to pop the rest of Resident # 210's medications (four meds). Then administered the medications to the resident. On 05/15/24 at 9:01 a.m., CMA #1 was asked where they disposed of the Eliquis medication that fell on the floor. They stated, In the trash. They were asked if they sanitize their hands after they picked the pill up off the floor. They stated, No. They were asked if there was hand sanitizer on the cart. They opened the cart then stated they use the ones on the hall walls. No hand sanitizer was observed in the medication cart. On 05/15/24 at 9:18 a.m., the DON was asked if staff were expected to sanitize their hands while passing medications. They stated yes, before each resident and after each resident. The DON was asked if staff dropped a pill on the floor, should they sanitize their hands. They stated yes, after they discard the pill.

Based on record review and interview, the facility failed to ensure bathing was offered to resident (#3 and #31) of five sampled residents reviewed for bathing. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: 1. Resident #3 had diagnoses which included mood disorder with anxiety. Resident #3's ADL's report, admitted [DATE], documented bathing was scheduled for Wednesdays and Saturdays on the 3-11 shift. The annual resident assessment, dated 01/06/23, documented the resident's cognition was intact. It documented the showers were very important, the resident required physical help of one person for bathing, and the resident had no documented rejection of care. On 03/29/23 at 7:19 a.m., Resident #3 stated they had not been receiving showers. Resident's #3's Documentation Survey Report form, dated January 2023, documented the resident was offered two out of eight baths and had received one out of eight opportunities for baths. Resident's #3's Documentation Survey Report form, dated February 2023, documented the resident had received one out of eight opportunities for baths. Resident's #3's Documentation Survey Report form, dated March 2023, documented the resident was offered three out of nine baths and had received one out of nine opportunities for baths. On 04/03/23 at 10:39 a.m., Resident #3 stated, I was supposed to get a shower last week and did not. On 04/03/23 at 10:52 a.m., CNA #4 stated Resident #3's showers were scheduled on the evening shifts and the resident required physical help of one person for bathing. On 04/03/23 at 11:07 a.m., the DON and Corp Nurse Consultant #1 were asked where the documentation was for showers/baths. The DON stated showers were documented by the CNAs in each resident's electronic medical record. The DON reviewed the resident's clinical records and stated the resident had scheduled showers for Wednesdays and Saturdays on the 3p-11p shift. On 04/03/23 at 11:09 a.m., the Corp Nurse Consultant #1 stated the resident's record documented two showers were received and one was refused for the month of March. On 04/03/23 at 11:11 a.m., the DON was asked how did the facility monitored to ensure residents were offered baths as scheduled. The DON stated, We do Q2 and our dash board will show missed showers. The DON and Corp Nurse Consultant #1 acknowledged missed showers. 48344 2. Resident #31 had diagnoses which included neurocognitive disorder with Lewy bodies, hemiplegia and hemiparesis, cerebrovascular disease affecting left non-dominant side, Parkinson's disease, muscle wasting and atrophy. Resident #31's ADL report, admitted [DATE], documented the resident's shower was scheduled for Tuesday and Thursday on 3-11 shift. Resident #31's ADL record, dated January 2023, did not contain documentation of showers. Resident #31's quarterly assessment, dated 02/02/2023, documented the resident's cognition was intact. It documented they required physical help in part of bathing activity with one person physical assist. Resident #31's ADL record, dated February 2023, documented Resident #31 missed four out of eight shower opportunities. On 03/29/23 at 6:54 a.m., Resident #31 stated they missed showers often. Resident stated, Staff don't give showers unless reminded. Resident stated missed showers started the last three months. Resident #31's ADL record, dated March 2023, did not contain documentation of showers for the last 30 days. On 04/03/23 at 10:52 a.m., CNA #4 stated showers were documented on the resident's clinical record. CNA #4 stated they report refusal to the charge nurse. On 04/03/23 at 10:47 a.m., LPN #4 stated showers were documented on the residents clinical record. LPN #4 stated they gave the resident multiple opportunities during the shift for a shower before a refusal was documented on the resident's clinical record. 04/03/23 at 11:15 a.m., the DON reviewed Resident #31's ADL documentation. She acknowledged there had been missed showers.

Based on record review, observation, and interview, the facility failed to ensure a clean homelike environment was provided for two (#4 and #48) of 32 sampled residents reviewed for environment. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: A Housekeeping policy, revised 06/29/12, read in part, .Cleaning procedures for the facility are carried out on a daily and weekly basis .There may also be resident rooms that require more than just daily cleaning . On 03/29/23 at 8:47 a.m., a wipe was observed under the head of Resident #48's bed. Dried, light, brown liquid was observed on the floor approximately two feet from the bed. A torn alcohol pad was observed on the floor next to the dried brown liquid. A white straw, black stir stick, and white tissue were observed on the floor, under the bed near the wall. On 03/29/23 at 9:13 a.m., CNA #1 was asked how staff ensured residents' rooms were cleaned. They stated they notify housekeepers when they needed to. CNA #1 stated they would call for a housekeeper when they were done in the room. CNA #1 stated they had worked yesterday and thought the floor looked the same. CNA #1 stated, The floor could use a mop. On 03/29/23 at 9:47 a.m., dried brown liquid was observed on the floor under Resident #4's peg tube pole. Dried black drops of liquid were observed in entry way of Resident #4's room. [NAME] streaks were observed on the floor from the doorway to the middle of the room. Resident #4 stated staff completed mopping weekly. On 03/30/23 at 8:25 a.m., a wipe was observed under the head of Resident #48's bed. Dried, light brown liquid was observed on the floor approximately two feet from the bed. A torn alcohol pad was observed on the floor next to the dried brown liquid. A white straw, black stir stick, and white tissue were observed on the floor, under the bed near the wall. Black streaks were observed on the floor from doorway of Resident #48's room to the middle of the room. On 03/30/23 at 8:31 a.m., housekeeping supervisor was asked how staff ensured a clean homelike environment. She stated they clean and sanitized everything. She stated they checked the floor, blinds, and curtains. She was asked how often the floor was swept and mopped. She stated, Every single day. She stated they moved furniture if the resident was out of the room, or at least reached under the furniture to sweep and mop. On 03/30/23 at 8:34 a.m., the housekeeping supervisor was shown Resident #4 and #48's room. She was asked what was the dry liquid by Resident #48's bed. She stated the resident probably had an accident. The housekeeping supervisor was asked to look under the bed. She stated she saw trash and stains. She was asked when the last time the room had been swept and mopped. She stated yesterday. Housekeeping supervisor was made aware of the observations yesterday morning. She stated she would follow up with her housekeeper to see what happened.

Based on observation, record review, and interview, the facility failed to provide a pest free environment for one (#3) of five sampled residents reviewed for pest control. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 101 residents resided in the facility. Findings: A Pest Control Policy policy, dated 10/24/2008, read in parts, .It is the policy of this facility to maintain an effective pest control program so that the facility is free of pest and rodents. The purpose of a pest control program is .to correct or eliminate infestation already in existence .The practice of preventative pest control is considered to be most economical and effective means of protecting our residents, employees and visitors .Maintenance personnel should ensure that the facility is free of herbage areas within the facility. All cracks and crevices should be sealed .The administrator is ultimately responsible for monitoring and delegating of the department functions . The facility's Completed Work Order, reviewed 12/01/22 though 03/30/23 did not contain documentation of work orders related to rodents. A Pest Sighting Log, dated 12/27/22, documented a rodent was observed in a resident's room and the pest control company was called. On 03/29/23 at 6:54 a.m., Resident #31 stated there were mice located their previous room. Resident #31 stated, I was moved from that room because I got tired of the mice. On 03/29/23 at 7:15 a.m., Resident #3 stated there were one or two mice in their room and have informed the Social Service Director and the Administrator. Resident #3 stated, I have told them several times. On 03/30/23 at 1:03 p.m., Resident #3's family member stated, A mice just ran over my foot and I went and got [Social Service Director] because they have not fixed this. The family member stated, I am taking [Resident #3] out of facility for fresh air. The family member stated, They just have a mouse trap in there. On 03/30/23 at 1:17 p.m., a mouse trap was observed behind the door of Resident #3's room with mouse droppings observed near the trap. A Pest Sighting Log, dated 03/30/23, documented a rodent was observed in the same resident's room that was previously observed on 12/27/22 and the pest control company was called. On 04/03/23 at 10:35 a.m., Resident #3 stated, There is like five mice now. They run from under the cabinet, under my bed, and over to my neighbor. They told me there were mouse droppings but no mouse caught. They have not offered me a different room. I can't even have food in my room. On 04/03/23 at 11:01 a.m., LPN #4 stated there was a mouse that lived at the end of the hall. They stated, I have seen it when I work the overnight shift. On 04/03/23 at 11:03 a.m., LPN #4 stated they had been working at the facility multiple years. They stated the mouse was the facility's mascot. They stated, currently, Resident #3 was the only one complaining about the rodents. On 04/03/23 at 1:02 p.m., the Administration was asked if she was aware of the pest control problem. She stated she knew there had been issues a couple of years ago but wasn't aware there had been a current problem until last week.

Based on record review and staff interview, it was determined the facility failed to ensure neurological assessments had been completed for a resident who experienced an unwitnessed fall for one (#1) of three sampled residents reviewed for falls. The facility identified 92 residents resided in the facility. Findings: Resident #1 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 01/29/20, documented the resident's cognition was severely impaired. She required extensive assistance of two people with transfers, bed mobility, dressing and bathing. Fall risk assessments had been conducted and the resident was noted to be high risk for falls. A nursing progress note, dated 11/23/19, documented the resident had an unwitnessed fall next to her bed. It documented, .Neuro (neurological) checks normal for resident . A Monitoring Neurological Status form, dated 11/23/19, documented, .Perform neurocheck initially every 15 minutes x (times) 1 hour, every 30 minutes x 1 hour, every hour x 4 hours, then every 8 hours. Documentation would continue every shift for total charting of 76 hours after incident. There was no documentation neurochecks had been completed every 15 minutes for the first hour or every 30 minutes x 1. There was no documentation neurochecks had been completed on the 7:00 a.m. to 3:00 p.m. shifts (every 8 hours) for three days. On 02/22/20 at 11:11 a.m., the corporate nurse was asked what the facility policy was for conducting neurochecks. She stated, following an unwitnessed fall or a witnessed fall and the resident hit their head. The corporate nurse was shown the neurological status monitoring record dated 11/23/19 and shown where there was no documentation of the every 15 minute checks x 4, every 30 minute checks x 1 and 7:00 a.m. to 3:00 p.m. 8 hour checks completed on the sheet. She was asked if neurochecks should have been completed. She stated, Yes.

Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure there was adequate staff to provide activities of daily living (ADLs) to dependent residents for one (#36) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility, 58 residents required assistance of one or more with bathing and 81 residents required assistance of one or more with transfers. Findings: Resident #36 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 08/25/19, documented the resident's cognition was moderately impaired. She required extensive assistance with transfers and physical help in part of bathing activity. The resident's bathing record documented the resident was to be bathed on Tuesdays, Thursdays and Saturdays. It documented during the weeks of 09/15/19 through 09/21/19, 10/06/19 through 10/12/19 and 10/20/19 through 10/26/19 the resident had been bathed twice each week. One day during each of those weeks documented not applicable. On 11/03/19 at 9:40 a.m., the resident and the resident's family member were asked if there was adequate staff to meet her needs and were those needs met without having to wait a long time. The resident's family member stated she had to wait 30 to 40 minutes at times for her call light to be answered. The resident stated there wasn't enough staff. She was asked if she was bathed according to her preference. She stated she was supposed to be bathed three times a week and sometimes she was bathed only twice. The resident's family member stated she could tell she wasn't bathed by the way her hair smelled. At 9:44 a.m., the resident's family stated the resident wanted to go to bed. The resident's family member activated the call light at the resident's bed. The light on the call light box was illuminated. At 10:25 a.m., the resident's call light had not been answered and the family member activated the emergency call light in the resident's bathroom. The light on the call box was illuminated. At 10:40 a.m., the resident's call light had not been answered. Certified nurse aide (CNA) #2 was observed on the resident's hallway. She was asked when the resident's call light had been activated. She reviewed the documentation in her call light notification pager. She stated the call light had been activated at 9:44 a.m. CNA #2 was asked what the policy was for answering call lights. She stated call lights were to be answered as quickly as possible. She was asked if the resident's call light was answered in a timely manner since it was activated at 9:44 a.m. She stated, No ma'am. She was made aware the resident had wanted to go to bed. On 11/05/19 at 12:29 p.m., CNA #1 was asked how often the resident was bathed. She stated on Tuesdays, Thursdays and Saturdays. She stated when residents were bathed it was documented in the their electronic record and on shower sheets. She stated there should be documentation the resident was bathed or if she refused. She was shown the resident's bathing record and asked what it meant when not applicable was documented. She stated she would have to say she wasn't bathed. At 12:32 p.m., the corporate nurse was asked to provide documentation for the reason the resident had not been bathed three times a week as scheduled for the above weeks. At 2:25 p.m., the corporate nurse stated she contacted the aides who worked during those weeks. She stated they indicated the resident had been bathed. She was made aware there was no documentation the resident had been bathed. She acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure physician's orders were followed to obtain daily weights for one (#243) of three sampled residents reviewed for weights. The facility identified one resident with orders for daily weights. Findings: Resident #243 had [DIAGNOSES REDACTED]. He discharged from the facility on 07/26/19. A physician's order, dated 07/14/19, documented, .daily weight Dx (diagnosis) :[MEDICAL CONDITION] one time a day related to HYPERTENSIVE [MEDICAL CONDITION] WITH HEART FAILURE . A vital signs report documented the resident had been weighed on 07/19, 07/21 and 07/22/19. On 11/06/19 at 12:36 p.m., the corporate nurse was shown the order for daily weights. She reviewed the resident's clinical record. She was asked if weights had been obtained as ordered. She stated staff obtained weights on 07/19, 07/21 and 07/22/19. She acknowledged the findings.

Based on observation, record review and resident, family and staff interviews, it was determined the facility failed to ensure there was adequate staff to provide activities of daily living (ADLs) to dependent residents for one (#36) of two sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility, 58 residents required assistance of one or more with bathing and 81 residents required assistance of one or more with transfers. Findings: Resident #36 had [DIAGNOSES REDACTED]. A quarterly resident assessment, dated 08/25/19, documented the resident's cognition was moderately impaired. She required extensive assistance with transfers and physical help in part of bathing activity. The resident's bathing record documented the resident was to be bathed on Tuesdays, Thursdays and Saturdays. It documented during the weeks of 09/15/19 through 09/21/19, 10/06/19 through 10/12/19 and 10/20/19 through 10/26/19 the resident had been bathed twice each week. One day during each of those weeks documented not applicable. On 11/03/19 at 9:40 a.m., the resident and the resident's family member were asked if there was adequate staff to meet her needs and were those needs met without having to wait a long time. The resident's family member stated she had to wait 30 to 40 minutes at times for her call light to be answered. The resident stated there wasn't enough staff. She was asked if she was bathed according to her preference. She stated she was supposed to be bathed three times a week and sometimes she was bathed only twice. The resident's family member stated she could tell she wasn't bathed by the way her hair smelled. At 9:44 a.m., the resident's family stated the resident wanted to go to bed. The resident's family member activated the call light at the resident's bed. The light on the call light box was illuminated. At 10:25 a.m., the resident's call light had not been answered and the family member activated the emergency call light in the resident's bathroom. The light on the call box was illuminated. At 10:40 a.m., the resident's call light had not been answered. Certified nurse aide (CNA) #2 was observed on the resident's hallway. She was asked when the resident's call light had been activated. She reviewed the documentation in her call light notification pager. She stated the call light had been activated at 9:44 a.m. CNA #2 was asked what the policy was for answering call lights. She stated call lights were to be answered as quickly as possible. She was asked if the resident's call light was answered in a timely manner since it was activated at 9:44 a.m. She stated, No ma'am. She was made aware the resident had wanted to go to bed. On 11/05/19 at 12:29 p.m., CNA #1 was asked how often the resident was bathed. She stated on Tuesdays, Thursdays and Saturdays. She stated when residents were bathed it was documented in the their electronic record and on shower sheets. She stated there should be documentation the resident was bathed or if she refused. She was shown the resident's bathing record and asked what it meant when not applicable was documented. She stated she would have to say she wasn't bathed. At 12:32 p.m., the corporate nurse was asked to provide documentation for the reason the resident had not been bathed three times a week as scheduled for the above weeks. At 2:25 p.m., the corporate nurse stated she contacted the aides who worked during those weeks. She stated they indicated the resident had been bathed. She was made aware there was no documentation the resident had been bathed. She acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure medications were administer as ordered for one (#33) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #33 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Vitamin C Tablet .Give 500 mg (milligrams) by mouth two times a day for Supplement . A physician's orders [REDACTED].[MEDICATION NAME] Allergy Tablet .Give 600 mg by mouth two times a day .for 7 Days . The scheduling details for the order documented the [MEDICATION NAME] was to be started on 09/02/19 on the evening shift. The (MONTH) 2019 Medication Administration Record [REDACTED] ~ on 09/02/19 on the evening shift and ~ on 09/03/19 on the morning shift. It was documented the last dose had been administered on 09/09/19 on the morning shift. An orders administration note, dated 09/02/19 at 10:22 p.m., documented, .[MEDICATION NAME] .600 mg by mouth two times a day .for 7 Days nurse notified . An orders administration note, dated 09/03/19 at 7:38 a.m., documented, .[MEDICATION NAME] .600 mg by mouth two times a day .7 Days WAITING ON PHARMACY TO SEND D/T (due to) NEW ORDER ON HOLIDAY CHARGE NURSE NOTIFIED . The (MONTH) 2019 MAR indicated [REDACTED]. An orders administration note, dated 11/10/19 at 10:21 p.m., documented, .Vitamin C Tablet .500 mg by mouth two times a day for Supplement .Waiting on pharmacy to deliver medication charge nurse notified . On 11/12/19 at 11:05 a.m., the director of nursing (DON) was asked what the protocol was for ordering and re-ordering medications. She stated pharmacy delivered medications everyday in the evening. She stated medications were to be re-ordered in advance. She was asked what a 9 indicated on the MAR. She stated it meant other/see nurse notes. The DON was asked to review the resident's physician's orders [REDACTED]. She acknowledged the findings.

Based on record review and staff interviews, it was determined the facility failed to ensure laboratory tests were obtained as ordered for two (#72 and #243) of five sampled residents reviewed for laboratory (lab) services. The Resident Census and Conditions of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: 1. Resident #243 had [DIAGNOSES REDACTED]. A physician's progress note, dated 07/24/19, documented, .Will go ahead and get another set of labs .Plan: recheck labs . A physician's orders [REDACTED].CMP (comprehensive metabolic panel) .CBC (complete blood count) . On 11/06/19 at 12:36 p.m., the corporate nurse was shown the order for lab and asked if it had been collected. She reviewed the lab program and acknowledged the lab had not been drawn. 2. Resident #72 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].due to increased confusion . On 11/06/19 at 8:15 a.m., the receptionist was asked to provide lab results for the above order. At 9:46 a.m., the corporate nurse stated the lab had not been completed.

Based on observation and staff interview, it was determined the facility failed to ensure: ~ food products were properly stored to prevent cross-contamination, ~ food products were discarded at designated times and ~ the floor was maintained in good repair. The facility identified 100 residents received services from the kitchen. Four residents received nutrition and hydration solely through a feeding tube. Findings: On 11/03/19 at 7:36 a.m., a tour of the kitchen was conducted. The following observations were made: ~ multiple raw hamburger patties were stored on a plate in a metal container next to plates of cut tomatoes, lettuce and slices of cheese on a shelf in the walk-in cooler. The metal container was stored above a ten pound box of fully cooked sausage links and a metal container of cooked sloppy Joes, ~ a 30 pound box of raw bacon was stored on a shelf next to a 20 pound box of romaine lettuce in the walk-in cooler, ~ a 12 pound box of raw pork sausage patties was stored on a shelf next to a metal container of cooked sloppy Joes in the walk-in cooler, ~ a 12 count carton of raw unpasteurized eggs was stored on a shelf on top of a box of cartons of vanilla nutritional drinks in the walk-in cooler, ~ there was a Ziploc bag of an opened two pound package of ready-to-eat sliced turkey breast date opened 10/19/19, on a shelf in the walk-in cooler and ~ the grout was worn down between the floor tiles in the dish wash area. On 11/04/19 at 11:15 a.m. the dietary manager (DM) was asked how foods were to be stored to prevent cross-contamination. She stated raw foods were to be stored on the bottom shelf and separated from ready-to-eat foods. She was asked how the floors were to be maintained in good repair. She stated they reported issues to maintenance. The DM was asked what the policy was for date marking food products. She stated food products were dated upon arrival and when they were opened. She stated food products, such as lunch meats, were to be discarded after three days of being opened. She was made aware of the above observations. She acknowledged the findings.

Based on record review and staff interview, it was determined the facility failed to ensure the physician and the resident's representative was notified of a fall for one (#292) of three sampled residents reviewed for falls. The Resident Census and Condition of Residents report, dated 11/04/19, documented 104 residents resided in the facility. Findings: Resident #292 had [DIAGNOSES REDACTED]. On 11/13/19 at 8:02 a.m., the resident and his family member were asked if he had sustained any falls. They stated he fell in the dining room around 6:30 a.m. Sunday morning. The resident was asked if he had hit his head or passed out. He stated he did not hit his head or pass out. He stated he was ok and the wheel chair got away from me. Nurses' notes were reviewed for the resident. There was no documentation to show the resident sustained [REDACTED]. There was no documentation to show the physician and resident's representative was notified of the fall. At 9:08 a.m., licensed practical nurse (LPN) #2 was asked if she had worked last Sunday, 11/10/19. She stated yes, she had worked the 11:00 p.m. to 7:00 a.m. shift on Saturday night. The LPN was asked if the resident had a fall Sunday morning. She stated the resident fell early in the morning, between 5:15 a.m. and 6:45 a.m. She was asked who called her to the dining room. She stated she does not remember who called her to the dining room on the walkie talkie. The LPN stated she assessed the resident on the floor and there were no bruises, skin tears or bumps. She stated the resident was assisted back in to his wheelchair, taken to his room and assisted in bed. The LPN stated she did a full assessment when the resident was assisted to bed. The LPN was asked if she had documented the assessment. She stated she had gotten busy on another hall and forgot about his fall and did not document the fall or the assessment. The LPN stated she documented her assessment on the incident report completed yesterday, (11/12/19). She was asked if she had notified the physician or family member at the time of the incident. She stated, No.

Based on record review and staff interview, it was determined the facility failed to ensure staff used the correct sling with a full body lift for one (#1) of three sampled residents reviewed for use of a full body lift during transfers. Resident #1 had a fall from a lift when the wrong size sling was used with the lift. The resident developed an infection of the left shoulder wound hematoma after the fall that required surgical intervention. The facility identified six residents who utilized a full body lift for transfers. Findings: A undated form, Lifting/Transferring, Demonstration, Gait Belt, Sit to Stand Lift, Hoyer lifts, documented, I have been shown the proper technique and ways to transfer a resident using the above listed equipment with return demonstration. I understand that it is my responsibility to follow the policies of St. Ann's while transferring a resident. One C.N.A. (certified nurse aide) may use the Sit to Stand Lift unless it has been noted that two C.N.A.'s (sic) are to be present. Two C.N.A's (sic) are to be present when using the Hoyer Lift to transfer a resident. NO Exceptions! NEVER leave a resident while they are up in the lift! . Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted with orders for Eliquis 5 milligrams (mg) twice a day and aspirin 81 mg every day for prevention. These medications thin the blood and can cause excessive bruising and bleeding. A nurse's note, dated 08/31/17 at 1:19 p.m., documented, CNA alerted nurse stating that CNAs x2 were attempting to transfer resident from bed to the wheelchair. Resident was placed in the sling. During the active transfer resident began to slide through the bottom of the sling. Aide began lower the hoyer lift in attempt to secure resident was unable to prevent resident from coming from the lift sling. Resident fell to floor with the assistance of aides. Nurse entered the room to find the resident laying on her back with her lower ext (extremities) over the legs of the hoyer lift. Resident stated that she did hit her head. Full body assessment performed. Resident denies pain or discomfort at this time. No skin concerns noted at this time. Neuro (neurological) check initiated. Resident assisted to the wheel chair requiring max (maximum) assist. Dr. notified of occurrence and returned understanding. No new orders received at this time. Resident husband (Name deleted) notified of occurrence and returned understanding. No further concerns at this time. An in-house incident report form and an Oklahoma State Department of Health incident report form were completed. A nurse's note, at 5:42 p.m., documented, Evaluation: Latent Signs of Injury/ Current Status: Resident in her bed resting comfortable at this time .Resident denies pain and stated, I fell out from the sling while they transfer me to my chair and landed on my bottom and I did hit the back of my head. No new bruise bumps or lumps noted to head or body. Old bruise noted to both arm. Neuro check continued and WNL (within normal limits) for her. Reminded staff to make sure proper placeme3nt (sic) of sling and resident is secure before transferring her with mechanical lift .Effectiveness Of Current Interventions: No further injury noted at this time and staff aware about fall and demonstrate proper use of Hoyer lift. A nurse's note, at 6:34 p.m., documented, The interdisciplinary team has met and reviewed the incident regarding safety. The interdisciplinary team has determined that the following revision to the resident's plan of care be implemented as follows: Hoyer lift with correct color sling for all transfers. Re-order of all slings colors and staff educated on use of sling during skills fair. A nurse's note, dated 09/01/17 at 9:51 p.m., documented, Evaluation: Latent signs of Injury/ Current Status: Resident continues on charting for fall, no bruise or bumps noted to head. Swelling noted to right hand and wrist area, Denies any pain. Dr. (Name deleted) notified .new order noted for X-ray right hand .POA (power of attorney) (Name deleted) notified about order too. X-ray completed and shows Degenerative changes with osteoporosis, no acute fracture noted . A care plan problem, last updated 08/29/17, documented, Focus: (Resident #1) is at risk for falls r/t (related to) Altered cardiac output, gait/balance problems, Incontinence, Psychoactive drug use, Use of multiple medications, hearing problems, and altered mobility. 08/31/17 Fall during transfer from bed to wheel chair.Denies injury/ reports hitting head. Goal: The resident will be free of falls through the next review date. Interventions: .8/31/17 Neuro checks .8/31/17 Replaced sling to hoyer . The facility's incident reports were reviewed from 08/31 through 10/12/17. There were no other incidents documented in regards to the lifts or lift slings. The medication administration records, dated 09/01 through 09/26/17, documented the resident received Eliquis 5 mg twice a day and aspirin 81 mg every day for prevention. An admission resident assessment, dated 09/05/17, documented the resident was cognitively intact with daily decision making-skills, was understood and understands, required extensive assistance of two staff members for transfers and had impaired range of motion to both lower extremities. A facility in-service form, dated 09/05/17, documented an in-service was held over the topics of abuse/neglect and lift use for transfers. A final x-ray report, dated 09/15/17, documented, .Findings: .A total shoulder arthroplasty is seen on the left side with no evidence for loosening of the hardware. The overall anatomic alignment is appropriate and no acute fractures or sulaxations are identified. No focal lytic or blastic lesions are seen .Impression: Stable shoulder arthroplasty . A nurse's note, dated 09/26/17 at 2:03 p.m., documented, 0800 (8:00 a.m.), Resident received routine medication. At this time resident was complaining of severe pai (sic). this nurse observed that the resident left shoulder was very swollen and large amount of purple bruising. Shoulder is warm to touch. Called and reported to Dr. (Name deleted), Dr. Stated to send the resident to (Name deleted) Hospital. Hospital emergency department notes, dated 09/26/17, documented, .Physical Exam: .morbidly obese .Musculoskeletal: She exhibits no edema. Left shoulder: She exhibits swelling (significant amount to anterior portion) Left upper arm: She exhibits swelling .Ecchymosis and swelling to proximal humerus. Entire left arm is swollen .RADIOLOGY: .Radiologist Impression FINDINGS/IMPRESSION: There is left shoulder prosthesis in place. The hardware appears intact. The surrounding bones also appears intact. There is suggestion of soft tissue swelling and the possibility of small collections of soft tissue emphysema. Recommend clinical correlation as to whether this might be an infection or residual from recent surgery . A hospital history and physical, dated 09/29/17, documented, .Physical Exam: .Upper Extremity: Significant pitting edema over the dorsum of the hand and digital edema. There is diffuse swelling and fluctuance anterior left shoulder .Diffuse cellulitis over the lateral deltoid and anterior shoulder. Gross digital motor is intact, but not to command, but she does move the left hand on request. She refuses to perform active range of motion or allow passive range of motion of the left shoulder. Large ecchymosis over the left shoulder. Slight increased temperature to palpation .the patient has guarding and apprehension with examination. A weak grip strength on the left versus right .X-rays: CT (computerized tomography) scan post (posterior) left reverse total shoulder replacement with diffuse fluid for possible hematoma versus abscess. IMPRESSION: Left shoulder pain after a fall from patient lift at skilled nursing facility. Distant history of reverse total shoulder. Deep abscess of the left shoulder .PLAN: .today will be incision and drainage of deep abscess .if osteo[DIAGNOSES REDACTED] or infection of hardware may result in eventual removal of the implant . A hospital operative/procedure report, dated 10/04/17, documented, Date of operation/procedure: 10/02/17 Preoperative Diagnoses: [REDACTED]. Underlying reverse total shoulder arthroplasty, left. Contusion with full-thickness skin necrosis with eschar, left shoulder secondary to injury at a nursing facitlity. [DIAGNOSES REDACTED] .Postoperative Diagnoses: [REDACTED].[DIAGNOSES REDACTED] .Procedure: .Repeat incision and drainage of deep abscess, left shoulder . A hospital discharge summary, dated 10/09/17, documented, .Problems/ [DIAGNOSES REDACTED].Infected hematoma left shoulder .Hospital course: found to have a principle [DIAGNOSES REDACTED].Ortho (an orthopedic physician) was consulted on admission and performed aspiration of shoulder which had MRSA .I&D (incision and drainage) was performed by Ortho on 9/28, 10/2 and 10/5 with closure. Pathology was sent by Ortho from OR (operating room) from bone and was consistent with osteo[DIAGNOSES REDACTED] . On 10/06/17 at 9:50 a.m., the administrator (ADM) stated a family member was upset because they were not the POA and staff would not give any information to the family member about the incident. On 10/12/17 at 10:00 a.m., the director of nursing (DON) was asked about the resident's transfer. She stated the sling was the wrong one and she was not sure where it had come from. The DON stated they had in-serviced the staff the same day of the incident and in-serviced the rest of the staff at the regular in-service on 09/05/17. She stated all of the lift slings and been re-ordered and replaced with universal slings. At 10:10 a.m., the ADM stated the resident's attending physician had seen the resident on 09/19/17 with the family present. The physician offered to sent the resident to the local hospital in regards to the left shoulder. She stated the family did not seem in a hurry or have a sense of urgency. The ADM stated a CT scan had been scheduled for 09/27/17 but the resident went to the hospital on [DATE].