Every finding on record at Stonehenge of Ogden

Based on observation, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, gloves were not changed and hand hygiene was not performed after touching dirty surfaces in the kitchen prior to touching food while plating the lunch meal. Findings included:On 6/30/26 at 11:33 AM, an observation and simultaneous interview were conducted with [NAME] 1 during the lunch meal service. [NAME] 1 stated that she had prepared a chicken salad sandwich with apples and celery for lunch. The Dietary Manager (DM) washed hands with soap and water and donned gloves. The DM placed the fruit container containing cantelope, honeydew, pineapple, orange, and grapes on a rolling cart on top of a cutting board. The DM moved and repositioned the cart and touched the cart handle with gloved hands. The DM then proceeded to touch the fruit with the same gloved hands while cutting the fruit into bite size pieces. [NAME] 1 washed her hands and donned new gloves. [NAME] 1 started the tray line and touched the croissant with gloved hands while placing a scoop of chicken salad inside. [NAME] 1 closed the refrigerator door with gloved hands and then proceeded with the next sandwich preparation. [NAME] 1 obtained a second bowl of chicken salad from the fridge and stated that this bowl did not contain celery or apples. [NAME] 1 washed her hands and donned new gloves. [NAME] 1 obtained a second box of croissants from the original packing box and removed the saran wrap. The original packing box and saran wrap were handled with [NAME] 1's gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:11 PM, [NAME] 1 obtained cold plates from the refrigerator and the door was closed with gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:15 PM, [NAME] 1 doffed gloves, washed hands and donned new gloves. [NAME] 1 obtained a new box of croissants from the original packing box and removed the saran wrap. [NAME] 1 touched the rolling cart containing the plate lids with gloved hands. [NAME] 1 obtained a stack of cold plates from the refrigerator and the door was closed with gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:21 PM, [NAME] 1 was handed a meal ticket from a Certified Nursing Assistant (CNA) who had delivered a tray to room [ROOM NUMBER]. The CNA reported that the resident had requested a croissant and did not receive one. [NAME] 1 touched the meal ticket with gloved hands and then returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:28 PM, [NAME] 1 obtained a stack of cold plates from the refrigerator and closed the door with gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:29 PM, a delivery man came into the kitchen stating he had a delivery. The delivery driver proceeded to show the DM the invoice while holding it over the food prep area. On 6/30/26 at 12:31 PM, [NAME] 1 obtained a container of cottage cheese from the refrigerator and served a portion. The refrigerator and cottage cheese container were handled with gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:35 PM, [NAME] 1 obtained a stack of cold plates from the refrigerator and closed the door with gloved hands. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 12:42 PM, [NAME] 1 obtained a package of hamburger buns and stated she ran out of croissants. [NAME] 1 returned to sandwich preparation without changing her gloves. On 6/30/26 at 1:39 PM, an interview was conducted with the DM. The DM stated that hand hygiene should be performed when they changed a task or started the day. The DM stated that hand hygiene should be performed prior to touching food items. The DM stated that if the [NAME] walked away from the food preparation area they should wash their hands and don new gloves upon their return to food preparation. The DM stated that hand hygiene should be performed and gloves changed if the [NAME] touched other surface areas that may contaminate the food. The DM stated that they would need to educate the delivery staff to stand at the red line and not enter the food preparation area.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 2 out of 31 sampled residents, the facility did not attempt a GDR for psychotropic medications in two separate quarters (with at least one month between attempts) and clinical contraindications were not documented in the resident medical records. Resident identifiers: 30 and 31.Findings included:1. Resident 31 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included major depressive disorder and insomnia.A physician's order dated 5/7/25, documented Auvelity Oral Tablet Extended Release 45-105 milligrams (mg) (Dextromethorphan Hydrobromide-Bupropion Hydrochloride), Give 1 tablet by mouth one time a day related to major depressive disorder for 3 days and then Give 1 tablet by mouth two times a day. The order was discontinued on 5/23/25. [It should be noted that Auvelity is classified as an anti-depressant.]A physician's order dated 5/23/25, documented Auvelity Oral Tablet Extended Release 45-105 mg, Give 1 tablet by mouth one time a day related to major depressive disorder for 3 days and then Give 1 tablet by mouth two times a day. The order was discontinued on 10/30/25. A physician's order dated 10/30/25, documented Auvelity Oral Tablet Extended Release 45-105 mg, Give 1 tablet by mouth two times a day related to major depressive disorder. The order was discontinued on 12/29/25.A physician's order dated 1/2/26, documented Auvelity Oral Tablet Extended Release 45-105 mg, Give 1 tablet by mouth two times a day for Depression. On 2/19/26, the Psychotropic Drug Review documented Auvelity 45-105 mg by mouth two times a day was initiated on 5/21/25. The form documented 11 episodes of verbalization of sadness. The form documented to review the medication again in 90 days and recommended no changes be made to the medication at that time.No documentation could be found that an attempt was made at a GDR for the Auvelity, and no documentation could be found with a rationale for a clinical contraindication for a GDR.On 6/30/26 at 7:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 31 was seen by a behavioral health provider and they ordered the Auvelity. The DON stated that she would look for a contraindication for a GDR form. On 6/30/26 at 11:24 AM, the DON provided a note from a behavioral health provider dated 6/30/26, that stated In my opinion, a decrease in any of their current psychiatric medications would result in deterioration. I strongly recommend that their psychiatric medications are not changed. No attempted GDR or clinical contraindication had been done prior to the State Survey Agency asking for this information. 2. Resident 30 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses which included depression, generalized anxiety disorder, and insomnia due to other mental disorders.A physician's order dated 3/18/25, documented paroxetine hydrochloride oral tablet 30 mg. Give 30 mg by mouth one time a day. The physician order was discontinued on 5/21/25. [It should be noted that paroxetine hydrochloride is classified as an anti-depressant.]A physician's order dated 5/22/25, documented paroxetine hydrochloride oral tablet 30 mg. Give 30 mg by mouth one time a day. The physician order was discontinued on 10/30/25.A physician's order dated 11/1/25, documented paroxetine hydrochloride oral tablet 30 mg. Give 30 mg by mouth one time a day. The physician order was discontinued on 2/26/26.A physician's order dated 2/27/26, documented paroxetine hydrochloride oral tablet 20 mg. Give 20 mg by mouth one time a day.It should be noted that resident 30 did not receive a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.On 7/1/26 at 10:08 AM, an interview was conducted with the DON. The DON stated they tried to GDR resident 30's as needed lorazepam that was hardly ever used and it sent resident 30 into a panic attack. The DON stated the psychotropic team reviewed the short term residents monthly and the long term resident quarterly. The DON stated that herself, social services, the pharmacy consultant, and Medical Director would attend the meeting. The DON stated that she would prepare the paper work and would discuss with the team who was needing a medication dose reduction and she would make recommendations to the team. The DON stated that it was ultimately up to the provider if they wanted to GDR the medication.

Based on interview and record review, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, staff were applying a PureWick external urinary catheter device without orders or training on how to use the device. Resident identifier: 28. Findings included:Resident 28 was admitted to the facility on [DATE] with diagnoses which included fracture around internal prosthetic right hip joint, muscle weakness, abnormality of gait and mobility, congestive heart failure, lymphedema, muscle wasting and atrophy. On 6/29/26 at 10:05 AM, an interview was conducted with resident 28. Resident 28 stated she wore a PureWick device at nighttime. Resident 28 stated that the facility was going to teach the staff how to use the PureWick device. Resident 28 stated that sometimes the staff did not plug the device into suction after they placed the device on her. Resident 28's physician orders were reviewed. No orders were found for the PureWick urinary device. Resident 28's June 2026 Medication Administration Record and Treatment Administration Record was reviewed. No documentation was found for the care, treatment, or monitoring of the PureWick device. On 3/10/26 at 1:04 PM the Nursing note documented, Pt [patient] cont [continued] on Doxycycline or [sic] UTI [urinary tract infection], tolerating well, no ASE [adverse side effects]. Pt using purewick this am [morning] while in bed. Pt encouraged to increase fluid intake. Voiding freely. On 6/21/26 at 9:24 AM, the progress note documented, . Genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints. Genitourinary Note: wears a purewick at night. On 6/26/26 at 12:45 AM, the Provider note documented that the resident was prescribed Lasix 40 milligram by mouth at bedtime for edema . Pt wants in pm [after midday] after she goes to bed with purewick. On 10/31/25, resident 28 had a care plan initiated for at risk for incontinence related to history of urinary incontinence. An intervention identified on the care plan was Pt using own [NAME]-wick [sic] at bedtime. The intervention was initiated on 3/26/26. On 7/1/26 at 9:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 28 had a urinary device. CNA 1 stated that she turned off the suction in the morning, pulled off the sponge and discarded it, dumped the urine and rinsed the canister, and placed it in the closet for use again at night. CNA 1 stated that resident 28 wore the PureWick at night only and staff removed the device in the morning. CNA 1 stated that she was shown how to remove the device by another CNA and no other education was provided by the facility for the care and treatment of the PureWick device. CNA 1 stated that she was not instructed on how to apply the device safely but she was sure it was the same concept for removal. CNA 1 stated that she was not aware of resident 28 having a history of UTIs. On 7/1/26 at 10:06 AM, an interview was conducted with Registered Nurse (RN)1. RN 1 stated that resident 28 had a PureWick that was used at night. RN 1 stated that she did not have any orders for the PureWick device and she would think that they needed an order for it. RN 1 stated that the CNAs took care of the device in the morning by removing it and cleaning it. RN 1 stated that resident 28's family provided all the equipment for the PureWick. RN 1 stated that the PureWick was not documented on the Treatment Administration Record and there was no documentation of the care and treatment of the device. RN 1 stated that potential complications of the device were infection and skin breakdown. RN 1 stated she would expect to see orders for monitoring the device to ensure there were no signs and symptoms of infection or any skin breakdown. On 7/1/26 at 10:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 28 used a PureWick device. The DON stated that the family provided the device and the facility staff were responsible for the care and use of it. The DON stated resident 28 used the urinary device at nighttime and it was discarded each morning after use. The DON stated that resident 28 should have orders for the PureWick device. The DON confirmed that resident 28 did not have orders for the PureWick and there was no monitoring for the care and treatment of the device. The DON stated that complications of using the PureWick device were UTI, skin breakdown, and not promoting urinary continence. The DON stated that staff had not been provided training on the device. The DON stated that it was up to resident 28 to apply and place the device and staff turned on the suction. The DON stated that the CNAs should know how to properly apply and remove the device.

Based on observation, interview and record review it was determined, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preferences. Specifically, for 4 out of 27 sample residents the facility was not dating the change of oxygen tubing and nasal cannulas, nor ensuring there was a physician order for the use of oxygen for two residents (residents 7 and 8). Resident Identifiers: 7, 8, 19, and 20. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included viral intestinal infection, hypokalemia, hypercalcemia, unspecified protein-calorie malnutrition, dyspnea, essential hypertension, insomnia, generalized anxiety disorder, major depressive disorder, and gastro-esophageal reflux disease. Resident 7's medical record was reviewed 6/24/24-6/27/24. On 6/24/24 at 10:27 AM, an interview was conducted with resident 7. Resident 7 stated that she used nocturnal oxygen. Resident 7 stated that she had never seen her cannulas changed on either the concentrator or the portable oxygen. On 6/24/24 at 10:28 AM, an observation was made of the portable oxygen's nasal cannula which was yellowish in color and draped across the back of the wheelchair. An observation was made that there was no date on the cannula attached to the portable oxygen. An observation was made that there was no date on the nasal cannula attached to the concentrator. Review of resident 7's medical record revealed no order for oxygen therapy. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included wedge compression fracture of unspecified lumbar vertebra, history of falling, unspecified asthma, sepsis, major depressive disorder, generalized anxiety disorder, essential hypertension, chronic kidney disease stage 3, gastro-esophageal reflux disease, and cardiac murmur. Resident 8's medical record was reviewed 6/24/24-6/27/24. On 6/24/24 at 12:50 PM, an interview was conducted with resident 8. Resident 8 stated that she used nocturnal oxygen. Resident 8 stated she was unsure how often her cannulas were changed. On 6/24/24 at 12:52 PM, an observation was made of resident 8's oxygen cannula and tubing. It was observed that there was no date on the cannula or oxygen tubing. Review of resident 8's medical record revealed no order for oxygen therapy. 3. Resident 19 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, heart failure, insomnia, obesity, adjustment disorder with anxiety, essential hypertension, gastro-esophageal reflux, and personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits. Resident 19's medical record was reviewed 6/24/24-6/27/24. On 6/24/24 at 9:46 AM, an interview was conducted with resident 19. Resident 19 stated that she used nocturnal oxygen. Resident 19 stated that she was unsure when her cannulas got changed. On 6/24/24 at 9:50 AM, an observation was made of resident 19's oxygen cannulas. It was observed that there were no dates on the oxygen cannula or tubing. 4. Resident 20 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure, paroxysmal atrial fibrillation, thrombocytopenia, unspecified protein-calorie malnutrition, chronic respiratory failure with hypoxia, unspecified osteoarthritis, trigeminal neuralgia, pulmonary hypertension, peripheral vascular disease, and history of falling. Resident 20's medical record was reviewed 6/24/24-6/27/24. On 6/24/24 at 11:19 AM, an interview was conducted with resident 20. Resident 20 stated that she was not aware that her cannulas required changing. Resident 20 stated that she used a concentrator and portable oxygen. On 6/24/24 at 11:20 AM, an observation was made of resident 20's oxygen concentrator and portable oxygen. There were no dates on the nasal cannulas for the concentrator or portable oxygen. On 6/26/24 at 12:01 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated nurses were in charge of changing out residents' cannulas weekly. LPN 1 stated that cannulas were changed on Fridays and the date was written on tape and placed on the cannula. On 6/26/24 at 1:16 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that oxygen tubing was changed weekly and required a nurse to sign on the treatment administration record [TAR]. The DON stated that tubing was dated when it was replaced. The DON stated that in order for oxygen to be placed on a resident, an order from the doctor was required before it could be placed. The DON stated that there were standing orders for oxygen use in order to maintain oxygen levels above 90%, but the medical provider needed to be notified of this to ensure an order was written.

Based on interview and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, an employee was observed in the kitchen area without a hair net; and a refrigerator was observed to have spoiled, undated and unlabeled food. Findings include: 1. On 6/24/24 at 12:51 PM, the Maintenance Director (MD) was observed to enter the facility kitchen. The MD was observed to check several lights and sprinkler heads on the kitchen ceiling. At 12:52 PM, the MD left the kitchen, obtained a ladder that had been placed near the dining room entrance, and re-entered the kitchen. At no time was the MD observed to place a hair net over his hair. 2. On 6/24/24 at 12:57 PM, an observation was made of the refrigerator in the dining room. The following was noted: a. An open bag of grapes with no date or label b. A styrofoam container of what appeared to be leftovers. This container was not dated or labeled. c. An open bag of chips with no date or label d. What appeared to be an onion in a plastic bag. The onion was green, moldy, and slimy. There was liquid leaking from the bag onto the refrigerator surface. e. Five open plastic containers of soda with no date or label. f. Several areas with sticky spills and debris. On 6/24/24, at 1:00 PM, an interview was conducted with Housekeeper (HSK) 1. HSK 1 stated she thought that the refrigerator in the dining room was for both residents and employees, but was unsure. HSK 1 stated that it was the dietary department's responsibility to clean the refrigerator in the dining room. On 6/24/24 at 1:02 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that she though that the refrigerator in the dining room was for both residents and employees, but that it was mostly the therapy department that used it. The DM stated that the dietary department and the housekeeping department took turns cleaning the refrigerator in the dining room.

Based on interview and record review it was determined, for 2 of 27 sampled residents, that the facility did not ensure that residents remained free from abuse, neglect, and misappropriation of property. Specifically, there were residents in a relationship that had not been evaluated to have the capacity to consent. Resident identifiers: 13 and 151. Findings include: A. Resident 151 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, with agitation, acquired absence of right leg below knee, acquired absence of left leg below knee, occlusion and stenosis of bilateral carotid arteries, and duodenal ulcer, without hemorrhage or perforation. Resident 151's medical records were reviewed between 6/24/24 and 6/27/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 151 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severely impaired cognition. A review of resident 151's care plan initiated on 12/13/23, revealed a focus area that, Sometimes I have paranoid thoughts or delusions: ie having bed made oversease [sic] that will grow his legs back, medications and treatments. The goal is, I do not want to be fearful or paranoid. Approaches included Avoid power struggles and If my delusions or hallucinations do not distress me and are not harmful, do not medicate me or try to make them go away. On 2/5/24 at 1:13 PM, a social work progress note revealed the following, Social Service Worker (SSW) notified daughter of newfound friendship with a female peer. On 2/15/24 at 6:30 PM, a nursing progress note revealed the following, Pt [patient] is sitting at bedside in wheelchair with [resident 13] from room [ROOM NUMBER]A resting in his bed with a shirt on wearing no briefs. I knocked and pt [patient] wants to be left alone with her and requested that I leave as soon as possible and shut the door. Instruction given to staff to make sure they are knocking first before entering the room. 2030 (8:30 PM) Pt [patient] stated that he was really concerned that [resident 13] wanted him to lift her from off the bed tonight, Education given to pt [patient] to always call for assistance from CNAs (certified nursing assistants) and not attempt transfers himself. Provider notified. On 2/15/24 at 9:00 PM, a nursing progress note revealed the following, CNA [name removed] reported that pt [patient] in room had his garments on and no bottoms. Social work notified to follow up. A review of resident 151's care plan initiated on 2/16/24 revealed a focus area that Resident has a special friend the resident likes to spend time with. The goal being that 'Resident will show affection towards their special friend only in private. Approaches included Remind resident to limit showing ffection [sic] in public to holding hands, Remind residents that if the residents want private time together, the resident must find a place that will not disturb their roommates, and Remind staff that if the door is closed to knock and allow a few extra seconds before entering the room. On 2/16/24 at 11:42 AM, a social work progress note revealed the following, SSW and [Director of Nursing] DON Spoke with resident regarding relationship with peer. Resident reports that he enjoys spending time with his friend. they enjoy watching movies and talking. Resident denies that him and peer have been intimate. Resident reports that things are good with him and his friend. On 3/26/24 at 10:18 AM a social work progress note revealed the following, resident continues to verbalize paranoid statements he continues to believe that people are out to get him. He continues to verbalize statements that do not make sense. He continues to report that he is building things, and that he needs to get to places and take care of business but is unable to report where he needs to go and what he needs to accomplish. He also continues to describe people that had an altered physical appearance with one eye telescopic mask, and people that are coming to get him and take him from them. He continues to believe that people are out to get him and then he wants to get with a lady and get married and then get away from the people that are out to get him. SSW reassured him he is safe and if strange people come to visit him to let us know and that the staff will help him with the situation. On 5/4/24 at 7:03 PM, a nursing progress note revealed the following, resident 151 was becoming agitated while in the dining room. I gave resident 0.25mg (milligrams) Lorazepam to help with his agitation and left the dining room. Approximately 15 minutes later, my aid wheeled the resident to me. I wheeled the resident back to his room and another resident, who he often visits with, was in his room. She was attempting to calm him down, as he was still agitated. She offered him two warmed blankets that he had requested. The resident accepted the blankets and then started speaking in nonsensical terms. He then threw the blankets on the floor. On 5/4/24 at 8:30 PM, a nursing progress note revealed the following, CNA reported that pt [patient] was in his wheelchair headed looking for a female resident 'to meet his needs.' He went into room [ROOM NUMBER]. On 5/4/24 at 9:00 PM, a nursing progress note revealed the following, Night medications given at the med (medication) cart. Agitated when attempt made to give him meds in his room. Pt [patient] requesting if he can 'have a little sex.' I changed the subject. He is confused and believes that it is morning. Agitated when he was told it was night time. Continue to monitor with 15 minute bed checks. A review of resident 151's care plan initiated on 5/10/24, revealed a focus area of Aggression - Physical/Verbal The resident can be physically and/or verbally abusive at times. The goal being that The resident will be able to express themselves without becoming aggressive. Approaches included If the resident appears to be getting anxious or restless, take them for a walk, do something active with them to use up their energy and decrease their anxiety. and Redirect the resident away from any residents who upset them. On 5/19/24 at 1:10 AM, a nursing progress note revealed the following resident 151 has passed away. B. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes, age related osteoporosis with current pathological fracture vertebra, sequela, spondylosis, moderate protein-calorie malnutrition, essential hypertension, dysphasia, depression, muscle weakness, gastro-esophagela reflux disease, and history of falling. Resident 13's medical record was reviewed 6/24/24-6/27/24. A Minimum Data Set [MDS] dated 11/3/23 revealed that resident 13 had a Brief Interview of Mental Status [BIMS] score of 7 which indicated severely impaired cognition. A care plan Focus addressing delusions/ hallucinations initiated on 5/2/23, documented [Resident 13] sometimes has paranoid thoughts and believes that someone is trying to hurt me or do bad things to me. The interventions included: a. Be sure my M.D. [medical doctor] or psychiatrist review my meds [medications] regularly and adjust them as needed. If I have command hallucinations where I might do what my voices tell me and get hurt, start a safety plan and get to the ER [emergency room ] if you cannot ensure my safety at the nursing home. b. If my delusions or hallucinations do not distress me and are not harmful, do not medicate me or try to make them go away. c. Listen to my feelings about what I am imagining and do not criticize A care plan Focus addressing relationship with special friend initiated on 2/16/24, documented resident has a special friend the resident likes to spend time with. The goal documented, resident will show affection towards their special friend only in private. The interventions included: a. Remind resident to limit showing affection in public to holding hands b. Remind residents that if the residents want private time together, the resident must find a place that will not disturb their roommates. c. Remind staff that if the door is closed to knock and allow a few extra seconds before entering the room. Review of resident 13's progress notes revealed the following: On 1/29/24 at 9:00 PM, a behavior note documented, Pt [patient] states that she enjoyed having pt in room [room number redacted]. the man without legs cuddling with her previously. Denies anything physical contact was inappropriate. On 1/31/24 at 1:21 PM, a social work note documented, SSW [Social Service Worker] spoke with resident about information received [sic] that she had told staff that she had allowed a male peer to sit on her bed with her while they watched a movie together. [resident 13] reported that she has found a friend and they enjoy spending time together. On 2/5/24 at 1:26 PM, a social work note documented, SSW spoke with residents daughter and informed her that her mom has new found friend and that they enjoy spending time together and doing various activities together. On 2/15/24 at 6:30 PM, a behavior note documented, Pt is resting on the bed of room [number redacted] with a shirt on with no brief on. Denies any inappropriate behavior. She remained in the room until apx [approximately] 2030 [8:30 PM]. On 2/15/24 at 9:00 PM, a behavior note documented, CNA [name redacted] reported that pt from room [room number redacted] also had his garments on with no bottoms. [Resident 13] had her bottoms off resting in his bed. Social work notified. On 2/16/24 at 11:23 AM, a social work note documented, SSW notified that Resident and peer spent alone time together. Resident verbalized that she is happy with her current relationship with her peer. She reports that they are good friends and that nothing has happened that they enjoy spending time together in peers bed watching movies and talking. She reports that peer is kind to her and that they have not been intimate. On 6/25/24 at 11:36 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she is not aware of any relationships between residents in the building either companions or sexual in nature. On 6/25/24 at 12:56 PM, an interview was conducted with the SSW. The SSW stated that she interviewed the residents in order to determine if the residents were able to consent to having a relationship. The SSW stated that there was the potential that these residents were engaged in physical contact. The SSW stated she went with the Director of Nursing to assess resident 13 for any harm. The SSW stated that she could not recall if the medical director was notified of the relationship the residents were having and it was typically the DON's responsibility to notify the medical doctor in regards to residents. The SSW stated that resident 13 was confused and said bizarre things at times. The SSW stated that she figured that the residents were both adults and they could consent to have a relationship with each other. The SSW stated that no formal assessment was done to determine if resident 13 was able to consent to have a relationship. On 6/27/24 at 9:59 AM, a second interview was conducted with the SSW. The SSW stated that resident 151 was typically very sweet and then suddenly, he became very agitated near the end of his life. SSW stated resident 151 did have delusions off and on, he would think he was doing business deals with people. The SSW stated that resident 151 and resident 13 would have meals and attend activities together, and that it was resident 151 that helped get resident 13 out of her shell and out of her room more. The SSW stated she did not see any public affection between resident 151 and resident 13, and that they were always very cordial. The SSW stated Stonehenge was not a behavioral health facility, so she was not much concerned when the two residents started showing signs of a closer relationship. The SSW stated that resident 151's daughter was in the process of gaining guardianship due to him having bad finances and making bad choices. The SSW stated that resident 151 and resident 13 would go back and forth into each other's beds. The SSW stated that it was told to her that resident 151 and resident 13 may have been unclothed at some point. The SSW stated that she went with the Director of Nursing (DON) and talked to both residents separately. The SSW stated that her and the DON asked the residents about consent and how to be safe and what it means. The SSW stated that she and the DON were satisfied with what the residents reported and informed the Administrator (ADM), and they proceeded to inform the residents' families. The SSW stated that resident 151's guardian liked that he had a special friend in the facility that he was able to spend time with. The SSW stated that she would put a progress note in the resident's chart when she talked to a resident about what the resident knows about consent, how to be safe when with a close friend, and if she has talked with family or a guardian. The SSW stated that it was determined to allow the relationship to continue by the interviews with resident 151 and resident 13. The SSW stated that she does not recall if the physician was ever notified of resident 151 and resident 13's relationship, and that it would have been the DON that would have contacted the physician. The SSW stated that since both residents were confused, she had initiated a care plan, and she also initiated a care plan in case the relationship progressed further. The SSW stated that when she spoke with resident 151 and resident 13, they both replied they liked being with each other. On 6/27/24 at 12:35 PM, an interview with the DON was conducted. The DON stated she was informed that resident 13 and resident 151 were found in bed together in a state of undress. The DON stated that she and the SSW went together to talk to the residents individually. The DON stated that resident 151 told her it was none of your damn business. The DON stated that both residents denied being undressed with each other, stating nothing happened, and they were just watching movies. The DON stated that she encouraged both residents to let staff know if anything did happen or may happen. The DON stated that during the investigation, due to the residents being under the blankets the Certified Nurse Assistant (CNA) thought they saw the residents without clothing on. The DON stated that resident 151 was alert to himself and was alert and oriented x 3 or 4. The DON stated that resident 151 was showing signs of terminal aggressions. The DON stated that the did not do any cognitive assessments on resident 13 or resident 151, and that the assessment was her and the SSW talking to the residents. The DON stated she is unsure if the incident between resident 13 and resident 151 went to an interdisciplinary team (IDT) meeting, and that she recalled it was her and the SSW that talked most about it. The DON stated that it would be the physician that would make the decision if a resident was able to give consent. The DON stated that either she or the SSW would contact the physician. The DON stated that resident 13 was not always alert and oriented, and this behavior tended to be worse at night. The DON stated if patients were alert and oriented then the facility had to respect their choices to have a relationship. The DON stated there was no policy in regards to residents and relationships that she was aware of. [Cross refer to F607] 50200

Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. In addition, the facility did not established polices and procedures to investigate any such allegations. Specifically, for 2 out of 27 sample residents, investigations and evaluations of ability to consent were not conducted after two residents were found to be in bed together. Resident identifiers: 13 and 151. Findings included: The facility's Abuse Prohibition Policies, dated 2024, was reviewed and documented the following information: The Provider Code of Conduct is to protect vulnerable clients (residents) from abuse, neglect, maltreatment and exploitation . Abuse, sexual-abuse and sexual exploitation, neglect, exploitation, and maltreatment are prohibited. A. No .individual . shall abuse, sexually abuse or sexually exploit, neglect, exploit or maltreat any client . 1. No person shall cause physical Injury to any client. All Injury to clients (explained or unexplained) shall be documented in writing and immediately reported to supervisory personnel. 2. No person by acting, failing to act, encouragement to engage In [sic], or failure to deter from will cause any client to be subject to abuse, sexual abuse or sexual exploitation, negleh, [sic] exploitation, or maltreatment. 3. No person shall engage any client as an observer or participant in sexual acts. 4. No person shall make unjust or Improper [sic] use of a client or their resources for profit or advantage. B. Failure to comply with this Code of Conduct may result in corrective action, probation, suspension, and/or termination of contract, license or certification, in accordance with administrative procedures act and Department of Human Services' regulations. POLICY: Our facilities will not condone any form of client/resident abuse or neglect. To assist In abuse prevention, all, csonnel[sic] are to report any signs and symptoms of abuse/neglect to their supervisor or to the Administrator .,mediately[sic]. A. Abuse of clients may include, but is not limited to: 1. Harm or threatened harm, meaning damage or threatened damage to the physical or emotional health and welfare of a client. 8. Sexual abuse and sexual exploitation will include, but not be limited to: 1. Engaging in sexual Intercourse with any client. 5. Committing or attempting to commit acts of sodomy or molestation with a client. REPORTING REQUIREMENTS POLICY . contracted, licensed or certified agency, Individual, or employee ls [sic] responsible to document and report abuse, . abuse and sexual exploitation . as outlined in this code and cooperate fully in any resulting investigation. 1. Any person will immediately report abuse, sexual abuse or sexual exploitation to the Administrator. 2. All other types of reports (meaning reports of an event that does not result in serious bodily injury to a patient) must be reported within 24 hours after forming the suspicion. The report must be made with the State Survey Agency and the Local Law Enforcement. The facility may not retaliate against an Individual who lawfully reports a reasonable suspicion of a crime. 3. All reports and documentation made regarding situations of abuse, sexual abuse and sexual exploitation, neglect, and exploitation will be made available upon request, or with court order when required by federal regulations, to appropriate Department of Human Services' personnel and law enforcement. A. Resident 151 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, with agitation, acquired absence of right leg below knee, acquired absence of left leg below knee, occlusion and stenosis of bilateral carotid arteries, and duodenal ulcer, without hemorrhage or perforation. Resident 151's medical records were reviewed between 6/24/24 and 6/27/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 151 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severely impaired cognition. A review of resident 151's care plan initiated on 12/13/23, revealed a focus area that, Sometimes I have paranoid thoughts or delusions: ie having bed made oversease [sic] that will grow his legs back, medications and treatments. The goal is, I do not want to be fearful or paranoid. Approaches included Avoid power struggles and If my delusions or hallucinations do not distress me and are not harmful, do not medicate me or try to make them go away. On 2/5/24 at 1:13 PM, a social work progress note revealed the following, Social Service Worker (SSW) notified daughter of newfound friendship with a female peer. On 2/15/24 at 6:30 PM, a nursing progress note revealed the following, Pt [patient] is sitting at bedside in wheelchair with [resident 13] from room [ROOM NUMBER]A resting in his bed with a shirt on wearing no briefs. I knocked and pt [patient] wants to be left alone with her and requested that I leave as soon as possible and shut the door. Instruction given to staff to make sure they are knocking first before entering the room. 2030 (8:30 PM) Pt [patient] stated that he was really concerned that [resident 13] wanted him to lift her from off the bed tonight, Education given to pt [patient] to always call for assistance from CNAs (certified nursing assistants) and not attempt transfers himself. Provider notified. On 2/15/24 at 9:00 PM, a nursing progress note revealed the following, CNA [name removed] reported that pt [patient] in room had his garments on and no bottoms. Social work notified to follow up. A review of resident 151's care plan initiated on 2/16/24 revealed a focus area that Resident has a special friend the resident likes to spend time with. The goal being that 'Resident will show affection towards their special friend only in private. Approaches included Remind resident to limit showing ffection [sic] in public to holding hands, Remind residents that if the residents want private time together, the resident must find a place that will not disturb their roommates, and Remind staff that if the door is closed to knock and allow a few extra seconds before entering the room. On 2/16/24 at 11:42 AM, a social work progress note revealed the following, SSW and [Director of Nursing] DON Spoke with resident regarding relationship with peer. Resident reports that he enjoys spending time with his friend. they enjoy watching movies and talking. Resident denies that him and peer have been intimate. Resident reports that things are good with him and his friend. On 3/26/24 at 10:18 AM a social work progress note revealed the following, resident continues to verbalize paranoid statements he continues to believe that people are out to get him. He continues to verbalize statements that do not make sense. He continues to report that he is building things, and that he needs to get to places and take care of business but is unable to report where he needs to go and what he needs to accomplish. He also continues to describe people that had an altered physical appearance with one eye telescopic mask, and people that are coming to get him and take him from them. He continues to believe that people are out to get him and then he wants to get with a lady and get married and then get away from the people that are out to get him. SSW reassured him he is safe and if strange people come to visit him to let us know and that the staff will help him with the situation. On 5/4/24 at 7:03 PM, a nursing progress note revealed the following, resident 151 was becoming agitated while in the dining room. I gave resident 0.25mg (milligrams) Lorazepam to help with his agitation and left the dining room. Approximately 15 minutes later, my aid wheeled the resident to me. I wheeled the resident back to his room and another resident, who he often visits with, was in his room. She was attempting to calm him down, as he was still agitated. She offered him two warmed blankets that he had requested. The resident accepted the blankets and then started speaking in nonsensical terms. He then threw the blankets on the floor. On 5/4/24 at 8:30 PM, a nursing progress note revealed the following, CNA reported that pt [patient] was in his wheelchair headed looking for a female resident 'to meet his needs.' He went into room [ROOM NUMBER]. On 5/4/24 at 9:00 PM, a nursing progress note revealed the following, Night medications given at the med (medication) cart. Agitated when attempt made to give him meds in his room. Pt [patient] requesting if he can 'have a little sex.' I changed the subject. He is confused and believes that it is morning. Agitated when he was told it was night time. Continue to monitor with 15 minute bed checks. A review of resident 151's care plan initiated on 5/10/24, revealed a focus area of Aggression - Physical/Verbal The resident can be physically and/or verbally abusive at times. The goal being that The resident will be able to express themselves without becoming aggressive. Approaches included If the resident appears to be getting anxious or restless, take them for a walk, do something active with them to use up their energy and decrease their anxiety. and Redirect the resident away from any residents who upset them. On 5/19/24 at 1:10 AM, a nursing progress note revealed the following resident 151 has passed away. B. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes, age related osteoporosis with current pathological fracture vertebra, sequela, spondylosis, moderate protein-calorie malnutrition, essential hypertension, dysphasia, depression, muscle weakness, gastro-esophagela reflux disease, and history of falling. Resident 13's medical record was reviewed 6/24/24-6/27/24. A Minimum Data Set [MDS] dated 11/3/23 revealed that resident 13 had a Brief Interview of Mental Status [BIMS] score of 7 which indicated severely impaired cognition. A care plan Focus addressing delusions/ hallucinations initiated on 5/2/23, documented [Resident 13] sometimes has paranoid thoughts and believes that someone is trying to hurt me or do bad things to me. The interventions included: a. Be sure my M.D. [medical doctor] or psychiatrist review my meds [medications] regularly and adjust them as needed. If I have command hallucinations where I might do what my voices tell me and get hurt, start a safety plan and get to the ER [emergency room ] if you cannot ensure my safety at the nursing home. b. If my delusions or hallucinations do not distress me and are not harmful, do not medicate me or try to make them go away. c. Listen to my feelings about what I am imagining and do not criticize A care plan Focus addressing relationship with special friend initiated on 2/16/24, documented resident has a special friend the resident likes to spend time with. The goal documented, resident will show affection towards their special friend only in private. The interventions included: a. Remind resident to limit showing affection in public to holding hands b. Remind residents that if the residents want private time together, the resident must find a place that will not disturb their roommates. c. Remind staff that if the door is closed to knock and allow a few extra seconds before entering the room. Review of resident 13's progress notes revealed the following: On 1/29/24 at 9:00 PM, a behavior note documented, Pt [patient] states that she enjoyed having pt in room [room number redacted]. the man without legs cuddling with her previously. Denies anything physical contact was inappropriate. On 1/31/24 at 1:21 PM, a social work note documented, SSW [Social Service Worker] spoke with resident about information received [sic] that she had told staff that she had allowed a male peer to sit on her bed with her while they watched a movie together. [resident 13] reported that she has found a friend and they enjoy spending time together. On 2/5/24 at 1:26 PM, a social work note documented, SSW spoke with residents daughter and informed her that her mom has new found friend and that they enjoy spending time together and doing various activities together. On 2/15/24 at 6:30 PM, a behavior note documented, Pt is resting on the bed of room [number redacted] with a shirt on with no brief on. Denies any inappropriate behavior. She remained in the room until apx [approximately] 2030 [8:30 PM]. On 2/15/24 at 9:00 PM, a behavior note documented, CNA [name redacted] reported that pt from room [room number redacted] also had his garments on with no bottoms. [Resident 13] had her bottoms off resting in his bed. Social work notified. On 2/16/24 at 11:23 AM, a social work note documented, SSW notified that Resident and peer spent alone time together. Resident verbalized that she is happy with her current relationship with her peer. She reports that they are good friends and that nothing has happened that they enjoy spending time together in peers bed watching movies and talking. She reports that peer is kind to her and that they have not been intimate. On 6/25/24 at 11:36 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she is not aware of any relationships between residents in the building either companions or sexual in nature. On 6/25/24 at 12:56 PM, an interview was conducted with the SSW. The SSW stated that she interviewed the residents in order to determine if the residents were able to consent to having a relationship. The SSW stated that there was the potential that these residents were engaged in physical contact. The SSW stated she went with the Director of Nursing to assess resident 13 for any harm. The SSW stated that she could not recall if the medical director was notified of the relationship the residents were having and it was typically the DON's responsibility to notify the medical doctor in regards to residents. The SSW stated that resident 13 was confused and said bizarre things at times. The SSW stated that she figured that the residents were both adults and they could consent to have a relationship with each other. The SSW stated that no formal assessment was done to determine if resident 13 was able to consent to have a relationship. On 6/27/24 at 9:59 AM, a second interview was conducted with the SSW. The SSW stated that resident 151 was typically very sweet and then suddenly, he became very agitated near the end of his life. SSW stated resident 151 did have delusions off and on, he would think he was doing business deals with people. The SSW stated that resident 151 and resident 13 would have meals and attend activities together, and that it was resident 151 that helped get resident 13 out of her shell and out of her room more. The SSW stated she did not see any public affection between resident 151 and resident 13, and that they were always very cordial. The SSW stated Stonehenge was not a behavioral health facility, so she was not much concerned when the two residents started showing signs of a closer relationship. The SSW stated that resident 151's daughter was in the process of gaining guardianship due to him having bad finances and making bad choices. The SSW stated that resident 151 and resident 13 would go back and forth into each other's beds. The SSW stated that it was told to her that resident 151 and resident 13 may have been unclothed at some point. The SSW stated that she went with the Director of Nursing (DON) and talked to both residents separately. The SSW stated that her and the DON asked the residents about consent and how to be safe and what it means. The SSW stated that she and the DON were satisfied with what the residents reported and informed the Administrator (ADM), and they proceeded to inform the residents' families. The SSW stated that resident 151's guardian liked that he had a special friend in the facility that he was able to spend time with. The SSW stated that she would put a progress note in the resident's chart when she talked to a resident about what the resident knows about consent, how to be safe when with a close friend, and if she has talked with family or a guardian. The SSW stated that it was determined to allow the relationship to continue by the interviews with resident 151 and resident 13. The SSW stated that she does not recall if the physician was ever notified of resident 151 and resident 13's relationship, and that it would have been the DON that would have contacted the physician. The SSW stated that since both residents were confused, she had initiated a care plan, and she also initiated a care plan in case the relationship progressed further. The SSW stated that when she spoke with resident 151 and resident 13, they both replied they liked being with each other. On 6/27/24 at 12:35 PM, an interview with the DON was conducted. The DON stated she was informed that resident 13 and resident 151 were found in bed together in a state of undress. The DON stated that she and the SSW went together to talk to the residents individually. The DON stated that resident 151 told her it was none of your damn business. The DON stated that both residents denied being undressed with each other, stating nothing happened, and they were just watching movies. The DON stated that she encouraged both residents to let staff know if anything did happen or may happen. The DON stated that during the investigation, due to the residents being under the blankets the Certified Nurse Assistant (CNA) thought they saw the residents without clothing on. The DON stated that resident 151 was alert to himself and was alert and oriented x 3 or 4. The DON stated that resident 151 was showing signs of terminal aggressions. The DON stated that the did not do any cognitive assessments on resident 13 or resident 151, and that the assessment was her and the SSW talking to the residents. The DON stated she is unsure if the incident between resident 13 and resident 151 went to an interdisciplinary team (IDT) meeting, and that she recalled it was her and the SSW that talked most about it. The DON stated that it would be the physician that would make the decision if a resident was able to give consent. The DON stated that either she or the SSW would contact the physician. The DON stated that resident 13 was not always alert and oriented, and this behavior tended to be worse at night. The DON stated if patients were alert and oriented then the facility had to respect their choices to have a relationship. The DON stated there was no policy in regards to residents and relationships that she was aware of. [Cross refer to F600] 50200

Based on observation, interview, and record review, it was determined, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment. Specifically, for 1 out of 24 sampled residents, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, myelodysplastic syndrome, severe protein-calorie malnutrition, type 2 diabetes mellitus without complications, bacteremia, sepsis, atherosclerotic heart disease, ascites, chronic systolic (congestive) heart failure, and acute kidney failure. On 1/9/23 at 10:55 AM, an observation was made of resident 17's tube feeding (TF). Resident 17's TF was infusing at a rate of 70 milliliters per hour (ml/hr) with a flush of 30 milliliters (ml) every (Q) four hours. The TF bag was labeled Glucerna 1.2 and dated 1/9/23 at 10:45 AM. Resident 17's medical record was reviewed on 1/10/23. A physician's order dated 12/31/22, documented Enteral Feed Order every shift Enteral Nutrition via pump: Glucerna 1.2 at 70mL/hr. Flush with 30mL Q4 hours. On 1/3/23 at 7:20 PM, a Nutrition/Dietary Note documented Note Text: Nutrition Readmit/TF change Inadequate PO [by mouth] intake r/t [related to] swallowing difficulty AEB [As Evidenced By] need for TF. Recent wt [weight] 164# [pounds] (12/14) from previous admit [admission], . is NPO [nothing by mouth]. Receiving TF order of Glucerna 1.2 @ 70 ml/hr x [times] 24 hrs [hours], H20 [water] flush 30 ml Q4 hrs x 24 [hrs]. Provides 2016 kcal [kilocalorie] (100%), 100.8 g [grams] prot [protein] (100%), (1352.4 ml free H20, +180 ml Flush, + 60 ml flush, +est [estimate] 120 ml) 1712.4 ml total H20. Current TF order does not meet hydration needs, and will update order to allow for feeding to be done overnight. New TF order: Glucerna 1.2 @ 120 ml/hr x 14 hrs, Flush 100 ml Q2 hrs x 14 hrs. Provides 2016 kcal (100%), 100.8 g prot (100%), (1352.4 ml free H20, +700 ml Flush, + 60 ml flush, +est 120 ml) 2232.4 mL total fluid (100%). It should be noted that resident 17's TF was not changed to the new order. On 1/11/23 at 7:20 AM, an observation was made of resident 17's TF. Resident 17's TF was infusing at a rate of 70 ml/hr with a flush of 30 ml Q4 hours. The TF bag was labeled Glucerna 1.2 and dated 1/11/23 at 2:00 AM. On 1/11/23 at 7:58 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated if she made a recommendation she would either fill out a telephone order (TO) or she would document the recommendation on a [NAME] sheet for recommendations and then she would give the sheet to either the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). The RD stated that currently the facility did not have an ADON so the sheet would have been given to the DON. The RD stated that she did make a recommendation to increase resident 17's TF on 1/3/23. The RD stated that she thought she had put the recommendation on the [NAME] sheet. On 1/11/23 at 8:07 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the RD would create a TO for any supplements or meal texture changes and the floor nurse or Unit Manager (UM) would put the orders in the resident's medical record. RN 1 stated the Speech Therapist would write a TO for TF changes and the nurses would implement the changes. On 1/11/23 at 11:07 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 17 had been NPO since admission to the facility. LPN 1 stated the RD would do an evaluation on the residents and the nursing staff would get the orders and implement whatever the RD was wanting. LPN 1 stated the RD should be giving the nurses a written order if a TF was changed. LPN 1 stated if the RD documented in a progress note the nurses would not necessarily review the notes. LPN 1 stated the RD came to the facility at night and would pass any recommendations to the night nurse. LPN 1 stated a written TO would be entered into the resident's medical record and LPN 1 would document in a progress note the changes that were made. LPN 1 further stated that after the TO was entered the TO would be placed in a box for the UM to review. On 1/11/23 at 11:14 AM, an interview was conducted with the UM. The UM stated the RD would fill out a TO and sign it. The UM stated that the floor nurse or the UM would input the orders into the resident's medical record and then the Medical Director would sign the orders. The UM stated that whoever received the order would input the order. The UM was unable to provide a TO regarding resident 17's TF increase. On 1/11/23 at 11:34 AM, an interview was conducted with the DON. The DON stated the RD would write a TO and give it to the nurses so they could make the changes recommended. The DON stated the TO would be given to the provider for review. The DON stated that most providers would not touch the RD's recommendations and would refer back to the RD. The DON stated the RD was new to the facility and wrote the recommendation for resident 17 on a form and emailed the form to the DON. The DON stated that she received a lot of emails and did not see the recommendation. The DON stated the RD recommendations typically would be implemented in one to two days. The DON stated that Tuesdays were the skin and weight meetings. The DON stated that she had questions regarding the RD's note and was trying to get a hold of her. The DON stated she did not know where the RD got the information on the note. The DON stated she was unsure if the RD understood the facilities process. The DON stated a TO could be written from the recommendation form sent by the RD and the DON was in the process of writing the TO to increase resident 17's TF. The DON stated that if a resident was NPO the resident would usually have a 24 hour feeding. A Dietary Recommendations form dated 1/3/23, was provided by the DON. The RD documented on the form under the Recommendations section 1. Glucerna 1.2 @ 120 ml/hr x 14 hr. 2. H2O Flush 100 ml Q2 hr x 14 hr. 3. Retake wt measurement. [Note: Resident 17 had one documented weight on 12/14/22, of 164 pounds.]

Based on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program that was designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 24 sampled residents, observations were made of staff exiting a resident's room that was on contact precautions and then entering another residents room without performing hand hygiene after having touched environmental surfaces in both rooms. Additionally, observations were made during wound care of staff not performing hand hygiene and cross contamination. Resident identifiers: 136. Findings included: 1. On 1/9/23 at 9:04 AM, an observation was made of Student Certified Nurse Assistant (SCNA) entering room [ROOM NUMBER]. room [ROOM NUMBER] was observed with signs posted on the door that stated contact precautions. The sign documented to perform hand hygiene before entering and before leaving the room, and to donn gloves, and a gown when entering the room. A personal protective equipment (PPE) cart was located outside the room and contained gloves, disposable gowns, and biohazard bags. The SCNA was observed wearing a N95 mask, but did not donn a gown or gloves, nor perform hand hygiene prior to entering the room. The SCNA removed a breakfast tray from room [ROOM NUMBER] and deposited the tray on a hall cart. The SCNA then entered room [ROOM NUMBER]. While inside room [ROOM NUMBER] the SCNA was observed to move the resident's bedside table and blankets, and proceeded to touch the resident's call light and television remote. The SCNA did not perform hand hygiene between room [ROOM NUMBER] and 317. The SCNA was interviewed upon exit of room [ROOM NUMBER]. The SCNA stated that she thought it was just when making contact with the resident that she had to donn the extra PPE. On 1/11/23 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if staff were providing dressing changes they needed to wear the required contact precaution PPE. Otherwise, the staff should be performing hand hygiene between every meal tray delivery or resident contact. 2. Resident 136 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, shortness of breath, pressure ulcer unspecified stage, pressure-induced deep tissue damage of sacral region, Parkinson's disease, anxiety disorder, and hypertension. On 1/9/23 at 10:52 AM, an observation was made of resident 136 lying supine in bed with bilateral feet elevated. An air mattress was noted on the bed. Resident 136's physician's order for the Coccyx/Left Buttock wound was to cleanse the area with normal saline (NS), apply skin prep, then cover with a foam dressing every three days and as needed for a deep tissue injury (DTI). The order was initiated on 1/6/23. On 1/5/22, the Admission Nursing Comprehensive Assessment documented a closed bed sore on the sacrum. Review of the progress notes documented: a. On 1/6/23 at 2:44 PM, the nursing note documented, New order to buttock blister. Clean with NS, place foam dressing. Check for placement every shift and change every 3 days. b. On 1/6/23 at 5:23 PM, the nursing note documented, Clarification: This area is not a blister area, but is a DTI and patient has had this at the hospital and also has a diabetic ulcer to right 2nd toe. On 1/10/23 at 1:14 PM, an observation was made of resident 136's dressing change to the coccyx wound performed by Licensed Practical Nurse (LPN) 1. LPN 1 was assisted by Certified Nurse Assistant (CNA) 3 and LPN 2. LPN 1 did not perform hand hygiene prior to the start of resident 136's dressing change. Resident 136 was turned onto the left lateral side. LPN 1 stated that dressing orders for the left gluteal and coccyx wound was for skin prep, cleanse with NS, and apply an adhesive bordered foam dressing. LPN 2 was observed to prepare and open multiple packages of 4 x 4 gauze dressing and placed on the bedside table. LPN 1 removed the old adhesive bordered foam dressing. The old dressing was observed not covering the wound bed fully and was bunched up in one corner. LPN 1 opened the old dressing fully with both hands and stated that it was dated 1/10/23. LPN 1 was observed to discard the old dressing, doff gloves, and new gloves were donned. LPN 1 did not perform hand hygiene. LPN 1 took a vial of NS and squirted it into the wound bed. LPN 1 wiped the wound bed with a 4 x 4 gauze. LPN 1 then gathered a tube of iodosorb cream from the bedside table and applied a dab to the back of the index finger and placed on the coccyx wound bed. LPN 1 stated that the iodosorb was hard to apply and did not stick to the wound bed. LPN 1 then applied some iodosorb cream to the center of the foam dressing and attempted to apply to the wound without success. LPN 1 then removed the iodosorb from the dressing with the index finger and applied to the wound bed again. LPN 1 then applied an adhesive bordered foam dressing to the wound. LPN 1 did not apply skin prep to the periwound. LPN 1 was observed to perform hand hygiene with alcohol based hand rub upon exit of resident 136's room. LPN 1 stated that hand hygiene should be performed before starting a dressing change and after removing the old dressing before the new dressing was applied. LPN 1 stated that she did not perform hand hygiene at these time. LPN 1 stated that any creams or ointments should be applied to the wound with a cotton tipped applicator and not the fingers. On 1/10/23 at 2:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that hand hygiene should be performed prior to a dressing change, after the removal of a dirty dressing, prior to applying new gloves, and upon completion of the wound care. The DON stated that creams or ointments should be applied to the wound bed with a cotton tipped applicator.

Based on interview and record review, it was determined, the facility did not ensure the resident's right to formulate an advanced directive. Specifically, for 1 out of 24 sampled residents, the resident's electronic medical record documented that the resident was a Do not attempt or continue any resuscitation (DNR) and Do not attempt to intubate (DNI) while the Physician Orders for Life-Sustaining Treatment (POLST) form documented the resident's wishes as Attempt to resuscitate, full treatment. Resident identifier: 136. Findings included: Resident 136 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, shortness of breath, pressure ulcer unspecified stage, pressure-induced deep tissue damage of sacral region, Parkinson's disease, anxiety disorder, and hypertension. Resident 136's electronic medical record dashboard documented the code status as DNR/DNI. On 1/5/23, resident 136's POLST documented Attempt to resuscitate, full treatment. On 1/10/23 at 9:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would look for a resident's code status in the electronic medical record on the resident dashboard and on the nurse/patient roster. LPN 1 stated that resident 136's dashboard documented the code status as DNR/DNI, and the nurse/patient roster documented DNR only. LPN 1 stated that she would have to update the nurse/patient roster to say DNI also. LPN 1 stated she would pull the resident's POLST and double check the status. LPN 1 stated that all of the nursing staff were responsible for ensuring that the computer dashboard matched the resident's POLST, and that nurses and nurse managers checked it. LPN 1 reviewed resident 136's POLST and confirmed that resident 136's POLST documented full code. LPN 1 was observed to change resident 136's code status in the electronic medical record to full code. LPN 1 stated absolutely they should both match. On 1/10/23 at 9:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the code status was an order in the electronic medical record and was located on the resident dashboard. The DON stated that the dashboard code status was confirmed with a signed POLST form. The DON stated that the nurse or unit manager should verify that the information was the same. The DON reviewed resident 136's signed copy of the POLST form and confirmed that it documented full code. The DON stated that in an emergency the staff would likely look at the resident dashboard and nurse/patient roster first to confirm a code status, and that it could be a delay in providing treatment when verified with the POLST. The DON stated that the dashboard should have been updated from the signed POLST form on file.

Based on interview and record review, it was determined, the facility did not ensure that when a resident was transferred or discharged that the appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 24 sampled residents, residents were transferred to the hospital and no documentation could be found that the receiving institution was provided the contact information of the practitioner, resident representative information, advanced directives information, comprehensive care plan, and all other necessary information to ensure a safe and effective transition of care. Resident identifiers: 15 and 137. Findings included: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, fall, peripheral neuropathy, chronic obstructive pulmonary disease, Crohn's disease, major depressive disorder, bipolar disorder, anxiety disorder, history of pulmonary embolism, hypothyroidism, hyperlipidemia, and post-traumatic stress disorder. On 1/9/23 at 9:32 AM, an interview was conducted with resident 15. Resident 15 stated that she had been transferred to the hospital a couple of times. Resident 15's progress notes revealed the following: a. On 1/8/23 at 8:00 PM, the note documented, Family requested transport to hospital for evaluation for falls, behaviors, Oxygen level. Patient is resting in w/c [wheelchair], with family in attendance. b. On 1/8/23 at 9:31 PM, the note documented, [family member] arrived at the facility and asked that we call an ambulance and have [resident 15] sent to [name of hospital] due to her psychotic behavior. Transport arrived, report was given to the EMTs [Emergency Medical Technicians] and [resident 15] was accompanied to the hospital by [family member]. It should be noted that no documentation could be found that indicated what information was provided to the receiving institution or provider. On 1/10/23 at 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that for hospital transfers they send a medication list, treatment list, copy of the resident face sheet, copy of the Physician Orders for Life-Sustaining Treatment (POLST), most recent history and physical, and the facility bed hold policy to the receiving provider. LPN 1 stated that a transfer assessment was completed and it would show what documents were sent with the resident to the hospital. LPN 1 stated that she would usually document in a progress notes what was sent. LPN 1 stated that if EMTs arrived quickly they would fax the documents to the hospital. On 1/10/23 at 2:32 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for resident transfers staff utilized a check off sheet that list what was to be sent with the resident to the receiving provider. The DON stated that the list included a medication list, face sheet, POLST, last in house provider note, last history and physical, recent labs, current bed hold policy, and current treatment list. The DON stated that the list sometimes was sent with the resident to the emergency room . The DON stated that the licensed nurse should document in a progress notes the documents that were sent to the hospital or receiving provider. 2. Resident 137 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, ataxia, vertigo, cardiac arrhythmia, osteoporosis, polymyalgia rheumatica, and chronic kidney disease. Resident 137's progress notes revealed the following: a. On 1/5/23 at 12:16 PM, the nursing progress note documented that resident 137 had a witnessed fall in the shower and landed on the left shoulder and hit the left side of the face. Resident 137 sustained a bloody nose, skin tear to left elbow, small abrasion on right thumb and a bump on the left scalp. The Nurse Practitioner was notified and ordered to send the resident to the hospital. b. On 1/5/23 at 3:47 PM, the physician progress note documented the history of present illness as Staff RN [registered nurse] notified me of this patient falling in the bathroom. She reports that she was getting a shower lost balance and hit her head on the floor causing epistaxis and severe L [left] shoulder pain. She is not at her baseline cognitively, she is usually A&O x 4 [alert and oriented times 4 to self, place, situation, and time] now about 1. This is an [AGE] year female in frail condition and having hit her head and with cognitive changes, concerns for subdural hemorrhage are paramount. I will send her to the ED [Emergency Department] for scans of both head and L shoulder. It should be noted that no documentation could be found of a discharge or transfer assessment, nor the documentation that was sent to the receiving provider. On 1/5/23, the hospital discharge paperwork documented that resident 137 stated that she had Advanced Directives and a copy was obtained from previous records. On 1/11/23 at 9:29 AM, a follow-up interview was conducted with the DON. The DON stated that the progress notes would document any transfers to the hospital. The DON stated that they did not have a policy for documenting what paperwork was sent to the receiving providers. The DON stated that some nurses would be more thorough with documentation of what was sent to the receiving provider. The DON stated that sometimes the emergency room would call and say they did not get any paperwork and she would respond that they gave the paperwork to the EMT. The DON stated that there was no place in the resident record where that information was specifically documented.

Based on interview and record review, it was determined, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene. Specifically, for 1 out of 24 sampled residents, a resident who required bathing assistance was not provided a shower since admission. Resident identifier: 141. Findings included: Resident 141 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, pneumonia, severe sepsis, congestive heart failure, chronic kidney disease, hyperparathyroidism, rheumatoid arthritis, and metabolic encephalopathy. On 1/9/23 at 9:13 AM, an interview was conducted with resident 141. Resident 141 stated that she had not had a shower since she had been admitted . Resident 141 stated it had been over a week since she had a shower. Resident 141 stated that she would need staff assistance with the shower. Review of resident 141's bathing task for the last 14 days revealed no documentation for bathing assistance that was provided, no activities of daily living (ADL) assistance needs, nor any resident preferences for bathing. On 1/4/23, resident 141's baseline care plan documented that resident 141 was at risk for alterations in ADL's due to weakness and a history of falls. No documentation could be found to indicate that resident 141 was assessed for staff assistance needed with mobility or showering/bathing. On 1/9/23 at 3:53 PM, a social work progress note documented that resident 141 had a Brief Interview for Mental Status score of 14, which would indicate that resident 141 was cognitively intact. On 1/11/23 at 8:10 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1 and Licensed Practical Nurse (LPN) 1. CNA 1 stated that the residents were scheduled for showers every other day. CNA 1 stated that they followed a chart that showed who was scheduled for a shower that day. CNA 1 stated that they documented the showers completed on a shower sheet. LPN 1 stated that the CNA Coordinator filled out the daily shower schedule for the CNAs to inform them of who was due for a shower that day. LPN 1 stated that when the CNA completed the shower they would give the shower sheet to the licensed nurse to review and then the sheet was sent to medical records to be scanned into the resident file. On 1/11/23 at 9:07 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that the shower sheets were not scanned into the resident medical record and the CNAs were supposed to document bathing tasks provided in the electronic medical record under tasks. On 1/11/23 at 10:15 AM, a follow-up interview was conducted with the CNA Coordinator. The CNA Coordinator stated that there were no shower sheets for resident 141 that documented that any showers were provided. The CNA Coordinator stated that she had spoken to Occupational Therapy and they had said they informed the CNA on 1/10/23, that resident 141 needed a shower. The CNA Coordinator stated that there was no documentation that showed resident 141 had received a shower on 1/10/23. The Coordinator stated that CNA 2 had reported that resident 141 had received a shower on 1/7/23, but that there was no documentation that could be found to verify the shower. The Coordinator stated that resident 141 had refused a shower on 1/5/23, but there was no documentation to verify the refusal. The CNA Coordinator stated that she needed to educate the CNAs on documenting refusals and showers provided. On 1/11/23 at 10:21 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 141 was an extensive 1 to 2 person assist for transfers, bed mobility, showers and toileting.

Based on observation, interview, and record review, it was determined, the facility did not ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, for 1 out of 24 sampled residents, an observation was made of wound care to a resident's coccyx pressure ulcer that was not consistent with the physician's orders for wound care. Resident identifier: 136. Finding included: Resident 136 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, pneumonia, shortness of breath, pressure ulcer unspecified stage, pressure-induced deep tissue damage of sacral region, Parkinson's disease, anxiety disorder, and hypertension. On 1/9/23 at 10:52 AM, an observation was made of resident 136 lying supine in bed with bilateral feet elevated. An air mattress was noted on the bed. Resident 136's physician's order for the Coccyx/Left Buttock wound was to cleanse the area with normal saline (NS), apply skin prep, then cover with a foam dressing every three days and as needed for a deep tissue injury (DTI). The order was initiated on 1/6/23. On 1/5/22, the Admission Nursing Comprehensive Assessment documented a closed bed sore on the sacrum. Review of the progress notes documented: a. On 1/6/23 at 2:44 PM, the nursing note documented, New order to buttock blister. Clean with NS, place foam dressing. Check for placement every shift and change every 3 days. b. On 1/6/23 at 5:23 PM, the nursing note documented, Clarification: This area is not a blister area, but is a DTI and patient has had this at the hospital and also has a diabetic ulcer to right 2nd toe. Resident 136's care plan for skin integrity alterations was initiated on 1/5/23, for the wounds on the right second toe and left buttocks and coccyx. An intervention identified was for the licensed nurse to perform treatments as ordered. On 1/10/23 at 1:14 PM, an observation was made of resident 136's dressing change to the coccyx wound performed by Licensed Practical Nurse (LPN) 1. LPN 1 was assisted by Certified Nurse Assistant (CNA) 3 and LPN 2. LPN 1 did not perform hand hygiene prior to the start of resident 136's dressing change. Resident 136 was turned onto the left lateral side. LPN 1 stated that dressing orders for the left gluteal and coccyx wound was for skin prep, cleanse with NS, and apply an adhesive bordered foam dressing. LPN 2 was observed to prepare and open multiple packages of 4 x 4 gauze dressing and placed on the bedside table. LPN 1 removed the old adhesive bordered foam dressing. The old dressing was observed not covering the wound bed fully and was bunched up in one corner. LPN 1 opened the old dressing fully with both hands and stated that it was dated 1/10/23. LPN 1 was observed to discard the old dressing, doff gloves, and new gloves were donned. LPN 1 did not perform hand hygiene. LPN 1 took a vial of NS and squirted it into the wound bed, and then wiped the wound bed with a 4 x 4 gauze. LPN 1 then gathered a tube of iodosorb cream from the bedside table and applied a dab to the back of the index finger and placed on the coccyx wound bed. LPN 1 stated that the iodosorb was hard to apply and did not stick to the wound bed. LPN 1 then applied some iodosorb cream to the center of the foam dressing and attempted to apply to the wound without success. LPN 1 then removed the iodosorb from the dressing with the index finger and applied to the wound bed again. LPN 1 then applied an adhesive bordered foam dressing to the wound. LPN 1 did not apply skin prep to the periwound. LPN 1 was observed to perform hand hygiene with alcohol based hand rub upon exit of resident 136's room. LPN 1 stated that the wound bed appeared excoriated, the skin was torn off, but no muscle, tendon, or bone was visible. LPN 1 stated that the wound did not have eschar or drainage noted. On 1/10/23 at 2:12 PM, a follow-up interview was conducted with the LPN 1. LPN 1 stated that the iodosorb was not supposed to be in resident 136's room and was for another resident. LPN 1 stated that the iodosorb was never ordered for resident 136's wound care. On 1/10/23 at 2:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that hand hygiene should be performed prior to a dressing change, after the removal of a dirty dressing, prior to applying new gloves, and upon completion of the wound care. The DON stated that creams or ointments should be applied to the wound bed with a cotton tipped applicator. The DON stated that the licensed nurse should verify the wound orders on the treatment administration record, and look at the order prior to treatment to verify that they had the correct supplies.

Based on interview and record review, the facility did not prevent misappropriation of resident's medications for 5 of 17 sample residents. Specifically, one nurse misappropriated narcotic medications from the electronic medication dispenser without administering the medications to the residents, and another nurse misappropriated medications from residents' narcotic prescriptions. Additionally, 17 residents who had been discharged from the facility had medications misappropriated. Resident identifiers: 8, 15, 19, 21, and 37. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/2/21, resident 37s medical record review was completed. Nursing notes revealed the following: a. On 7/26/21 at 11:20 PM, resident 37 complained to the night nurse, registered nurse (RN) 1 that she did not receive her pain medication at 6:15 PM. Resident 37 contacted her family, who called RN 1 and stated that resident 37 did not get her medications. RN 1 turned the care of resident 37 over to another nurse. b. On 7/27/21 at 12:04 PM, resident 37 reiterated that she did not receive a pain pill with her evening medications on 7/26/21 and requested a written medication schedule. c. On 7/28/21 at 11:15 AM, a discharge summary revealed that resident 37's family picked up resident 37 who left against medical advice (AMA). d. On 7/29/21 at 1:23 PM, a minimum data set (MDS) note revealed that resident 37 was scheduled for home health, but was not allowed to take her medications when she left the facility because she left AMA. A Concern Form Log revealed that on 7/27/21, resident 37 expressed concern that she was not receiving her evening medications. An investigation report was completed and revealed that resident 37 stated that she did not feel safe in the facility. Resident 37 stated that she did not believe she was receiving proper care, including receiving her pain medications. The report revealed that resident 37's family was upset and threatened RN 1. Resident 37's family contacted the police who responded to the complaint by going to the facility. The report revealed that the police asked resident 37's family to leave the facility. RN 1's employee file was reviewed. RN 1 had an employee termination record dated 8/6/21, due to forgery of a controlled drug record. RN 1's employment application revealed that RN 1 had previous charges of drug diversion. RN 1's employee file contained an employment application that included convictions for misdemeanors in 2006, 2008, 2017 and 2018. These were reportedly for theft, attempting to acquire a controlled substance, [and] endangerment. RN 1 was not fingerprinted as a condition of employment. RN 1's Division of Professional Licensing (DOPL) record was reviewed. RN 1 had four cases associated with her RN license, which was Active on Probation. RN 1 had the following issues: a. RN 1's nursing license was revoked on 3/28/2006 due to taking controlled substances. b. On 7/13/10 RN 1 was found guilty of altering a prescription. c. On 10/29/11, RN 1 was guilty of theft by deception. d. On 10/26/11, RN 1 was guilty of assault and admitted to drug rehab. e. On 3/18/15, RN 1 returned to probation and on 3/24/15 RN 1 received a conditional license. f. On 8/26/15, RN 1 had a positive narcotic test. g. On 10/6/15 RN 1 reported to DOPL that she had relapsed and was taking oxycodone. h. On 10/20/15, RN 1 refused a drug test. i. On 10/26/21, RN 1 took a drug test and was positive for [MEDICATION(S)] without a prescription. j. On 11/20/15, RN 1 refused a drug test. k. In 11/2015, RN 1 was terminated from work in a nursing home. l. RN 1 surrendered her nursing license in June, 2016. m. In December, 2019, RN 1 reapplied for licensure and received a conditional license n. On 1/7/2020, RN 1 was granted an RN license. o. On 8/9/2020, RN 1 could work under general supervision. p. On 9/21/2020, RN 1 was hired by the facility. The Office of Inspector General (OIG) cleared RN 1 to work as a nurse on 10/8/2020. On 9/1/21 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the problem with RN 1 was discovered when another nurse reported that a narcotic was signed out that they did not administer. The DON investigated the narcotic logs and found that there were medications that were signed out at times before the medications were delivered from the pharmacy. The DON also stated that narcotics were administered for residents who did not take narcotic medications, and in higher amounts by RN 1 than for other nurses. On 9/1/21 at 2:30 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that when the facility wanted to hire RN 1, they were required to consult the corporation when a nurse had a blemish on their record. The CRN stated that they looked up RN 1's license and did a background check and knew that she had diverted medications. The CRN stated that the references RN 1 provided reported that she was a very good nurse. The CRN stated that the corporation worked with the DOPL case worker for RN 1 and determined the requirements to employ RN 1. The CRN stated that they wanted to give RN 1 a second chance but waited until there were no stipulations on her license to hire here. The CRN stated that the previous DON felt that RN 1 was doing better and saw that DOPL removed the stipulations from her license quickly. 2. Resident 19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/21 at 1:00 PM, an interview was conducted with resident 19. Resident 19 stated that he had pain associated with his knee replacement surgery, and took Tylenol for pain. Resident 19 stated that he did not want to become addicted to narcotics, and therefore he did not take any. Resident 19 stated that he had narcotics prescribed for him just in case he had additional pain, but he had not needed to take them. On 9/2/21, resident 19's electronic medical record was reviewed. Resident 19's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The narcotic tablets were obtained by RN 1. The electronic medication dispenser (Medex) record was reviewed. Resident 19 had two oxycodone 5 mg tablets obtained by RN 2 on 7/31/21. 3. Resident 8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8 had the following medications procured from the Medex electronic medication dispenser by RN 2 on the following dates: a. 2 tablets on 6/11/21 at 3:34 PM b. 4 tablets on 6/12/21 at 6:13 AM c. 4 tablets on 6/12/21 at 11:30 AM d. 2 tablets on 6/12/21 at 1:29 PM e. 2 tablets on 6/13/21 at 6:26 AM f. 2 tablets on 6/13/21 at 5:09 PM g. 3 tablets on 6/16/21 at 6:23 AM h. 3 tablets on 6/16/21 at 2:02 PM i. 2 tablets 6/16/21 at 5:54 PM j. 2 tablets on 6/22/21 at 8:32 AM k. 4 tablets on 6/22/21 at 12:03 PM l. 4 tablets on 6/23/21 at 8:18 AM m. 4 tablets on 6/23/21 at 9:23 AM n. 4 tablets on 6/28/21 at 9:34 AM o. 4 tablets on 6/30/01 at 6:35 AM p. 3 tablets on 6/30/21 9:54 AM q. 4 tablets on 6/30/21 at 4:57 PM 4. Resident 21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed that RN 2 removed [MEDICATION(S)] 10 mg for resident 21 on the following dates: a. 3 tablets on 6/21/21 at 8:14 AM b. 6 tablets on 6/21/21 at 4:34 PM c. 6 tablets on 6/29/21 at 7:41 AM d. 3 tablets on 6/29/21 at 12:09 PM e. 6 tablets on 6/29/21 at 12:10 PM f. 3 tablets on 6/30/21 at 11:04 AM 5. Resident 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed that RN 2 retrieved narcotics for resident 15 from the Medex machine [MEDICATION(S)]/Apap (acetaminophen) 7.5/325 milligrams (mg) on the following dates: a. 4 tablets on 6/1/21 at 6:14 AM b. 2 tablets on 6/1/21 at 12:59 PM c. 2 tablets on 6/2/21 at 8:15 AM d. 4 tablets on 6/7/21 at 9:39 AM e. 4 tablets on 6/11/21 at 4:17 PM f. 4 tablets on 6/13/21 at 7:56 AM [MEDICATION(S)]/APAP 10/325 mg on the following dates: a. 3 tablets on 6/7/21 at 6:59 AM b. 4 tablets on 6/7/21 at 1:59 PM c. 4 tablets on 6/7/21 at 3:05 PM d. 4 tablets on 6/11/21 at 6:06 AM e. 4 tablets on 6/11/21 at 10:01 AM f. 3 tablets on 6/11/21 at 5:45 PM g. 4 tablets on 6/12/21 at 5:01 PM h. 4 tablets on 6/15/21 at 12:19 PM i. 4 tablets on 6/15/21 at 1:38 PM j. 4 tablets on 6/15/21 at 5:35 PM k. 4 tablets on 6/16/21 at 6:21 AM l. 4 tablets on 6/16/21 at 7:32 AM m. 4 tablets on 6/16/21 at 5:41 PM n. 2 tablets on 6/21/21 at 6:22 AM o. 4 tablets on 6/21/21 at 10:46 AM p. 2 tablets on 6/21/21 at 4:34 PM q. 4 tablets on 6/22/21 at 8:31 AM r. 4 tablets on 6/23/21 at 7:30 AM s. 4 tablets on 6/23/21 at 9:22 AM t. 4 tablets on 6/24/21 at 6:26 AM u. 4 tablets on 6/24/21 at 5:40 PM v. 4 tablets on 6/28/21 at 6:49 AM w. 4 tablets on 6/28/21 at 9:33 AM x. 4 tablets on 6/29/21 at 6:40 AM y. 4 tablets on 6/29/21 at 7:42 AM z. 4 tablets on 6/30/21 at 6:33 AM aa. 4 tablets on 6/30/21 at 9:51 AM 6. In addition to the sample residents, 17 residents had narcotics procured from the electronic medication dispenser. In total, 417 narcotic tablets were removed from the electronic medication machine without them being administered to the residents for which they were procured. On 8/1/21 at 2:19 PM, the Unit Manager (UM) was interviewed. The UM stated that the reports for medications being taken out of the Medex electronic medication distribution machine were sent to the previous DON. On 9/1/21 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the problem with RN 2 was discovered by a Family Nurse Practitioner (FNP). The Pharmacy sent signature pages to the FNP for the residents who had medications administered from the Medex machine. The FNP recognized that there were medications available for the residents in the narcotic drawer in the nurses' carts, and no medication was needed from the Medex machine. The FNP was investigating these anomalies when RN 2 admitted to taking medications from the Medex machine. The DON stated that no medications were taken from the residents directly, and all residents appeared to have received the medication they required. The DON stated that there was no narcotic count problem for RN 2. On 9/1/21 at 2:30 PM, an interview was conducted with the CRN. The CRN stated that the previous DON had changed the two-person authentication method and fingerprint needed to take medications out of the Medex machine so that one nurse could take narcotics or antibiotics out of the system independently. On 9/1/21 at 3:00 PM, an interview was conducted with the Administrator (ADM). The ADM stated that reporting to the police, DOPL and the DEA (Drug Enforcement Agency) was not completed when the facility discovered that RN 2 had taken medications from the Medex machine, and that RN 1 was not reported to the DEA. There were no written policies and procedures for handling the Medex machine.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to prevent the transmission of communicable diseases for 1 of 17 sample residents. Specifically, a staff member entered and exited a newly admitted resident's room, who was on 14 day isolation, without donning and doffing appropriate personal protective equipment (PPE). Resident identifier: 137 Findings include: Resident 137 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 137 was designated as a new admit, requiring isolation and transmission-based precautions for 14 days due to the COVID-19 pandemic. On 8/30/21 at 7:14 AM a small plastic cart with PPE was observed outside resident 137's room. A transmission based precautions (TBP) sign was observed on resident 137's door that read: New Admission 14 Day Quarantine, What you MUST wear when entering room For any reason DON (Put on) · N95 mask · Gown · Gloves · Face shield DISCARD (do not leave room with any PPE on) · N95 mask · Gown · Gloves · Face shield Start date 8/22 End date 9/4 On 8/30/21 at 8:18 AM, Licensed Practical Nurse (LPN) 1 was observed entering and exiting resident 137's room without donning or doffing appropriate PPE. LPN 1 retrieved a pain medication for resident 137 from the medication cart in the hallway. LPN 1 was observed entering resident 137's room a second time without donning appropriate PPE to administer the pain medication to resident 137. On 8/30/21 at 9:07 AM, the Certified Nursing Assistant (CNA) Coordinator was observed wearing full PPE, (N95 mask, gown, gloves and face shield) when she delivered resident 137's breakfast to his room on Styrofoam plates. On 8/31/21 at 2:40 PM, an interview was conducted with CNA 1. CNA 1 stated that newly admitted residents are isolated in their room for 14 days because they do not know whether these residents have COVID-19 or not. CNA 1 stated she had to wear full PPE, (N95 mask, gown, gloves and face shield) when she entered their rooms during that 14 day isolation period. On 8/31/21 at 3:14 PM, an interview was conducted with LPN 2. LPN 2 stated that new admits, who have not been vaccinated for COVID-19, are isolated in their rooms for 14 days after admit. LPN 2 stated that if she needed to provide care for a newly admitted resident, she had to wear full PPE (N95 mask, gown, gloves and face shield) when she entered that resident's room. On 9/1/21 at 12:41 PM, an interview was conducted with the Nurse Manager/Infection Preventionist (NM/IP). The NM/IP stated that all newly admitted residents are considered unvaccinated for COVID-19 and placed on TBP for 14 days in their rooms. The NM/IP further stated that staff are expected to don and doff full PPE (N95 mask, gown, gloves and face shield) when providing care to these residents. On 9/1/21 at 1:37 PM, an interview was conducted with LPN 1. LPN 1 stated that unvaccinated new admits are isolated for 2 weeks and all care providers are expected to wear full PPE when entering their rooms. When asked about when he entered resident 137's room on the morning of 9/30/21 without PPE, LPN 1 stated he should have donned PPE prior to entering the room but did not.

Based on interview and record review, the facility failed to establish an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure all residents were assessed for all Centers for Disease Control and Prevention (CDC) signs and symptoms of COVID-19 including oxygen levels daily, none of 32 residents screened for all signs and symptoms of COVID-19. -Ensure all staff and visiting essential personnel were assessed for all signs and symptoms of COVID-19 at the beginning of their shift or upon entry to facility, none of 51 staff and visiting essential personnel. These failures have the potential to expose all residents, staff, and visiting essential personnel to COVID-19 (a [MEDICAL CONDITION] infection that could lead to serious harm or death) or other healthcare associated infections. Findings include: A. The facility failed to ensure residents, staff and visiting essential personnel were assessed for all signs and symptoms of COVID-19 daily (residents) or upon entry to the facility (staff and visiting essential personnel). During a review of the COVID MONITORING SHIFT REPORT, (facility name) Employee Screening Form, and COVID 19 ADMISSION SCREENING TOOL, zero of 32 residents, zero of 49 staff, and zero of two visiting essential personnel were assessed for all signs and symptoms of COVID-19. During an interview on 8/18/20 at approximately 12:00 PM, with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), the DON was asked where resident screenings for COVID-19 would be in the resident record, the DON stated, You won't find them in the resident EMR. (electronic medical record) We use a COVID MONITORING SHIFT REPORT, a tool the nurses use each shift, but it isn't uploaded to resident EMR. The only thing you will find in the EMR is a change of condition note. The DON then was asked to supply completed resident screening sheets if available as well as initial Staff & Visitor screening tools. Forms provided by DON are; COVID MONITORING SHIFT REPORT, undated; (facility name) Employee Screening Form, undated; COVID 19 ADMISSION SCREENING TOOL, dated 03/07/2020. Review of the Infectious Disease Threat, Infection Control Measures During, provided on 8/18/20, document undated showed, Policy Interpretation and Implementation i. Displaying signs and or posters .exposed to or have symptoms . j. Screening visitors at facility entry points for symptoms of the infectious disease; and k. Screening employees for symptoms before coming on duty and send any symptomatic employees home. Review of the CDC Symptoms of Coronavirus, accessed 8/18/20, last updated 5/13/20, at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, revealed: Watch for symptoms People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea Review of the CDC Preparing for COVID-19 in Nursing Homes, accessed 8/18/20, last updated 6/25/20 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed; Core Practices .Educate Residents, Healthcare Personnel, and Visitors about COVID-19 . Provide information about COVID-19 (including information about signs and symptoms) Regularly review CDC's Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes. Evaluate and Manage Residents with Symptoms of COVID-19: - Actively monitor all residents upon admission and at least daily for fever (T (temperature) 100.0oF) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below. -Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. During a review of facility's resident screening tool, COVID MONITORING SHIFT REPORT, undated, revealed; Name, Hall, Date, Shift Instructions: IF POSITIVE FOR ANY OF THESE QUESTIONS: Make a note acknowledging symptoms and interventions with Provider notification. Did any of your patients/residents have a fever greater than 100.4? ________________. If yes, who: _______________. Interventions? ______________. Did any of your patients/residents have a cough? ________. Dry ______ Productive_______. If yes, who: _______________. Did any of your patients/residents have SOB? ____________. O2 needed? _____________. Baseline oxygen or new need? _____________? If yes, who: _____________. Did any of your patients/residents have sore throat? __________. Did any of your patients/residents have diarrhea: _________. DO YOU FEEL THAT ANY POSITIVE SYMPTOMS COULD BE RELATED TO INFECTION OR COVID 10 (ex: pt has UTI and has a documented fever or symptoms the provider has addressed) Are the symptoms new onset? New onset symptoms that have not been addressed need to be reported to the provider immediately Are any of your patients/resident on precautions? __________. Why ___________. Is this a new order or previously ordered and house providers are aware? ____________. Did you place any patient or resident on precautions during your shift? If so, why? ______________? Did you perform a head to toe assessment? __________. What signs and symptoms are present? ____________? What provider was notified? What are the new orders? ______________. Did you document your assessment, interventions and new orders? _____________. Did you notify the patient/family of all new orders? __________. All necessary information passed on to oncoming staff? __________. any positive symptoms need to be put on transmission based precautions. If the res has come with a current infection and has similar symptoms related to COVID symptoms we need to perform a thorough assessment to ensure this is a new onset or we believe it is different than current condition. Notify house provider. The facility did not provide any evidence of residents being screened/assessed for all COVID-19 symptoms (noted in the above CDC reference). During a subsequent review of the facility's employee screening tool, (facility name) Employee Screening Form, form creation is undated, revealed; columns for, Date, Time, Employee Name (Print only-First and last name, Temp, Cough/SOB/Diarrhea (Circle one) column answers Yes or No; COVID-19 Exposure column answers Yes or No; and Verified by: Initials. The facility did not provide any evidence of any staff/employees being screened/assessed for all COVID-19 symptoms (noted in the above CDC reference). Review of the COVID 19 ADMISSION SCREENING TOOL, dated 03/07/2020, revealed; TO BE COMPLETED FOR EACH 'ESSENTIAL VISITOR' VISITOR FULL NAME: In the last 14 days, have you traveled to a high risk/restricted country or city within the US? (China, Iran, South Korea, Italy Japan, New York, etc. __________) Yes _________ No ___________ Do you have any of the following: a) Fever? Document Temp: __________ b) Cough? Yes _________ No ___________ c) Shortness of Breath? Yes _________ No ___________ d) Diarrhea Yes _________ No ___________ Have you had contact with someone with OR under investigation for [MEDICAL CONDITION] (COVID-19)? Yes _________ No ___________ Have you been in another facility (hospital or LTC) since you were last here? Includes as a visitor or patient. a. If yes, Please list facilities where you have been. ___________________________ Yes ________ No ___________ Patient Name (if seeing patient): Date: Time: Reason for Visit: Address: Phone Number: Staff Signature: Date: The facility did not provide any evidence of essential visitors being screened for all COVID-19 symptoms (noted above in the CDC reference). Review of subsequent staff education, informational letters, posters and policies supplied by the NHA, DON & Infection Preventionist (IP) revealed; CDC printout titled; Symptoms of Coronavirus (COVID-19), dated April 13, 2020, with known symptoms (Trouble breathing, Persistent pain or pressure in the chest, New confusion or not able to be woken, Bluish lips or face) current as of the date on the printout. Letter titled, Dear (facility) Employees, undated, revealed; Effective Friday, March 13, 2020 .all employees must be screened by a nurse at the nurse's station .taking body temperature .answering questions about symptoms and/or travel . Further review of employee training, Inservice Letter to Employees re: COVID-19, document is undated, but stapled to Employee In-service Record In-service: COVID-19 Safety Awareness sign-in sheets dated, 4/10/2020, revealed in pertinent part; 2 .symptoms of respiratory illness. Those symptoms include: cough, fever, sore throat, runny nose, and or shortness of breath. 8. Overall COVID 19 Employee Safety: . follow screening process. 9.monitoring vitals to include any early onset of the aforementioned most common COVID-19 symptoms . FACTS ABOUT COVID-19 . Symptoms include: Fever, Cough, Shortness of breath, Rare cases-possible pneumonia, multi-organ failure and in some cases death. Centers for Medicare and Medicaid Services (CMS) QSO-20-29-HN COVID-19 Focused Survey for Nursing Homes, dated and released 5/8/2020, states: 4. Infection Surveillance Has the facility established/implemented a surveillance plan, based on a facility assessment, for identifying (i.e., screening), tracking, monitoring and/or reporting of fever (at a minimum, temperature is taken per shift), respiratory illness, and/or other signs/symptoms of COVID-19. Did the facility provide appropriate infection surveillance? 5. Visitor Entry Did the facility perform appropriate screening, restriction, and education of visitors? 6. Education, Monitoring, and Screening of Staff Is there evidence the facility has provided education to staff on COVID-19 (e.g., symptoms, how it is transmitted, screening criteria, work exclusions)? How does the facility convey updates on COVID-19 to all staff? Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)? QSO 20-29: Q & A Q: Can you clarify what symptoms CMS is referring to in the requirement to report if three or more residents or staff have respiratory symptoms within 72 hours of each other? A: Respiratory symptoms consistent with COVID-19 are shortness of breath, difficulty breathing, new or change in cough, sore throat, or new loss of taste or smell. To a lesser extent, symptoms have included new sputum production, rhinorrhea (persistent watery discharge from the nose), or hemoptysis (the coughing up of blood). For more information on updated symptoms, please view CDC's webpages: Symptoms of Coronavirus and Preparing for COVID-19: Long-term Care Facilities, Nursing Homes. Review of employee training, Covid-19 Donning, Doffing, and Reusing PPE, document is undated, but stapled to Employee In-service Record In-service: COVID-19 PPE sign-in sheets dated, 5/8/2020 revealed; No noted updates listing all COVID-19 symptoms. Additional review of employee training, MANDATORY ALL-STAFF June 10th 2020, INFECTION CONTROL IN THE COVID-19 ERA, stapled to Employee In-service Record In-service: Infection Control in the COVID-19 ERA sign-in sheets dated, June 10, 2020, revealed; Signs and symptoms . The following symptoms may appear 2-14 days after exposure. Fever, Cough, Shortness of breath, Sore Throat. For Our Residents: If they develop a fever, signs and symptoms of respiratory illness the resident needs to be put on isolation (Droplet) Precautions immediately. Until further notice. No noted updates listing all COVID-19 symptoms were provided by the facility. Review of the facility's policy, Visitation and Infection Disease Control Policy-SHOG Updated to Address the Coronavirus Disease 2019 (COVID-19), dated 11 Jun 20, revealed; Policy Interpretation and Implementation .1a. Standard &/or contact &/or droplet precautions .2b.signs and symptoms of a respiratory infection while on the job . 2c. Facility will have a process to detect early symptom onset for respiratory infection, to include COVID-19, among current residents and clear communication instructions to when to contact the provider and subsequently notify the local health department and/or state health department. 2c1.monitoring for s/sx of COVID-19 to include fever, shortness of breath, cough, sore throat, diarrhea, body aches. Review of most recent employee training, Follow Five Steps to Wash Your Hands the Right Way, document is undated, but stapled to Employee In-service Record In-service: Sign in for Covid testing/Inservice sign-in sheets dated, 8/12/2020, revealed; Tips for Social Distancing. No noted updates listing all COVID-19 symptoms were provided to the surveyors. Review of the facility's Infection Prevention and Control Committee, provided on 8/18/20, document undated, showed; Duties of the Committee .21. Maintain access to current CDC, OSHA (Occupational Safety and Health Administration) and State/Federal regulations, guidelines and recommendations relative to infection control issues in healthcare facilities. 2f. The facility monitors the Federal CDC website and state public health sources along with CMS transmissions to understand COVID-19 . 2g. Signs should be posted throughout the facility describing ways to prevent the spread of germs. https://www.cdc.gov/coronavirus/2019-ncov/downloads/stop-the-spread-of-germs.pdf. This site was accessed on 8/18/20, last updated 8/6/20. Signs posted throughout the facility were dated 4/13/20. A subsequent review of the facility's Monitoring Compliance with Infection Control, provided 8/18/2020, document undated, showed; Policy Interpretation and Implementation .8. Gaps identified in infection prevention and control processes are addressed promptly. Further review of the facility's SECTION V: EMERGENCY RESPONSE, document undated, revealed; 7. All prospective residents and employees should be screened to identify exposure to novel influenza. Screen for fever and respiratory symptoms . 8. Residents, employees, contract employees and visitors should be evaluated daily for symptoms. Employees should be instructed to self-report symptoms and exposure. On 8/19/18 at 4:02 PM, in an exit interview with the NHA and DON the findings of the survey were discussed. The NHA acknowledged.

Based on interview and record review it was determined, for 1 of 26 sampled residents,that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility did not administer a resident's antihypertensive and diuretic medications with adequate monitoring as ordered by the physician. Resident identifier: 93. Findings include: Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 7/30/19. A review of the physician's orders [REDACTED]. a. On 7/27/19, [MEDICATION NAME] 50 milligrams (mg) in the morning for HTN. Hold for a blood pressure (BP) less than (<) 130/80 per nephrology. b. On 7/27/19, [MEDICATION NAME] 40 mg in the morning for [MEDICAL CONDITION] for 5 days. Hold for a BP< 130/80 per nephrology. c. On 7/27/19, [MEDICATION NAME] 25 mg in the morning for [MEDICAL CONDITION] for 5 days. Hold for a BP< 130/80 per nephrology. A review of the (MONTH) 2019 Medication Administration Record [REDACTED] a. On 7/28/19, a BP of 123/83. b. On 7/30/19, a BP of 118/62. c. On 7/31/19, a BP of 125/62. On 7/31/19 at 8:05 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that prior to administering a resident medication that had parameters she would check the vital signs sheet. RN 1 stated that the Certified Nursing Assistants (CNA) obtain the resident vital signs in the morning. RN 1 stated that a residents vital signs would be documented on the resident MAR indicated [REDACTED]. RN 1 further stated that a progress note would be completed documenting the vital signs and why the resident medication was not administered. On 7/31/19 at 11:05 AM, an interview was conducted with RN 2. RN 2 stated that if a resident had medication parameters they would show on the resident MAR. RN 2 stated that the entered parameters on the MAR for resident 93 were to hold the medication if the BP was less than 130/80. RN 2 stated that if the systolic BP or the diastolic BP were outside of the parameters he would typically hold the medication. RN 2 stated that the CNA staff would obtain the resident vital signs for the nursing staff. RN 2 further stated that medication parameters were typically to hold if the resident BP was less than 120/60. RN 2 stated that he would clarify with nephrology the BP parameters for resident 93. On 7/31/19 at 11:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were standard medication parameters that the nursing staff were use to using. The DON stated that the nursing staff need to follow the parameters set by the physician and clarify the medication orders and parameters when necessary. The DON stated that she was unsure about the medication parameters for resident 93 and they should have been clarified with nephrology.

Based on interview and record review it was determined, for 1 out of 26 sampled residents, that the facility did not consult with the resident's physician and notify the resident representatives when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. Specifically, the physician was not contacted when one resident's wound worsened and another was unresponsive and unable to take medications including an antibiotic. Resident identifiers: 35 and 40. Findings include: 1. Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19, resident 35's medical record was reviewed. The following nursing notes were identified: a. On 7/27/19 at 6:17 PM, Nurse and patient noticed that the wound on her upper, outer left thigh is wider and deeper than previously assessed. WCTM (will continue to monitor). b. On 7/28/19 at 12:57 PM, Pt (patient) c/o (complains of) LLE (left lower extremity) outer thigh wound having increased pain and drainage, dressing removed and writer noticed wound is deeper and draining, there is a odor to drainage. Nurse contacted wound nurse and orders given for packing to be done to wound. wound cleansed with saline and packed with packing strip, nurse noticed redness and warmth around wound. NP (nurse practitioner) notified of changes. WCTM. No documentation was located in the medical record indicating that the physician had been notified when resident 35's wound was assessed on 7/27/19. On 7/31/19 at 8:41 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the physician would be notified for abnormal anything such as vitals out of range, new symptoms, or new problems. LPN 1 stated that if the wound was not expected to get worse, the physician should be notified about it. On 7/31/19 at 9:08 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated sometimes staff would hold off notifying the physician if the unit manager who was experienced with wounds would be seeing the resident soon. RN 2 then stated that the physician or nurse practitioner would be notified if a wound dehisced. On 7/31/19 at 9:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the physician would be notified if there was an acute need or something that would require a new order. The DON stated that if a wound was worsening, the physician should be notified. The DON was showed resident 35's nursing progress notes. The DON affirmed that the initial identification on 7/27/19 should have been passed on to the physician. 2. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/19, resident 40's medical record was reviewed. A progress notes dated 7/27/19 at 9:27 AM, documented Nurse tried waking up the resident to give him the medications for this morning and he was non responsive. Nurse moved his arms, called his name, moved his shoulders and he's still non responsive. The CNA (Certified Nursing Assistant) tried to feed him his breakfast and the resident still was non responsive. WCTM. According to the nursing progress notes, the following medications were held due to resident 40 being non responsive: a. [MEDICATION NAME] 1000 milligrams (mg) b. [MEDICATION NAME] V Potassium 500 MG c. Acidophilus/Pectin Capsule x 1 capsule d. [MEDICATION NAME] Acid 1500 MG e. [MEDICATION NAME] 20 MG f. [MEDICATION NAME] 10 MG g. Aspirin 81 MG h. Cranberry Extract 450 MG i. [MEDICATION NAME] Tablet 500 MG j. [MEDICATION NAME] Fiber 1 Packet k. [MEDICATION NAME] Tablet 10 MG l. [MEDICATION NAME] Mandelate 1 Gram m. Multi-Vitamin/Minerals Tablet n. [MEDICATION NAME] 500 MG o. [MEDICATION NAME] Tablet 10 MG No documentation was located in the medical record indicating that the physician had been notified when resident 40 was non responsive and his medications were held. On 7/31/19 at 8:41 AM, an interview was conducted with LPN 1. LPN 1 stated that if there was abnormal anything she would contact the physician. LPN 1 stated that if medications were missed, the physician would be notified. LPN 1 stated if a resident was not responsive the physician and family members would be notified. On 7/31/19 at 9:08 AM, an interview was conducted with RN 2. RN 2 stated that the physician would be notified if a resident was not responsive and missed medications because of it. On 7/31/19 at 9:36 AM, an interview was conducted with the DON. The DON stated that the physician should be notified if a resident was unarouseable and unable to take their medications. The DON stated she was aware of resident 40's unarouseable state and missed medications on 7/27/19. The DON stated she spoke with the nurse and educated her about notifying the physician. The DON stated she had a big concern about the antibiotic being missed and really focused on educating the nurse about it.

Based on observation, interview and record review, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food was expired and dish washer temperatures did not meet required level required to sanitize dishes. Findings include: On [DATE] at 8:02 AM, an initial observation was conducted of the kitchen. The following expired foods were identified in the dry storage area: a) A can of Hominy with a best by date of [DATE] b) Two boxes of pumpkin pie cake mix with a best by date of [DATE] c) A blue velvet cake mix with a best by date of [DATE] d) A red velvet cake mix with a best by date of [DATE] e) Two boxes of spice cake mix with a best by date of [DATE] f) Two boxes of spice cake mix with a best by date of [DATE] g) A spice cake mix with a best by date of [DATE] h) A spice cake mix with a best by date of [DATE] i) A spice cake mix with a best by date of [DATE] j) A carrot cake mix with a best by date of [DATE] The Dietary Manager (DM) was present for these findings. The DM stated many of the cake mixes were recently purchased. On [DATE] at 8:40 AM, the dish washer was observed. It was observed to be a high temperature machine. The manufacturer's label stated the required temperature for sanitation for the wash was 150 degrees Fahrenheit and for the rinse was 180 degrees Fahrenheit. A load was placed in the dish washer. The rinse temperature was 172 degrees Fahrenheit. A second wash was observed. The rinse temperature reached 177 degrees Fahrenheit. The DM stated It probably won't (hit temperature) because it hasn't been used for a minute. Immediately, a request was made of the dish washer temperature logs from (MONTH) to present. The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Breakfast rinse temperature: 179 b) [DATE] Dinner wash temperature: 147, Rinse temperature: 177 c) [DATE] Dinner rinse temperature: 179 d) [DATE] Lunch wash temperature: 142 e) [DATE] Dinner wash temperature: 148 f) [DATE] Breakfast wash temperature: 148 g) [DATE] Breakfast wash temperature: 147, Lunch wash temperature: 144 The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Breakfast wash temperature: 149, Lunch wash temperature: 145 b) [DATE] Dinner wash temperature: 147 c) [DATE] Lunch wash temperature: 149 d) [DATE] Lunch wash temperature: 141 e) [DATE] Lunch rinse temperature: 172 The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Lunch wash temperature: 145 b) [DATE] Lunch wash temperature: 148 c) [DATE] Dinner wash temperature: 146 d) [DATE] Dinner wash temperature: 148 e) [DATE] Lunch wash temperature: 148 The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Dinner wash temperature: 147 b) [DATE] Breakfast wash temperature: 149 c) [DATE] Dinner wash temperature: 147 d) [DATE] Dinner wash temperature: 148 The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Dinner rinse temperature: 179 b) [DATE] Lunch wash temperature: 147 The following temperatures were identified for the month of (MONTH) (YEAR): a) [DATE] Dinner rinse temperature: 178 b) [DATE] dinner rinse temperature: 177 c) [DATE] Dinner rinse temperature: 177 d) [DATE] Dinner wash temperature: 145, Rinse temperature: 174 e) [DATE] Breakfast rinse temperature: 179, Dinner rinse temperature: 170 f) [DATE] Dinner rinse temperature: 178 g) [DATE] Breakfast wash temperature: 147 h) [DATE] Dinner rinse temperature: 176 On [DATE] at 8:45 AM, the dish washer was observed again. It was observed that the rinse temperature reached 172 degrees Fahrenheit. A second load was put through and the temperature reading was 179 degrees Fahrenheit. A third load was put through and the reading was 181 degrees Fahrenheit. The DM and administrator were present for the observation. The DM stated that the dish washer had to be run a few times to warm up before it reached the proper temperature. The DM stated that her staff was aware of the required temperatures and would run a load again if the temperature wasn't reached. It was pointed out that during the initial observation and this observation, no staff was readily present and monitoring the temperature of each load. The DM stated that a repair company was called on Tuesday (,[DATE]) and said the machine was fine. The DM stated that she would call the company again.

Based on observation and interview, it was determined, for 8 of 25 sample residents, that the facility environment did not remain as free of accident hazards as is possible. Specifically, eight resident rooms had hot water temperatures ranging from 130 degrees Fahrenheit (F) to 138 degrees F. Resident identifiers: 1, 3, 13, 19, 23, 25, 88 and 133. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:20 AM, an observation was made of the hot water in resident 1's sink. The temperature of the hot water was observed to be 130 degrees F. On 6/21/18 at 10:00 AM, an observation was made with the facility Maintenance Director (MD) of the hot water in resident 1's sink. The hot water was observed to be 130 degrees F per the surveyor analog thermometer. The hot water was observed to be 127 degrees F per the MD's infrared thermometer. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/21/18 at 8:24 AM, an observation was made of the hot water in resident 3's sink. The temperature of the hot water was observed to be 136 degrees F. On 6/21/18 at 10:05 AM, an observation was made with the facility MD of the hot water in resident 3's sink. The hot water was observed to be 138 degrees F per the surveyor analog thermometer. The hot water was observed to be 132 degrees F per the MD's infrared thermometer. 3. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:25 AM, an observation was made of the hot water in resident 13's sink. The temperature of the hot water was observed to be 130 degrees F. 4. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:15 AM, an observation was made of the hot water in resident 19's sink. The temperature of the hot water was observed to be 134 degrees F. 5. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:10 AM, an observation was made of the hot water in resident 23's sink. The temperature of the hot water was observed to be 137 degrees F. On 6/21/18 at 10:20 AM, an observation was made with the facility MD of the hot water in resident 23's sink. The hot water was observed to be 138 degrees F per the surveyor analog thermometer. The hot water was observed to be 131 degrees F per the MD's infrared thermometer. 6. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:05 AM, an observation was made of the hot water in resident 25's sink. The temperature of the hot water was observed to be 132 degrees F. On 6/19/18 at 10:05 AM, an interview was conducted with resident 25. Resident 25 stated that the water in her sink was too hot. On 6/21/18 at 10:38 AM, an observation was made with the facility MD of the hot water in resident 25's sink. The hot water was observed to be 134 degrees F per the surveyor analog thermometer. The hot water was observed to be 124 degrees F per the MD's infrared thermometer. 7. Resident 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:30 AM, an observation was made of the hot water in resident 88's sink. The temperature of the hot water was observed to be 130 degrees F. On 6/19/18 at 10:30 AM, an interview was conducted with resident 88. Resident 88 stated that the water in her sink was too hot. 8. Resident 133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/19/18 at 10:00 AM, an observation was made of the hot water in resident 133's sink. The temperature of the hot water was observed to be 132 degrees F. On 6/21/18 at 9:50 AM, an observation was made of the mixing valve attached to the facility boiler. The mixing valve was observed to be set at 134 degrees F. The two hot water supply valves were observed to be set at 150 degrees F and 146 degrees F. On 6/21/18 the water temperature logs recorded by the facility MD were observed. The water temperature logs revealed that the facility MD had checked facility hot water temperatures on a weekly basis, picking random rooms. The temperatures that had been written on the log ranged from 107 degrees F to 123 degrees F. On 6/21/18 at 10:20 AM, an interview was conducted with the facility MD. The facility MD stated that he had a hard time holding an analog thermometer under the water and thought that the infrared temperature would make things easier. The facility MD stated that it was obvious to him that the infrared thermometer was not getting accurate readings of the hot water temperatures and that he needed to change that out to an analog thermometer.

Based on observation, interview and record review, it was determined that the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 34 sample residents. Specifically, one resident developed two pressure ulcers that were determined to be avoidable. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/13/17 at 9:55 AM, resident 52 was observed to be sitting in a wheelchair in his room. Resident 52 did not have a foam cushion in place to the right arm rest of the wheelchair and was not wearing a pressure relieving device to his right lower extremity. Resident 52's right foot was resting on the floor. On 3/13/17 at 11:39 AM, Unit Manager (UM) 2 was interviewed. UM 2 stated that resident 52 had a stage 3 pressure ulcer to his right elbow which measured 1.7 centimeters (cm) in length X (by) 1.5 cm in width X 0.2 cm in depth and an unstageable pressure ulcer to his right heel which measured 1.5 cm in length X 1 cm in width. UM 2 stated that resident 52 did not have any pressure ulcers at the time that he was admitted to the facility. On 3/15/17 from 7:15 AM through 1:25 PM, resident 52 was observed: a. 9:05 AM, Resident 52 was seated in his wheelchair. Resident 52 did not have a pressure relieving device to his right heel and the wheelchair foot rest were not in place. Resident 52 was observed to propel himself in his wheelchair using his lower extremities which placed additional pressure to the wound on his right heel. b. 10:32 AM, Resident 52 was ambulating in the hallway with a therapist. Resident 52 was not wearing shoes. c. 1:25 PM, Resident 52 was sitting in his wheelchair. Resident 52 was not wearing shoes or a pressure relieving device to his right heel. Resident 52's right heel was resting on the floor. Resident 52's medical record was reviewed on 3/15/17. On 1/25/17, the facility licensed nursing staff completed an admission Minimum Data Set (MDS) assessment for resident 52. The licensed nursing staff documented that resident 52 required extensive assistance of two or more people for bed mobility and that he had no skin unhealed pressure ulcers. On 1/28/17, a facility licensed nurse completed an Admission Skin Assessment for resident 52. The licensed nurse did not document that resident 52 had any skin breakdown or concerns related to resident 52's right elbow or right heel. On 2/1/17, the facility licensed nursing staff completed a fourteen day MDS assessment for resident 52. The licensed nursing staff documented that resident 52 required extensive assistance of two or more people for bed mobility. The licensed nursing staff documented that resident 52 had one unstageable pressure ulcer that measured 4.8 cm in length by 4.6 cm in width with eschar (black, brown or tan tissue that adhered firmly to the wound bed or ulcer edges that was softer or harder than the surrounding skin). On 2/15/17, the facility licensed nursing staff completed a 30 day MDS assessment for resident 52. The licensed nursing staff documented that resident 52 required extensive assistance of two or more people for bed mobility. The licensed nursing staff documented that resident 52 had two unstageable pressure ulcers, the largest of which measured 1.7 cm in length by 1.5 cm in width. Review of the initial Skin Integrity Care Plan developed for resident 52 documented that resident 52 had a potential for skin breakdown related to immobility. The goals that were developed included that resident 52 had a low risk of skin breakdown, with a Braden Score of 20. The approaches that were developed to achieve the goal included weekly skin checks, maximize patient's mobility, protect heels, use a pressure support surface if patient was bed or chair bound, and to float heels as tolerated. Review of the physician's orders [REDACTED]. a. 1/18/17, Sling to Right arm r/t (related to) humerus fx (fracture). (Note: There was not an order to keep the right arm sling in place at all times.) b. 1/18/17, Weight bearing Status: NWB (non-weight bearing) RUE (right upper extremity). c. 1/27/17, D/C (discontinue) Wound Care Topical Every other day. Cleanse with NS (normal saline). Apply skin prep and then a foam dressing (every other day). d. 2/2/17, D/C Dressing change to right elbow: Clean elbow with NS, apply small amount of hydrogel to necrotic wound bed and apply [MEDICATION NAME] with pad. Change every other day and PRN (as needed). e. 2/5/17, Thera m multivitamin (*Multivitamin and Minerals) 1 tab Oral Daily. f. 2/5/17, Vitamin C 500 MG (milligrams) ([MEDICATION NAME] Acid) one tab Oral Daily q (every) day. g. 2/5/17, Zinc Sulfate 220 MG CAP (capsule) (Zinc Sulfate) one tablet Oral Daily for 14 days. h. 2/8/17, D/C Wound Care: Right Elbow Unstagable (sic) wound. Clean area with NS. Skin Prep Peri-wound. Apply hydrogel to escar (sic) area. Cover with padded foam dressing. Change every other day and PRN. i. 2/8/17, D/C Wound Care: Right Heel DTI (deep tissue injury). Clean area with NS. Apply skin prep, let dry. Ensure heels are floated when in bed. j. 2/14/17, D/C Wound care to unstageable pressure ulcer to right heel. Cleanse with NS, apply hydrogel, and cover with foam dressing. Change every 3 days and prn. k. 2/17/17, Elbow wound - no debridement monitor closely for infection continue current dressing. l. 2/21/17, Start Bactrim 80/400 (mg) BID (twice a day) X (for) 10 days cellulite R (right) elbow. m. 2/28/17, Wound Care: R elbow pressure ulcer: cleanse with NS, apply mesh AG (silver), apply foam dressing, change every 3 days and prn. n. 2/28/17, D/C Wound care: R heel pressure ulcer: cleanse with NS, apply metahoney (sic) cut to fit, apply boardered foam dressing, change every 3 days and PRN. o. 3/3/17, Wound care: R heel pressure ulcer, cleanse with NS, apply [MEDICATION NAME] cut to fit, apply bordered foam dressing, change every 3 days and prn. Review of the progress notes for resident 52 revealed the following entries: a. 1/18/17 at 11:05 PM, Patient was admitted to facility for a right humerus fracture. Patient is alert and oriented, hard of hearing and wears hearing aids. Patient requires a one person assist for ADL's (activities of daily living) and transfer (sic) to the wheelchair and toilet due to no use of right arm.Patient states pain is a 2/10 at all times, and takes no prn pain medication. b. 1/19/17 at 10:58 PM, .Pt. (patient) is alert and oriented x (times) 4 (person, place, time, and situation) and is pleasant and compliant with staff and cares.Pt. requires a one person assist for ADL's and transfer (sic) to the wheelchair and toilet due to no use of right arm. Pt. states that pain is present and is a 2/10. Pt. takes PRN Tylenol but has no (sic) requested any this shift. c. 1/20/17 at 2:46 PM, Patient admitted for care d/t (due to) a right humerus fracture. Wears a sling to RUE for comfort and immobilization. Patient requires assistance with most ADL's. PRN pain medication given this shift per patient request. Patient is compliant with medications and treatments. Nursing staff manages patients medications and assists with ADL's as needed. d. 1/25/16 at 10:51 PM, patient (sic) was admitted to facility for a right humerus fracture. patient (sic) is alert and oriented x4. Patient requires a one person assist with a walker, or wheelchair for ambulation, and transfers. Patient wears a sling to that right arm for support. Patient is compliant with nursing staff, and nursing cares.Patient stated mild pain at time of assessment, and was given a prn pain pill . Patient has no new skin issues. e. 1/27/17 at 10:56 AM, Patient is on alert charting due to new skin issue. New wound orders have been put in place until assessed by MD (Medical Doctor). WCTM (Will Continue To Monitor). (Note: Resident 52 was seen by the facility physician on 1/27/17. The facility physician documented, I was also informed that he has a new pressure ulcer on the right elbow. We have forwarded him to the wound care clinic; they have us putting dressings and we are following this appropriately and following their suggestions. f. 1/28/17 at 1:07 AM, Patient admitted to facility for right humerus fracture. Patient is alert and oriented x4. Patient requires one person assist with a wheelchair, and walker for ambulation, and transfers. Patient is pleasant and compliant with staff, and is able to make needs know (sic).stated mild pain at time of assessment. g. 1/25/17 at 5:53 PM, Patient admitted into the facility for fractured right humerus. A&O (alert and oriented) X3 (person, place and time) makes all needs known. Pleasant and cooperative with all staff and cares. 1 person assist with bathing, transfers, bed mobility.Patient complains of pain in his right arm, takes Tylenol for pain and states that he receives significant relief from it. h. 1/30/17 at 5:15 PM, Alert x4 able to make all needs known, right shoulder, forearm and hand swollen with fading bruises, arm in sling hard eschar noted on elbow no drainage, foam drsg (dressing) to area for padding due to tenderness.Medicated for elbow pain x2 (twice) with poor effect (the primary care physician) texted through med tunnel for stronger med for pain, no call back yet. Is compliant with meds (medications) and tx (treatment) as ordered. Has walked in the hall several times with PT (Physical Therapy) gait steady balance good. i. 1/31/17 at 8:44 AM, Right elbow eschar firm no drainage, no sign of infection, cleansed with ns prep skin to area foam drsg to site. area 4.8cm x 4.6cm. j. 2/1/17 at 11:34 PM, Patient admitted to facility for right humerus fracture. Patient is alert and oriented x4 . Patient requires one person assist for bed mobility, transfers, and toileting due to arm fracture to dominant arm. Patient is pleasant and compliant of nursing staff, and the cares they provide.was given prn pain medication . k. 2/4/17 at 2:47 PM, Patient at facility for Right humerous (sic) fracture and wears sling on RUE. Pt. is alert and oriented x4 and able to make needs known.and c/o (complained of) pain in RUE this afternoon and was given PRN pain med (medications) per mar (Medication Administration Record).is a x1 (one person) assist with transfers and ADL's. Pt. has wound on right elbow that is covered with new dressing today and is clean and dry. Pt. is pleasant and cooperative with staff and cares . l. 2/6/17 at 12:50 PM, Pt. is alert and oriented x 4 able to make needs known, admitted to facility for right humerus fx,continues to have sling on right arm, bruising to arm, shoulder, slowly diminishing, requested prn pain (medications), given with good results . pt. is one person ext. (extensive) assist with toileting, transfers, bed mobility . m. 2/8/17 at 2:51 AM, Pt. is alert and oriented x 4, able to make needs known, admitted to facility for right humerus fx, arm remains in sling, bruising to arm continues to diminish, pt. is one person ext. assist with transfers, toileting, bed mobility, . n. 2/8/17 at 11:24 AM, Wound care done this AM. Right elbow continues to improve. Area with eschar. (Area measures 1.7 (cm) x 1.5 (cm)) Order to clean area with NS. Apply skin prep to peri-wound. Apply hydrogel to wound bed. Cover with Padded foam dressing and change every other day. Right heel noted with DTI. Area noted to be intact, dark purple in color, nonblanchable. (Area measures 1 (cm) x1 (cm)). Order to clean with NS. Apply skin prep BID. Ensure heels are floated when in bed. o. 2/10/17 at 2:41 PM, Pt here for skilled nursing and rehab for a right humerus fracture, sling in place. Alert and oriented X4.Compliant with medication regimen, given PRN pain pills for pain.1 person extensive assist for transfers. Bandages to elbow and LLE (left lower extremity) skin tear changed as ordered. Increased redness to LLE noted, will have MD evaluate today. p. 2/13/17 at 1:03 AM, Pt. is alert and oriented x 4, able to make needs known, admitted to facility for right humerus fx, right arm in sling, bruising continues to diminish . pt. is pleasant and cooperative with staff and cares . q. 2/14/17 at 3:15 AM, Pt. is alert and oriented x 4, able to make needs known, admitted to facility for right humerus fx, NWB, has sling on, bruising to arm continues to diminish, requested prn pain medication tonight, effective upon follow up . pleasant and cooperative with staff and cares . r. 2/14/16 at 4:35 PM, Wound care: .R heel pressure ulcer now an unstageable ulcer with hard slough 100% (percent) measuring 1 (cm) x 1.5 (cm) . Change dressings to cleanse with NS, apply hydrogel and cover with foam dressing every 3 days and prn. Unstageable pressure ulcer to R elbow measures 1.8 (cm) x 1.2 (cm) . 100% eschar present with blanchable periwound. Continue current treatment. s. 2/23/17 at 2:23 PM, Patient admitted into the facility for right humerus fracture. Patient is NWB on his right arm. A&O X4, able to make all needs known. Patient has wounds on his right foot and RLE (right lower extremity) which have bandages that are changed regularly, no infection noted. t. 2/17/17 at 11:44 PM, Patient admitted to facility for a right humerus fracture, and fall. patient is alert and oriented x4 . Patient is pleasant and compliant of nursing staff. Patient has wounds to right foot that are managed by facility, and a right elbow wound that will continue to be monitored per NP (Nurse Practitioner) orders.Patient stated moderate pain at time of assessment. u. 2/24/17 at 12:13 PM, Late entry for 2/21/17 wound care: R elbow pressure ulcer continues to be unstageable with signs of improvement including reduction in eschar and more slough with small measurements at 1.2 (cm) x 1.6(cm) . Continue current treatment. R heel pressure ulcer continues to be unstageable with hard slough 100%, continue current treatment. v. 2/18/17 at 5:55 PM, Wound care: .R heel unstageable with 100% slough measuring 1.2 (cm) x 1.3 (cm) ., change treatment to cleanse with NS, apply metahoney cut to fit, apply bordered foam dressing, change every 3 days and prn. R elbow pressure ulcer unstageable with slough wound base measuring 1.6 (cm) x 1.7 (cm) . with undermining present at 12-2 o' clock at 0.2 cm, change dressing to cleanse with NS, apply mesh AG, apply foam dressing, change every 3 days and prn. Nutritional needs assessed by RD (Registered Dietitian). w. 3/7/17 at 12:26 PM, Wound Rounds 3/7/17: .Assessed right heel unstageable PU (pressure ulcer). PU measures 1.5 cm x 1 cm, depth not measurable due to non viable tissue. 90% white slough to wound base with 10% red granulation to perimeter of wound. Dry flaky skin to peri wound, no redness, no S/S (signs or symptoms) of infection or induration. Moderate serosanguineous drainage, no odor. Applied [MEDICATION NAME] to wound base and covered with bordered foam dressing. Assessed right elbow unstageable PU. PU measures 1.7cm x1.5cm x 0.2cm. Unstageable changed to stage 3. 90% red granulation tissue to wound base with 10% biofilm that comes off easily with cleansing. Moderate serous drainage, no odor. Intact periwound with no S/S of infection. Applied AG mesh over wound base and covered with bordered foam dressing. Nutritional interventions in place and monitored by RD. x. 3/8/17 at 3:49 PM, Patient admitted to facility for a right humerus fracture. Patient is able to go without sling on his arm.1 person moderate assist with ADLs. A&O X4 able to make all needs known. Takes Tylenol for pain and reports significant pain relief.Wound on heel healing well, patient seen by podiatrist yesterday and wound care nurse. The facility licensed nursing staff documented the following on Wound Progress Report (s): A. Right Elbow: i. 1/31/17, The right elbow was swollen and discolored. The pressure ulcer measured 4.8 cm in length by 4.6 cm in width, was unstageable and had 100% hard eschar to the wound bed. ii. 2/8/17, The right elbow pressure ulcer measured 1.7 cm in length by 1.5 cm in width, was unstageable with eschar to the peri-wound. iii. 2/14/17, The right elbow pressure ulcer measured 1.8 cm in length by 1.2 cm in width, was unstageable with eschar to the peri-wound. iv. 2/21/17, The right elbow pressure ulcer measured 1.2 cm in length by 1.6 cm in width, was unstageable with 75% eschar and 100% slough. There was mild to moderate drainage without an odor. v. 2/28/17, The right elbow pressure ulcer measured 1.6 cm in length by 1.7 cm in width, was unstageable with undermining at 12 o'clock and 2 o'clock that measured 0.2 cm. The right elbow wound had serosanguineous drainage without an odor. vi. 3/7/17, The right elbow pressure measured 1.7 cm in length by 1.5 cm in width by 0.2 cm in depth. The pressure ulcer was a stage III with no undermining, 90% granulation tissue and 10% bio film. There was a moderate amount of serous drainage. B. Right Heel: i. 2/8/17, The right heel deep tissue injury measured 1 cm in length by 1 cm in width. The wound bed was dark purple and intact. ii. 2/14/17, The right heel pressure ulcer measured 1 cm in length by 1.5 cm in width. The pressure ulcer was unstageable with 100% hard slough to the wound bed. iii. 2/21/17, The right heel pressure ulcer measured 1 cm in length by 1 cm in width. The pressure ulcer was unstageable with 100% hard slough to the wound bed. iv. 2/28/17, The right heel pressure ulcer measured 1.2 cm in length by 1.3 cm in width. The pressure ulcer was unstageable with 100% slough to the wound bed. v. 3/7/17, The right heel pressure ulcer measured 1.5 cm in length by 1 cm in width. The pressure ulcer was unstageable with 90% slough and 10% granulation tissue to the wound bed. The right heel had a moderate amount of serosanguineous drainage without an odor. On 3/15/17 at 9:05 AM, Registered Nurse (RN) 1 was observed while changing the bandages on resident 52's right elbow and right heel. RN 1 stated that resident 52's pressure ulcer to the right heel developed because of pressure. RN 1 measured resident 52's pressure ulcer at 2.25 cm in length by 2 cm in width. RN 1 cleansed the right heel with normal saline, placed [MEDICATION NAME] to the wound base and covered with a foam gauze. RN 1 then cleansed resident 52's right elbow with normal saline. RN 1 measured resident's 52's elbow pressure ulcer to be the size of a dime with slough to the wound bed. RN 1 placed [MEDICATION NAME] to the wound base and covered with a foam dressing. On 3/15/17 at 9:27 AM, Certified Nurse Assistant (CNA) 2 was interviewed related to resident 52's care needs. CNA 2 stated that resident 52 required minimal assistance of 1 person to stand and needed no other assistance from the staff. On 3/15/17 at 1:30 PM, RN 3 was interviewed. RN 3 stated that she had only worked at the facility for a couple of weeks and was hired as the facility's wound nurse. RN 3 stated that she remeasured the wound on resident 52's right elbow. RN 3 stated that the wound measured 0.9 cm in length by 0.9 cm in width. On 3/16/17 at 8:50 AM, RN 4 was interviewed. RN 4 stated that resident 52 had a lot of bruising to the right arm and a lot of pain related to the humerus fracture. RN 4 stated that she did not remove resident 52's sling to check the skin but would kinda peek inside the sling to check from skin breakdown. RN 4 stated that she documented a note in the physician Communication Log related to resident 52's right elbow pressure ulcer. Review of the physician Communication Log documentation revealed an entry, dated 1/27/17, Patient has new unstageable pressure ulcer on right elbow. Needs debridement. On 3/16/17 at 9:15 AM, Occupational Therapist (OT) 1 was interviewed. OT 1 stated that resident 52 had a lot of pain related to his right humeral fracture when he was admitted to the facility. OT 1 stated that he was the only staff member who gave resident 52 his showers. OT 1 stated that he identified the right elbow pressure ulcer towards the end of January 2017 and immediately reported the pressure ulcer to the charge nurse. OT 1 stated that he documented the pressure ulcer in a Word document and placed it in resident 52's medical record. OT 1 documented the following: Jan (January) 27, 2017 .Pt was seen in am for a shower. During the bathing of his R UE (upper extremity) therapist noticed skin breakdown on the R elbow. It was about the size of a thumb nail and black. Tender to the touch. Nursing was notified and addressed the sore. Prior to today's shower, pt was resistive to movement of the arm and pressure ulcer was not noticed until today. Foam was cut and lined sling w (with)/foam extending from wrist to 2 (inches) from elbow to provide support top arm but removed any pressure from the elbow. Arm rests on w/c (wheelchair) was altered to remove pressure as well as foam wedge to insert next to his right side while seated in w/c. Turbagrip on R arm for [MEDICAL CONDITION] management w/elbow cut out. (OT 1) 1-27-17 On 3/16/17, a written statement from UM 1 was provided. UM 1 document, .During the investigation into patient's wounds in early February I went and talked to the patient about non-compliance with footwear. Patient stated that he did not like to wear his socks or shoes because it was uncomfortable on his swollen feet. I suggested slippers and he said he had some but didn't like wearing them either. (Note: There was no documentation in resident 52's care plan of refusals to wear foot wear. In fact, the facility licensed nurses documented that resident 52 was pleasant and cooperative. On 3/16/17, a written statement from OT 1 was provided. OT 1 documented, .Upon admit, pt was (sic) bruises on R shoulder and torso as well as R UE. Pt had 3+ (plus) [MEDICAL CONDITION] R arm and was unable to move fingers, wrist, or elbow due to the [MEDICAL CONDITION] and pain. Pt's right arm was in sling which was to be on at all times except for bathing. No ROM (range of motion) to shoulder - but could begin PROM (Passive Range of Motion) to elbow, hand and wrist. During bathing, a gait belt was used as a temporary sling to hold arm in position. No skin breakdown on the elbow was noted during bathing - but bathing that arm was so painful that it would have been difficult to determine if pain was from tissue breakdown on the elbow vs (versus) the [MEDICAL CONDITION] causing the pain. Sling was on during therapy, day and night except for bathing. Turbigrip was placed on arm for [MEDICAL CONDITION] management and retrograde massage was done during therapy for [MEDICAL CONDITION] management. It was during retrograde massage while sling was in place that pt noted that the elbow was sore. Upon inspection, a small skin breakdown on the elbow was noted. Nursing was notified. Sling was modified by adding foam to the sling on forearm portion to keep pressure off the elbow. Foam wedge was added to w/c for pt to rest arm on and keep pressure off elbow. On 3/16/17 at 8:30 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that resident 52's pressure ulcers absolutely should not have happened. The DON stated that the pressure ulcer to resident 52's right elbow was related to the wheelchair arm rest and that the licensed nursing staff would kinda peek inside the sling to check resident 52's elbow. The DON stated that the Occupational Therapist was the only staff member that removed the sling on shower days. The DON further stated that resident 52's right heel pressure ulcer developed from pressure. The DON stated that resident 52 continued to have pressure applied to the right heel. Additionally, the DON stated that resident 52 had not been sent to the wound care clinic as documented by the facility physician on 1/27/17. The DON stated that he completed investigations related to resident 52's pressure ulcers. Review of the Director of Nursing Summary of Investigation on 1/31/17 documented, (Resident 52) was admitted to the facility on [DATE] s/p (status [REDACTED]. He was wearing a sling to his right arm that he maintained at all times for comfort and positioning. Orders were written to keep sling in place to right arm with no conditions for removal written with no ROM. This made sense as the smallest of movement to his right arm causes him extreme pain, creating difficulty for assessment of skin integrity inside the sling. As time progressed from his admission, his pain has decreased enough to allow for some basic therapy and movement. On 1/27/2017, it was reported to this DON that a scab had been found to his right elbow, slightly below his elbow-found when removing the sling. Investigation began per protocol. .Closer investigation showed that the 'scab' was a sore covered with Eschar. Its etiology was reasonably related to his positioning in the wheelchair - as he did not move his arm much, there was some opportunity for pressure where his elbow met the arm of the wheelchair. This pressure likely began as soon as his arm was placed in the sling after his fracture and has continued without detection due to his decreased nerve sensation that was masked from his acute fracture pain and his lack of fine sensation from diabetic nerve damage. Other potential causes for nerve disruption was his history [MEDICAL CONDITION]. The Immediate plan was to offload pressure. A foam wedge has been placed in his wheelchair to prevent further pressure to the site. As (resident 52) is A&OX4 and is now aware of the area of pressure, we believe that healing can begin. A Foam dressing was immediately applied to right elbow for additional padding and monitoring was implemented per protocol.Further complicating the wound healing is his ROM restriction which keeps his elbow in the sling for prolonged periods of time. Plan is to offload pressure, attempt healing, and continue to assess weekly and as indicated to ensure progress.It is likely that this will be a slow healing wound until he is able to remove the sling permanently. Review of the Director of Nursing Summary of Investigation on 2/9/17 documented, (Resident 52) admitted to the facility on [DATE] s/p sustaining a right Humerus fx . On 2/8/17, it was reported to this DON that a bruise had been found to his Right Heel measuring 1cm X 1cm. Investigation began per protocol. Investigation shows that the 'bruise' presents as a Deep Tissue Injury and does not appear to be open. Its etiology was reasonably related to his limited movement. As he is unable to use his right arm for anything, he has compensated by using his feet (specifically heels) for moving around in his wheelchair. This could result in increased pressure resulting in a deep tissue injury. This has continued without detection due to his decreased nerve sensation that was masked from his acute fracture pain and lack of fine sensation from the diabetic nerve damage. Other potential causes for nerve disruption was his history of [MEDICAL CONDITION]. The Immediate plan was to offload pressure. Order written to apply skin prep to the area BID to help prevent friction that could lead to skin breakdown. In addition, an order was written to ensure that his heels are floated whenever possible. As (resident 52) has DM II (Diabetes Mellitus Type 2), he has altered sensation to his extremities which contributes to complexity of wound healing. He prefers not to be laying in bed and is often found in his wheelchair as it allows him ability to move about his room. This further complicates the healing process as there will frequently be pressure exerted on his right heel. Patient encouraged to offload whenever possible and to ensure that he wears gripper socks to minimize friction that could lead to skin breakdown. Plan is to offload pressure, attempt healing, and continue to assess weekly and as indicated to ensure progress.It is likely that this will be a slow healing wound due to the continued proximity of pressure to the wound.