Every finding on record at Sun City Post Acute

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring and supervision to prevent avoidable accident for one Resident (#1). The deficient practice could result in an inadequate supervision of residents and further accidents.Findings include:Resident #1 was admitted to the facility on August, 24, 2025 with diagnoses that included other symptoms and signs involving cognitive functions and awareness, Wernicke's Encephalopathy, other abnormalities of gait and mobility, and unsteadiness on feet.A quarterly minimum data set (MDS) assessment dated [DATE] revealed that the resident had a brief interview for mental status (BIMS) score of 8, which indicated moderate cognitive impairment.A care plan focus initiated on November 28, 2025 revealed that Resident #1 exhibited behavior problems that include, but are not limited to wandering, exit-seeking, rummaging through other's belongings, throwing and pushing items, agitation, restlessness, hallucinations, delusions and displays poor safety awareness.Review of the facility's 5-day incident report investigation revealed that on December 7, 2025 at 5:55pm, Licensed Practical Nurse (LPN / Staff #14) had heard the door alarm from the unit (dementia) entrance inside the facility. Staff #14 assessed and began to sweep the unit to account for all residents, where she found that at approximately 7:37 pm Resident #1 was unaccounted for and began a search for him. An additional alarm was heard; and that, the sound came from the facility's main entry door. Staff #14 called Certified Nursing Assistant (CNA / Staff #27) to aide in the search. Staff #27 later found Resident #1 quickly wheeling himself away at approximately less than 500 feet from the facility driveway entrance. The facility 5-day report revealed that the resident attempted to get away from the staff member, tipped his wheelchair, and scrapped his knee in the process. The resident was then sent to the hospital for evaluation.A change of condition (CoC) progress note dated December 7, 2025 at 9:00 p.m. revealed that the resident was sent to the hospital for increased behaviors, altered mental status (AMS), visual hallucinations, psychosis, aggressive behaviors, exit seeking behaviors, yelling out at nursing staff, and redirection difficulty.An observation conducted on December 30, 2025 at 11:00 a.m. from within the dementia unit revealed that an emergency unit exit had a sign on the door, 'Emergency Exit Only. Push until alarm sounds. Door can be opened in 15 seconds'. Additionally, the same message was on the facility's main exit door sign.An interview was conducted with Licensed Practical Nurse (LPN / Staff #30) on December 30, 2025 at 11:18 am which confirmed that Resident #1 was in the locked dementia unit. Staff #30 stated that residents should not go out; and that, there is always someone with the residents. Staff #30 stated that she had heard that Resident #1 had eloped and accomplished that by going out the unit door.An additional observation conducted on December 30, 2025 at 11:20 am revealed Staff #30 demonstrated how the door operates, with the indicated sign was pressed for a few seconds and triggered the door alarm to beep. After a few more seconds a steady alarm began to sound which allowed the door to be opened.An interview with certified nursing assistant (CNA / Staff #47) was conducted on December 30, 2025 at 11:33am. Staff #47 revealed that she was aware that Resident #1 had a recent elopement. Staff #47 revealed that the doors to the unit are equipped with an alarm and that, they usually have staff in the hallway and dining room nearby.An interview with Director of Nursing (DON / Staff #5) was conducted on December 30, 2025 at 12:3 9am who revealed that the facility's front doors are locked and prevent access from the outside, but people can get out from the inside due to fire safety and that an alarm will sound. Staff #5 stated that staff should act if there is a fire or resident leaving. Staff #5 revealed that receptionist hours are from 7:00 am to 7:00 pm; and that, the lobby was monitored after-hours by - staff going back and forth near nurse's station, and rounding. Additionally, Staff #5 revealed that a risk to elopement was that a resident could hurt themselves.An observation was conducted, in conjunction with Staff #5, on December 30, 2025 at 12:39 am who revealed that the location where Resident #1 was found was at the end of the facility driveway -- next to the city sidewalk and near the street.Review of the facility provided policy titled Wandering and Elopements, revised March, 2019, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interviews, record review, and the state agency reporting system, the facility failed to ensure resident rights to informed consent regarding insurance changes for 4 of 5 sampled residents (#1, # 2, #3 and #4). Failing to fully inform what a change in plan can do, may cause a delay in care, change benefits to assist a resident that was chosen for a specific reason or harm to a resident. Findings include: - Resident #1 was admitted on [DATE] with medical diagnoses that include: cellulitis, anemia, peripheral vascular disease, type 2 diabetes mellitus with hyperglycemia. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating that resident #1 was cognitively intact. - Resident #2 was admitted on [DATE] with medical diagnoses that include hemiplegia, affecting right dominant side, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, senile degeneration of brain. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 10 indicating that resident #2 has moderate cognition impairment. - Resident #3 was admitted on [DATE] with medical diagnoses fracture of the lower end of right radius, fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate right leg, anemia, essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, acute kidney failure. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that resident #3 was cognitively intact. - Resident #4 was admitted on [DATE] with medical diagnoses that include unspecified dementia with other behavioral disturbances, other sequelae of cerebral infarction. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 03 indicating that resident #4 has severe cognition impairment. An interview was conducted with Social Services Director (Staff #15) on February 27, 2025 at 9:08 AM and revealed that there was concern regarding insurance and Medicare. There is a current resident, resident #3 that brought it to staff member #15's attention. Resident #3 had left voice mail messages around the beginning of the month, asking why there was a change to the insurance. Resident #3 was concerned because copays may not be covered. When investigated, found out that resident #3 was disenrolled from the AZ Complete plan. After that resident #1 was discovered to have a change. The interview was cut short due privacy and staff members going in and out of the room that was connected to the conference room. Resident #1, Resident #2, Resident #3 and Resident #4 names were given to contact about insurance changes. An interview was conducted with resident #1's Power of Attorney (POA) on February 27, 2025 at 1124 am when unable to reach resident #1. The POA stated that staff member #20 is the one who went into resident #1's room and talked to who he thought was resident #1 but was the roommate. The roommate said he was resident #1 and signed the papers to switch insurance. Now the problem is getting resident #1 back onto insurance. Resident #1 was to have angioplasty on February 26, 2025. Now has to wait until [DATE], when the new insurance is in effect. Resident #1 also had over $700 in medications that insurance did not cover. Staff member #10 was met at the pharmacy and paid for the medications with a business card. Another bill was just sent to staff #10 for $180 and was told staff #10 would take care of it. An interview was conducted with Social Services Director (Staff #15) on February 27, 2025 at 1:03 pm. Staff #15 stated that a long term patient's husband called and asked why did the insurance change and that the husband had changed it back in a timely manner. However the patient then died 3 days later. A name was not provided due to staff #15 having to reverify the name. The next resident, resident #2's Power of Attorney (POA) emailed staff member 15 on [DATE], regarding changes with the insurance. An investigation was started on resident 2's insurance. A public fiduciary of resident #4 submitted a report in January regarding the change as well. The interview then switched from resident issues to the topic of getting more part Bs in the morning meeting and it was a daily thing. This started in August or September (2024). At first staff member #15 did not understand the importance of getting more Bs. Administrator staff member #5 and Therapy Director Staff #10 would discuss how many Bs they now have in the morning meeting. The Bs are when residents are disenrolled from Medicare advantage plans to straight Medicare A and B. The old unit manager was let go when voiced concerns over changing insurance. As the only social worker (staff #15) it took time to call and talk, to investigate. The more that was investigated, staff #15 knew that offering resources to the residents was needed and it was staff #15's job duty. Administrator in Training (AIT) staff member #20, was doing what was told by Staff member #10 to do. An email was shown to staff member #10 regarding resident#4 from the public fiduciary (PF) and staff member #10 stated they can't refuse. Resident #4's PF argued with staff #10 and staff #10 said that the family was okay therapy. Then resident #3 was discovered. After resident #3 then resident #1. Resident #1's POA was pissed. Resident #1's POA told staff #15 that staff #10 was going to pay all the bills. Resident #1's POA also emailed the business manager staff #35. The old social worker from there notified staff #15 of this. Staff #10 was also making us do respiratory programs. The respiratory therapist left because of this. An email was observed from resident #1's POA dated February 13, 2025 7:34 pm. The email was sent to staff #15. The email stated that staff member #20 called her on [DATE] at 1:35pm. Then spoke with staff member #10 on the 29th from resident #1's phone about the mistake and was told they would take care of it and that they would make it right. An interview was conducted with resident #2's POA on February 27, 2025 at 2:52 pm and revealed that the POA was contacted as to why the resident's insurance was changing. Was contacted by staff #10 and was told that resident #2 could have greater access to physical therapy. The POA was all for increased therapy if resident #2 was for having more therapy and if the insurance was equal or better. The POA was assured that was the case and then authorized the change. The POA stated that resident #2 said that he is not getting the therapy, but has Alzheimer's and can't remember when they go into his room. The POA lives out of state and has not seen resident #2 for a few months. An interview was conducted on February 27, at 3:25 pm with resident #1. Resident #1 stated that he did not sign any papers to switch to Medicare A and B. Resident #1 stated that he found out about the changes when his POA informed him. Appointments were canceled and a procedure had to be rescheduled because the doctor did not take that insurance. An interview was conducted with resident #4's PF on February 27, 2025 at 3:50 pm revealed that it was brought to her attention from resident #4's case worker. The administrator thought resident #4 would be great for therapy. No consent was given by the PF. The PF contacted staff #10 and was told the daughter consented. They never reached out to the PF to see if resident #4 wanted therapy. Was told that AIT staff #20 was the one that reached out to daughter to get the consent. The PF then went and enrolled resident #4 into hospice. Resident #4 expired on February 12, 2025. An interview was conducted with resident #3 on February 28, 2025 at 8:46 am and revealed that the resident is at the facility for wound care and therapy. Resident #3 stated that she did not sign to transfer insurance because new insurance was picked in November. In December had an accident that landed a hospital stay and then to the facility for therapy. Resident #3 did not understand why the doctor was disconnected from her, so spoke to staff #15. Resident #3 was taking pain medications and could not remember signing anything because of being out of it. Resident # 3 stated that she needs the transportation benefit. Resident #3 requested to speak with her son. The interview continued with resident #3, son, and daughter in law on speaker phone. The accident that happened in December started the insurance issues. The first insurance was good through the end of December then the new insurance began in January, which was confusing in the beginning. The first insurance company would not talk to us unless we were on a three way call and that is how the insurance was found out. Resident #3 received a call from insurance #2 that started in January, regarding that the insurance was canceled and was switched to Medicare. That was on a Friday ,d+[DATE] weeks ago. Either on [DATE] or February 7. Nobody authorized the change to Medicare AB plan. Resident #3 stated that she researched the plans because of the added extra benefits. The medication administration record (MAR) was noted for resident #3 to have received pain medication, oxycodone 5mg 1 tablet by mouth at least once a day during the month of January. Twice a day for 28 days of the month of January and three times a day for 12 of the days in January. Four times a day for 2 of the days in January. An interview was conducted with resident #4's daughter with the permission of resident #4's PF on February 28, 2025 at 09:58 am and revealed that the daughter was asked if she had a copy of resident #4's Medicare stuff and stated that she did not and stated to call the other sister. A call was then placed to the other sister on February 28, 2025 at 10:03 am. There was no answer and request was made to call back. An interview was conducted with Director of Rehab staff member #5 on February 28, 2025 at 10:46 am and revealed that therapy orders are obtained by a request from nursing and sometimes the doctors request therapy. If a resident has a decline and the aids (certified nursing assistants) will let staff member #5 know and will get them on a case load. Evaluations are done on the residents and that is submitted to the insurances. When asked if staff #5 has seen an increase in Medicare A and B residents, staff #5 stated yes and that a handful (of residents) have wanted it (therapy) and with that change they are able to do it. The business office will run the common working file and will notify the therapy department when those changes occur. The morning meeting does not mention changing to A and B much now. There was a time frame when it did happen a lot. An interview was conducted with the Director of Nursing (DON) staff member #25 on February 28, 2025 at 1109 am and revealed that she was aware of one resident with an issue of insurance that was changed. Staff #25 does not remember the resident's name and that he is no longer at the facility. Staff member #25 attempted to contact Administrator staff #10 on February 28, 2025 at 1112 am by text. At 1114 am staff #25 texted the surveyor's number to staff #10. An update was given by clinical resource nurse staff #30 that staff #10 was in a president's meeting and will call the surveyor later. An interview was conducted with billing office staff member #35 on February 28, 2025 at 1140 am and revealed that she was unaware of any issues with insurance complaints. It is customary once or twice to check resident's insurance to see if the plan has changed, especially the at the first of the year. When a resident changes insurance there is no form filled out. There were some changes of residents having Medicare plans and going to AB. An interview was conducted with Administrator staff #10 on February 28, 2025 at 1147 am and revealed that resident #1 was a skilled patient and was going through therapy and getting close to a discharge date . AIT staff #20 went and spoke with resident #1 and it was the roommate. Realized he was confused, then spoke to the sister of resident #1 and explained these are the benefits and this makes sense and was on board. Then assisted the resident (resident #1's roommate) to switch. Staff #10 saw resident #1 in the hallway and stated he heard that resident #1 was switching insurances and that was when resident #1 stated that he never spoke to staff #20 about switching and did not want switch. Then staff 10 spoke with the POA of resident #1 and informed the POA that they would stop the switch. Then it was too late to switch. Staff #20 thought the roommate was resident #1 but it wasn't and now we are helping him switch back. Any out of pocket, we (staff #10) will help with. There were other residents. Resident #5 and Resident #4. Resident #4, the daughter was talked to when the daughter was not the decision maker and it should have been the fiduciary. Resident #4 was not alert and oriented to make a decision but actually needed therapy. Then resident #4 declined and went on hospice. Resident #3 - That was done by staff #20. Staff #20 had a conversation with resident #3 and family and had no concerns. Staff #10 stated that he heard they were happy. An interview was conducted with AIT, staff #20, on February 28, 2025 at 1222 pm and revealed that he is not employed at that facility and is not assigned to the facility as of February 1, 2025. Prior to that his title was operations, which is like an internship to get into the company. Staff #20 would go around to the residents and would tell them that they could get more therapy and have safe discharge. Went to resident #1, had not known him prior and thought he could benefit from therapy. Always getting options that could benefit. Asked his name (to the roommate) and was not super cognitive and then called the POA. Looking back, now knows why the name was a super barrier. Resident #1's sister (POA) was on board because resident #1 could not come home early. Staff #20 then stated that I laid it all that he had an advantage plan and to a Medicare plan, he could stay longer. Staff #20 did not know that switching plans would effect resident #1's upcoming procedure because it was never brought up. Staff #20 has spent countless hours trying to fix and wanted to do everything to fix. Staff #20 stated that there was no form to sign, just their presence when switching. Nothing was printed. Staff #20 revealed the same happened with resident #3. Just completed the form online. There is no confirmation. They receive something in the mail. When staff #20 was questioned regarding other benefits it affects when residents leave the facility and it affects their transportation, I was not aware, I'm not too in depth with what happens. Resident rights policy reviewed. It is the policy of this facility that resident rights be followed per state and federal guidelines as well as other regulative agencies. Four residents that resided in this facility had their Medicare advantage plan switched to Medicare A and B. They were not fully aware of the consequences and effects that switching plans will do once they leave the facilty.

Based on observations, clinical record review and staff interviews, the facility failed to ensure that medications were not left at bedside and was not readily available for use for one resident (#282). This deficient practice could result in residents not receiving medications as ordered by the physician and in increased risk of side effects. Findings include. Resident #282 admitted on [DATE] with diagnoses of chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease, and other nonspecific abnormal finding of lung field. The clinical record revealed a physician order for amoxicillin-pot clavulanate (antibiotic) 875-125 mg (milligram) give 1 tablet by mouth every 12 hours for bacterial infection pneumonia for 10 days. During an observation conducted on March 19, 2024 at 10:03 a.m., resident #282 stated that he forgot to take his pill. The resident then got out of his bed, went to his bedside table, and took a white oval-shaped tablet off the top of the table. The tablet was clearly marked with AMC on one side and 875/125) on the other. The resident stated that the nurse gave him this pill earlier that morning and he had told the nurse he would take it after breakfast because he did not want to take it on an empty stomach. A request was made to show the nurse the pill, prior to ingesting. The resident became upset and said that he had to take the tablet since it was already too late. The resident (#282) placed the tablet in his mouth, but pulled it out immediately after and said that the tablet was too hard to swallow. licensed practical nurse (LPN/staff #123) who assigned to the resident stated that the tablet that resident #282 took was amoxicillin-pot clavulanate 875-125 mg that was prescribed to the resident. An interview with director of nursing (DON/staff #105) and the LPN (staff #123) was conducted on March 19, 2024 at 10:06 a.m. The LPN stated she administered the medication to resident #282 at 7:15 a.m. and had watched the resident take his medication. The LPN said that, the antibiotic amoxicillin was scheduled for 8:00 a.m., and was allowed to administer the medication one hour before and one hour after the scheduled time. The LPN (staff #123) stated the risks of taking the antibiotic at a later time would cause the resident to not get the required dose and would be too close together before the next scheduled dose; or, the resident could also miss a dose. Further, the LPN said that there were no risks associated with taking the prescribed antibiotic outside of the scheduled parameters. During an interview conducted with Director of Nursing (DON/staff #107) on March 20, 2024 at 3:15 p.m., the DON stated when administering medications, the nurse would hand the medication to the resident, stand and watch the resident take the medication as ordered by the physician. The DON said that if the resident should refuse their medications they would let the provider know and document the refusal. The DON further stated it was her expectations that a nurse would not leave medications with a resident to be taken at a later time and that they are to destroy the medication and let the provider know and at no time leave medications at a resident's bedside.

Based on clinical record review, resident and staff interviews and review of facility policy, the facility failed to ensure reasonable care was exercised for the protection of one resident's (#64) personal property from loss or theft. The deficient practice could result in residents' personal property not being kept from loss or theft. Findings include: Resident #64 was admitted on [DATE] with diagnoses of peripheral vascular disease, major depressive disorder, unspecified dementia, psychotic disturbance, mood disturbance, anxiety and acquired absence of right leg below knee. Review of the admission note dated October 6, 2021 revealed the resident was admitted from the hospital with no clothing. Per the documentation, there was a wallet with social security card, two keys, credit card and a sealed envelope. Further review of the clinical record revealed there were no personal inventory list for resident #64. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident had moderate cognitive impairment. During an interview with resident #64 conducted on March 19, 2024 at 10:53 a.m., the resident was partially undressed while he was laying on his bed. Resident #64 had a shirt and an incontinence brief on. The resident stated he had been waiting for some shorts or pants from the certified nurse assistant (CNA) so he could get out of bed. The resident also stated that he was missing five pair of pants; and that, he had spoken to laundry and nursing staff about this but the issue had not been resolved. An observation of the resident's personal closet was conducted during the interview and revealed there were a couple of soiled shirts on the bottom of the resident's closet, but there were no pants or shorts found. Another observation was conducted on March 19, 2024 at 11:58 a.m. Resident #64 continued to be on his bed with no pants or shorts on. The resident stated that he was still waiting on some pants to put on. An interview was conducted with a CNA (staff #132) on March 21, 2024 at 12:42 p.m. The CNA stated the process for a new admissions personal property was to list and mark all resident belongings on a personal inventory list. She stated the completed personal inventory list was then given to the nurse who gives it to the social services department. The CNA stated that when a family or the resident brings in new items at the facility, a new personal inventory sheet was completed by the CNA; and that, any personal clothing will have their name labeled on them. The CNA further stated that due to missing clothing issue, the facility had a new system in place. The CNA said that each resident was provided with a laundry bag with their name on it; and, all soiled personal clothing goes in the bag and taken to laundry to be laundered. She said that the cleaned laundered clothes will be placed in the same bag and returned to the resident. Further, the CNA stated that if a resident was missing personal laundry they communicate this to laundry who will try to locate the missing items and a grievance form was also sent to the laundry. An interview was conducted on March 21, 2024 at 12:53 p.m. with a licensed practical nurse (LPN/staff #156) who stated that the facility has a checklist which was completed by the CNA for newly admitted residents; and that, anything of value will go to social services. The LPN said the document was uploaded by medical records and updated in the resident's files. She stated residents clothing was identified by their room number or by their name and the residents have their own personal closet in their rooms. The LPN further stated that if a resident was missing personal clothing the facility process was that staff will check with laundry for the missing clothing then go to social services. In an interview with the Director of Social Services (SSD/staff #87) conducted on March 21, 2024 at 12:58 p.m., the SSD stated an inventory list was completed upon resident admission; and, the following day the social services department will make sure that the form was completed and scanned by medical records. He stated the personal inventory list was uploaded into the resident's miscellaneous records; and that, the resident's inventory list was updated with new items or any new items brought in for the resident. The SSD said that if a resident was missing any personal items there will be a grievance form that is submitted to social services. However, the SSD said that the grievance can be submitted to the social services office verbally or by completing the form; and, he will bring the grievance to the morning meeting. The SSD said that staff will give the grievance on missing personal items including clothes to the appropriate department head who will then need to resolve the issue. The SSD said that the department head notifies social services if the items have been located or not; and that, if the items were not located the resident was reimbursed financially or clothes from the donation closet will be given to the resident. He said the resident had the choice on which resolution they want. Regarding resident #64, a review of the clinical record was conducted with the SSD who stated that there was no admission or updated personal inventory sheet completed found for resident #64 since the resident's admission. On 03/21/24 at approximately 2:30 p.m., an observation of the resident's (#64) closet was conducted with the SSD (staff #87). There were clean clothes with the resident's name hanging in the closet. Resident #64 stated that he was pleased to have his clothes returned. A review of the clinical record was conducted with the SSD immediately following the observation. The SSD stated that a personal inventory list had not been created to reflect the clothing items in the resident's closet. Review of the facility policy on Personal Property revealed that residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.

Based on observations and staff interviews, the facility failed to ensure there were no expired medications readily available for resident use; and,failed to ensure that medications were not left unattended. The deficient practice could result in increase risk for side effects and resident having access to unnecessary medictions. Findings include: A medication cart observation in the A-hall was conducted with a licensed practical nurse (LPN (staff #191) on March 21, 2024 at 9:59 a.m. There was an expired enteric coated aspirin was found in the top drawer of the medication cart. The LPN removed the bottle from the medication cart; and, the LPN stated that she had been through that cart multiple times looking for outdated medications. In an interview with another LPN (staff #198) conducted on March 21, 2024, the LPN stated that if an expired medication was given to the resident, she would notify the unit manager and the doctor, make a notation in the resident's clinical record. During the medication pass observation conducted with another LPN (staff #92) on March 22, 2024 at 8:26 a.m., the LPN was preparing the medications for administration. The LPN pressed the Bumetanide 1 mg (milligram) out of the blister package and into the medication cup. The blister package had an expiration date of January 30, 2024. The LPN then started to prepare another medication and placed it on the same medication cup. The LPN started to walk away from the cart with the medication cup. An interview was conducted with the LPN immediately following the observation and the LPN read the date on the blister pack out loud and then pulled a different blister package for Bumetanide with an expiration date of April 30, 2024. The LPN could not explain why the Bumetanide blister pack with expiration date of January 30, 2024 was still in the medication cart and is readily available for resident use. The LPN left the blister pack with the expired Bumetanide on top of the medication cart and proceeded to give the unexpired medication to the resident in the room. A review of the Bumetanide blister pack with expiration date of January 30, 2024 revealed that pill numbers of 1 through 14 and 22 through 30 were punched out. An interview with the director of nursing (DON/staff #107) conducted on March 22, 2024. The DON stated that the LPN (staff #92) had informed her of the expired medication but did not inform of the expired medications being left on the top of the cart unattended. The DON further stated that there should be no expired medications in the medication carts; and, staff were not to leave medications unattended.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure that two residents (#620 and # 600) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents. Finding includes: -Regarding Resident # 620 Resident #620 (alleged victim) was admitted to facility on October 5, 2023 with diagnosis included senile degeneration of brain, muscle weakness, depression, obstructive, and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 06 indicating that the resident has severe cognitive impairment. The MDS also indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. Review of the care plan initiated on September 14, 2023 revealed the resident at risk for experiencing adjustment issues related to change in customary lifestyle and routines and/or difficulty accepting placement in center. Interventions included review ADL status for impact on social involvement and provide ADL assistance, as needed, to increase social involvement. Review of resident #620 progress note on December 30, 2023 at 4:10p.m. from nurse revealed that certified nursing assistant (CNA) witnessed resident #725 punch resident #620 in his face at the doorway to room [ROOM NUMBER]. Resident #725 admits to punching resident #620 and stated that he found resident #620 in his bed. He further stated that resident #620 pushed him when he attempted to pull resident #620 out of his bed. Resident #620 had a small tear on left cheek and a bruise to left hand. Resident #725 had no noted injuries or bruises, neither he lost balance or fell . Resident #620 son arrived few minutes after incident and stated that he feels his father is fine and has no concern. Review of the entity reported incident revealed that incident occurred on December 30, 2023 at 3:30p.m. It further stated that a small skin tear was noted to left cheek of the resident #620, no other injury noted. An observation of resident #620 was made on January 4, 2024 at 9:25 a.m., and there was bruise in his left cheek. -Resident # 725 (alleged perpetrator) was admitted to facility on June 26, 2023 with diagnosis included cervical disc disorder, peripheral vascular diseases, unspecified dementia, psychotic disturbance, mood disturbance and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 12 indicating that the resident is moderately impaired. The MDS also indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. Review of resident #725 progress note on December 30, 2023 at 4:10p.m. from nurse revealed that certified nursing assistant (CNA) witnessed resident #725 punch resident #620 in his face at the doorway to room [ROOM NUMBER]. Resident #725 admits to punching resident #620 and stated that he found resident #620 in his bed. He further stated that resident #620 pushed him when he attempted to pull resident #620 out of his bed. Resident #620 had a small tear on left cheek and a bruise to left hand. Resident #725 had no noted injuries or bruises, neither he lost balance or fell . Resident #620 son arrived few minutes after incident and stated that he feels his father is fine and has no concern. Review of the entity reported incident revealed that incident occurred on December 30, 2023 at 3:30p.m. It further stated that altercation involved - resident #725 found resident #620 in his bed and a small skin tear was noted to left cheek of the resident #620, no other injury noted. An Interview was conducted with Registered Nurse (RN, staff #525) on January 3, 2024 at 3:44p.m., and he stated that resident #620 wander halls at night and he did not recall of any altercation happened between either resident. An interview was conducted with resident #725 on January 4, 2024 at 8:42 a.m., and he stated that he came to his room and found resident #620 was sleeping in his bed. I just asked resident #620 to get up and pull him with his wrist. It did not last long and resident #620 went back. An Interview was conducted with licensed practical nurse (LPN, staff #500) on January 4, 2024 at 9:13 a.m., and she stated that she heard from night nurse staff #525 that resident #620 got punched in his face by resident #725 because resident #620 was on wrong bed and mark on resident face was very visible. Resident #620 dementia is very advanced and he may not recall the incident. An Interview was conducted with social service director (staff #555) on January 4, 2024 at 9:41 a.m., and he stated that resident #620 was lying on resident #725 bed and resident #725 told resident #620 to get out of his bed and that is how altercation happened, no one got injured. An interview was conducted with resident #620 son on January 4, 2024 at 12:01 p.m., and he stated that he went to facility on December 30, 2023 at random visit and observe injury in his father left side of face and small skin tear in his left hand. He further stated that his father is safe at facility and he is not highly concern and facility is doing great job. Review of the facility policy Freedom from Abuse, Neglect and Exploitation revised 10/2022 stated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. ----------- -Regarding Resident # 600 Resident # 600 (alleged victim) was admitted to facility on June 30, 2023 and discharged on [DATE]. Resident diagnosis included malignant neoplasm of prostate, unspecified hearing loss, legal blindness, sepsis, acute kidney failure, unspecified dementia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. Review of the care plan initiated on July 18, 2023 revealed the resident at risk for complications related to the use of psychotropic drugs and is prescribed antianxiety medication. Interventions included monitor for side effects of anti-anxiety. Review of the entity reported incident revealed that incident occurred on October 5, 2023 at 9:15 a.m. It further stated that certified nursing assistant (CNA) heard banging coming from room [ROOM NUMBER], when she went into room then resident #600 stated that resident #705 hit him with TV remote control, but CNA did not witness. -Resident # 705 (alleged perpetrator) was admitted to facility on April 4, 2023 with diagnosis included displaced intertrochanteric fracture of right femur, type 2 diabetes mellitus with diabetic neuropathy, unspecified dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 12 indicating that the resident is cognitively intact. The MDS also indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. Review of the care plan initiated on October 28, 2023 revealed the resident at risk for complications related to the use of psychotropic drugs and is prescribed anti-depressant and antianxiety medication. Review of resident #705 progress note on October 8, 2023 at 2:05p.m. from behavior revealed Patient refused all medications this shift. Patient observed by this RN trying to go into patient's room across the hall. This RN stopped patient and patient stated that he was going in there to tell the patient to shut up. This RN redirected patient and patient said F you to this RN. Later patient was heard telling his roommate to get out of the room. This RN tried to redirect patient once again and received same response. Review of the entity reported incident revealed that incident occurred on October 5, 2023 at 9:15 a.m. and resident #705 interviewed stated that he did not recall event. Resident became agitated and stated that he did not want to talk any further. An interview was conducted with Social Service Director (staff #555) on January 4, 2024 at 9:41 a.m., and he stated that during his investigation he interviewed both residents. Resident #600 mentioned that he did complained about resident #705 not using his call light. Resident #600 further stated that on day of incident he asked resident #705 not to slam and use call light because he is watching TV and then resident #705 got offended and grab resident #600 and pushed him. Resident #600 did not report that. Both residents separated and moved to different hallway. No injuries to either resident. An interview was conducted with Director of Nursing (DON, staff #560) January 4, 2024, and she stated that she was not aware of the incident and came to know today. When asked if criteria are present, should that be substantiated or unsubstantiated then she stated that it depends on if it was seen, witnessed, injury, or indication of self-inflicted or self-harm. Review of the facility policy Freedom from Abuse, Neglect and Exploitation revised 10/2022 stated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on observations, resident and staff interviews, facility documentation and review of policy, the facility failed to ensure that residents (#94, #151, #162, & #27) meals were provided at scheduled times. The deficient practice could result in residents not receiving their meals on time. Findings include: Resident #94 was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease, stage 3, need for assistance with personal care and muscle weakness. The state database information received on October 24, 2022 stated that the facility administrator was notified of care concerns regarding the resident on October 24, 2022 at approximately 8:30 am. The admission MDS (Minimum Data Set) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident's cognition was intact. The MDS assessment revealed the resident was independent with eating. The facility investigation report dated October 31, 2022 revealed that on October 24, 2022, the company compliance line notified the facility that there was an allegation that resident #94 waited for an extended time to be transferred and provided dinner. The report included that resident #94 was interviewed and stated he was happy with the meals and the timeliness they were provided. Review of the resident council minutes from May 2022 through October 2022 revealed residents stated they wanted the food hot and in a timely manner under the dining services concerns for each month. The October 25, 2022 resident council minutes stated that the kitchen director assured he would work on all complaints. The meal service time posted stated the following times for meal times for the different units: 1) AOU unit - Breakfast 8:00 am, lunch 12 pm, Dinner 5:30 pm 2) Memory unit - Breakfast 8:10 am, lunch 12:10 pm, Dinner 5:40 pm 3) 2nd Floor Dining Room- Breakfast 8:20 am, lunch 12:20 pm, Dinner 5:50 pm 4) 2nd Floor Hall Tray- Breakfast 8:35 am, lunch 12:35 pm, Dinner 6:05 pm An interview was conducted with resident #151 on November 29, 2022 at 12:48 pm. She stated that meals are normally late and meals are delivered late a lot of the time. She stated she received dinner at 7:15 pm and breakfast as late as 10:00 am. During an observation of the lunch meal distribution on the 100 hallways (AOU unit) on November 29, 2022, lunch meal distribution was observed around 1:33 pm. During an interview conducted with a Certified Nursing Assistant (CNA/staff #118) on November 29, 2022 at 3:27 pm, she stated that meals are occasionally late and lunch is usually late. She stated when the CNAs are late picking up residents' tray and are late bringing the cart back to the kitchen, this will put the kitchen behind. During a breakfast observation conducted on November 30, 2022 at 8:51 am, it was observed that the residents on the AOU unit had not received their breakfast. During an interview with a CNA (staff #74) on November 30, 2022 at 8:54 am, she stated that she did not know when breakfast got delivered in the first floor as she usually worked on the second floor and the second floor receives breakfast around 8:00 am to 8:10 am. She stated the kitchen is sometimes late with delivering meals and is not more than 20 minutes late. She stated the kitchen will notify the staff if they are running late and will state it was due to short staff in the kitchen. During the breakfast observation on AOU unit on November 30, 2022, it was observed that the unit received the breakfast cart at 9:03 am. An interview was conducted with a CNA (staff #120) on November 30, 2022 at 12:49 pm. He stated that the first floor (AOU unit) does not receive lunch until 12:00 pm to 12:30 pm. He stated the kitchen does not notify the staff if the meal is going to be delivered late. He stated the kitchen always tries to be on time with the meals. During the lunch observation conducted on November 30, 2022, it was observed that the lunch tray cart arrived on AOU unit at 12:50 pm. During an interview with a Registered Nurse (RN/staff #58) on November 30, 2022 at 12:52 pm, she stated that there was a new staff member in the kitchen who started working last week therefore there has been a delay with meals. However, she stated meals are normally delivered on time. During an observation conducted on December 1, 2022 at 9:25 am on first floor 100-unit, resident #162 was observed saying that he did not know what time the staff were bringing the breakfast. An interview was conducted with another resident (#27) on December 1, 2022 at 9:27 am. She stated that she had not received breakfast yet. She stated the meals are late most of the time and that she is diabetic. An interview was conducted with the kitchen manager (staff #107) on December 1, 2022 at 10:12 am. He stated that he had not heard complaints on timeliness of meal delivery. He stated the kitchen has been pretty consistent with meal delivery and generally the meal carts come out on time. He stated if meal time states 8:00 am, 8:30 am will be unusually late for meals to be delivered. He stated an issue with timeliness of meal delivery has not really happened. He stated there is a window for the kitchen to serve the meals and stated meals should be delivered on time as residents will be sitting waiting for their food. He stated the week had been difficult as he had to send a staff home during the start of service line due to testing positive for COVID-19 and the kitchen got their supplies delivered. He stated that they did not change their responsibility on delivering the meals on time. An interview was conducted with the Director of Nursing (DON/staff #46) on December 1, 2022 at 11:29 am. She stated that she had not heard of meals being delivered late. She stated there have been few challenges but the kitchen has been running smoothly. She stated she is aware of dining service complaints from a few residents unrelated to timeliness of meal. She stated it is important for the meals to be delivered on time for quality of care reasons as the facility is the resident's home and if the meal is not delivered on time, the food might possibly be cold. 46606 -Continued Dining Observations During the kitchen tray line observation conducted on November 29, 2022 at 1:30 p.m., the kitchen was observed to run out of food and was short meals for 5 residents who were located in the Memory Care Unit. The staff appeared to not know what to do and had to figure out what to serve the residents. The lunch menu consisted of Beef Chili Corn Chip Casserole, seasoned peas, flour tortilla, Chicken Vegetable Soup, and grapes. An interview with the Kitchen Manager (staff #107) was conducted on November 29, 2022 at 1:49 p.m. Staff #107 stated that the kitchen had not ran out of food in a long time. He also stated that they were usually done plating by 12:30 p.m. By this time, staff #107 had determined that they would serve Roasted Turkey, Mashed Potatoes, gravy and peas. Per posted meal time, the meals for the 5 residents was already late 1 hour and 39 minutes. In response to the meal shortage and change in menu, the following was the timeline of observed events for November 29, 2022: 1:52 p.m. - started plating turkey meal (1 hour and 42 minutes past posted meal time) 1:57 p.m. - last cart containing the meals for the 5 residents in the Memory Care Unit left the kitchen (1 hour and 47 minutes past posted meal time) 2:05 p.m. - last food cart containing the 5 resident meals was delivered to the Memory Care Unit (1 hour and 55 minutes past posted meal time) 2:11 p.m. - meal tray finally delivered to the residents (2 hours and 1-minute past posted meal time) The following is a dining timeline observation of breakfast in the Memory Care unit conducted on November 30, 2022: 8:52 a.m. - the food cart had not arrived at the unit. (42 minutes past posted meal time) 9:06 a.m. - the food cart containing breakfast still had not arrived at the unit. There were 4 residents in the dining room waiting for breakfast. (56 minutes past posted meal time) 9:09 a.m. - food cart finally arrived at the unit. It was dropped off by the Kitchen Manager (staff #107) without any conversation with the unit nurse/staff regarding why the meals were late. (59 minutes past posted meal time). 9:10 a.m. - staff began passing out breakfast trays to the residents (1 hour past the posted meal time) The following is a dining timeline observation of lunch in the Memory Care unit conducted on November 30, 2022: 12:16 p.m. - food cart containing lunch was yet to arrive in the unit. There were 2 residents in the dining room waiting for lunch. 12:31 p.m. - lunch cart still had not arrived in the unit. (21 minutes past posted meal time) 12:48 p.m. - still no lunch at the unit. There were 5 residents waiting in the dining room for lunch (38 minutes past posted meal time) 1:00 p.m. - a food cart containing lunch finally arrived in the unit. Staff were observed putting trays in the dining room. Residents were escorted to the dining room to have their meals. (50 minutes past posted meal time) 1:09 p.m. - staff started delivering meals to the residents who ate in their room (59 minutes past the posted meal time) An interview was conducted with a Licensed Practical Nurse (LPN/staff #68) on November 30 at 8:52 a.m., she stated that on a good day, they get breakfast between 8:00 a.m. to 8:30 a.m. Staff #68 stated that she does not even want to look at the clock to see how late it is. She said that the kitchen never notifies them when food is going to be late or why it is late. An interview was conducted with the Dietary Manager (staff #170) on December 1, 2022 at 10:13 a.m. Staff #170 stated that he attended the resident council meetings. He stated that he was not aware of timeliness issues or grievances from residents. Staff #170 stated that they are pretty consistent but there are times when they run late. He admitted that the kitchen does not inform the units if meals are delayed. However, this is because meals are normally on time. He stated that if breakfast is scheduled for 8:00 am, then 8:30 am would be unusually late and that is not a normal occurrence. When informed that breakfast on November 30 did not arrive at the Memory Care Unit until 9:09 a.m., he stated he was not aware it was late. He stated that it is important to have meals served as advertised and that it was the expectation. Review of the facility policy titled Meal Distribution revised September 2017 revealed meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. The policy further revealed the nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents.

Based on clinical record review, observations, staff interviews, and the facility's policy and procedure, the facility failed to inform one resident (#90) and or the resident's representative in advance regarding the risks and benefits of proposed treatment and care related to the use of a Geri chair. The sample size was 2. The deficient practice could result in residents and representatives not being informed of the risks and benefits to using a Geri chair. Findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side and repeated falls. A quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated the resident had no cognitive impairment. Review of a general progress note dated November 19, 2022 at 7:15 a.m. revealed the resident was found on the floor and was placed in a Geri chair to bring out to the nurse's station. Review of a general progress note dated November 20, 2022 at 5:39 a.m. stated the resident was found lying on the floor two times (the prior shift), and that the resident was placed in a Geri chair for the resident's safety around 11:00 p.m. During an observation conducted on November 28, 2022 at 12:16 p.m., it was observed that resident #90 was sitting in a reclined Geri chair by the nurses' station. Record review revealed no rational documentation for the use of the Geri chair. An interview with resident #90 was attempted on December 1, 2022 at approximately 9:37 a.m. However, the resident was unable to participate in the interview. An interview was conducted on December 1, 2022 at 9:40 a.m. with a licensed practical nurse (LPN/staff #13) in the resident's room. She stated the resident does not have a regular wheelchair and that the resident uses a Geri chair when out of bed, otherwise the resident would try to get out. Staff #13 further stated the staff reclines the Geri chair so the resident cannot get out of it; it makes it difficult. Staff #13 stated the Geri chair has a tray that goes in the front for meals and drinks. She stated the tray stays on the Geri chair to hold the resident's drink, and that the resident cannot get out of the Geri chair unless the resident is helped by the staff. During the interview, the resident's legs were exposed which revealed several brown scabs in various sizes and multiple scratches on both anterior legs. However, review of the clinical record revealed no evidence that the resident and or the resident ' s representative were informed of the risks and benefits of the Geri chair. An interview was conducted with a certified nursing assistant (CNA/staff #117) on December 1, 2022 at 9:50 a.m. He stated that he was very familiar with resident #90. Staff #117 stated the resident gets up and sits in the geriatric chair 3-4 times a week for about 6 hours or more, then the resident is put back to bed and changed. Staff #117 stated resident #90 cannot get out of the Geri chair by himself. Further, he stated the staff recline a Geri chair so the resident cannot get out of the Geri chair. Staff #117 stated the tray was used for meals and drinks which was attached in front of the chair. A second observation was conducted on December 2, 2022 from 9:49 a.m. until 10:06 a.m. Resident #90 was sitting in the Geri chair that was placed in front of the nurses' station. The Geri chair was in a reclined position, and a lap tray was attached. There was a disposable white cup of water that was placed on the lap tray, beyond the resident's reach. Resident #90 made several attempts to get out of the Geri chair by continuously kicking both legs up and down, and both legs hit the lap tray several times. The resident made several attempts to reach towards the lap tray but was unsuccessful because the Geri chair was reclined. The resident was unable to get out of the Geri chair or remove the lap tray independently. An interview was conducted with a LPN (staff #16) on December 2, 2022 at 9:49 a.m. She stated the resident's chair is called a Geri chair and that resident #90 gets up in the Geri chair daily. Staff #16 stated the resident cannot get out of the Geri chair because of mobility. She stated the lap tray was placed on the Geri chair to hold the water. Staff #16 stated she did not know an assessment should be done related to the use of a Geri chair. She accessed the resident's record and stated she did not see a Geri chair assessment or consent in the resident's record. An interview was conducted with the Director of Nursing (DON/staff #46) on December 2, 2022 at 9:09 a.m. She stated the resident's Geri chair was used for comfort. The DON stated prior to the use of the device, the facility did not obtain a consent and no assessment was conducted. The DON stated the resident started using the Geri chair in October 2022. She stated the risks for using the Geri chair included potential harm to the resident's legs from attempting to get out of it, and depending on how the resident is positioned, the resident could also strain himself. Further, she stated the Geri chair could cause increased restlessness and agitations to the resident. Review of a facility policy, Restraints: Use of, stated residents have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The definition of physical restraint included any manual method, physical or mechanical device, or equipment that is attached or adjacent to the patient's body; cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body. The policy included there must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint, and that a consent must be obtained prior to the application of the restraint from the resident or the resident's representative.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure an evaluation and ongoing assessment was completed regarding the use of a physical restraint for one resident (#90). The sample size was 2. The deficient practice could result in improper use of restraints and possible injury to residents. Findings include: Resident #90 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side and repeated falls. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had no cognitive impairment. Review of a general progress note dated November 19, 2022 at 7:15 a.m. revealed the resident was found on the floor and was placed in a Geri chair to bring out to the nurse's station. Review of a general progress note dated November 20, 2022 at 5:39 a.m. stated the resident was found lying on the floor two times (the prior shift), and that resident was placed in Geri chair for resident's safety. During an observation conducted on November 28, 2022 at 12:16 p.m., it was observed that resident #90 was sitting in a reclined Geri chair by the nurses ' station. An interview with resident #90 was attempted on December 1, 2022 at approximately 9:37 a.m. However, the resident was unable to participate in the interview. An interview was conducted on December 1, 2022 at 9:40 a.m. with a licensed practical nurse (LPN/staff #13) in the resident's room. She stated the resident does not have a regular wheelchair and that the resident uses a Geri chair when out of bed, otherwise the resident would try to get out. She stated the resident cannot get out of the Geri chair unless the resident is helped by the staff. An interview was conducted with a certified nursing assistant (CNA/staff #117) on December 1, 2022 at 9:50 a.m. He stated that he was very familiar with resident #90. Staff #117 stated the resident gets up and sits in the geriatric chair 3-4 times a week for about 6 hours or more, then the resident is put back to bed and changed. Staff #117 stated resident #90 cannot get out of the Geri chair by himself. Further, he stated the staff recline a Geri chair so the resident cannot get out of the Geri chair. However, record review revealed no evaluation or ongoing assessment to support the rationale regarding the initial and continued use of the Geri chair. A second observation was conducted on December 2, 2022 from 9:49 a.m. until 10:06 a.m. Resident #90 was observed sitting in the Geri chair that was placed in front of the nurses ' station. The Geri chair was in a reclined position, and a lap tray was attached. There was a disposable white cup of water that was placed on the lap tray, beyond the resident's reach. Resident #90 made several attempts to get out of the Geri chair by continuously kicking both legs up and down, and both legs hit the lap tray several times. The resident made several attempts to reach towards the lap tray but was unsuccessful because the Geri chair was reclined. The resident was unable to get out of the Geri chair or remove the lap tray independently. An interview was conducted with an LPN (staff #16) on December 2, 2022 at 9:49 a.m. She stated the resident's chair is called a Geri chair and that resident #90 gets up in the Geri chair daily. Staff #16 stated she did not know an assessment should be done related to the use of a Geri chair. She accessed the resident's record and stated she did not see a Geri chair assessment or consent in the resident's record. An interview was conducted with the Director of Nursing (DON/staff #46) on December 2, 2022 at 9:09 a.m. She stated the resident's Geri chair was used for comfort. The DON stated prior to the use of the device, there was no consent and no assessment was conducted for the use of the Geri chair. The DON stated the resident started using the Geri chair in October 2022. She stated the risks for using the Geri chair included potential harm to the resident's legs from attempting to get out of it, and depending on how the resident is positioned, the resident could also strain himself. Further, she stated the Geri chair could cause increased restlessness and agitations to the resident. Review of a facility policy, Restraints: Use of, included the definition of physical restraint as any manual method, physical or mechanical device, or equipment that is attached or adjacent to the patient's body; cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body. The policy further included when the use of restraints is indicated, the resident's will be evaluated for the use of restraints or protective devices during the nursing assessment process. The policy included there must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint, and that a consent must be obtained prior to the application of the restraint from the resident or resident ' s representative.

Based on clinical record review, staff interviews, and review of the Resident Assessment Instrument (RAI) Manuel, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed for one sampled resident (#26). The deficient practice could affect residents' continuity of care. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, unspecified Dementia unspecified severity, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Contracture of muscle right and left lower leg, and Chronic Pain Syndrome. A physician's order dated October 28, 2022 stated for the resident to be placed on hospice services. The resident was admitted into hospice services on October 28, 2022, however there was no evidence that the significant change MDS assessment had been completed until November 30, 2022. During an interview conducted with the MDS coordinator (registered nurse/staff #35) on November 30, 2022, she stated that she has 14 days after she is notified that a resident has gone onto hospice to complete a significant change MDS assessment. The Coordinator stated that she was just finding out today that the resident was placed on hospice. Staff #35 stated she has 14 days from today to note that the significant change has taken place. During an interview with the Director of Nursing (registered nurse/staff #46) on December 1, 2022 at 7:50 AM, she stated that there was a miscommunication between hospice and the clinical team in that they did not notify the facility that the resident had gone into hospice. According to the RAI manual, a Significant Change Status Assessment (SCSA) is required to be performed, when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice provider and remains a resident at the at the nursing home. The assessment reference date (ARD) must be within 14 days of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between hospice and the nursing home is in place. The policy also included that this is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on clinical record review, observation, staff interviews and review of policy, the facility failed to ensure that two residents (#1 and #150) who were unable to carry out activities of daily living (ADLs) were consistently provided care regarding oral care and incontinence care. The sample size was 6. The deficient practice could result in residents with unmet ADL care. Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, Parkinson's disease, Schizophrenia and need for assistance with personal care. During an observation of the resident conducted on November 28, 2022 at 11:11 am, the resident's teeth were observed to be black with white substance build up in between the teeth. Review of the baseline care plan dated November 11, 2022 revealed the resident required assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to recent illness, hospitalization resulting in fatigue, activity intolerance, confusion. The care plan also revealed the resident exhibits or is at risk for oral health or dental care problems as evidenced by missing teeth. Interventions stated to provide oral hygiene/mouth care twice per day and use a mouth rinse as appropriate. The admission Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 1 indicating the resident's cognition was severely impaired. The MDS assessment revealed that the resident was an extensive assistance with one-person physical assistance with personal hygiene. Review of the Point of Care Certified Nursing Assistant (POC CNA) documentation from November 11, 2022 through November 29, 2022 revealed the resident had received oral care twice on the 6AM to 2pm shift on November 15 and 20, 2022 and personal hygiene care three times on the 6AM to 2pm shift on November 15 and 20, 2022 and 10 pm to 6AM shift on November 21, 2022. All other shift documentation was left blank. Review of the clinical record did not reveal the resident received oral care or personal hygiene care on the shifts with no documentation. An interview was conducted with a Certified Nursing Assistant (CNA/staff #118) on November 29, 2022 at 3:27 pm. She stated personal hygiene including oral care is provided to the resident who needs assistance in the morning before breakfast and is documented in the POC. She stated if the care is not documented then one cannot tell that the care was done. An interview was conducted with another CNA (staff #74) on November 30, 2022 at 8:54 am. She stated that the staff should document ADL care including assistance with personal hygiene each shift in POC. An interview was conducted with a CNA (staff #120) on November 30, 2022 at 12:49 pm. He stated residents who need assistance with ADL care including personal hygiene and brushing are assisted each shift and it is documented in POC. He stated if the care is not documented, it does not mean it was not done as the facility has staff from the registry who might not have access to the POC. He stated resident #1 needed one-person assistance for personal hygiene and the resident ' s teeth were normal for the resident's age. An interview was conducted with a Registered Nurse (RN/staff #58) on November 30, 2022 at 12:52 pm. She stated that the CNAs assist resident #1 with ADL care. She stated the CNAs should be documenting ADL care provided in the resident's electronic record. She stated if there is no documentation of ADL care then that meant the care was not provided. She stated for the staff who do not have access to electronic charting, there is paper charting available for them to chart. She stated the staff should be charting on paper if the electronic chart is not available. An interview was conducted with the Director of Nursing (DON/ staff #46) on December 1, 2022 at 11:29 am. She stated that her expectation is for the staff to document ADL care in POC after the care is provided to the resident. She stated the facility is aware of challenges with lack of POC documentation and there has been constant education with the staff. She stated due to staffing challenges and use of registry staff; the facility is aware that the staff members were not documenting ADL care. The DON stated if the staff did not have access to POC, they should be documenting it in the paper chart. She stated it is important to chart as if it is not charted, it did not happen and if one is summoned to the court, the case will be hard to prove without documentation. The facility policy titled Activities of Daily Living (ADLs) revised on June 1, 2021 included that a resident who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated that ADL care is documented every shift by the nursing assistant. 47179 -Resident #150 was admitted to the facility on [DATE] with diagnoses that included nutritional deficiency, muscle weakness, and need for assistance with personal care. Review of the comprehensive assessment of the resident's bladder and bowel continence revealed the resident was always incontinent. In addition, the facility's comprehensive assessment of the resident's functional status including how the resident uses the toilet room, commode or bedpan; cleanses self after elimination; and changes pad revealed the resident required extensive assistance with one person assist. Review of a Follow Up Question Report regarding toileting dated November 21, 2022 revealed the resident had total dependence for toilet use and required full staff performance. Review of the care plan dated November 21, 2022 revealed the resident was at risk for or was experiencing adjustment issues related to change in customary lifestyle and routines and/or difficulty accepting placement in the center. Interventions included providing room visits for care needs. Review of the documentation survey report for November 2022 revealed staff assisted the resident on November 21, 2022 with bowel and bladder toileting; however, no other documented assistance was present for the remainder of November 2022. An interview was conducted on November 30, 2022 at 12:55 p.m. with a RN (staff #62). According to the RN, resident needs are known on admission and by reviewing prior documentation on what they can and cannot do. The RN stated these needs include toileting that are modified as necessary with therapy, nursing, and family collaboration. The nurse also stated that CNAs are primarily responsible for assisting residents with toileting, among other tasks, and documenting it upon competition. For example, he said, CNAs document the size of the stool, the quality (normal vs. abnormal) and urine quality (foul smell) and then notifies the nurses. The nurse also stated that it is important to document because it optimizes resident care for the best outcome and determines if care requires adjustments or changes, for example, for an abnormal bowel or bladder, their medications or food can be adjusted and diagnostic tests are ordered. The RN attempted to verify resident #150's chart for daily toileting records but no records were found, the toileting task said, not applicable. He then said it might not be right because that is where CNAs document and there must be a different area. An interview was conducted on November 30, 2022 at 1:38 p.m. with a RN (staff #58). According to the RN, to determine the needs of each resident, a staff would look at the resident's chart and census sheets. She added that it is the responsibility of the CNAs to perform showering, toileting, and changing residents and that nurses help too. Also, she said that CNAs are supposed to document each time they perform any tasks, ADLs, and toileting, because if there is a change in the resident's condition, for example, constipation, they can give something for it or if the resident is not producing urine, they need to know because there can be sometime wrong with their kidneys or bladder. The nurse verified that resident #150 was a dependent resident. When inquired if nurses perform toileting tasks, she said yes and they told the CNAs to document because she is not able to chart on the CNAs tasks. An interview was conducted on November 30, 2022 at 2:21 p.m. with a CNA (staff #108). According to the CNA, she goes over the residents' chart to determine their needs, and/or inquires from the resident what they can do on their own and what they can be assisted with. She stated that it is the responsibility of the CNAs to perform resident tasks which include assisting with showering, toileting and changing. Also, she stated that the residents' chart reveals continence status and whether they need assistance due to difficulties with a limb or body part. She added that if toileting is performed it is documented but on a good day, when she has time to chart. She said it is important to document toileting because if a resident is constipated or experiencing any bladder and bowel issues it may be due to medications. The CNA stated that she is not familiar with their charting since she is an agency employee and sometimes does not have access to the point click care. When she attempted to sign into the chart she received an error. She stated that she has not had access for two weeks. At this time another CNA (staff #120), added that there are occasions where they cannot document at all due to lack of tablets or functioning computers. The CNA attempted to sign on to a computer and was not able to sign on. An RN (staff #58) stated that if CNAs are unable to chart on the computer, they are to do paper charting. When staff #58 was asked if there were paper charting for resident #150, she stated there was not one. An interview was conducted on December 1, 2022 at 11:29 a.m. with the director of nursing (DON/staff #46). According to the DON, staff determine the needs of each resident through reports, the physician, MDS coordinator, and from each other. The DON stated that the CNAs are responsible for showering, toileting, and changing tasks and they are to document on shower sheets, and on the point-of-care charting on the electronic medical record charting software; however, she explained the challenges she had faced with agency employees currently working at the facility who do not document the tasks being performed for the residents. Furthermore, she stated that she is constantly educating the staff to document completed tasks but during the first half of the year agency CNA employees were not able to log-in to document; therefore, they were to document on paper but it has not been happening and that it is a work-in-progress. Lastly, she said it is important to chart; if it is not charted, then it did not happen, it shows no care was being provided. On December 1, 2022, a request was made for any paper charting on Daily Toileting Activity for November 2022. According to the DON, there was no paper charting for the resident (#150). Review of the facility's policy title, Continence Management revealed the patients will be assessed for the need for continence management as part of the nursing assessment process to provide appropriate treatment and services for patient with urinary incontinence to minimize urinary tract infections and restore continence to the extent possible as well as to provide appropriate treatment and services for patients incontinent of bowel to restore continent to the extent possible. Practice standards include, developing individualized interventions plan of care based on information from assessment and voiding records and plan of care documentation including documenting daily toileting activity in point click care-ADL-plan of care.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure proper skin assessment necessary to identify and treat lice infestation of one sampled resident (#69). The deficient practice could result in undetected lice infestation of residents. Findings include: Resident #69 was admitted on [DATE] with diagnoses that included schizophrenia, type 2 diabetes mellitus, dementia, gastroesophageal reflux disease, and age-related cataract. A care plan initiated on February 15, 2021 revealed that the resident was at risk for decreased ability to perform ADL(s) (activities of daily living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to diabetes, dementia. Interventions indicated to provide the resident with set-up to extensive assists for bathing, grooming, personal hygiene and dressing. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident had severe cognitive impairment. A skin monitoring comprehensive CNA (certified nursing assistant) shower review sheet dated September 10, 2022 did not indicate any skin issues/concerns or findings. A nursing progress note dated September 12, 2022 at 10:30 p.m. revealed that the resident complained of itching. Staff assisted the resident in the shower when bugs were noticed in the resident's hair and body. It further stated that the resident's bed and linen was checked and it was discovered to also have small bugs present. Further review of hard copy shower sheets did not reveal a corresponding shower sheet documentation for the September 12, 2022 shower mentioned in the progress note. Another nursing note dated September 12, 2022 at 11:00 p.m. indicated that the nursing supervisor on duty was notified of findings. It further noted that the resident was assessed and that the staff was unable to identify the small bugs. The note also stated that the resident continued to complain of pain and discomfort. A progress note dated September 12, 2022 revealed the nurse practitioner was notified. An order was written to send the resident to the ER (emergency room ) for further evaluation regarding the excessive itching, pain, and discomfort related to the small bugs on the resident's entire body. Review of the order summary report revealed an order dated September 13, 2022 to send the resident to the ER via non-emergency for further evaluation for excessive itching, pain, and discomfort. Review of the emergency room Report dated September 13, 2022 revealed the resident presented to the ER with very itchy scalp and possible lice. The report stated that the resident had numerous admits [nits] throughout the hair with brown lice crawling throughout the hair on the resident's head. The resident was diagnosed with pediculosis capitis and discharged with a prescription. A physician order dated September 13, 2022 prescribed Permethrin 5%. Direction for use was to apply it to the head to toes topically one time only for lice for 1 day. It was further instructed to provide two bottles and provide a nit comb. A physician order dated September 14, 2022 indicated: - isolation for treatment of head lice 9/13/2022 - quarantine for treatment of head lice 9/13/2022 every day and night shift A progress note dated September 14, 2022 revealed the resident was diagnosed with lice. It further noted that Permethrin treatment was done that morning. All clothing was bagged and sent to the laundry. Other personal items were bagged in the resident's room for two weeks. The note stated that the facility attempted to notify the resident's relative without success and that the resident was placed in isolation. Review of the Skin Monitoring: Comprehensive CNA Shower Review sheet dated September 14, 2022 noted that the resident was in isolation for lice and to monitor for lice. However, it did not state whether there were lice or nits were noted. An order dated September 15, 2022 indicated for assessment to scalp and hair every day for monitoring of lice, nits, and eggs. The Skin Monitoring: Comprehensive CNA Shower Review sheet dated September 15, 2022 stated to monitor for lice. However, it did not state whether there were lice or nits noted. A progress note dated September 15, 2022 revealed the nurse spoke with the resident's relative notifying of the lice diagnosis and treatment. It also noted that permission was obtained to cut the resident's hair. The Skin Monitoring: Comprehensive CNA Shower Review sheet dated September 16, 2022 stated to monitor for lice. However, it did not state whether there were lice or nits noted. A progress note dated September 16, 2022, revealed several lice nits have been noted but no live activity. It also noted that the resident hair was getting cut to the shoulders. Further review of the Skin Monitoring: Comprehensive CNA Shower Review sheets revealed no documentation for September 17 & 18, 2022. A Skin Monitoring: Comprehensive CNA Shower Review sheet dated September 19, 2022 stated that nits were noted, no lice, and to monitor. A progress note dated September 19, 2022 revealed a nurse assessed the resident's scalp, hair, and body. During the assessment, several nits were noted but no lice. It stated continued isolation per protocol. The note also stated the resident had been treated and will be reassessed and treated as needed. The note further noted the resident was showered and the nit comb was used and hair was washed twice. Review of a nursing progress note dated September 20, 2022 revealed the resident's scalp, hair, and body was assessed. The note further stated that there were no lice, nits, or eggs noted during the assessment. The resident was showered and hair was washed twice. The resident's clothing and linen were changed. A progress note dated September 21, 2022 stated that the resident's scalp and hair was assessed for lice and nits before the second treatment was given. The note stated that two nits were noted. Medication was applied to the scalp and hair as ordered. The resident was showered after the recommended wait time. Review of the September 2022 work orders did not reveal any work order for the terminal cleaning of the resident's room. Review of the September 2022 Medication Administration Record (MAR) revealed that the resident was provided the permethrin treatment as ordered. It also revealed the resident was quarantined for treatment as ordered. During an interview with the Infection Control Preventionist/Registered Nurse (IPC/RN/staff #60) conducted on December 1, 2022 at 9:01 a.m., she stated that when a resident is found to have lice, the facility tries to contain the situation by checking on all residents and placing the infected party on contact precaution. She stated an order is then obtained for lice treatment. Staff #60 stated the infected resident is restricted from activities for 7 days, and they will remove the roommate if only one of them is infected. The IPC stated the room is terminally cleaned, all belongings cleaned, and put into bags. She also stated the physician is notified. Staff #60 stated treatment is documented on eMAR (electronic medication administration record). She stated she was unsure of where terminal cleaning is documented, however, a work order is put in for the terminal cleaning of the room. She stated that prior to this week, the last lice incident involved resident #69. She stated that during that time, they tried to look at how it originated, checked the scalp, notified the family, and moved the roommate to another room. She stated that to her recollection resident #69 was not covered head to toe right away and should not have been sent out. Staff #60 stated that they educated staff to pay more attention when assessing residents. The IPC stated that when resident #69 was found to have lice, she involved Admissions to move the roommate to another room. She stated the staff took hair brushes, changed out sheets, and shampooed the resident. She stated the bed was wiped down. She stated that prior to that she was not familiar with the policy and procedure for lice as that was her first lice incident. She stated she educated the staff but the training was not documented (no sign-in sheets). An interview was conducted with the Environmental Director/Housekeeping (staff #84) on December 1, 2022 at 9:18 a.m. Staff #84 stated that rooms occupied by residents who have lice are deep cleaned. She stated everything is packed and cleaned. She stated Clorox is used to wipe and disinfect the room. She stated everything is wiped down and clothing is washed. Staff #84 stated that they currently have a room occupied by a resident with lice, and that there was another incident regarding lice in the facility approximately a month ago. She said that housekeeping is normally notified by the infection control nurse or the director of nursing (DON) regarding room(s) that have to be deep cleaned. During an interview with a Certified Nursing Assistant (CNA/staff #74) conducted on December 2, 2022 at 9:34 a.m., she stated that during showers, a resident's skin, hair, nails, and private areas are assessed for anything noticeable and documented on the shower sheets. She stated the nurse then signs the sheet before the end of the shift. She stated that on the resident's electronic record, it allows them to document that a resident was showered or refused. Staff #74 stated however, not all residents have bathing options on PCC so CNAs normally document on the hardcopy Skin Monitoring: Comprehensive CNA Shower Review sheet. Staff #74 said that in the year she had been working in the facility, there had been no training provided regarding detection of lice and what to do if someone had lice. She stated that since this week, a resident was detected with lice, this is the first time she has ever seen it. She also stated that since she is the one that found it on a resident the other day, the nurse she notified had been the one that had provided her information of what to do. Staff #74 stated the nurse informed the ICP and the resident was placed in isolation. Staff #74 stated housekeeping came in and cleaned the room while the treatment was being provided to the resident, and all clothing was bagged and put in the laundry for washing. An interview was conducted on December 2, 2022 at 11:42 a.m., with the Director of Nursing (DON/staff #46), who stated that the expectation is that during showers, the resident's skin and nails are assessed. The DON stated the nurse should be informed of any abnormalities. She further stated that she expects residents are assisted with the shampooing of their hair. She said her expectation is that residents' bodies are inspected holistically during showers. The DON stated the shower sheets are where findings are documented, and it should be also documented on PCC under the CNA tasks. She stated that however, due to access issues, PCC documentation is hit or miss, and that to back it up, CNAs use the hardcopy Skin Monitoring: Comprehensive CNA Shower Review sheet. Review of the facility policy titled Pediculosis (Body, Head, Pubic Lice) reviewed November 15, 2022 revealed the signs and symptoms of pediculosis as: - graying body of all three types of pediculosis (lice) is visible without a magnifying glass - with head and pubic lice, visible nits (eggs) on hair shafts - intense itching - visible hemorrhagic areas - visible bites - bites on body, infected with impetigo or pyoderma Furthermore, it indicated to continue regular bathing of the resident. The facility policy titled Skin Integrity and Wound Management revised September 1, 2022 stated that the nursing assistant will observe skin daily and report any changes or concerns to the nurse.

Based on clinical record review, staff interviews and facility policies and procedures, the facility failed to ensure pressure ulcer assessment was completed for one resident (#248). The sample size was 5. The deficient practice could result in the resident not receiving the appropriate pressure ulcer treatment. Findings include: Resident #248 was admitted on [DATE] with diagnoses of sepsis, anemia, hypomagnesemia, melena, difficulty in walking, and bacteremia. A nursing note dated August 6, 2022 indicated that the resident was alert and oriented to person, place, time, with modified independence in decision making skills for daily routine. The note also revealed a skin check was completed on the resident and no skin injury or wounds were noted. The Skin Check assessment dated [DATE] stated the resident did not have any skin injury and or wounds. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The assessment also revealed the resident was at risk for developing pressure ulcer and/or injuries, and did not have any pressure ulcer and/or injuries, or any other skin problems. The August 14, 2022 Skin Check assessment revealed the resident did not have any skin injury and or wounds. However, it included the integumentary care plan was revised to add the following interventions: - Provide resident and/or healthcare decision maker education regarding risk factors and interventions - Observed skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanche easily - Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered - Obtain dietitian consult as needed/ordered - Pressure redistribution surface to bed as per guidance - Provide wound treatment as ordered - Provide supplements as ordered - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status The Skin Check assessment dated [DATE] revealed the resident had a skin injury/wound but that it was not new, and that it was not a previously noted skin injury/wound that was recorded. A Nursing Documentation assessment dated [DATE] revealed that the integumentary portion was left unanswered. Questions unanswered pertained to review of the integumentary system, skin check, and wound summary note. A Wound Care progress note dated August 24, 2022 revealed the resident was seen and was observed to have a right heel intact blister. The note included the blister was cleaned, assessed, measured, and redressed as per order. The note stated that the resident tolerated the treatment well, and that the area will continue to be monitored closely. Another Nursing Documentation assessment dated [DATE] revealed the integumentary portion was again left unanswered. Questions unanswered pertained to review of the integumentary system, skin check, and wound summary note. The Braden scale assessment dated [DATE] indicated a score of 20 with category marked as not applicable. The assessment noted that the resident had no impairment, and was occasionally moist with no mobility limitation. Friction and shear were noted as a potential problem. The Skin Check assessment dated [DATE] indicated the resident did not have a skin injury and/or wound. The care plan initiated on August 28, 2022 revealed the resident was at risk for skin breakdown related to decreased mobility, and that the resident had actual skin breakdown related to pressure injury to the left heel. Goals included that the left heel will show signs of improvement. Interventions included: - Provide wound treatment as ordered - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status However, review of the Order Summary Report with a date range of August 1 through August 31, 2022 revealed no orders (discontinued or completed) pertaining to the care, treatment, or monitoring of the resident's heel. Review of the resident's August 2022 Skin/Wound Evaluation log indicated a left heel wound with an initial date of August 8, 2022. The log revealed the following information: - August 8: The wound was described as a blister that was 100% serous. It measured 3.5 centimeters (cm) in length, with a width of 5 cm. It noted that there was no drainage and the surrounding tissue and edges were described as healthy. The note also included the provider was not notified and the care plan was not updated. - August 18: The wound was still described as a blister and was still 100% serous. The measurements were the same from the August 8 evaluation. It noted that there was no drainage and the surrounding tissue and edges were described as healthy. It again stated the provider was not notified and the care plan was not updated. - August 24: The wound was described as intact 100%. The measurements stayed the same. It noted that there was no drainage and the surrounding tissue and edges were described as healthy. It again stated the provider was not notified and that the care plan was not updated. Further review of the resident's clinical record did not reveal instructions for care and/or treatment of the resident's heel. Additionally, the only progress notes stating care/treatment of the heel, identified care provided to the right heel (August 24) which was contradictory to the wound log and care plan which identified the location of the wound as left heel. An interview with a Registered Nurse (RN)/Wound Nurse (staff #62) was conducted on December 1, 2022 at 9:46 a.m. Staff #62 stated that the process for wound care is that he goes in and looks at all the resident's skin and wounds. He stated he provides cleaning, assessment, stage the wound, and dress the wound per physician order. Staff #62 stated there is a nurse practitioner that he normally rounds with. He stated documentation is placed in notes in the resident's electronic record and charted. The RN stated documentation includes measurement and the way the wound was dressed, assessed. Staff #62 stated that when a new admission comes in, any observation regarding the skin is relayed to him. He stated that if a resident has a blister, the resident is added to the list and it is looked at during official rounds. Resident #248's clinical record was reviewed with staff #62. Staff #62 agreed that the resident did not have any physician orders pertaining to heels. He stated that for residents with blisters, basically he looks for intact dressing and heel protection. He stated the standard is an assessment every week to measure and document improvements and color. Staff #62 stated that as far as dressing changes, it should be done three times a week and if soiled. He stated that he is the one that would be doing the dressing changes. He said he does not know why there were no orders for resident #248 since there should have been one. A follow-up interview was conducted with the Wound Nurse (staff #62) on December 2, 2022 at 10:32 a.m. Staff #62 stated that the wound schedule is that he and the Assistant Director of Nursing (ADON) come in the morning and assess the skin of new admissions and document it. He stated that if a resident is admitted on the weekend then the assessment is done by the weekend staff for the initial skin assessment. He stated the staff then notifies him of any issue and then he conducts his own assessment. He stated that if there is a new issue, then staff lets him know. He stated that any kind of wound is followed by the Nurse Practitioner and he will also look at it and follow up. Staff #62 stated that if a blister is on a pressure point then it is considered a pressure ulcer. Staff 362 stated usually, it is categorized as pressure but not staged, it is non-stageable because it is a blister and is usually treated using betadine. He stated it is dressed three times a week and as needed if soiled or dislodged. When asked if resident #248 was followed by the wound Nurse Practitioner for the blister, he stated he believed so but he was not sure since he does not know if there was a nurse practitioner during that time frame. An interview with a Licensed Practical Nurse (LPN/staff #68) was conducted on December 2, 2022 at 11:25 a.m. Staff #68 stated that for a heel pressure ulcer, she would notify the nurse practitioner and float the resident's heels. The LPN stated she would expect there would be a physician order for treatment and care of the wound. An interview was conducted with the Director of Nursing (DON/staff #46) on December 2, 2022 at 11:42 a.m. Staff #46 stated that the expectation is that the resident's skin is assessed. The DON stated a skin assessment is normally scheduled on the same day as the shower so that the body can be checked holistically. She stated that when a resident has a wound/injury on the heel, the nurse should be made aware. She stated something has to be put in place to address the concern and if treatment is needed. The DON stated an order has to be in place so that it can be placed on the treatment administration record/medication administration record. The facility policy titled Skin Integrity and Wound Management revised September 1, 2022 stated for daily monitoring of wounds or dressings for presence of complications or declines. The policy stated to monitor the status of the dressing and status of tissue surrounding the dressing. The policy also stated to determine the need for heel off-loading, and notify the physician. The facility policy titled Nursing Documentation revised June 1, 2022 indicated that documentation includes information about the patient's status, nursing assessment and interventions, expected outcomes, evaluation of the patient's outcomes, and responses to nursing care.

Based on clinical record review, observations, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#63) was consistently provided meals and assistance to eat to maintain adequate nutrition. The sample size was 4. The deficient practice could result in nutritional needs of residents not being met. Findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, displaced intertrochanteric fracture of left femur, major depressive disorder, muscle weakness, and need for assistance with personal care. A care plan initiated on May 30, 2022 identified that the resident required assistance for ADL (activities of daily living) care which included eating. The goal was that the resident's ADL care needs will be anticipated and met. A physician's order dated May 30, 2022 stated regular diet, regular texture. Another care plan initiated on June 2, 2022 indicated that the resident has a nutritional risk and sign of weight loss for 90 days. The goal stated the resident will consume 100% of at least two meals every day. Interventions stated to supervise/cue/assist as needed with meals. Review of the Nutritional assessment dated [DATE] revealed a score of 4 with a category marked as nutritional problems. The assessment included the resident's current meal intake was variable. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident had severe cognitive impairment. The MDS assessment also indicated that the resident required a one-person physical assist for eating activities. Review of a Nutritional assessment dated [DATE] revealed a score marked as NA (not applicable) and category marked as no concerns identified. A nursing note dated October 4, 2022 revealed the resident's family had concerns regarding the resident not eating as well as usual. A nutrition progress note dated October 21, 2022 revealed the resident's intake varied and the resident was noted to have poor appetite the month prior but that the resident appetite was back to normal. The note also stated the resident had weight loss and the contributing factor was poor intake. Review of the October 2022 task charting log titled Meal revealed no information regarding resident #63's eating self-performance, eating support provided, and amount eaten on the following dates and meal times for October on: 1 - breakfast, lunch, and dinner 2 - dinner 3 - breakfast, lunch, and dinner 4 - dinner 5 through 22 - breakfast, lunch, and dinner 23 - breakfast and lunch 24 through 31 - breakfast, lunch, and dinner Further review of the Meal documentation log for November 2022 revealed no information regarding the resident's eating self-performance, eating support provided, and amount eaten on the following dates and meal times for November on: 1 - breakfast, lunch, and dinner 2 - dinner 3 through 20 - breakfast, lunch, and dinner 21 - dinner 22 - dinner 23 - dinner 24 - dinner 25 - dinner 26 and 27 - breakfast, lunch, and dinner 28 - dinner 29 - dinner 30 - breakfast, lunch, and dinner An observation was conducted on November 29, 2022 at 2:05 p.m. A Licensed Practical Nurse (LPN/staff #68) was observed taking the tray away from the resident's room. Staff #68 stated that the resident ate almost all the food. An observation of the tray revealed the plate only had a couple bites of the chili and the tortilla left. A follow up observation was conducted on December 1, 2022 at 9:32 a.m. The resident was observed to be asleep and there was no food tray on the table. A Registered Nurse (RN/staff #72) was observed picking up trays. When asked about resident #63's tray, she looked at the cart and found the tray with the food still in it and it appeared untouched. When asked if the resident was helped with eating, she referred me to the Certified Nursing Assistant (CNA) to answer the question. Review of a Care Plan Meeting progress note dated December 1, 2022 revealed the resident was a max assist for all ADL. It noted the resident only eats the noon meal and eats it at 100%. It indicated the resident does resist care by staff at times and that the family is with the resident daily to spend time with the resident. A 30-day look back was conducted on December 2, 2022 at 1:37 p.m. to review the Meal task and amount eaten. The log revealed that only 7 days had data and provided the following information: November 21: 25% eaten November 21: 100% eaten November 22: 25% eaten November 22: 100% eaten November 24: 25% eaten November 24: 100% eaten November 25: 25% eaten November 25: 100% eaten November 28: 0% eaten November 28: 100% eaten November 29: 0% eaten During an interview with the Certified Nursing Assistant (CNA/staff #74) conducted on December 2, 2022 at 9:34 a.m., she stated that as a CNA she checks residents to see if they need assistance and if so, she helps feed them and encourage them to eat. She stated that resident #63 requires full assistance. She stated the resident is Spanish speaking so when she is feeding the resident, she uses a translation app to inform the resident about the food. Staff #74 stated the resident is combative but she does try to encourage and assist the resident to eat. She stated that if the resident does not like the food, the resident will spit it out. She said the resident does drink the liquids but will not usually eat the food. She stated the resident's family comes in at lunch so they are normally the one that assists the resident with lunch. She said that when a resident does not eat she notifies the nurse. Staff #74 stated meal intake for residents is documented in their electronic record especially for residents that are full assistance. She said that if it is not documented then that means the CNA did not do the charting. Staff #74 said that her practice is to document throughout the day and after the meals before the shift ends. An interview was conducted with an LPN (staff #68) on December 2, 2022 at 11:25 a.m. Staff #68 stated that for meal intake, the CNA is usually responsible for monitoring meal intake visually. She stated meal intake is documented in the nursing notes. The LPN stated that she notifies the Nurse Practitioner (NP) of concerns and if the resident is not eating. She stated that resident #63 eating habits are bad. She stated the resident does not allow staff to assist with meals but will allow the family to. She stated the staff have tried but the resident would not open their mouth and would spit the food out. She stated that the resident's family brings food and drinks such as Powerade/Gatorade and the spouse feeds the resident the lunch meal. Staff #68 stated that she has not documented the resident's eating habits recently but has documented progress notes. She stated the meal intake should be documented on the resident's electronic record. The LPN stated that if it is not documented, it might mean the CNA did not get to it. An interview was conducted on December 2, 2022 at 11:42 a.m. with the Director of Nursing (DON/staff #46). The DON stated that the expectation for meal intake is that the resident is observed for the amount eaten and the amount is documented. She expects the documentation to occur every shift and for however many times the resident eats. She stated that expects for the CNA to make the nurse aware if a resident is not eating. The DON stated that she expects the nurse to make sure the physician is aware that a resident is not eating. She stated the resident's family must also be made aware and that the resident should be monitored. The facility policy titled Food and Nutrition Services Goals and Objectives revised June 15, 2018 stated that a resident's nutritional status is assessed, an individualized plan of care is implemented, and outcomes are monitored and evaluated to promote optimal nutritional status. The facility policy titled Activities of Daily Living (ADLS) revised June 1, 2021 indicated that residents are assessed upon admission, quarterly, and with a significant change to identify his/her status in all areas of ADLs, inability to perform, risk for decline and ability to improve. A resident who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. ADL documentation that is not documented within 24 hours of occurring is considered late documentation. The facility policy titled Nursing Documentation revised June 1, 2022 indicated that documentation includes information about the resident's status, nursing assessment and interventions, expected outcomes, evaluation of the patient's outcomes, and responses to nursing care.

Based on clinical record review, observation, resident and staff interviews, and the facility's policy and procedure, the facility failed to provide respiratory care in accordance with the professional standard of practice for one sampled resident (#54). The deficient practice could result in adverse effects to residents. Findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and atherosclerotic heart of native coronary artery without angina pectoris. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. During an observation conducted on November 28, 2022 at 10:37 a.m., a nebulizer machine was observed attached to nebulizer tubing sitting on top of an air conditioning unit. The nebulizer chamber contained unknown particles, beige in color, and the tubing was moist. The nebulizer tubing was not cleaned and bagged. An immediate follow up interview was conducted with resident #54 who stated he used the nebulizer treatment that day, once a day, and that the nurse told him he could use it as needed. However, review of the clinical record revealed no physician order for the nebulizer treatment. A second observation was conducted on November 30, 2022 at 11:57 a.m. During the observation, it was noted that the resident was sleeping on a recliner. A nebulizer tubing was sitting on top of the air conditioning unit with moist particles on the tubing, no date, no plastic bag, and with diffused beige particles present on the mouthpiece and the chamber. An interview was conducted on December 1, 2022 at 9:32 a.m. with resident #54 who was found playing games on the computer in his room. Resident #54 stated he was given a nebulizer treatment that morning, and that the nurse has not changed the tubing or the mouth piece for over a month. Further, resident #54 stated he rinses the nebulizer tubing and chamber sometimes after use. An interview was conducted on December 2, 2022 at 9:28 a.m., with the Director of Nursing (DON/staff #46). Staff #46 stated when a nebulizer medication is administered, the chamber should be rinsed, bagged, dated and placed at the bedside. Staff #46 stated the nebulizer tubing and chamber is changed every Sunday or every seven days. Staff #46 stated the risk of not cleaning and maintaining the nebulizer equipment included placing the resident at increased risk for respiratory infection, and it can diminish the efficacy of the medications. An interview was conducted on December 2, 2022 at 9:49 a.m. with a licensed practical nurse (LPN/staff #16). Staff #16 accessed resident #54's record and stated that she did not see an order for the nebulizer treatment and that there was no record on the TAR (treatment administration record) indicating the nebulizer mouthpiece was changed. Further, staff #16 stated the order for the nebulizer treatment was not reinstated when the resident was readmitted from the acute hospital on November 15, 2022. Review of the facility policy, Nebulizer: Small Volume, with a revision date of July 15, 2022, stated to verify order for medication, dosage, frequency, and mode of delivery. The procedure was to rinse the small volume nebulizer (SVN) mouthpiece and T piece with sterile water and dry, place in a treatment bag labeled with patient name and date, and replace and date the set up daily.

Based on a clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#25) received pain medication as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #25 was admitted to the facility on [DATE], with diagnoses that included other Sequelae of Cerebral Infarction, Hemiplegia, Unspecified affecting left dominant side, Chronic Obstructive Pulmonary Disease, unspecified, Fibromyalgia, and Systemic Lupus Erythematosus, unspecified. A review of the resident's care plan initiated on May 28, 2022 revealed the resident was at risk for alterations in comfort related to deconditioning and that the resident was prescribed an opioid medication for pain control. Review of the physician orders dated August 10, 2022, revealed an order for Percocet (opioid analgesic) 5-325 milligrams by mouth every 6 hours as needed for moderate to severe pain (pain levels 6-10). A review of the Medication Administration Record (MAR) dated November 2022, revealed that on November 3, 2022 Percocet was administered for a pain level of 5, on November 10, 2022 for a pain level of 4, on November 13. 2022 for a pain level of 4, on November 17, 2022 for a pain level of 4, on November 21, 2022 for a pain level of 4, on November 24, 2022 for a pain level of 5 and on November 25, 2022 for a pain level of 5. During an interview conducted with the Unit Manager (staff #58) on November 30, 2022. She stated the pain scale for the opioid medication is 6-10, and that the resident should be given Tylenol for pain levels l-5. She stated the MAR for November 2022 indicates Percocet was being administered for pain levels of 4 & 5. The Unit Manager stated that there are times when the resident may ask for the opioid medication even though their pain level is 4 or 5. She stated that in this case, that there should be notes to indicate this and that for this resident there are no notes indicating this was the case. During an interview conducted with the Director of Nursing (DON) on November 30, 2022, she stated that if the resident has orders for Tylenol and an opioid pain medication, the pain scale used is 0-5 for Tylenol and 6-10 for the opioid pain medication. The DON stated that the orders should be followed. After reviewing the MAR for November 2022, the DON stated that documentation should have been done and the administration of Percocet for lower levels of pain would be looked into. The facility's policy Medication Administration stated the purpose of the policy is to provide a safe, effective medication administration process. A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to residents and accepted standards of practice will be followed.

Based on clinical record reviews, observation, staff interviews, and policy reviews, the facility failed to monitor the target behaviors for antipsychotic use for one resident (#68) and failed to ensure antipsychotic medication was not administered without proper diagnosis for one resident (#90). The sample size was 5. The deficient practice could result in medications being administered unnecessarily. Findings include: -Resident #68 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder and anxiety disorder. The baseline care plan dated October 25, 2022 included that the resident was at risk for complications related to the use of psychotropic drugs. Interventions stated to complete the behavior monitoring flow sheet and to monitor for continued need of medication related to behavior and mood. The admission Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident was cognitively intact. The MDS assessment also revealed that the resident received antipsychotic and antidepressant medications during the 7 day look back period. Review of the Order Summary revealed orders for: -Seroquel oral tablet 200 mg (milligrams) (Quetiapine Fumarate) give 200 mg by mouth in the evening for schizoaffective disorder AEB (as evidence by) auditory hallucinations ordered October 24, 2022 - Sertraline HCL, give 100 mg by mouth one time a day for depression AEB lack of interest in activities ordered October 25, 2022 and discontinued dated November 3, 2022. - Sertraline HCL oral tablet give 75 mg by mouth one time a day for depression AEB lack of interest in activities ordered November 4, 2022 Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2022 and November 2022 revealed no monitoring of target behavior for Seroquel (antipsychotic) and Sertraline (anti-depressant). Review of the resident's clinical review did not reveal evidence of behavior monitoring for Seroquel and Sertraline. An interview was conducted with a Registered Nurse (RN/staff #58) on November 30, 2022 at 12:52 pm. She stated that residents on psychotropic medications are monitored for behaviors and side effects every shift. She stated during the medication administration, the MAR prompts the nurses to enter any target behaviors observed. The RN stated it is important to monitor target behaviors for residents on psychotropic medications to know whether to increase or decrease the medication and also to know if the medication is working for the resident or not. An interview was conducted with the Director of Nursing (DON/staff #46) on November 30, 2022 at 2:56 pm. She stated if a resident is on a psychotropic medication, behaviors are monitored when the medication is administered. She stated behaviors charting is in the MAR and done when the medication is administered. The DON stated charting is done by exception during the shift when the medication is not scheduled and a behavior is noted. She stated the policy is that behaviors are charted in the MAR when the medication is given. The facility policy titled Behaviors: Management of symptoms revised on October 24, 2022 stated residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The policy further stated the purpose is to minimize the use of psychotropic medications, including antipsychotics, for residents with behavioral symptoms. The policy stated that staff will monitor for and document in the medical records any exhibited behavioral symptoms. 45311 -Resident #90 was admitted to the facility on [DATE] with diagnoses that included repeated falls, hemiplegia and hemiparesis following unspecified cerebrovascular diseases affecting left dominant side, and other symptoms and signs involving cognitive functions and awareness. A practitioner notes dated September 12, 2022 at 11:35 a.m., stated related to psychiatric, the resident is cooperative. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident had no cognitive impairment. The assessment included the resident's mood interview (PHQ-9) which indicated no symptoms, and no behavior or potential psychosis. Per the assessment, the active diagnoses included cerebrovascular accident and no psychiatric mood or disorder. Review of the nursing progress notes dated August 23 and 29, 2022; September 7, 2022; November 12 and 19, 2022 revealed the resident was found on the floor. A care plan with a revision date November 23, 2022 included a problem that the resident is at risk for complications related to the use of psychotropic drugs. The care plan goal stated the resident will have the smallest most effective dose without side effects, and the resident will have a decrease in episodes of inability to sleep. The interventions included monitoring for changes in mental status and functional level and reporting to the physician as indicated; monitoring for continued need of the medication as related to behavior and mood, and obtaining psych evaluation as ordered. However, review of the clinical record revealed no psych evaluation related to the use of the antipsychotic medication Seroquel, no documented mental illness, and no appropriate indication of use/monitoring. Review of general notes dated November 28, 2022 at 3:33 p.m., stated the hospice nurse visited and was updated on the resident's condition such as restlessness, awake during night, redirected by the staff and the use of Ativan per the physician order. Further, the notes included a new order was received for Seroquel at bedtime. However, further record review revealed no auditory/visual hallucination, no psychosis, and no physical aggression. Review of the physician order dated November 28, 2022 included Seroquel 25 mg by mouth at bedtime for major depressive disorder as evidenced by sleeplessness. Review of MAR dated November 2022 indicated the medication was administered as ordered. During an observation conducted on December 1, 2022 at 9:17 a.m., resident #90 was observed lying in bed. A breakfast tray was within the resident's reach but untouched. The resident was not able to participate in the interview due to the inability to keep eyes open. A follow up interview was conducted with a licensed practical nurse (LPN/staff #13) who was in the resident's room during the observation period. Staff #13 stated resident #90 was a little sleepier that morning and that the resident did not touch breakfast. An interview was conducted with a certified nursing assistant (CNA/staff #117) on December 1, 2022 at 9:50 a.m. Staff #117 stated he was very familiar with resident #90 and that he frequently was assigned to care for the resident. Staff #117 stated he has not seen the resident with any behavioral issues, no complaints of hallucination, and hearing voices. Staff #117 stated resident #90 was always pleasant, cooperative, and compliant with care. On December 1, 2022 at 8:00 a.m., additional records were requested to support the use of the antipsychotic medication. Staff #46 (DON) stated there was no psych consult, no assessment, no evaluation for the use of the antipsychotic medication Seroquel because the hospice physician ordered the medication. An interview was conducted on December 2, 2022 at 8:53 a.m. with the DON (staff #46). During the interview, staff #46 stated if Seroquel is ordered, her expectation included appropriate diagnosis, behavior and consent. Staff #46 stated Seroquel is used for schizophrenia, bipolar disorder, and Huntington's disease. Staff #46 stated the behavior manifestation for antipsychotic medications included yelling out, aggression, visual and auditory hallucinations. Staff #46 reviewed the resident's records and stated she agreed there was no indication for using Seroquel. Staff #46 stated hospice has this idea that they can place a resident on an antipsychotic medication to provide comfort. The DON stated the risk for the resident who is taking antipsychotic medication included increased confusion, altered mental status and drowsiness. Further, staff #46 stated resident #90 normally gets up on the Geri chair 3-4 times a week, and if the resident was sleepy it might be the new medication (Seroquel). Review of the facility policy, Restraints: Use of, with a revision date June 15, 2022, stated the resident has the right to be free from any chemical restraints imposed for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms. Per the policy, there must be documentation identifying the medical symptom being treated. Further, the policy stated, a physician order alone (without supporting clinical documentation) is not sufficient to warrant the use of restraint.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure two out of two residents (#24 and #61) sampled received necessary treatment and services to promote healing and prevent new ulcers from developing. The deficient practice could result in pressure ulcer complications and new pressure ulcer formation. Findings include: -Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note dated March 13, 2020 revealed a skin check was completed and the heels, area between toes, and bony prominences appeared free from redness, maceration or breakdown. A nursing assessment dated [DATE] revealed the resident was admitted for therapy and wound care, and that the resident had an external fixation device to the lower right extremity with six pins into the skin wrapped with ace wrap from the knee to the ankle. The assessment included a Braden Scale for predicting pressure ulcer risk score of 14 which indicated the resident was at moderate risk for developing pressure ulcers. The assessment also included the resident had intellectual/development disability. Review of the clinical record did not reveal a baseline care plan had been initiated regarding the skin. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognition. The assessment included the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. The assessment also included pressure reducing devices to the bed and chair. Review of the Braden Scale dated March 20, 2020 revealed a score of 14, which indicated that the resident was at moderate risk for pressure sores. Review of the Braden Scale dated March 27, 2020 revealed a score of 16, which indicated the resident was at mild risk for pressure sores. Regarding the left heel wound #1: Review of a skin integrity report dated April 21, 2020 revealed the resident had a left heel blister that measured 6.0 centimeters (cm/length) x 11.0 cm (width) x 0 cm (depth), had moderate amount of serous drainage, healthy surrounding tissue and wound edges, and no pain present. The place on the form to document the initial wound date was blank, the wound type was not documented, and the name of the staff conducting the assessment was not included. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse wound care note dated April 22, 2020 revealed the left heel was noted to have a blister that was cleaned, assessed, measured and dressed per order. A skin integrity report dated April 30, 2020 included the left heel wound was an open blister that measured 5.5 cm x 6.5 cm x 0, had small amount of serous drainage, healthy surrounding tissue and wound edges, and no pain was present. The wound type was not documented. A care plan initiated on April 30, 2020 revealed the resident had actual skin breakdown and pressure ulcers to the left heel. The goal was that the wound would heal as evidenced by decrease in size, absence of [CONDITION(S)] and drainage and/or presence of granulation. Interventions included lower extremity protectors, weekly wound assessments to include measurements and description of the wound, provide wound treatment as ordered, and weekly skin assessments. Review of a nurse wound care note dated April 30, 2020 revealed the left heel blister was cleaned, assessed, redressed per order, foam foot and heel protectors are on bilateral feet, and no pain. Review of the Treatment Administration Record (TAR) for April revealed the treatment was provided as ordered. The skin integrity report dated May 7, 2020 included the left heel wound was an open blister that measured 5.0 cm x 6.0 cm x 0, had small amount of drainage, healthy surrounding tissue and wound edges, and no pain was present. The report did not include the type of drainage or the wound type. Review of the May 2020 TAR revealed no documentation that the heel wound treatment was completed on May 9, 2020. A nursing progress note dated May 12, 2020 included heel protectors were in place. Review of a progress note from the Wound Care Center dated May 14, 2020 revealed the center had received a referral from the PCP (primary care physician) for wound care, evaluation, and treatment. The note stated the left heel unstageable pressure ulcer (wound #1) had obscured full-thickness skin and tissue loss, measured 5.5 cm x 6.5 cm width with no measurable depth and had an area of 35.75 square cm. The note included there was no drainage noted, the wound bed had 76-100% eschar, the temperature of the peri wound was within normal limits, and the resident reported a pain level of 2 on a scale of 0-10. However, the skin integrity report dated May 14, 2020 revealed the left heel wound was a hard, closed, blister that measured 5.0 x 6.0 cm x 0, had no drainage, the surrounding tissue and wound edges were healthy, and no pain was present. The report did not include eschar. A wound care progress note dated May 14, 2020 revealed the left heel blister was dry, closed, and appeared to be improving. No pain expressed by the resident. Review of the TAR for May 2020 revealed no documentation that the left heel wound treatment was completed on May 15. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skin integrity report dated May 20, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. A wound care note dated May 21, 2020 revealed the left heel wound was doing better with new intact skin noted on an area of the heel. The note included the left heel wound was cleaned, assessed, measured and redressed as per order, and no pain was present. Review of a skin integrity report dated May 28, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. Review of a wound care note dated May 28, 2020 revealed the left heel wound was doing much better. The note included the blister was removed and a small amount of eschar remained. The note also included the left heel wound was cleansed, assessed, measured and redressed as per orders. The skin integrity report dated June 4, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. The note did not include whether the eschar had resolved or not. A wound care note dated June 10, 2020 revealed the left heel wound was closed with 100% epithelial tissue. The note included lotion was applied to the foot and heel, the foot would be kept in a Prevalon boot to offload pressure. A nurse progress note dated June 13, 2020 revealed a friction reducing device was used to position the resident in bed. Review of the quarterly MDS assessment dated [DATE] revealed the resident had no pressure ulcers but was determined to be at risk for developing pressure ulcers. The assessment there were pressure reducing devices to the bed and chair. A skin integrity report dated July 8, 2020 revealed the resident had an in house acquired pressure wound to the left heel with an initial wound date of July 7, 2020. The report included the left heel pressure wound had epithelial tissue, measured 2.5 cm x width 1.5 cm x 0, had no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The report did not include the stage of the pressure wound. Continued review of the clinical record did not reveal a treatment had been ordered for the reoccurrence wound to the left heel. The skin integrity report dated July 15, 2020 revealed the left heel unstageable pressure ulcer measured 2.0 cm x 1.5 cm x 0, epithelial tissue appearance, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated July 21, 2020 revealed the left heel unstageable pressure ulcer measured 1.2 cm x 1.0 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was pain present. The skin integrity report dated July 28, 2020 revealed the left heel unstageable pressure ulcer measured 1.2 cm x 1.1 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. Again, the signature and/or initials of the assessor was not documented. The skin integrity report dated August 5, 2020 revealed the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The signature and/or initials of the assessor was not documented. A skin integrity report dated August 12, 2020 stated the left heel was healed, intact, with healthy surrounding tissue and wound edges. A skin integrity report dated August 19, 2020 stated the left heel unstageable pressure ulcer was intact and measured 1.1 cm x 1.1 cm x 0 and was intact with healthy surrounding tissue and would edges. The skin integrity report dated August 26, 2020 revealed the left heel wound was healed. Review of the skin integrity report dated September 2, 2020 revealed there was now an unstageable pressure ulcer to the left heel. The report stated the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm, was intact with deep purple color, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated September 9, 2020 revealed the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm, was intact with deep purple color, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated September 16, 2020 revealed the left heel wound was healed, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the clinical record did not reveal any ordered wound treatments to the left heel since the last order was discontinued on June 10, 2020. A wound observation was conducted on August 3, 2021 at 12:13 p.m. with the assistant Director of Nursing/wound nurse (ADON/staff #64). The ADON removed the dressing from the left heel. No pressure ulcer was observed. The ADON stated scar tissue was the site of the previous wound. The ADON cleansed the left heel and applied a square adhesive edge dressing to the left heel. Regarding left heel wound #2: Review of a skin integrity report dated September 16, 2020 revealed the resident had an unstageable pressure ulcer to the left heel that measured 4.0 cm x 19.0 cm x 0 that was deep purple and intact. The note included the surrounding tissue and wound edges were healthy and that there was pain present. Continued review of the clinical record did not reveal a treatment order for this pressure ulcer. The quarterly MDS assessment dated [DATE] revealed the resident had no pressure ulcers and was determined to be at risk for developing pressure ulcers. The assessment included there were pressure reducing devices to the bed and chair. Review of the skin integrity report dated September 26, 2020 revealed an unstageable pressure ulcer to the left heel that measured 4.0 cm x 19.0 cm x 0 cm. The note included the ulcer was deep purple and intact, and that the surrounding tissue and wound edges were healthy. The note also included pain was present. The skin integrity report dated September 30, 2020 revealed the pressure ulcer to the left heel had healed, the surrounding tissue and wound edges were healthy, and that pain was present. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care center progress note dated October 6, 2020 stated the left heel deep tissue pressure injury (wound #2) had persistent non-blanchable deep red, maroon, or purple discoloration. The note included the wound measured 4.0 cm x 19 cm x 0 cm with an area of 76 square cm, scant amount of serosanguineous drainage was noted, no odor, the wound bed had no slough, no eschar present, and the temperature of the peri-wound was within normal limits. The note also included the resident reported a pain level of 5 out of 0-10. A skin integrity report dated October 7, 2020 revealed the left heel deep tissue pressure ulcer was deep purple and intact, and could not be staged. The report included the ulcer measured 4.0 cm x 19.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. Review of a practitioner note dated October 7, 2020 revealed the resident did not like to get out of bed and fights staff with re-positioning. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed a revision date of October 7, 2020 that the resident had actual skin breakdown to the left heel blister. Interventions dated October 10, 2020 included offloading heels while in bed, turning and repositioning, pressure redistribution surfaces to bed and chair, utilize positioning devices, and to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin integrity report dated October 14, 2020 revealed the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. The note did not include the signature and/or initials of the staff completing the assessment. The wound care center note dated October 15, 2020 revealed the left heel unstageable pressure ulcer (wound #2) had obscured full-thickness skin and tissue loss, measured 4.0 cm x 6.0 cm x 0 cm with an area of 24 square cm, the wound bed had 76-100% eschar, no drainage noted, and the resident reported no pain. Review of the October 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A practitioner note dated October 21, 2020 revealed the wound team would be in that day to evaluate the left heel wound with eschar. The note included the resident was non-compliant with turning and fights staff with re-positioning, did not want to get out of bed, and did not want heels elevated. The note also included the resident became agitated and would fight with staff and the practitioner when being touched and when staff were trying to treat the heels. Review of an electronic record wound evaluation dated October 21, 2020 included the stage two pressure ulcer (wound #2) to the left heel was three months old and in house acquired. The evaluation also included the ulcer measurements were 4.65 cm x 4.98 cm x 0 cm, and the area was 19.76 cm. Review of the clinical record revealed the treatment to the left heel wound was discontinued on October 21, 2020 and no new treatment was ordered at that time. The skin integrity report dated October 22, 2020 revealed the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and pain was present. The note did not include the signature and/or initials of the staff completing the assessment. A skin integrity report dated October 29, 2020 stated the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. The note did not include the signature and/or initials of the staff completing the assessment. Review of the Certified Nursing Assistant (CNA) documentation for October 2020 revealed the following: -69 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 14 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -72 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 14 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) was applied on any shift. A nursing progress note dated November 9, 2020 revealed the resident was not allowing staff to reposition her. Review of an electronic record wound evaluation dated November 10, 2020 (12 days after the last assessment) included the left heel unstageable pressure ulcer (wound #2) was four months old and in house acquired. The evaluation included that the dressing was intact and saturated. The evaluation also included the ulcer measured 2.82 cm x 3.55 cm x 0.25 cm with an area 8.25 cm, the wound bed was 50% granulation and 50% eschar, light amount of serosanguineous drainage with a faint odor was noted after cleansing, the peri-wound edges were non-attached and the surrounding tissue was macerated and blanching. The evaluation stated the resident pain was assessed. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to notify the PCP/nurse supervisor if decline noted. A skin integrity report dated November 12, 2020 revealed the left heel wound was healed. However, review of an electronic record wound evaluation dated November 16, 2020 revealed the left heel unstageable pressure ulcer (wound #2) measured 3.55 cm x 3.53 cm x 0.25 cm with an area of 10.39 cm, and the wound bed was 40% granulation and 60% eschar. The evaluation did not include an assessment of the wound edges or surrounding tissue, or the presence or absence of exudate and pain. A nursing progress note dated November 16, 2020 revealed the resident was repositioned with pillows and shifted back to the previous position. The note included the nurse attempted to explain to the resident the importance of off-loading heels, attempt was unsuccessful. Review of a nursing progress notes dated November 19 and 20, 2020 revealed the presence of a low air loss mattress and that the resident refused to be repositioned or off load heels. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify PCP/nurse supervisor if decline noted. Review of the November 2020 TAR revealed no documentation that the treatments to the left heel was completed on November 24. Review of the clinical record did not reveal that a weekly skin assessment was completed between November 19 and December 1, 2020. An electronic record wound evaluation dated November 25, 2020 included the unstageable pressure ulcer to the left heel (wound #2) measured 2.07 cm x 3.57 cm x 0 cm with an area of 5.77 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, or an assessment of the wound edges and surrounding tissue. Review of the November 2020 TAR revealed no documentation that the treatment to the left heel was completed on November 30. An electronic record wound evaluation dated November 30, 2020 stated the left heel unstageable pressure ulcer (wound #2) measured 1.38 cm x 0.91 cm x 0 cm with an area of 0.94 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, an assessment of the wound edges and surrounding tissue, or the signature and/or initials of the assessor. Review of the CNA documentation for November 2020 revealed the following: -50 out of 90 shifts did not contain documentation of the bed mobility task being completed, including 6 out of 30 days that did not contain documentation of the bed mobility task being completed on any shift. -53 out of 90 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 6 out of 30 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift. Review of the December 2020 TAR revealed no documentation that the treatment to the left heel were completed on December 9. An electronic record wound evaluation dated December 10, 2020 (10 days after the last assessment) included the unstageable pressure ulcer to the left heel (wound #2) measurements were 1.61 cm x 1.66 cm x 0 cm, with area 2.17 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, an assessment of the wound edges and surrounding tissue, or the signature and/or initials of the assessor. A Skin and Wound evaluation dated December 15, 2020 revealed the left heel unstageable pressure ulcer had obscured full-thickness skin and tissue loss due to slough and/or eschar. The wound measurements were 2.0 cm x 2.1 cm x 0 cm with area 2.9 cm. The evaluation included the in-house acquired pressure ulcer had been present for 1-3 months, no exact date was documented. Another Wound Evaluation for the same date, December 15, 2020, included the unstageable pressure ulcer to the left heel (wound #2) was five months old and in house acquired. This evaluation included the measurements were 1.98 cm x 2.07 cm x 0 cm with an area of 2.94, and that the closure percent was between 80 and 90%. The assessments dated December 15, 2020 differed regarding how long the wound had been present; did not include documentation of the wound bed or the presence or absence of exudate; did not include documentation of the wound edges, surrounding tissue, or presence or absence of pain. The assessments also did not include the signature and/or initials of the assessor. A quarterly MDS assessment dated [DATE] revealed the resident had two unstageable pressure ulcers/suspected deep tissue injury, was receiving pressure ulcer care, and pressure reducing devices were to the bed and chair. Review of the December 2020 TAR revealed no documentation that the treatments to the left heel were completed on December 26, 28, or 30. A Nutritional assessment dated [DATE] included the resident was receiving multivitamin, [MEDICATION(S)], and vitamin C for wound diagnosis. The assessment included the resident had pressure ulcers to the bilateral heels which were improving. The assessment also included to keep interventions in place as oral intake was fair and the wound was not completely healed. Review of the CNA documentation for December 2020 revealed the following: -52 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 5 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -56 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 8 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift. The wound care center progress note dated January 7, 2021 revealed the left heel pressure ulcer (wound #2) was now a stage 3 pressure ulcer. The note included the ulcer measured 3.0 cm x 3.2 cm x 0.2 cm depth, with an area of 9.6 square cm and a volume of 1.92 cubic cm. The note also included the wound bed had 76-100% pink granulation, a moderate amount of sero-sanguineous drainage was noted with no odor, the peri-wound skin did not exhibit [CONDITION(S)] or [CONDITION(S)] and the temperature was within normal limits, and the resident's pain was 1 on a scale of 0-10. This assessment was 23 days after the last assessment. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A NP progress note dated January 18, 2021 included staff would attempt to get the resident out of bed for all meals, although the resident does fight with staff when cares are being given. Review of a wound care center progress note dated January 21, 2021 revealed the stage 3 left posterior heel pressure ulcer (wound #2) measured 1.0 cm x 0.8 cm x 0.2 cm with an area of 0.8 square cm and a volume of 0.16 cubic cm. The note included the wound bed had 76-100% pink granulation, a scant amount of sero-sanguineous drainage was present with no odor, the peri-wound skin exhibited scarring and the temperature was within normal limits, and the resident pain was 1 on a scale of 0-10. This assessment was 14 days after the last assessment. Review of the CNA documentation for January 2021 revealed the following: -52 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 11 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -64 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 12 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) was applied on any shift. A wound care center progress note dated February 4, 2021 (14 days after the last assessment) revealed the unstageable left posterior heel pressure ulcer had obscured full-thickness skin and tissue loss, measured 1.0 cm x 0.8 cm x 0 cm with an area of 0.8 square cm, the wound bed had 76-100% eschar, no drainage was noted, the peri-wound skin exhibited scarring, and the temperature was within normal limits. The also revealed the resident reported pain at a 1 on a scale of 1-10. The wound care center progress note dated February 11, 2021 stated the unstageable left posterior heel pressure wound had obscured full-thickness skin and tissue loss, measured 1.0 cm x 0.8 cm x 0 cm with an area of 0.8 square cm, the wound bed had 76-100% eschar, no drainage was noted, the peri-wound exhibited scarring, and the resident reported no pain. The wound care center progress note dated February 18, 2021 stated the unstageable left posterior heel pressure wound had obscured full-thickness skin and tissue loss, measured 1.0 cm x 0.8 cm x 0 cm with an area of 0.8 square cm, the wound bed had 76-100% eschar, no drainage was noted, the peri-wound exhibited scarring, the temperature was within normal limits, and the resident reported no pain. Review of the February 2021 TAR revealed no documentation that the left heel wound treatments were completed on February 18 or 25. Review of the CNA documentation for February 2021 revealed: -55 out of 84 shifts did not contain documentation of the bed mobility task being completed, including 9 out of 28 days that did not contain documentation of the bed mobility task being completed on any shift. -58 out of 84 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 10 out of 28 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift. A wound care center progress note dated March 4, 2021 (14 days after the prior assessment) revealed the unstageable left posterior heel pressure ulcer had obscured full-thickness skin and tissue loss, measured 0.8 cm x 0.4 cm width x 0 cm with an area of 0.32 square cm, the wound bed had 76-100% eschar, no drainage was noted, the peri-wound skin exhibited scarring, and the temperature was within normal limits. The note included the resident reported no pain. Review of the March 2021 TAR revealed no documentation that the left heel wound treatment was completed on March 6. Review of the clinical record did not reveal that a weekly skin assessment was completed between March 4 through 16, 2021. A quarterly MDS assessment dated [DATE] revealed the resident had two unstageable pressure ulcers/deep tissue injuries with pressure ulcer care and pressure reducing devices to the bed and chair. However, review of the clinical record provided revealed only one pressure ulcer to the left heel. Review of the March 2021 TAR revealed no documentation that the left heel wound treatment was completed on March 13. Review of a nutrition/wound follow up progress note dated March 17, 2021 revealed the resident current oral intake with meals averaged 80% of most meals and the resident accepts supplement daily. Will change supplements and vitamins due to wound and oral intake improving. Recommend liquid protein 30 milliliters (ml) two times a day and 8 ounces (oz) chocolate milk with meals. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note dated March 18, 2021 revealed that the resident refused to get up. The NP progress note dated March 18, 2021 revealed the NP discussed the resident with psychiatry and that the resident would be re-evaluated for ongoing cares, refusal of care and possible depression. Review of the wound care center progress note dated March 25, 2021 (21 days after the last assessment) revealed the resident had chronic wounds to the heel secondary to prolonged inactivity. The left heel was stable, covered with eschar covered without signs or symptoms of infection. The left heel stage three pressure ulcer measured 3.5 cm x 0.6 cm x 0 cm and the wound base was 100% eschar. The note included there was no exudate, and the peri-wound was normal temperature with scar tissue. The note also included the resident showed a marked preference for lying supine and resisted nursing staff members' attempts at position changes. The note did not address whether the resident had pain or not. Review of the clinical record did not reveal a weekly skin assessment was completed between March 25 through 27, 2021. The March 2021 TAR revealed no documentation that the left heel wound treatments were completed on March 26. The CNA documentation for March 2021 revealed: -47 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 6 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -47 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 6 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#24) received treatment and care in accordance with professional standards regarding wound/skin treatments and monitoring. The sample size was 18. The deficient practice could result in adverse outcomes for residents. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding the external fixator pin sites: Review of a nurse progress note dated March 13, 2020 revealed the resident was a new admission from the hospital and had an external fixation device to the right lower extremity with six pins into the skin with ace wraps from the knee to ankle. The nurse was unable to assess the skin underneath related to agitation by the resident when the nurse attempted to look. The care plan initiated on March 14, 2020 stated the resident required assistance for mobility related to an external fixator to the Right Lower Extremity. The care plan did not address the altered skin integrity or care needs related to the external fixator to the right leg. A practitioner note dated March 16, 2020 revealed the resident had an external fixator applied to the right lower extremity and the pin sites were intact. The note included to lightly soak the pin sites with [MEDICATION(S)] daily, and continue to monitor fixator pin sites; and wound care consulted. A physician order dated March 17, 2020 included for lightly soaked [MEDICATION(S)] drain sponges to the pin sites daily and to keep the right lower extremity (RLE) loosely wrapped with ace wraps. The March 2020 Treatment Administration Record (TAR) revealed no documentation that the pin site treatments were completed on March 20 & 21, and March 26 & 27. A practitioner note dated April 6, 2020 revealed the right lower extremity fixator pin sites were intact, no redness or drainage evident. The note included to continue to monitor fixator pin sites, wound care following, and discussed with nursing to continue pin site care. Review of the April 2020 TAR revealed no documentation that the pin site treatments were completed April 9-11. Review of a practitioner note dated April 14, 2020 revealed the upper lateral thigh pin site had minimal redness, appeared to be picked at, discussed with nursing to have wounds see this. The April 2020 TAR revealed no documentation that the pin site treatment was completed on April 17. A practitioner note dated April 30, 2020 revealed the right upper thigh lateral pin site had redness and that wounds was following closely. Review of a nurse progress note dated May 12, 2020 revealed the resident pulled on the bars of the fixator to move the leg after staff positioned it, and removed the gauze from the upper 2 pins after pin care before staff left the room. Review of nurse progress notes dated May 18, 2020 revealed the resident continued to move the right leg using the bars of the external fixator, and pulls the gauze from the upper pins. Review of a nurse progress note dated May 20, 2020 revealed the resident continued to move the leg using the external fixator bars and remove gauze from upper pins after pin care. Review of a nurse progress note dated June 7, 2020 revealed the resident continued to move and reposition the right leg using the bars of the external fixator, and take the upper pin gauze off. Review of a nurse progress note dated July 6, 2020 revealed redness noted around the upper pin site, area warm to touch with no drainage. The resident continues to move the right leg using the external fixator bars and pull the [MEDICATION(S)] gauze off pin sites as soon as it is applied. A practitioner note dated July 6, 2020 revealed notification by nursing that the upper outer fixator site was red. Physical examination included the right lower extremity pin site intact, increased redness noted to the upper pin site, no drainage. A physician order dated July 6, 2020 stated [MEDICATION(S)] Tablet (antibiotic) 100 milligram (mg) by mouth two times a day for 10 days for pin site redness. Review of a practitioner note dated July 20, 2020 revealed the right lower extremity external fixator pin sites were intact, redness noted to the upper pin site, and that the resident was likely picking at the site. Review of a practitioner note dated August 20, 2020 revealed the top pin site infection with swelling, increased redness, and minimal warmth and that the resident needed to see the surgeon. A physician order dated August 20, 2020 included [MEDICATION(S)] Tablet 100 mg by mouth two times a day for seven days for right leg pin site infection. The September 2020 TAR revealed no documentation that the pin site care treatments were completed on September 10 and 16. A practitioner note dated September 16, 2020 revealed the right top pin site infection had increased redness, warmth, and minimal drainage. Review of a physician order dated September 16, 2020 revealed for [MEDICATION(S)] tablet 100 mg by mouth two times a day for 14 days for pin infection. The September 2020 TAR revealed no documentation that the pin site care treatments were completed on September 17-18, and 23. A practitioner note dated September 24, 2020 revealed right lower extremity external fixator top pin site with redness, warmth, and increased yellowish drainage. The note included that a wound culture and labs were obtained. Review of a practitioner note dated October 5, 2020 revealed the wound result of multi drug resistant Staphylococcus aureus. A physician order dated October 5, 2020 revealed for [MEDICATION(S)] (antibiotic) 800-160 mg, give one tablet by mouth two times a day for staphylococcus for 7 days. The practitioner note dated October 9, 2020 stated awaiting orthopedic physician to give further recommendations regarding the fixator; the resident not allowing staff to clean sites. Review of the October 2020 TAR revealed no documentation that the pin site treatments were completed on October 14, 19-21, 23, 25, or 28-30. Review of the November 2020 TAR revealed no documentation that the pin site treatments were completed on November 1-3, 5, 9, 11, 24, or 30. Review of the December 2020 TAR revealed no documentation that the pin site treatments were completed on December 9, 26, 28, 30. A practitioner note dated December 31, 2020 revealed the fixator was removed from the right lower extremity and an immobilizer was applied. The note included the resident would not allow the practitioner to see or touch the leg. Review of a nurse progress note dated January 6, 2021 revealed a skin check was performed. The note included multiple surgical incisions to the right lower extremity were well approximated with sutures where the external fixator was removed by orthopedics. Review of a practitioner note dated January 18, 2021 revealed the right lower extremity surgical scars were healed. Regarding the buttock wound: Review of physician orders dated October 23, 2020 revealed: -Left upper buttock shearing, apply [MEDICATION(S)] cream two times a day every day shift, notify Primary Care Physician (PCP)/and nurse supervisor if decline noted. -Left upper buttock shearing, apply [MEDICATION(S)] cream two times a day every night, notify Primary Care Physician (PCP)/and nurse supervisor if decline noted. Review of the October 2020 TAR revealed no documentation that the treatments to the left upper buttock were completed on the day shift October 25, or 28-30 and on the night shift October 25-28. Review of the November 2020 TAR revealed no documentation that the treatments to the left upper buttock were completed on the day shift November 1-3, 5, 9, or 11 and on the night shift November 9-11. Regarding the right ankle: The physician orders dated May 22, 2021 included: -Monitor inner ankle for infection or change of condition every day shift. -Monitor inner ankle for infection or change of condition every night shift. Review of the May 2021 TAR revealed no documentation that the monitoring of the right ankle was completed the day shift on May 29. Review of the June 2021 TAR revealed no documentation that the monitoring of the right ankle was completed the day shift on June 3-5, 10, 18-19, and 26 and the night shift on June 8 or 18. Review of the July 2021 TAR revealed no documentation that the monitoring of the right ankle was completed the day shift on July 1-2 or the night shift on July 13. Review of a physician's order dated July 27, 2021 revealed: Remove old dressing to right dorsal ankle, cleanse with wound cleanser, pat dry with clean gauze, apply skin prep to peri wound, cover with calcium alginate and a foam dressing. Change 3 times a week and as needed for saturation and/or dislodgement. Review of the July 2021 TAR revealed no documentation that the monitoring of the right ankle was completed on the day shift on July 28. Regarding the right heel: Review of a progress note from the Wound Care Center dated January 7, 2021 revealed the right heel wound (wound #3) was now a full thickness surgical wound. A review of the TARs for February 2021, March 2021, and April 2021 revealed a physician order dated January 8, 2021 had been transcribed onto the TARs to cleanse the right heel wound with normal saline, apply silver alginate and cover with dry dressing. Review of the February 2021 TAR revealed no documentation that the right heel wound treatments were completed on February 18 or 25. Review of the March 2021 TAR revealed no documentation that the right heel wound treatments were completed on March 6, 13, or 26. Review of the April 2021 TAR revealed no documentation that the right heel wound treatment was completed on April 15. A physician's order dated April 20, 2021 included to clean bilateral heels with wound cleanser, pat dry, apply [MEDICATION(S)], and cover with dressing daily. Further review of the clinical record did not reveal this treatment was provided or that the order was transcribed onto the TAR/MAR (Medication Administration Record) for April 2021. A nurse progress note dated May 22, 2021 revealed the right heel wound was closed and was blanching. Physician orders dated May 22, 2021 included: -Monitor the right heel for infection or change in condition every day shift. -Monitor the right heel for infection or change in condition every night shift. Review of a practitioner note dated May 26, 2021 revealed that the practitioner examined the resident wounds and advised staff to place heels in protective booties. Review of the May 2021 TAR revealed no documentation that the monitoring of the right heel was completed the day shift on May 29. Review of the June 2021 TAR revealed no documentation that the monitoring of the right heel was completed the day shift on June 3-5, and 10 or the night shift on June 8. A practitioner note dated June 17, 2021 revealed the right heel had resolved. Review of the June 2021 TAR revealed no documentation that the monitoring of the right heel was completed the day shift on June 18-19, and 26; and the night shift on June 18. Review of the July 2021 TAR revealed no documentation that the monitoring of the right heel was completed the day shift on July 1-2, and 28; and the night shift on July 13. An interview was conducted on August 6, 2021 at 8:34 a.m. with the Assistant Director of Nursing/Registered Nurse/Wound Care nurse (staff #64). She stated that the hall nurse does the wound care in the facility for both pressure and non-pressure wounds. She stated the treatment was completed if the nurse signed it off on the TAR. Staff #64 stated that if there was a blank on the TAR (no initials for the scheduled treatment time and date) it meant the treatment was probably not done. Staff #64 stated that if it was not signed, it was not done. Staff #64 stated that staff is expected to complete the treatments and to sign the treatment as completed on the TAR. The Wound Care nurse stated that if the treatment was not completed there would be a risk for infection and worsening of wounds. An interview was conducted on August 6, 2021 at 10:45 a.m. with the Director of Nursing (DON/staff #9). She stated that the hall nurse would maintain the treatments on wounds, pressure and non-pressure. Staff #9 stated that she would know that the treatment was completed by the nurse signing the treatment as complete on the TAR. She stated that if the care was not documented as completed on the administration record, the care was not done. The DON stated that if a resident refused the care, the staff should document the refusal. She stated that the risk of not completing the wound care for a resident was potential worsening wounds, new wounds, or infection. The DON stated that she had identified the issue of staff not signing off on completion of care on the MAR/TAR and that she would have to assume that the care was not given as she had no other way to show that it was. The facility's policy on Skin Integrity Management dated June 1, 2021 revealed: The implementation of an individual patient's skin integrity management occurs within the care delivery process. The purpose included to provide safe and effective care to manage treatment and promote healing of all wounds. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. For surgical wounds, follow specific orders from the surgeon. Review of the facility policy for nursing documentation dated June 1, 2021 revealed: Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the patient's condition, situation, and complexity. Documentation for subsequent and/or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools. Nursing documentation will follow company policy and procedure and federal and state regulations. The purpose is to communicate the patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Practice standards included: Documentation includes information about the patient's status, nursing assessments and interventions, expected outcomes, evaluation of the patient's outcomes, and response to nursing care; Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion; The patient's record specifies what nursing interventions were performed by whom, when, and where; all patients information will be documented, scanned, or entered in the appropriate section of the clinical record following established guidelines. Review of the facility policy for Clinical Record: Charting and Documentation revealed: The purpose is to provide a complete account of the patient's total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. Chart pertinent changes in the patient's condition, reaction to treatment, medication, etc., as well as routine observations. Document treatments, medications, vital signs, and weights as required/requested.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure three of four sampled residents (#214, #33, and #17) were weighed per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: -Resident #214 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan was initiated on July 19, 2021 that stated resident #214 was at nutritional risk due to end stage renal disease, diabetes, recent right above knee amputation and pressure ulcer on the sacrum. The goal was that the resident would maintain a stable weight. Interventions included monitoring unplanned weight loss/gain for changes in nutritional status. The admission Minimum Data Set (MDS) assessment dated [DATE] included the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment included the resident had no swallowing disorder or dental issues, and required supervision while eating. It also included the resident was receiving [CONDITION(S)]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) for July 2021 revealed the resident was away from the facility and could not be weighed on July 22, and included a check mark indicating the resident weight was obtained on July 29, 2021. However, review of the clinical record revealed no documentation that a weight was recorded on July 29, 2021. Further review of the clinical record revealed the only weight recorded for resident #214 was at admission on July 15, 2021. An interview was conducted with resident #214 on August 4, 2021 at 12:00 pm. The resident stated that he did not think anyone at the facility had weighed him since he was admitted . The resident stated he is weighed at the [CONDITION(S)] center on the days he receives [CONDITION(S)], but no one from the facility has weighed him. An interview was conducted on August 5, 2021 at 9:30 am with a certified nursing assistant (CNA/staff #16) who was working on the hall where resident #214's room was located. Staff #16 stated one of her responsibilities is to weigh the residents. She stated she is supposed to weigh most of the residents once a week. Staff #16 stated she will usually weigh a resident when she is assisting them with getting into bed. She stated she writes the weight down on a piece of paper and gives it to the nurse. Staff #16 stated that is the only place she documents the residents' weight. An interview was conducted with the Assistant Director of Nursing (ADON/staff #64) on August 5, 2021 at approximately 10:15 am. Staff #64 stated the residents are weighed at admission and then weekly for 4 weeks. She stated that after 4 weeks, the residents are weighed monthly. She stated the resident's weight is documented in the chart, and it will be included on the MAR. Staff #64 stated that if there is a check mark on the MAR, it indicates that action was completed. The ADON stated if there was a check mark on the weights order on the MAR, the weight should be documented in the resident's chart. An interview was conducted with the Director of Nursing (DON/staff #9) on August 5, 2021 at 11:30 am. The DON stated newly admitted residents are weighed on admission and then weekly for 4 weeks. She stated some of the residents have separate orders for weights and are weighed according to those orders. Staff #9 stated the resident's weights are recorded in the chart and there is a weights book at the nursing station. The DON stated that she did not think resident #214's weight had been taken as ordered, or according to the facility policy. -Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan dated June 9, 2021 revealed the resident was at nutritional risk as evidenced by the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated the resident's cognition was intact. The MDS assessment also revealed the resident had no swallowing disorder and no dental issues; and required limited one-person assistance with eating. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed the following weights: June 8, 2021 - 152.8 pounds (lbs.) (Wheelchair) June 17, 2021 - 143 lbs. (Wheelchair) June 30, 2021 - 152.8 lbs. (Wheelchair) July 5, 2021 - 167.2 lbs. (Standing) July 24, 2021 - 163.2 lbs. (Wheelchair) July 30, 2021 - 164.1 lbs. (Standing) July 31, 2021 - 164.2 lbs. (Standing) August 3, 2021 - 144 lbs. (Standing) A review of the MAR and Treatment Administration Record (TAR) for June 2021 revealed the resident refused to be weighed on June 24, 2021. Review of the MAR/TAR for July 2021 revealed no weights documented on July 8, 2021 and a check mark indicating weights were obtained on July 1, 7, 14 and 15, 2021. However, review of the clinical record revealed no documentation of weights on July 1, 7, 8, 14 and 15, 2021. A review of the CNA task for weights revealed no weights were documented. An interview was conducted with a CNA (staff #68) on August 4, 2021 at 12:00 PM. She stated that most of the residents in the unit are weighed once a month. Staff #68 stated the nurses will tell the CNAs which residents need to be weighed. She stated sometimes the CNAs have not weighed residents because of being short-staff and residents requiring two persons assistance. During an interview conducted with a Licensed Practical Nursing (LPN/staff #44) on August 4, 2021 at 2:39 PM, she stated that she did not know about the weights not being done. She stated the nurses will tell the CNA know when a weight is needed. The LPN reviewed the resident's clinical record and stated that she was not at the facility in June 2021. She stated for July she was at the facility on July 7, 8 and 14, 2021 and it may have been her that made a mistake. During an interview conducted with a CNA (staff #41) on August 5, 2021 at 1:05 PM, the CNA stated most of the residents get weighed two times a month. She stated the nurses tell the CNAs when a resident need to be weighed and that the nurse documents the weight. During an interview conducted with another LPN (staff #20) on August 5, 2021 at 1:37 PM, she stated that residents are weighed according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the order pops up in PCC for the nurses to enter the weight. The LPN further stated all weights entered can be viewed under weights and vitals in PCC. An interview was conducted with the DON (staff #9) on August 5, 2021 at 3:00 PM. She stated that her expectation is for the staff to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also stated the CNAs document the weights in the weight book in the nurses' station. She further stated that all weights should be entered into PCC. During an interview with an LPN (staff #71) on August 6, 2021 at 11:34 AM, the LPN stated the nurses will tell the CNA when a resident need to be weighed. The LPN stated the nurses will document the weight in PCC. She stated there is no weight book. She stated the CNAs write the weight on a piece of paper and gives it to the nurse who will enter the weight into PCC. The LPN also stated that other than the piece of paper, she was not aware of any other location the CNAs document weights. Staff #71 stated that if there are no weights in PCC for a resident on a day a weight was ordered, more than likely the weight was not obtained. -Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a document dated May 2, 2021 at 4:06 pm from another facility that stated the resident's weight was 140 pounds. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A bed rail evaluation with an effective date of May 18, 2021 revealed a place to document the resident's most recent weight. However, no weight was documented. A Lift Transfer Reposition form with an effective date of May 18, 2021 revealed a place to document the resident's most recent weight. However, no weight was documented. The admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident had intact cognition. The assessment included the resident's weight was 140 pounds. A nutritional assessment with an effective date of May 28, 2021 revealed the admission weight was pending and that the hospital weight was 140 pounds. The assessment included the dietician would continue to follow weights. Continued review of the clinical record did not reveal any other weights as of August 2, 2021. However, review of the clinical record after this revealed a weight of 160 pounds on July 13, 2021 at 3:34 pm and a weight of 141 pounds on August 3, 2021 at 3:52 pm on the Weights and Vitals Summary. An interview was conducted with an LPN (staff #71) on August 4, 2021 at approximately 9:47 am. The LPN stated the CNA typically weighs the resident upon admission but that the nurse can weigh the resident also. She stated that if a resident requires two-person assistance to be weight, then two staff will weigh the resident. The LPN stated the weight would be documented in the electronic medical record. An interview was conducted with the DON (staff #9) on August 4, 2021 at 12:21 pm, who stated residents need to be weighed upon admission depending on when the resident arrived. The DON stated the CNA typically weighs new admissions. Staff #9 stated that she did not know if there was an exact time frame allowed for weighing the resident but the sooner the better. The DON stated that she did not want the weight from a previous facility to be used as an admission weight because it could create inaccuracies. The DON also stated sometimes weights are documented in a binder kept by the RNA (Restorative Nursing Assistant) but that the weights need to be documented in the electronic medical record. The facility's policy titled Weights and Heights revised June 1, 2021, revealed patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. The policy further revealed additional weights may be obtained at the discretion of the interdisciplinary care team. The policy stated the purpose is to obtain baseline weight, identify significant weight change and to determine possible causes of significant weight change. The policy also included the hospital weight will not serve as an admission or re-admission weight.

Based on observations, clinical record review, staff and resident interviews, facility documentation, review of the Center for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were initiated and implemented for one resident (#170) with suspected [MEDICAL CONDITIONS] infection. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The resident census was 65. The deficient practice could result in the spread of infection to residents and staff. Findings include: On (MONTH) 22, 2019 at 1:00 p.m., the Condition of Immediate Jeopardy was identified. The Administrator was informed of the facility's failure to initiate and follow infection control procedures for one resident (#170), with suspected [MEDICAL CONDITION] infection. A stool specimen for [MEDICAL CONDITION] had been sent out on (MONTH) 21, 2019 and the resident had not been placed on contact precautions, pending the laboratory results. Therapy staff had been observed in the resident's room providing care without the use of PPE (personal protective equipment) and the resident had been observed in the therapy gym receiving therapy, with another resident and two staff present. The Administrator presented a plan of correction on (MONTH) 22, 2019 at 3:45 p.m. The Administrator was informed that the plan of correction needed to be revised to include that all facility staff need to receive in-service education regarding infection control precautions for [MEDICAL CONDITION]. A revised plan of correction was presented on (MONTH) 22, 2019 at 4:25 p.m. and was accepted. The plan of correction included the following corrective actions: The therapy gym was cleaned and two residents who were in the therapy gym at the time that resident #170 was receiving therapy were placed on change of condition observations for any signs of loose/watery stools for 48 hours; all residents who resided on unit 1 were to be assessed and placed on observation for loose/watery stools for 48 hours; all staff members were to be provided in-services which would include transmission based precautions and control measures, and placing residents on contact precautions while awaiting results of stool culture testing for [MEDICAL CONDITION]; staff designee will monitor laboratory orders for stool culture orders or reports of residents with loose watery stools and then verify that they have been placed on contact precautions, pending stool culture results. Multiple observations were conducted on (MONTH) 22, and 23, 2019 of the facility implementing their plan of correction. Staff in-services were being completed and staff interviewed were knowledgeable regarding infection control procedures, including that residents were to be placed on contact precautions when they are suspected to have [MEDICAL CONDITION] and are to remain on contact precautions, pending the results of the stool culture testing. In addition, resident #170 was placed on contact precautions, pending the results of the stool culture test. As the facility was implementing their plan of correction and there were no additional concerns identified, the Condition of Immediate Jeopardy was abated on (MONTH) 23, 2019 at 11:00 a.m. Specifics regarding resident #170: Resident #170 was admitted on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. Review of the hospital records dated prior to admission revealed that resident #170 received IV (intravenous) antibiotics, which included [MEDICATION NAME] 750 mg (milligrams) on (MONTH) 3, 2019 and [MEDICATION NAME] 1 gm (gram) on (MONTH) 5, 2019. Physician transfer orders from the hospital dated (MONTH) 6, 2019 included that resident #170 had received [MEDICATION NAME] 1 gm IV on (MONTH) 6, and that the next dose was scheduled to be received (at the facility) on (MONTH) 7. Review of the facility physician orders [REDACTED]. A nurses note dated (MONTH) 6, 2019 at 9:00 p.m. included that a possible allergy to Ceftraxone had been identified and review of the physician orders [REDACTED]. A baseline care plan completed on (MONTH) 8, 2019 included that resident #170 was confused, received physical and occupational therapy, used a wheelchair, was totally dependent on staff assistance for toileting and hygiene, was incontinent of bowel and received [MEDICATION NAME] 1 gm for two days. An Admission MDS (Minimum Data Set) assessment dated (MONTH) 12, 2019 included that resident #170 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. Per the MDS, resident #170 was frequently incontinent of bowel, required extensive assistance from two staff with transfers and extensive assistance from one staff for toileting and personal hygiene. The MDS also included that resident #170 used a walker and a wheelchair and had received antibiotics on a regular basis. A physician's orders [REDACTED]. A nurses note dated (MONTH) 21, 2019 at 2:36 p.m. included that a stool specimen had been collected at 1:35 p.m. and the lab had been notified to pick up the specimen. Review of the clinical record revealed there was no documentation that the resident was having diarrhea/loose stools from admission through (MONTH) 21, 2019. A physician's progress note dated (MONTH) 22, 2019 included documentation that resident #170's chief complaint was follow-up for diarrhea. The resident complained of having loose stools 2-3 times for the past several days. The resident denied rectal bleeding, abdominal pain, nausea, vomiting or fever. Per the note, the resident had a history of [REDACTED]. Review of systems included that all systems were negative except for diarrhea, and that the resident had acute diarrhea and to rule out [MEDICAL CONDITIONS]. On (MONTH) 22, 2019 at 11:35 a.m., an observation was conducted of the resident lying on his bed. At this time, a therapy staff member (staff #70) was observed inside of the room. The therapy staff member was assisting the resident with maneuvering on the bed and was not wearing a gown or gloves. In addition, there was no indication that resident #170 was on contact precautions for suspected [MEDICAL CONDITION] infection, such as an isolation cart with PPE outside of the resident's room. An interview was conducted on (MONTH) 22, 2019 at 11:37 a.m. with the Unit Manager (staff #37) and the resident's nurse (Licensed practical Nurse/LPN/staff #39). Staff #39 stated that she sent the stool sample to the lab for [MEDICAL CONDITION] on (MONTH) 21, because the resident had diarrhea for two days and the stool was loose, watery and malodorous. Staff #37 stated that they would only isolate a resident, if the results of the stool culture were positive for [MEDICAL CONDITION]. She also stated that the resident had not been receiving antibiotics. When asked how the facility was protecting other residents from potential exposure to [MEDICAL CONDITION] since resident #170 had not been placed on contact precautions, staff #37 repeated that they would place resident #170 on isolation, if the results of the stool culture for [MEDICAL CONDITION] were positive. Staff #37 said that the resident was not currently on isolation for [MEDICAL CONDITION], and that they are not isolating him at this time. Staff #39 said the lab had notified the facility today that they were unable to complete the processing of the stool specimen, which had been sent yesterday and that another specimen needed to be sent. Staff #39 said she was waiting for the resident to have another loose bowel movement, so she could send the specimen to the lab. Further review of the clinical record revealed there was documentation that another stool specimen needed to be sent. During an interview conducted on (MONTH) 22, 2019 at 11:40 a.m. with the Director of Nursing (staff #30), staff #30 stated he was not aware of any stool specimens that had been sent to the lab over the weekend and had not been notified that any stool specimens for [MEDICAL CONDITION] had been sent to the lab yesterday. An observation of resident #170 in the therapy gym was conducted on (MONTH) 22, 2019 at 12:15 p.m. Resident #170 was seated in the therapy gym receiving services from a therapist. In addition to resident #170, there was one other resident and two therapy staff who were also present in the therapy gym. During the observation, the resident stated that he had diarrhea earlier this morning. Resident #170 was seated in the therapy gym receiving services from a therapist. Neither resident #170, the other resident or therapy staff were wearing any PPE. During an interview conducted on (MONTH) 22, 2019 at 12:20 p.m. with a CNA (Certified Nursing Assistant/staff #1), the CNA stated that resident #170 had an episode of diarrhea at 11:30 a.m. today, which consisted of a large amount of watery loose stool with mucus, and a strong odor. During an interview conducted on (MONTH) 22, 2019 at 12:25 p.m. with the resident's nurse (LPN/staff #39), she stated that she was not aware the resident had diarrhea at 11:30 a.m. today. Another interview was conducted with staff #30 on (MONTH) 22, 2019 at 12:30 p.m. Staff #30 stated that resident #170 will need to be placed on isolation precautions, if the results of the stool culture are positive for [MEDICAL CONDITION] and until then, the resident was on standard precautions. He stated that standard precautions include maintaining the resident in his room, wearing gloves when assisting the resident, and hand washing after removing gloves. Staff #30 stated he was not aware that therapy staff had assisted the resident in his room without wearing gloves, or that the resident was in the therapy gym with no protective equipment on. When asked how residents were being protected from possible exposure to [MEDICAL CONDITION] he stated, I will have to check. During an interview conducted on (MONTH) 22, 2019 at 1:20 p.m. with staff #30 and a Nurse Consultant (staff #87), staff #87 stated that although a stool specimen for [MEDICAL CONDITION] culture had been sent to the lab for resident #170, he did not fit the profile of having suspected [MEDICAL CONDITION], according to the facility's infection control protocols and did not require isolation precautions for [MEDICAL CONDITION]. Staff #87 also stated that because the CNA's had not documented more than one loose stool, the resident did not have diarrhea. When asked about the nurse and CNA who reported that the resident was having episodes of diarrhea, and how staff were protecting other residents from possible exposure to [MEDICAL CONDITION], staff #87 stated I see what you mean. An interview was conducted on (MONTH) 22, 2019 at 1:30 p.m. with a CNA (staff #44). The CNA stated that resident #170 had a loose stool earlier in the day and when she assisted with cleaning the resident, she had not taken any specific infection prevention precautions. She stated that if a resident has a loose stool, she documents the loose stool and notifies the nurse. An interview was conducted on (MONTH) 22, 2019 at 2:32 p.m. with the physician for resident #170 (staff #86). The physician stated that the nurse caring for resident #170 had called him yesterday (April 21) and described the resident's diarrhea symptoms to him. He stated that he gave the nurse an order to send a stool specimen for [MEDICAL CONDITION] culture. The physician further stated that the resident should have been placed on isolation precautions yesterday, when it was suspected that he may have [MEDICAL CONDITION]. A nurses note dated (MONTH) 23, 2019 at 8:54 a.m., included that a change in condition had been noted and symptoms included diarrhea on (MONTH) 20, 2019. The note included that the physician had been notified on (MONTH) 21, 2019 at 2:00 p.m., orders had been obtained and a stool sample had been sent for [MEDICAL CONDITION] culture. An interview was conducted on (MONTH) 23, 2019 at 1:31 p.m. with the therapy staff (staff #70) who had been observed assisting resident #170 in his room on (MONTH) 22 at 11:35 a.m. Staff #70 stated that she had not been notified that a stool sample for [MEDICAL CONDITION] for resident #170 had been sent, or that resident #170 was suspected to possibly have [MEDICAL CONDITION]. Staff #70 said that if she had been notified of the suspected [MEDICAL CONDITION], the resident would have received therapy services in his room, and he would not have been brought to the therapy gym. Review of a policy and procedure titled, Infection Prevention and Control Program Description revealed that the infection prevention and control program is a comprehensive process that addresses preventing, identifying, reporting, investigating and controlling infections and communicable diseases. The policies and procedures are based on national standards including recommendations from the Centers for Disease Control (CDC). Activities of the program include implementation of standard and transmission based precautions, and infection prevention and control practices followed by staff. Goals of the program include decreasing the risk of infection for patients and staff and implementing appropriate control procedures. The policy also included that the (facility) infection control Preventionist is responsible for initiating specific precautions to prevent the transmission of infection. Review of a policy titled, [MEDICAL CONDITION] revealed to place patients with more than three diarrheal stools in presumptive contact precautions, while waiting for test results to come back. A policy and procedure titled, Contact Precautions included that in addition to standard precautions, contact precautions will be used for diseases transmitted by direct or indirect contact with the patient or the patient's environment. The purpose of the policy is to reduce the risk of microorganisms by direct or indirect contact. The process included placing a sign on the patient's door which reads, STOP. Please see the nurse before entering the room and that staff must wear gown and gloves when entering the room, and that before exiting the room, remove and bag gown and gloves and wash hands upon exiting the room. Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. Risk factors include antibiotic use, serious underlying illness and age over 65. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. [MEDICAL CONDITION] spores can live for months or sometimes years on surfaces. For prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care, and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The policy also stated that before exiting the patient room, discard gowns and gloves, and wash hands to contain the [MEDICAL CONDITION] pathogens.

Based on closed clinical record review and staff interview, the facility failed to provide care and services to prevent the development of two avoidable pressure ulcers for one resident (#191). The sample size was three. Findings include: Resident #191 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed an initial nursing assessment dated [DATE], which included the resident was non-weight bearing due to a fracture and required assistance with all activities of daily living. The assessment included the resident had 2+ [MEDICAL CONDITION] to bilateral lower extremities. Under the skin section, it was documented that the resident had excoriation to the buttocks area, but there was no documentation the resident had any pressure ulcers. However, a CNA shower sheet dated February 5, 2013, documented the resident had red heels. According to the Braden Scale for predicting pressure sore risk dated February 5, 2013, the resident was assessed at mild risk for the development of pressure ulcers, despite having skin breakdown to the buttocks area and red heels upon admission. A care plan addressing the risk for skin breakdown was completed on February 5, 2013, which included risk factors of diabetes, muscle weakness, recent [MEDICAL CONDITION] and immobility. Approaches included treatment per orders, notify physician of deterioration in skin condition, complete weekly skin assessments, and to offload heels in bed. The care plan did not reflect that the resident had any excoriation to the buttocks area or red heels. A physician's orders [REDACTED]. Nurse's notes from February 7 and 8, documented 2-3+ [MEDICAL CONDITION] to the resident's bilateral lower extremities and that the heels were off loaded. An initial care plan for risk of skin breakdown was developed on February 8, 2013. The goal was to maintain skin integrity and interventions included to reposition every two hours and as needed, float heels/heel boots, and to monitor for changes in skin integrity. Review of the February treatment record revealed the Altrac-Tan cream was not applied to the resident's heels on February 9. Nurse's notes dated February 11, 2013, included the resident's bilateral lower extremities had 3 to 4+ [MEDICAL CONDITION] with weeping, legs were elevated, the resident was on diuretic therapy and that the physician was notified. The at risk for skin breakdown care plan was updated on February 11. Additional approaches included for a low air loss mattress, "heel bows," and to offload heels. On February 12, a nurse's note documented the resident had 3+ [MEDICAL CONDITION] to the lower extremities and that the legs were being elevated with pillows. According to the February treatment record, the Altrac-Tan cream had not been applied to the resident's heels on February 13. In addition, the treatment record did not include the physician's orders [REDACTED]. A nurse's note dated February 13, included the resident had 4+ [MEDICAL CONDITION] to lower extremities with weeping and that the physician was notified. A weekly skin assessment was completed on February 13. There was no documentation of any concerns to the resident's heels. However, physician's orders [REDACTED]. The orders also included to cleanse the right heel with normal saline, apply [MEDICATION NAME], cover with foam and wrap with Kerlix daily. The orders further included for "heel bows" to bilateral heels at all times, to float the heels at all times and for a low air loss mattress. Review of the February treatment record revealed the order for the heel bows to the bilateral heels was initiated on February 14, despite this being an intervention on the February 11 care plan. The physician's orders [REDACTED]." Regarding the left heel pressure ulcer: Review of the Wound Assessment Progress Report dated February 14, 2013, revealed a pressure ulcer to the left heel that measured 4 centimeters (cm) x 4 cm and was red and purple in color, with surrounding skin intact. The stage was unable to be determined. The note did not indicate if the wound was open. Review of the skin condition care plan dated February 14, revealed documentation of a pressure ulcer to the left heel along with treatment orders. Interventions included weekly skin assessments, pressure relieving mattress, "heel bows," reposition every 2 hrs and as needed, heel protectors/boots and to off load heels. A 14 day MDS assessment was completed on February 17, 2013, and identified the resident had developed an unstageable pressure ulcer, which was necrotic and was not present upon admission. A nurse's note dated February 18, documented the resident's left heel was red and purple, with a mushy center and that the wound was closed. The Wound Assessment Progress Report dated February 23, showed that the wound measured 4.5 x 4.5 cm, the wound bed was red with a purple dark center, had a small amount of reddish "purplish drainage", and the stage was unable to be determined. The note also indicated the wound had declined. There was no documentation the physician had been notified of the decline in the wound status at that time. Further review of the clinical record revealed there was only intermittent nursing note documentation for February 2013, that the resident's heels were floated. There was no documentation to show that the resident's heels were floated daily as ordered. According to the March treatment record, the wound treatment was changed on March 4. The treatment included to cleanse the left heel with normal saline, apply [MEDICATION NAME], cover with foam, and wrap with Kerlix every day. Also on the treatment record was an area to now document that the resident's heels were being floated at all times each shift. A nurse's note for March 5, documented that the left heel eschar was debrided and healthy tissue was underneath and that the wound continues to have dark purple edges. The note further included the certified nursing assistants (CNAs) were given education regarding the floating of the resident's heels and to use proper linen for the air mattress. Prior to this note, there was no documentation indicating the left heel had any eschar present. The Wound Assessment Progress Report dated March 5, 2013, ten days after the last assessment, documented the wound measured 5 x 6.5 cm, the wound bed was red with a purple dark center with a small amount of "purplish" drainage, and surrounding tissue was macerated. The note further included the wound had declined. In the section to document the percentage of necrotic tissue, a line had been drawn through the area. There was also no documentation the wound was debrided. The next pressure ulcer assessment was dated March 18, thirteen days after the last assessment. The wound measured 5 x 6 cm, the wound bed was red and "purulent" and the surrounding tissue was macerated. The wound note documented the wound had "improved." On March 19, 2013, a nursing note revealed documentation that the left heel was draining a small amount of thick purplish/brownish fluid, possibly purulent, and the physician was aware. According to the March treatment record, the wound treatment was not rendered to the left heel on March 22, 2013. Per the Wound Assessment Progress Report dated March 26, the wound measured 4 x 5.5 cm, the wound bed was described as black, and there was a minimal amount of slight green drainage. However, the documentation indicated the wound had "improved." There was no documentation that the physician was notified at this time regarding the condition of the left heel pressure ulcer. A physician's orders [REDACTED]. The order included to cleanse the left heel with normal saline, gently pat dry and apply [MEDICATION NAME] cream to eschar area, skin prep to wound margin, cover with foam and Kerlix daily and as needed for soilage. According to the Wound Assessment Progress Report dated April 2, the wound measured 4 x 5.5 cm, the wound bed was 100 percent necrotic and the surrounding skin was intact. Despite this, the note indicated the wound had improved. Again, there was no documentation that the physician was notified that the wound was now 100 percent necrotic. The Wound Assessment Progress Report dated April 10, documented the wound measured 4 x 5 cm, was 100 percent necrotic and there was [DIAGNOSES REDACTED] to the surrounding skin. Regarding the right heel pressure ulcer: Review of the Wound Assessment Progress Report for February 14, revealed a pressure ulcer to the right heel that measured 4 x 4 cm, wound bed was red and purple with no drainage, and the stage was unable to be determined. Physician orders [REDACTED]. A nurse's notes dated February 15, documented the right heel had a purple center and was open. The Wound Assessment Progress Report dated February 18, 2013, documented the resident's right heel was 4 x 3.75 cm, with 100 percent granulation to the wound bed and the stage was unable to be determined. The Wound Assessment Progress Report dated February 23, included the right heel measured 3 x 2.5 cm, the wound bed was red and was a stage 2. The note also indicated the wound had improved. According to the Wound Assessment Progress Report dated March 5, 2013, 10 days after the last assessment, the wound measured 2 x 2.5 cm, the wound bed was pink with a purple center and the stage was unable to be determined. The next wound assessment was done on March 18, thirteen days after the last assessment. The Wound Assessment Progress Report documented the right heel pressure ulcer measured 2 x 2 cm, the wound bed had a purple center with pink edges, and was unstageable. The note indicated the wound had improved. Review of the March treatment record revealed there was no documented evidence that wound care was rendered to the right heel on March 22. The next pressure ulcer assessment was dated March 26, eight days after the last assessment. Per the Wound Assessment Progress Report, the right heel measured 2 x 2 cm, the wound bed was 100 percent necrotic tissue with a minimal amount of light blackish drainage, and the surrounding skin had slight [DIAGNOSES REDACTED]. There was no documentation that the physician was notified of the deterioration of the wound at this time. A physician's clarification order was obtained on March 28, 2013, which included to cleanse the right heel with normal saline, gently pat dry, apply [MEDICATION NAME] to eschar area, skin prep to wound margins, cover with foam, reinforce with Kerlix and change daily and as needed. Per the Wound Assessment Progress Report dated April 2, the right heel pressure ulcer measured 2 x 2 cm, the wound bed was 100 percent necrotic, surrounding skin had slight [DIAGNOSES REDACTED] and there was a minimal amount of light blackish drainage. Further review of the clinical record revealed there were no further wound assessments of the right heel. On April 12, 2013, the resident was discharged with unstageable pressure ulcers to the left and right heel. In an interview on April 30, 2013, the director of nursing stated that the nursing staff had care planned and provided care per facility policy and physician orders.

Based on observations, review of the closed clinical record, the facility's incident and investigative reports, a review of the hospital records, staff interviews, and review of facility policies, the facility failed to ensure that adequate supervision was provided for one resident (#2) with wandering behaviors, who sustained a fall from a second floor balcony, which resulted in significant injuries. The sample size was one of three. Findings include: Resident #2 was originally admitted on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A facility form titled, Initial Wandering/Exit Seeking/Elopement Evaluation, dated [DATE], included that the resident was not at risk for wandering upon re-admission to the facility. Review of the closed clinical record revealed that the resident had been examined by psychiatry on [DATE], and on [DATE], and medication changes were initiated. The [DATE] entry included the resident would be examined again in four weeks. Clinical record documentation revealed the resident had wandered outside of the facility on [DATE] at 8:00 a.m. The incident and investigative reports included the resident eloped from the facility and that visual checks of the resident would be implemented every 15 minutes. A wandering care plan was developed and included that 15 minute checks would be implemented for the next three days. However, a review of a safety monitoring record (undated) which was included in the facility's investigative report, revealed that the visual checks of the resident were only completed from 11:00 p.m. until 9:45 p.m., the next day. A physician's progress note dated [DATE], included that staff had reported to this physician that the resident had exited the facility and had been located on the facility's grounds. The progress note also included the resident was not usually a wanderer. A second physician's progress note dated [DATE], included that nursing staff had reported to this physician that over the last several weeks the resident had been exhibiting increased behaviors, as evidenced by verbal outburst-out of context to the situation, and explosive and escalating anger associated with throwing objects. The progress note also included that no infectious cause for the increased behaviors had been identified and that a psychiatry evaluation and follow up was indicated. A nursing note entry dated [DATE] at 11:00 a.m., included that the resident was found outside the facility in the parking lot. The incident and investigative reports included that 15 minute checks of the resident would be implemented. A review of the 15 minute visual check record revealed that the checks had been implemented on [DATE], and had been concluded on [DATE] at 6:00 a.m. Again, the 15 minute visual checks had not been implemented for three days, as indicated on the risk for elopement care plan. Further review of the clinical record revealed there was no documented evidence that the resident was re-assessed for wandering risk or that increased supervision was consistently provided, despite the resident exiting from the second floor to the first floor via the elevator and having eloped twice out of the facility. A quarterly MDS (Minimum Data Set) assessment dated [DATE], included that the resident did not have any memory, hearing or visual deficits, had modified independence for daily decision making, had wandering behavior, required supervision with ADLs (Activities of Daily Living), required a wheelchair or walker for mobility, and had a history of [REDACTED]. Another physician's progress note dated [DATE], included that the facility staff had contacted this physician to report the resident's exit seeking behavior. The entry also included that the resident was argumentative, throwing cloths at the nurses, and was trying to get on the elevator to leave. According to the documentation, a request for the psychiatrist to follow up as soon as possible would be made. A social service progress note also dated [DATE], included that the resident's wandering behavior and option to move the resident to a secured unit had been discussed with a family member, who was not in agreement at this time. A psychiatric progress note dated [DATE], included that the resident was examined and that medication changes were implemented. Per the documentation, the resident would be seen again in four weeks for a follow up. A review of the March through [DATE], nursing note entries revealed documentation that the resident had exhibited some confusion, that she had exited the second floor nursing unit via the elevator multiple times, that she had eloped from the facility twice, that she had increased anger and agitation and that the verbal and physical outbursts were escalating. However, there was no documentation that increased supervision and monitoring had been provided to ensure the resident's safety. A nursing note entry dated [DATE], included that at approximately 7:00 a.m., the CNA (Certified Nursing Assistant) had gone to the resident's room in preparation to assist her with a shower. According to the documentation, the CNA left the resident's room and when she returned, she could not locate the resident. Per the documentation, the licensed staff and CNA began a search of the second floor for the resident. At this time, the resident's walker was observed in the activities room, her shoes on the second floor balcony, and a chair was in the corner of the balcony near the ledge. The entry further included during a search of the downstairs outdoor area the resident was located laying on the ground under the balcony area and that 911 was called and the resident was transferred to the hospital. According to the incident report dated [DATE], the resident jumped off the second floor balcony and that she had been followed by psychiatry for depression. A review of the facility's investigative report revealed documentation of the above incident and that the resident had been followed by the psychiatrist for an increase in symptoms as evidenced by agitation, aggressive behaviors and wandering. The facility's report also included documentation that the resident would go outside onto the second floor balcony two to three times a week for fresh air. A review of the hospital records revealed that the resident attempted suicide by jumping off a second floor balcony, sustaining a fall from 20 feet. The resident sustained [REDACTED]. The facility's investigative report further documented the resident was placed on impatient hospice services and expired on [DATE] at 1:00 p.m. An observation of the second floor balcony was conducted during the survey and revealed that it was located inside an outcove within the activities room and was not visible from the nursing station or hallways. The balcony area was enclosed with a wall and fence, which was approximately five feet tall, and overlooked a grassy and rock area. A the time of this observation, the balcony door was locked with a key code. An interview was conducted on [DATE] at 8:50 a.m., with the Activity Director. She stated that prior to this incident the second floor balcony was not secured and was always accessible to residents. She stated that this resident would go outside onto the balcony several times a week, without supervision. An interview was also conducted on [DATE] at 9:45 a.m., with the DON (Director of Nursing). The DON stated initially the resident had free run of the facility but that recently she had to be confined to the second floor nursing unit, due to increased behaviors of agitation, aggression, and wandering. She also stated that the staff knew to supervise the resident, but was unable to provide documented evidence that increased supervision had been provided to ensure the resident's safety. At this time, the elopement risk assessment tool and safety monitoring records were reviewed. Although the DON stated that the elopement risk assessment should have been updated after the two elopements in March and [DATE], she was unable to locate any additional elopement risk assessments. The DON further acknowledged that the visual safety checks should have been completed every 15 minutes for three days, but again, she was unable to locate any additional documentation that included the elopement care plan intervention had been entirely implemented. Additional interviews were conducted with licensed and direct care staff on [DATE] and 31, 2012. According to the staff, the resident had exhibited increased agitation and wandering behaviors. The staff also stated that the second floor balcony area was accessible to residents and that a security system, of either cameras and/or an alarm on the door were not in place at the time of this incident. Although staff stated that they had safety concerns because the resident wanted to leave the facility and go home, no instruction was given to provide increased supervision or monitoring of the resident. Per the staff, they just knew to keep an eye on her. Despite the resident's elopement incidents and staff's safety and wandering concerns, the resident was not provided increased supervision when going out onto the second floor balcony. In addition, the facility's report included that the police were notified and a report was generated, however, the facility was unable to provide the report for review. A facility policy titled Wandering Resident included, "The facility will assess residents wandering potential upon admission." The policy also included the following: 7. If wandering behaviors is identified for any current residents who previously have not exhibited these behaviors, a Wandering Resident Screen form is completed as soon as the behavior is identified...8. If a resident exhibits wandering behaviors that escalate and results in the resident achieving exit from the facility, the resident is retrieved and safety checks implemented. 12. In case of a pattern of wandering or escalating wandering, the facility may initiate discharge protocol for discharge to a safer environment.