Every finding on record at The Carrolton of Nash

Based on observation and staff interviews, the facility failed to clean 1 of 1 fryer, 2 of 4 kitchen walls, and 1 of 1 air conditioner wall unit. The facility also failed to allow cook pans, meal trays, and dishes to completely dry prior to assemblage and stacking. These practices had the potential to affect food served to residents. The findings included:Based on observation and staff interviews, the facility failed to clean 1 of 1 fryer, 2 of 4 kitchen walls, and 1 of 1 air conditioner wall unit. The facility also failed to allow cook pans, meal trays, and dishes to completely dry prior to assemblage and stacking. These practices had the potential to affect food served to residents. The findings included: An observation of the kitchen and interview with the Dietary Manager was conducted on 1/12/26 at 10:12 AM. The bottom of the fryer was covered with a dark brown liquid and food crumbs. The food crumbs were also seen along all inside walls. The Dietary Manager stated that the fryer was last cleaned 2 weeks ago. Review of the Weekly After Each Use Cleaning Schedule for the months of November 2025 through January 2026 revealed that the fryer was last cleaned on 12/25/25. During a follow-up interview with the Dietary Manager conducted on 1/14/26 at 11:59 AM. She revealed that there was not any new grease to replace the grease in the fryer with until 1/13/26. It was used twice the week before (once was for chicken and the other was for fish). The fryer was also used on 1/12/26 in the evening for fried fish. The Dietary Manager stated that fryer grease should be changed at least weekly. A continuous observation of the kitchen and interview with the Dietary Manager was conducted on 1/14/26 from 11:48 AM to 11:55 AM. A yellow, sticky substance was observed on the wall behind the bread rack and around the bulletin board. The substance was also seen below the air conditioner. The Dietary Manager stated that the walls were probably not cleaned in over a month. She further stated that cleaning the walls was not included in the current cleaning schedule; however, they should be included. The air conditioner wall unit above a preparation table directly to the right of the kitchen entrance had a black/brown substance inside the unit as well as covering the spaces over the filter. The Dietary Manager stated the last time the air conditioner unit was cleaned was during the months of Summer 2025 and it was not included in the cleaning schedule but should be. The Administrator was interviewed on 1/15/26 at 10:14 AM and stated the cleaning of the fryer, as well as the walls and air conditioner unit should be completed in a timely, consistent manner. A continuous observation of the kitchen and interview with the Dietary Manager was conducted on 1/12/26 from 9:57 AM to 10:09 AM. Over seventy meal trays stacked ready for use on the tray line were observed with wet nesting. The Dietary Manager stated that all meal trays should be air dried. Normally, they were left on a rack on top of the meal carts to fully dry. The Dietary Manager then instructed kitchen staff to re-wash and air dry all the meal trays. Fifty-five plastic juice cups were observed with wet nesting stacked by two on top of each other under the tea machine ready for service. The Dietary Manager stated that she had a newly hired staff member (Cook #2) who required further training. Four full-service pans on the cook's clean cart were observed with wet nesting. Ninety-one (91) plate bottoms behind the tray line were observed with wet nesting. The Dietary Manager stated that [NAME] #2 was responsible for air drying all dishes/trays that were observed with wet nesting, but he had only been working at the facility for a few days. The Dietary Manager indicated that kitchen orientation usually included three days of training. The Dietary Manager noted [NAME] #2 was still in training and had completed three days as a cook and this was the first day of three for training as a dietary aide, which included the dish room. During a follow-up interview with the Dietary Manager on 1/14/26 at 12:00 PM, she revealed that the kitchen staff on 1/12/26 were moving too fast during dish washing and did not allow enough time for all items to air dry. She stated that there was a process in place for air drying all dishes washed; however, the staff were just rushing. She should not have put all the responsibility on [NAME] #2 being a new staff member. An observation of the kitchen was conducted on 1/13/26 at 10:04 AM. Nine full pans and 73 meal trays were observed with wet nesting. An interview was conducted with Dietary Aide #1 on 1/13/26 at 10:06 AM. She stated that she was responsible for air drying the meal trays on 1/13/26 after breakfast meal. Dietary Aide #1 further stated all dishes and silverware needed to be air dried before service. Dietary Aide #1 indicated there might have been some wetness around the edges of the meal trays because her hands had gloves on that were wet. She indicated that the meal trays were air dried prior to the observation at 10:04 AM. An interview was conducted with [NAME] #1 on 1/13/26 at 10:07 AM. He stated he was responsible for cleaning the pots/pans this morning (1/13/26) after breakfast meal. [NAME] #1 stated the Dietary Manager went over the importance of air drying during his orientation when he was first hired 5 months ago. However, he claimed that he already knew about letting all pots/pans air dry before storage because he was in food service for over 30 years. This morning, he indicated that he had too many pots/pans to clean, and there was not enough room to air dry them all. The Administrator was interviewed on 1/15/26 at 10:14 AM. She revealed that all dishes and pans should be air dried prior to use/storage.

Based on record review, observation, and interviews with resident, Nurse Practitioner (NP), and staff, the facility failed to provide care in a safe manner resulting in the resident sustaining a closed head injury (occurs when a strong force hits the head causing the brain to shake without breaking the skin or skull) and a dislocation of the right shoulder with a right humerus fracture (a break in the top part of the upper arm bone near the shoulder) during the provision of a bed bath by Nurse Aide #1. The resident was evaluated at the Emergency Department (ED) and nonoperative management with a shoulder sling and orthopedic follow up was determined. The deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents.The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (weakness on side of the body) following cerebral infarction affecting the right dominant side, vascular dementia, age related physical debility, generalized muscle weakness and osteoarthritis. Resident #8's care plan revealed the following:- A focus area last revised on 1/2/24 for the risk of falls related to immobility. The interventions included following the facility fall protocol and reviewing information on past falls and attempt to determine cause of fall and remove potential causes.- A focus area last revised on 6/6/24 for an activities of daily living self-care performance deficit related to osteoarthritis. The interventions included total dependence on staff for bathing and for turning and repositioning in bed as necessary. - A focus area last revised on 6/6/24 for chronic pain related to osteoarthritis. The interventions included give analgesics (pain relievers) as ordered by the physician; monitor and document for side effects and effectiveness; and monitor, document, and report signs and symptoms related to osteoarthritis, acute fractures and compression fractures.The annual Minimum Data Set assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment with disorganized thinking and inattention. Resident #8 had impaired functional range of motion affecting one side of her upper extremity and one side of her lower extremity. She was non-ambulatory and dependent on staff for activities of daily living. Resident #8 received antiplatelet medication and scheduled pain medication. Her weight was 241 pounds. Resident #8's active physician's orders for November 2025 included an order initiated on 9/11/21 for aspirin 81 milligrams (mg) daily. Resident #8 had no other physician orders for blood thinning medication. The physician's orders also included an order initiated on 7/29/24 for acetaminophen 650 mg four times a day for pain. Resident #8's pain monitoring on the Medication Administration Record (MAR) from 11/1/25 to 11/16/25 revealed her pain level ranged from 0 to 7 (on a scale of 0 to 10 with 10 being the worst pain possible). A health status note dated 11/17/25 at 12:59 PM written by Nurse #1 revealed Resident #8 was found face down on the floor next to the bed. Resident #8 was assessed to have a large bump on the left side of her forehead with pain and was sent to the emergency department. The post fall incident report completed by Nurse #1 revealed Resident #8 had a fall on 11/17/25 at 8:15 AM while Nurse Aide (NA) #1 was providing care. A statement dated 11/17/25 completed by NA #1 revealed the following information. She was performing personal care on Resident #8 and while trying to roll the resident on her left side the bed continued moving with her. Resident #8 continued to roll and NA #1 caught her by the breast and stomach area. NA #1 indicated the geriatric wheelchair (a padded chair with a wheeled base) and nightstand held the resident up keeping her from hitting the floor. NA #1 reported she screamed and yelled for help. NA #3 and NA #2 came to assist NA #1. NA #1 reported they could not push or lift Resident #8 back onto the bed. NA #1 indicated they guided the resident to the floor very slowly face down because she was rolling to the left side towards the floor. NA #1 stated Nurse #2 assisted them with using the mechanical lift to place Resident #8 back on the bed.An interview was conducted with NA #1 on 1/14/26 at 1:48 PM. NA #1 reported she worked on the 7:00 AM to 3:00 PM shift on 11/17/25 and was assigned to care for Resident #8. NA #1 stated she entered Resident #8's room to give her a bath. The resident was in a private room. When entering the resident's room, her bed was located on the left side of the room with the left side of the bed against the left wall and the head of the bed against the wall where the window was located. A nightstand was located on the wall with the window between the right side of the bed and the window. The nightstand was not in direct contact with the bed when the bed was positioned against the left wall. The resident's geriatric wheelchair (ger-chair) was also positioned on the right side of the bed, not in direct contact with the bed. NA #1 stated she raised the bed up to her waist height, locked the bed, and explained to Resident #8 that she was there to give her a bath. NA #1 reported that as she was attempting to remove Resident #8's shirt, the resident complained of right shoulder pain. NA #1 stated this complaint of shoulder pain was not new. NA #1 stated she proceeded to give Resident #8 a bed bath. NA #1 indicated she unlocked the bed so she could move it away from the left wall in order to be able to fully access the resident from both sides to provide care. When the bed was moved away from the left wall it resulted in the nightstand being in closer proximity to the head of the bed on the right side. She stated she thought she had re-locked the bed after moving it away from the wall. NA #1 indicated she positioned herself on the left side of the bed (between the bed and the left wall), she went to roll the resident away from her (toward the right side of the bed), and both the resident and the bed began rolling away from her. NA #1 revealed she didn't realize the bed wheels weren't locked until the resident and bed began to move at the same time. She indicated to her knowledge; there was nothing wrong with the locking mechanism on the bed. NA #1 stated she grabbed Resident #8 across the middle of her torso and held her with all her strength. The resident was positioned with her head, shoulders and legs hanging off the bed with most of her weight being unsupported by the bed. NA #1 stated she yelled out for help while holding on to Resident #8. NA #1 stated NA #2 and NA #3 came into the room to assist her with trying to lift Resident #8 back onto the bed. NA #1 reported they were unable to assist Resident #8 back onto the bed and the three staff lowered Resident #8 down to the floor. NA #1 stated Resident #8 was positioned face down when they lowered her to the floor. She indicated that everything happened so fast, but she recalled Resident #8 stated that her head hurt. NA #1 stated she was not aware of whether Resident #8 had hit her head on the nightstand that was directly beside the bed but explained that there was nothing else the resident could have hit her head on.A statement dated 11/17/25 written by NA #3 revealed she was doing morning care rounds when she overheard NA #1 yelling for help. NA #3 indicated she stepped into the hall to follow the voice which led her to Resident #8's room. NA #1 was holding Resident #8 from the side of the bed in the resident's trunk area. NA #3 stated she helped NA #1 by holding Resident #8's leg and thigh area that was stuck between the geri-chair and the bed. NA #3 stated NA #2 overheard them yelling. NA #3 indicated that NA #2 came in and held Resident #8's head and arm that was hanging off the bed. NA #3 noted that she, NA #2 and NA #1 tried to push Resident #8 back onto the bed but there was no room to maneuver. NA #3 stated the bed continued moving so they lowered the resident slowly to the floor face down because there was no room to turn Resident #8. NA #3 indicated Resident #8 may have hit her head on the nightstand. NA #3 stated nursing was called for assistance after Resident #8 was lowered to the floor. NA #3 stated Nurse #2 entered the room once Resident #8 was on the floor and helped staff get the resident back on the bed with the mechanical lift.An interview was conducted with NA #3 on 1/14/26 at 1:58 PM. NA #3 reported she worked the 7:00 AM to 3:00PM shift on 11/17/25 and was not assigned to Resident #8. NA #3 stated she was in another resident's room when she heard someone yelling help, help. NA #3 stated she hurried down the hall following the voice. NA #3 reported when she entered Resident #8's room, NA #1 was holding Resident #8 on the bed by her torso. NA #3 indicated she (NA #3) began holding Resident #8's legs. She indicated NA #2 also heard yelling and provided assistance. NA #3 stated Resident #8's bed continued to move even though the three of them were trying to hold the resident steady. NA #3 reported that Resident #8's head was situated by the nightstand and the resident's geri-chair was on the same side as the nightstand. NA #3 explained that there was not a lot of space to maneuver the resident as they tried to assist her back on the bed. NA #3 stated she, along with NA #1 and NA #2, assisted Resident #8 to the floor. NA #3 reported Resident #8 was positioned faced down with her right arm beneath her once she was lowered to the floor. NA #3 stated she did not recall Resident #8 complaining of any pain. She indicated if the resident hit her head, she must have hit it on the nightstand that was directly next to the bed. NA #3 stated Nurse #2 came in and assessed Resident #8 and then Nurse #2 assisted NA #1 and NA #2 to transfer Resident #8 to the bed using the mechanical lift. A statement dated 11/17/25 written by NA #2 revealed she walked into Resident #8's room where 2 NAs (NA #1 and NA #3) were yelling for help. The resident was halfway on the bed, on her side and the NAs were holding onto her. NA #2 indicated she ran in and grabbed the resident's leg and the other 2 NAs were trying to keep the resident from rolling any further but saw that they could no longer hold her so they had to lower the resident to the floor.An interview was conducted with NA #2 on 1/14/26 at 1:37 PM. NA #2 stated she heard NA #1 yelling out for help and she hurried down the hall to Resident #8's room. NA #2 stated when she entered the room NA #1 was on the left side of the bed near the center of the bed and NA #3 was on the right side near the center of the bed. NA #2 stated NA #1 and NA #3 yelled at her to hurry up, hurry up and grab her leg. NA #2 reported that the three of them were unable to lift Resident #8 back onto the bed due to the resident's body weight not being supported by the bed. NA #2 stated they assisted Resident #8 to the floor and the resident complained of right shoulder pain because she was laying on her right shoulder. NA #2 indicated that Nurse #1 and Nurse #2 entered the room and assisted with assessing and positioning Resident #8. NA #2 stated she did not see Resident #8 hit her head. An interview was conducted with Nurse #1 on 1/14/26 at 3:02 PM. Nurse #1 reported she worked the 7:00 AM to 3:00 PM shift on 11/17/25. Nurse #1 stated she was the nurse that was assigned to Resident #8 on 11/17/25. Nurse #1 indicated she heard the staff yelling for help and when she entered the resident's room, Resident #8 was already on the floor facing down with her right arm underneath her. Nurse #1 stated Resident #8 was assessed by Nurse #2 and was able to move all four extremities. Nurse #1 reported that Nurse #2 informed her that Resident #8 denied any pain when completing range of motion. Nurse #1 stated Resident #8 was assisted by Nurse #2 to turn over. Nurse #1 revealed she was able to see that Resident #8 was visibly injured as the resident had a large knot on her forehead. Nurse #1 stated Resident #8 was not her usual talkative self, and she appeared to be in pain. Nurse #1 reported the resident complained of right arm pain when she was transferred from the floor to the bed using the mechanical lift. Nurse #1 stated Resident #8 had chronic generalized pain and took scheduled acetaminophen. Nurse #1 stated she completed a neurological check and there were no abnormalities. Nurse #1 indicated she called Emergency Medical Services to send Resident #8 out due to the large knot on her head and right arm pain. An interview was conducted with Nurse #2 on 1/14/26 at 3:32 PM. Nurse #2 reported he worked the 7:00 AM to 3:00 PM shift on 11/17/25. Nurse #2 stated he was not the nurse that was assigned to Resident #8. Nurse # 2 stated he was responding to the overhead page for Code Green (critical situation requiring immediate intervention). Nurse #2 stated when he entered Resident #8's room he observed the resident lying face down on her stomach with her right arm underneath her. Nurse #2 stated there were 4 or 5 staff already in the room when he arrived. He reported he assessed Resident #8 for pain, and she was able to move all four extremities. He indicated Resident #8 denied any pain during his assessment. Nurse #2 stated he assisted the three NAs in getting Resident #8 on the mechanical lift pad. Nurse #2 stated he did not recall seeing a bump on Resident #8's head but he did ask her about her right leg because she was positioned with the right leg underneath her. Nurse #2 stated Resident #8 denied any pain in her leg. The ED after summary visit dated 11/17/25 revealed Resident #8 was seen for a head injury and was diagnosed with a fall, closed head injury, and dislocation of her right shoulder. Resident #8 received Fentanyl (powerful opioid pain medication) intravenously (directly into the vein) for right shoulder pain. X-rays were conducted of the right shoulder and right humerus which revealed a right shoulder dislocation and a fracture of the right humerus. A CT (computed tomography) was conducted of the cervical spine and the head and there were no abnormalities. A sling was applied to the right arm for comfort. Orders were given to immobilize right arm, call the orthopedic surgeon to schedule your follow up appointment and Acetaminophen every 6 hours as needed for pain. A health status note dated 11/17/25 at 2:30 PM written by Nurse #1 revealed Resident #8 returned to her room via stretcher with her right eyelid darkened and right eye swollen closed. Resident #8 was alert and denied pain at that time. Resident #8 had her right arm in a sling.The November MAR revealed Resident #8 received her scheduled dose of acetaminophen 650 mg at 4:30 PM on 11/17/25 after return from ED. Resident #8 rated her pain at 0 on a scale of 0 to 10. The MAR further revealed that Resident #8's pain monitoring from 11/17/25 through 11/30/25 revealed her pain level ranged from 0 to 8. Resident #8's pain was managed with the scheduled Acetaminophen. A physician progress note dated 11/20/25 revealed Resident #8 was seen by the NP for follow up after the 11/17/25 fall. Resident #8 was sent to the ED due to a hematoma (a collection of blood that forms outside of the blood vessels) on her forehead and right shoulder dislocation. Resident #8 reported she was still having pain in her right arm and shoulder. Resident #8 indicated the lump on her head was tender but did not bother her otherwise. The resident denied any headaches or changes to her vision. She had an appointment on 11/20/25 with orthopedics and her arm was in a sling. An interview with the NP on 1/14/26 at 2:47 PM who monitored Resident #8 revealed she was made aware that Resident #8 had fallen and sustained a hematoma to the head by the on-call provider. She indicated she followed up with Resident #8 on 11/20/25 per staff request. She explained it was normal protocol for the in-house provider to see a resident after a fall. The NP stated Resident #8 was alert when she assessed her and complained of pain to her right shoulder and arm. She indicated this was pain from the injury to her right shoulder and arm. She explained that Resident #8 did have generalized pain and was on scheduled pain medication (acetaminophen) 4 times a day. She further explained that the resident had a history of chronic pain due to osteoarthritis and the acetaminophen was effectively managing the resident's pain to her shoulder and arm. The NP stated Resident #8 had a sling to her right arm and was scheduled to see orthopedics later that afternoon (11/20/25). Review of the orthopedic report of consultation dated 11/20/25 revealed Resident #8 was seen for right proximal humerus fracture dislocation and wore a shoulder sling/ brace for comfort. The consultation further revealed that surgery for the humerus fracture would be high risk for minimal benefit. The orthopedist ordered physical therapy for range of motion exercises. Resident #8 was to return for a follow-up appointment in 6 weeks with the orthopedist. Orthopedic documentation dated 1/6/26 indicated Resident #8 was seen by the orthopedist for follow up and the shoulder sling was removed.During an observation and interview of Resident #8 on 1/12/26 at 3:47 PM, the resident was sitting up in her geri-chair at the bedside. During the interview Resident #8 was confused and unable to give any details about the fall that occurred on 11/17/2025. Resident #8 denied any pain as a result of the fracture and dislocation.An interview with the Director of Nursing on 1/15/26 at 12:20 PM revealed she was notified by Nurse #1 of Resident #8's fall with hematoma to her forehead and complaint of right arm and shoulder pain on 11/17/25. The Director of Nursing obtained statements from staff and confirmed Resident #1 had a fall while being cared for by NA #1. The Director of Nursing stated NA #1, NA #2 and NA #3 verbally told her what happened and she had them write statements. The Director of Nursing stated it was likely this incident resulted in the right shoulder dislocation and fracture. She indicated that the resident did have chronic osteoarthritis. The Director of Nursing stated NA #1 should have made sure the resident's bed was locked and Resident #8 should have been a 2 person assist due to her size and physical limitations. She indicated the resident had been assessed for the number of staff needed to assist with providing care back in September 2025. She explained that Resident #8 had been able to assist the staff some with rolling her over on her side at that time.

Based on record review, and resident and staff interviews the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 10 of 33 residents reviewed for advance directives (Residents #2, #14, #22, #42, #45, #49, #72, #80, #109, and #427). The findings included: a. Review of Resident #2's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease, and a history of a stroke. The review revealed a full code Physician order dated 8/23/24. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. b. Review of Resident #14's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, and kidney failure. The review revealed a full code Physician order dated 10/18/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. c. Review of Resident #22's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and chronic obstructive pulmonary disease. The review revealed a do not resuscitate Physician order dated 7/10/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #42's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. The review revealed a do not resuscitate Physician order dated 8/24/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. e. Review of Resident #45's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke, heart failure, and diabetes. The review revealed a full code Physician order dated 7/26/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. f. Review of Resident #49's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included high blood pressure and seizure disorder. The review revealed a do not resuscitate Physician order dated 10/4/24. The was no documentation in the record for education regarding a formulation of an advance directive and/or the opportunity to formulate an advance directive was offered. g. Review of Resident #72's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and diabetes. The review revealed a do not resuscitate Physician order dated 1/17/22. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. h. Review of Resident #80's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease, diabetes, and a history of a stroke. The review revealed a full code Physician order dated 4/12/23. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. i. Review of Resident #109's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and diabetes. The review revealed a do not resuscitate Physician order dated 7/1/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. j. Review of Resident #427's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and kidney failure. The review revealed a do not resuscitate Physician order dated 10/9/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive was offered. An interview was completed on 10/22/24 at 1:30pm with the facility's Administrator. She revealed at this time the facility only discussed the resident's code status with the resident and/or their responsible party. An interview was completed on 10/23/24 at 11:37am with the facility's Admission's Director. The Admission's Director stated she only discussed code status with the resident and/or their responsible party. An interview was completed on 10/23/24 at 12:07pm with the facility's Social Worker. The Social Worker stated she only reviewed the resident's code status with the resident and/or responsible party. A follow-up interview was completed on 10/24/24 at 11:41am with the facility's Administrator. The Administrator stated the Social Worker was new to the position. She stated the Social Worker was unaware of the requirement for providing education regarding the formulation of an advance directive, not just regarding a resident's code status.

Based on observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when 1) Unit Manager #2 failed to wear a gown and did not perform hand hygiene between glove changes while performing tracheostomy care for a resident on Enhanced Barrier Protection (EBP) (Resident #112), 2) when the Wound Treatment Nurse failed to perform hand hygiene between glove changes during the observation of wound treatment (Resident #115), and 3) when Nurse Aide #1 was observed carrying uncontained dirty linen in the hallway. The facility also failed to implement its hand hygiene policy when Nurse Aide #1 failed to perform hand hygiene and remove gloves before entering and exiting 2 of 2 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER]) observed for infection control practices. The findings included: The facility's Infection Prevention and Control Program policy last updated 10/01/23 indicated all staff should assume that all residents were potentially infected or colonized with an organism that could be transmitted while providing resident care services. The policy stated hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. The policy further noted all staff shall use personal protective equipment (PPE) according to the established policy governing the use of PPE. Further review of the Infection Prevention and Control Program policy revealed in part soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled linen room. The facility's Enhanced Barrier Precautions (EBP) policy dated 4/01/24 revealed EBP was an infection control intervention designed to reduce transmission of multidrug-resistant organisms that used targeted gown and glove use during high contact resident care. The policy further stated EBP would be initiated for any resident with indwelling medical devices (such as tracheostomy tubes and feeding tubes) and wounds (such as pressure ulcers). The policy noted that personal protective equipment (PPE) for EBP was only necessary when performing high-contact care activities which included wound care and device care such as tracheostomy care. Review of the facility's Hand Hygiene policy last updated 10/01/22 indicated hand hygiene was to be conducted before resident care procedures, before and after handling clean or soiled linens, before applying and after removing personal protective equipment (PPE), including gloves. 1a. Resident #112 had signage posted on the door that alerted staff that the resident was on EBP. The signage noted that providers and staff must wear gloves and gown for the following high-contact resident care activities which included device care or use including tracheostomy. A large double door cabinet was observed in the hall stocked with PPE, which included disposable gowns. A continuous observation was conducted on 10/23/24 from 9:48 am through 10:35 am of tracheostomy care for Resident #112. Unit Manager #2 was observed to enter Resident #112's room, perform hand hygiene with hand sanitizer, and prepare supplies for tracheostomy care. Unit Manager #2 was observed to perform hand hygiene, don sterile gloves and began tracheostomy care for Resident #112 without a disposable gown in place. Unit Manager #2 was observed to touch the sterile supplies with her dirty glove and stopped tracheostomy care, removed supplies, removed gloves, completed hand hygiene, and left Resident #112's room to obtain more supplies. At 10:02 am Unit Manager #2 returned to Resident #112's room with additional supplies, performed hand hygiene, donned gloves, and prepared supplies. Unit Manager #2 was observed to perform hand hygiene, donned sterile gloves, and began tracheostomy care for Resident #112 without a disposable gown in place. #2 Unit Manager #2 completed Resident #112's tracheostomy care at 10:35 am, which included suctioning, without a disposable gown in place throughout the observation. An interview was conducted with Unit Manager #2 on 10/23/24 at 3:05 pm. Unit Manager #2 confirmed Resident #112 was on EBP for the tracheostomy, and staff were required to wear a disposable gown when tracheostomy care and suctioning were performed for Resident #112. She stated she did not realize she did not wear one until she was asked by this surveyor if Resident #112 was on EBP. Unit Manager #2 stated disposable gowns were readily available for use and it should have been used during the tracheostomy care observation. An interview was conducted with the Infection Preventionist (IP) on 10/24/23 at 8:55 am who revealed all staff, which included Unit Manager #2, had been educated on the use of proper PPE for residents on EBP. The IP stated PPE supplies including disposable gowns were available outside of Resident #112's room and the gown should have been on when Unit Manager #2 performed tracheostomy care. b. A continuous observation was conducted on 10/23/24 from 9:48 am through 10:35 am of tracheostomy care for Resident #112. At 10:23 am Unit Manager #2 was observed to place a sterile suction kit on Resident 112's overbed table, perform hand hygiene, open the sterile kit and attempt to don the sterile gloves. Unit Manager #2 was unable to don the sterile gloves fully and removed the sterile gloves and placed the gloves in the trash. Unit Manager #2 then opened Resident #112's bottom dresser drawer and obtained a new sterile suction kit and placed the kit on the overbed table. Unit Manager #2 was observed to open the sterile suction kit and place the sterile gloves from inside the kit onto her hands without performing hand hygiene after obtaining supplies from Resident #112's drawer. Unit Manager #2 was observed to complete Resident #112's tracheostomy care and suctioning, removed gloves and performed hand hygiene. During an interview on 10/23/24 at 3:05 pm with Unit Manager #2 she revealed she was required to perform hand hygiene between glove changes when she performed Resident #112's tracheostomy care. Unit Manager #2 stated she changed the gloves so often during the observation that she just forgot to do hand hygiene after getting more supplies from the drawer and before she put on the sterile gloves to suction Resident #112's tracheostomy. An interview was conducted with the Infection Preventionist (IP) on 10/24/23 at 8:55 am who revealed all staff, which included Unit Manager #2, had received education on hand hygiene and the education was completed yearly and as needed. She stated hand hygiene was to be completed before gloves were donned and again when gloves were removed. The IP stated Unit Manager #2 was required to perform hand hygiene before donning the sterile gloves from the suction kit when tracheostomy care was provided to Resident #112. During an interview on 10/24/24 at 10:48 am with the Interim Administrator she revealed all staff were required to follow the facility's infection prevention and control program policies. 2. During a continuous observation of a pressure ulcer treatment on 10/23/24 at 3:39 pm through 3:54 pm the Wound Treatment Nurse was observed to perform hand hygiene, don clean gloves, and remove Resident #115's soiled dressing from the right hip. The Wound Treatment Nurse then removed the soiled gloves, and donned clean gloves without performing hand hygiene. The Wound Treatment Nurse then cleansed the right hip wound bed with gauze and normal saline and prepared and placed the wound dressing on Resident #115's right hip wound. The Wound Treatment Nurse did not remove the dirty gloves or perform hand hygiene after cleansing the wound bed or before preparing and placing the wound treatment dressing on Resident #115's right hip wound. Resident #115 then turned onto the right side and the Wound Treatment Nurse removed the soiled dressing from the left hip. The Wound Treatment Nurse then removed the soiled gloves and without performing hand hygiene, donned clean gloves and cleansed the left hip wound with gauze and normal saline. The Wound Treatment Nurse prepared the new dressing and placed the dressing on Resident #115's left hip without removing the dirty gloves or performing hand hygiene after cleansing the wound bed and before placing the new wound dressing on Resident #115's left hip. The Wound Treatment Nurse then removed the soiled gloves and performed hand hygiene. An interview was conducted on 10/23/24 at 3:55 pm with the Wound Treatment Nurse who revealed the dirty gloves should have been removed after the wound bed was cleansed and hand hygiene should have been completed between the glove changes. The Wound Treatment Nurse stated she just realized that she did not change gloves and perform hand hygiene in between glove changes during the observation. The Wound Treatment Nurse was unable to say why she did not change her gloves when moving from dirty to clean or perform hand hygiene between glove changes, but she confirmed she had received education on proper PPE use and handwashing. During an interview on 10/24/24 at 9:03 am with the Infection Preventionist (IP) she stated hand hygiene education was completed for all staff annually and as needed. The IP stated the Wound Treatment Nurse was educated to complete hand hygiene between glove changes and to change gloves when moving from dirty to clean tasks. During an interview on 10/24/24 at 10:48 am with the Interim Administrator she revealed all staff were required to follow the facility's infection prevention and control program policies. 41772 3. A continuous observation was conducted on 10/24/24 at 9:01 AM. Nurse Aide #1 was observed to exit room [ROOM NUMBER] with gloved hands. Nurse Aide #1 removed the gloves and walked across the hall to room [ROOM NUMBER] without performing hand hygiene. Nurse Aide #1 returned to room [ROOM NUMBER] without performing hand hygiene. Nurse Aide #1 was observed exiting room [ROOM NUMBER] with gloved hands and carrying dirty linen that was not contained in a plastic bag. Nurse Aide #1 was observed to walk down the 700 hall and turn the doorknob to the dirty laundry room door. An interview was conducted with Nurse Aide #1 on 10/24/24 at 9:07 AM. Nurse Aide #1 stated she was aware that she was supposed to carry dirty linen in a plastic bag and remove her gloves when exiting a resident's room. Nurse Aide #1 stated she did not have any plastic bags, so she carried the linen to the dirty laundry room with her gloves on. Nurse Aide #1 stated she was unaware that she had not performed hand hygiene after removing her gloves and before entering room [ROOM NUMBER]. An interview was conducted with the Director of Nursing (DON) on 10/24/24 at 9:32 AM. The DON stated Nurse Aide #1 should have had plastic bags available, taken off her gloves and immediately washed her hands before leaving the room. The DON further stated Nurse Aide #1 should have performed hand hygiene between resident rooms.

Based on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of a resident transfer for 2 of 5 residents reviewed for hospitalization (Resident #2 and Resident #42). The findings included: 1a. Resident #2 was admitted to the facility on [DATE]. The nursing progress note dated 7/02/24 at 3:00 pm revealed Resident #2 was transferred to the hospital for evaluation of change in mental status. Resident #2 was discharged from the facility on 7/02/24 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #2's 7/02/24 transfer to the hospital on 10/23/24. b. The nursing progress note dated 8/12/24 at 3:38 pm revealed Resident #2 was transferred to the hospital for evaluation of altered mental status. Resident #2 was discharged from the facility on 8/12/24 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #2's 8/12/24 transfer to the hospital on 10/23/24. 2a. Resident #42 was admitted to the facility on [DATE]. The nursing progress note dated 7/21/24 at 9:00 am revealed Resident #42 was transferred to the hospital for evaluation. Resident #42 was discharged from the facility on 7/21/24 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #42's 7/21/24 transfer to the hospital on 10/23/24. b. The physician progress note dated 8/20/24 revealed Resident #42 was transferred to the hospital for further evaluation. Resident #42 was discharged from the facility on 8/20/24 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #42's 8/20/24 transfer to the hospital on 10/23/24. A telephone interview was conducted on 10/23/24 at 03:29 pm with the Ombudsman who revealed she had not received written notification of hospitalization discharges for the last 6 months. An interview was conducted with Social Worker #1 on 10/23/24 at 3:49 pm who revealed she started working at the facility in April 2024 and she was educated at that time to send the transfers and discharges to the Ombudsman. Social Worker #1 stated she had not sent any discharge and transfer information to the Ombudsman since she started at the facility because she forgot the information was to be sent monthly. Social Worker #1 reported it was her fault that she had not sent the information to the Ombudsman prior to today (10/23/24). During an interview on 10/24/23 at 10:24 am with the Interim Administrator she revealed she was not sure why Social Worker #1 had not sent any information to the Ombudsman. The Interim Administrator stated Social Worker #1 was educated upon hire, but she felt Social Worker #1 just forgot to send the lists to the Ombudsman monthly.

Based on observation, record reviews, staff interviews, the facility failed to ensure there was a physician's order in place for the size of an indwelling urinary catheter and frequency to change the indwelling urinary catheter for 1 of 1 resident reviewed for catheters (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included disorder of kidney and ureter. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment with no behaviors present. He was coded as dependent on staff for toileting and had an indwelling urinary catheter. A review of a care plan dated 10/5/24 revealed Resident #49 was care planned for an indwelling urinary catheter. The goal was for Resident #49 to be/remain free from catheter-related trauma and have no signs and symptoms of urinary tract infection through review date. The interventions included monitor and document sign and symptoms of infection. Review of a physician's order revealed an order dated 10/7/24 for a size 20 French (FR) urinary indwelling catheter. Review of a physician progress note dated 10/8/24 revealed Resident #49 had a chronic catheter and was admitted to the hospital for possible infection. Review of a health status note dated 10/17/24 revealed Resident #49 was out to a urology appointment and returned with no new orders. A review of the consultation progress notes for urology dated 10/17/24 revealed an order to change 16 FR indwelling urinary catheter every month and call office with issues. A review of the electronic health record revealed no order in place for 16 FR indwelling urinary catheter change every month. An observation was conducted of Resident #49 with Nurse Aide #4 on 10/23/24 at 09:45 AM. Resident #49 had a 16 French indwelling urinary catheter that was connected to a urinary drainage bag. An interview was conducted with Unit Manager #2 on 10/23/24 at 03:39 PM. She stated Medical Records was out during the week of October 17th. The Unit Manager stated she was responsible for taking off the orders. She reported that Medical Records Clerk normally scanned in the information from consults and would either call on the phone to let her know to review or she would bring her a stack of consults for her to review. An interview was conducted with the Medical Records Clerk on 10/23/24 at 3: 48 PM. She stated she reviewed the information from consults when a resident returned for an appointment. The Medical Record Clerk stated she scanned the consults into the electronic medical records then gave the hard copy of the consult to the unit manager. An interview was conducted on 10/23/24 at 3:59 PM. The Interim Administrator verified the medical records clerk scanned the consults into the system. The Administrator stated the unit managers were responsible for entering the orders into the electronic medical record when the residents returned from appointments.

Based on observations, record review, and staff, resident, Respiratory Therapist, and Nurse Practitioner interviews, the facility failed to obtain a physician order for liters of oxygen and the fraction of inspired oxygen (FiO2) for a resident with a tracheostomy for 1 of 1 resident reviewed for respiratory care (Resident #112). The findings included: Review of the hospital speech therapy consultation provided by the facility dated 9/05/24 revealed Resident #112 had a tracheostomy (a surgical opening through the front of the neck into the windpipe for an air passage to help breathe) and was on a trach collar (a soft plastic mask that fits over the tracheostomy) with 5 liters of oxygen with 28% FiO2 (percentage of oxygen in the air that a person inhales). Review of the hospital discharge summary dated 9/08/24 revealed no orders were noted for Resident #112's oxygen or FiO2 settings. Resident #112 was readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypercapnia (carbon dioxide retention), pneumonia, and tracheostomy. Review of the nursing progress note dated 9/08/24 at 11:08 am by Nurse #3 revealed Resident #112 was scheduled to return to the facility from the hospital in the afternoon. Nurse #3 further noted that Resident #112 had a tracheostomy and would be returning to the facility on 5 liters of oxygen at 28% FiO2. An attempt to interview Nurse #3 on 10/24/24 at 12:30 pm was unsuccessful. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #112 had clear speech and was cognitively intact. Resident #112 was coded for oxygen therapy, suctioning, and tracheostomy. The care plan dated 9/21/23 and last reviewed on 10/03/24 revealed Resident #112 had a care plan in place for tracheostomy related to impaired breathing mechanics with an intervention of oxygen settings via trach at 5 liters continuous with 28% humidity. A record review conducted on 10/21/24 of the physician orders revealed no orders for oxygen or FiO2 settings for Resident #112's tracheostomy. An observation and interview conducted with Resident #112 on 10/21/24 at 10:45 am revealed Resident #112's oxygen concentrator (a machine that gives extra oxygen) was set to 5 liters and the compressor's (machine that pushes air through a bottle of water to pick up moisture) FiO2 was set to 35%. The oxygen tubing was noted to be connected to the concentrator water humidification bottle which was connected to the tracheostomy tubing and Resident#112's trach collar. Resident #112 was observed in bed with no respiratory distress noted. Resident #112 stated she had the tracheostomy for about one year and had just been in the hospital. During an interview on 10/22/24 at 2:01 pm with Medication Aide #1 she revealed she was assigned to Resident #112's hall but she was not able to do the respiratory care since she was not a nurse. Medication Aide #1 stated Unit Manager #2 was responsible for Resident #112's care due to the tracheostomy. An observation of Resident #112's room with Unit Manager #2 was conducted on 10/22/24 at 2:07 pm. Resident #112 was noted to be in bed with the trach collar in place. Unit Manager #2 confirmed Resident #112's oxygen was set to 5 liters and the FiO2 was set to 35%. An interview with Unit Manager #2 was conducted on 10/22/24 at 2:18 pm. Unit Manager #2 revealed Resident #112's settings for the oxygen at 5 liters and 35% FiO2 were her normal settings since returning from the hospital, and the physician order should be in the computer. Unit Manager #2 confirmed no physician orders were in place for Resident #112's 5 liters of oxygen or 35% FiO2 for the tracheostomy. She stated she recalled being told in report from the hospital that Resident #112 was coming back to the facility with 5 liters of oxygen and the FiO2 was at 35% but she would have to look for the discharge information to review and confirm. Unit Manager #2 stated she was responsible for entering Resident #112's physician orders and was unable to state why the oxygen and FiO2 orders were not put back in place when Resident #112 returned to the facility from the hospital. An interview was conducted on 10/24/24 at 9:27 am with the Nurse Practitioner (NP) who revealed the provider did not determine the settings required for Resident #112's tracheostomy. The NP stated it was the facility's standard practice to obtain Resident #112's tracheostomy oxygen and FiO2 settings when she returned to the facility and once obtained the provider would confirm and sign the order. A telephone interview was conducted on 10/24/24 at 9:52 am with the Respiratory Therapist (RT) who revealed she last saw Resident #112 on 10/09/24 for a tracheostomy change only and she did not review any orders at that time. The RT stated Resident #112's settings would normally come from the hospital discharge record or if needed she could provide. The RT stated she was fine with the setting of 35% for the FiO2 for Resident #112 because the FiO2 setting was for humidification purpose only. The RT stated when a trach collar was used for Resident #112's tracheostomy, the oxygen order and FiO2 settings were needed. An interview was conducted with the previous Director of Nursing (DON) on 10/24/24 at 9:06 am who revealed Resident #112's oxygen and FiO2 settings would have been received by the hospital or given in report from the hospital. The previous DON stated Unit Manager #2 was responsible to obtain Resident #112's orders and confirm the orders with the NP. The previous DON stated admission orders were reviewed during the clinical meetings, and she stated the missed orders for Resident #112's oxygen and FiO2 settings should have been identified when reviewed during the clinical meeting. The previous DON was unable to state how the orders for Resident #112 were missed for so long.

Based on observation, staff interviews, the facility failed to dispose/discard expired medications in 2 of 4 medication carts (200 Hall, 700 Hall medication cart) observed for medication storage. The findings included: 1a. An observation was conducted of the 700 Hall medication cart on 10/22/24 at 11:43 AM. One opened bottle of Simethicone 80 milligrams (mg) had an expiration date of July 2024. An interview was conducted with Medication Aide #2. Mediation Aide #2 stated the medication should have been discarded. Medication Aide #2 stated the medication aide/nurse assigned to the cart was responsible for checking for expired medications each shift. 1b. An observation of the 200 Hall medication cart on 10/22/24 at 11:43 AM revealed an open bottle of Moxifloxacin 0.5% eye drops with a prescription filled date of 9/20/24 and had an open date of 9/20/24. The bottle was labeled by the pharmacy: Administer 3 drops to right eye 3 times a day for 3 days. The manufacturer's package insert indicated any unused ophthalmic moxifloxacin should be discarded 30 days after you first opened the bottle to avoid getting another eye infection. The moxifloxacin medication was outdated and not discarded from the medication cart. An interview was conducted with Medication Aide # 3. Medication Aide #3 stated the medication should have been discarded once the resident completed the doses. Medication Aide #3 stated the medication aide/nurse assigned to the cart was responsible for checking for expired medications each shift An interview was conducted with the Interim Director of Nursing and Interim Administrator on 10/22/24 at 3:28 PM. The interim Administrator stated the medication aides and nurses assigned to the medication cart were responsible for checking carts for expired medication. The Administrator stated expired medications were to be removed from the cart immediately.

Based on record review and staff interviews, the facility failed to sign off documentation for physician orders of cleansing area to right ankle and applying Calcium Alginate and Cleanse left lateral ankle and apply Santyl ointment daily, in the Treatment Administration Records (TAR) for 1 of 2 reviewed residents for treatment (Resident #94). Resident #94's TAR had blanks where staff were to indicate if treatment was administered or an indication that the treatment was not administered with an explanation on the reverse side of the TAR for 1 of 2 residents reviewed for documentation (Resident #94). The findings included: Physician orders for Resident #94 dated 9/20/24 revealed orders for cleansing area to right lateral ankle and applying of calcium alginate with silver cover with superabsorbent gelling fiber with silicone border to promote wound healing daily. Physician orders for Resident #94 dated 9/27/24 revealed an order for cleansing left lateral ankle and apply Santyl ointment to plain calcium alginate daily. During a telephone interview with Nurse #1 on 10/24/24 at 8:10 A.M. she revealed she provided care to Resident #94 regularly but was not aware she did not sign off on the TAR on 10/3/24, 10/5/24, 10/6/24, 10/10/24, 10/13/2024, 10/19/24, and10/20/24. During an interview with Nurse #2 on 10/24/2024 at 8:17 A.M. She revealed she provided Resident #94's wound care on 10/19/24 at 10 P.M. but could not remember why she did not document the treatment on the TAR. A telephone interview with Unit Manager #1 on 10/24/24 at 8:30 A.M. revealed she was not sure why nursing staff failed to document wound care provided to Resident #94 on the TAR on 10/3/24, 10/5/24, 10/6/24, 10/10/24, 10/13/2024, 10/19/24, and10/20/24. She further stated nursing staff are required to document whether Resident #94 agreed to or declined care. In an interview with the Director of Nursing (DON) on 10/24/24 at 9:11 A.M. she revealed nursing staff were required to document medication administration even when there is a refusal. During an interview with the Administrator on 10/24/24 at 9:15 A.M. she stated that nursing staff are required to document the care provided to residents.

Based on observations and staff interviews, the facility failed to maintain a clean and sanitary homelike environment as evidenced by dried substance on the top and front of an oxygen concentrator and dried enteral feeding on the floor for 1 of 4 rooms reviewed for environment (room [ROOM NUMBER]). The findings included: An observation was conducted on 10/21/24 at 11:02 am in room [ROOM NUMBER] the oxygen concentrator was observed to have a dried beige substance on the top and multiple dried lines down the front of the concentrator. The floor had multiple round, dime sized, brown hardened substance on the floor near the feeding tube pole and resident bed. Observations of room [ROOM NUMBER] conducted on 10/22/24 at 1:59 pm and 10/23/24 at 9:38 am revealed the oxygen concentrator was observed to have multiple dried, beige, substance on the top and dried in lines down the front of the concentrator. The floor had multiple round in shape, dime sized, brown hardened substance on the floor near the feeding tube pole and resident bed. An observation and interview were conducted with the Housekeeping Manager on 10/23/24 at 11:22 am. The Housekeeping Manager revealed that all resident rooms were cleaned daily using the 5 and 7 step method which included sweeping, mopping, wiping outer surfaces of furniture and equipment used such as the concentrator and wheelchair. The Housekeeping Manager confirmed the oxygen concentrator was something that should have been wiped down daily by the housekeeping staff and the floor where the dried enteral feeding was observed was to be mopped every day. The Housekeeping Manager stated he did random checks of resident rooms to ensure the cleaning was being completed, but he had not checked room [ROOM NUMBER] to ensure it was done properly. During an interview on 10/23/24 at 11:39 am with Housekeeper #1 who confirmed she was assigned to room [ROOM NUMBER] on 10/20/24, 10/22/24, and 10/23/24. Housekeeper #1 stated she cleaned room [ROOM NUMBER] on 10/20/24 but was unable to get the dried substance off the floor in the room, but she did not see the concentrator was dirty. She stated she did not notify the manager regarding room [ROOM NUMBER]'s floor, but she stated she should have reported that she was unable to get the floor clean. Housekeeper #1 stated she went into room [ROOM NUMBER] on 10/22/24 to clean but did not clean the room because the nurses were doing something with the tube feeding. She stated she should have gone back to room [ROOM NUMBER] to clean later but she never went back. Housekeeper #1 stated she told the resident when she went in the room today (10/23/24) that she would be back later to clean the room but had not been to room [ROOM NUMBER] to clean yet. An interview was conducted on 10/24/24 at 12:10 pm with the Interim Administrator who stated resident rooms were to be cleaned daily.

Based on observations and staff interviews, the facility failed to maintain the area surrounding the grease bin free of grease buildup and debris. This included 1 of 1 grease bin observed. The findings included. During an observation of the dumpster area on 3/27/23 at 9:45 AM the grease bin was observed. The 4 foot lip of the grease bin was observed with grease dripping down and the ground was soiled with thick black layers of grease buildup. On 3/28/23 at 3:37 PM an observation was conducted with the Dietary Manager and the grease bin was observed to be in the same condition. An interview was conducted with the District Dietary Manger on 3/28/23 at 4:11 PM. She revealed the maintenance director had removed the grease and would pressure wash the area. In an interview on 3/29/23 at 9:08 AM, the Maintenance Director indicated he had noticed the grease bin and planned to contact the company to replace it. He revealed he had shoveled up the grease, power washing was unable to clean the stain off the cement pad and he would find a compatible chemical to clean the area. An interview was conducted with the Interim Administrator on 3/28/23 at 4:24 PM. He revealed they would get the area cleaned up.

Based on observation, record review and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 1 resident (Resident #47) reviewed for self-administration of medication. The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. The resident ' s care plan dated 1/16/23 did not include the self-administration of medication. There was not an assessment for Resident #47 in the medical record to determine if it was safe for the resident to self -administer medication. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. On 3/26/23 at 11:13 AM Resident #47 was observed lying on the bed with a cup containing 7 tablets sitting on the bedside table. Resident #47 was resting on the bed with his eyes closed. An interview was conducted with Medication Aide #1 on 3/26/23 at 11:15 AM. Medication Aide #1 stated she had left Resident #47 ' s medication at the bedside because he was not awake. The Medication Aide stated she had been told by other staff she could leave Resident #47 ' s medication at the bedside and he would take it when he woke up. Further interview with Medication Aide #1 revealed that she had been educated not to leave resident ' s medication at the bedside. During an interview with the Director of Nursing on 3/28/23 at 3:44 PM. The DON stated the Medication Aide should have made sure Resident #47 took his medication or attempted to offer the medication at a later time. The DON stated medication should never be left at a resident ' s bedside.

Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to obtain physician orders for supplemental oxygen (Resident #74) and tracheostomy care and suctioning (Resident #82) for 2 of 5 residents reviewed for respiratory care. Findings included: 1. Resident #74 was readmitted to the facility on [DATE] and had cumulative diagnoses which included asthma, low blood oxygen, and stroke. Record review of the hospital discharge record dated 2/13/23 revealed Resident #74 was diagnosed with COVID-19, acute hypoxic (low blood oxygen) failure, and he did not have an order for supplemental oxygen upon discharge. The care plan dated 2/15/23 revealed Resident #74 had a care plan for oxygen therapy related to respiratory illness with intervention to provide oxygen 2 L via nasal canula (NC) continuous humidified. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #74 had severe cognitive impairment and was coded for oxygen use. Observations on 3/26/23 at 10:51 am and 3/27/23 at 1:51 pm revealed Resident #74 had oxygen at 3 L via NC in use. A record review conducted on 3/27/23 of the physician orders revealed no order for supplemental oxygen use for Resident #74. During an interview on 3/27/23 at 2:50 pm Nurse #2 confirmed Resident #74 had oxygen at 3 LNC in place. She stated a physician order was required for Resident #74's oxygen but she was unable to find the order. Nurse #2 was unable to state why the order for Resident #74's supplemental oxygen was not in place. An interview was conducted on 3/29/23 at 9:20 am with Nurse #3, who was assigned to Resident #74 upon return from hospital, revealed she completed Resident #74's readmission and was given in report from the transportation staff that Resident #74 was on oxygen at 2L via NC. She stated she was unable to state why the order for supplemental oxygen for Resident #74 was not entered but stated the oxygen did require a physician order. During an interview on 3/28/23 at 12:30 pm the Nurse Practitioner (NP) revealed she was not aware Resident #74 was on supplemental oxygen, but she stated a physician order was required. An interview was conducted on 3/29/23 at 11:29 am with the Director of Nursing (DON) who revealed the supplemental oxygen for Resident #74 required a physician order. The DON stated Resident #74's supplemental oxygen order was just missed. 20710 2. Resident #82 was readmitted on [DATE] with diagnoses that included chronic respiratory failure, coronary artery disease, and tracheostomy status. Review of the quarterly Minimum Data Set completed on 12/5/22 revealed Resident # 82 was severely cognitively impaired. The MDS coded the resident as receiving oxygen use, suctioning and tracheostomy care. The care plan dated 5/27/20 and updated on 10/8/22 revealed Resident #82 had a care plan for tracheostomy care related to respiratory illness with intervention to provide suctioning and change tracheostomy inner cannula every day. Record review of the physician orders dated 6/22/22 revealed Resident #82 had an order to suction the tracheostomy every shift for respiratory distress/ increased secretion. The order was discontinued on 11/25/22. Record review of the physician orders revealed an order dated 8/24/22. Review of the order revealed Resident #82 had an order to change tracheostomy inner cannula every day every evening shift. The order was discontinued on 11/25/22. A record review conducted on 3/28/23 of the physician orders revealed no order for suctioning tracheostomy for Resident #82. A record review conducted on 3/28/23 of the physician orders revealed no order for provide trach care for Resident #82. An interview was conducted on 3/29/23 at 11:02 AM with the Director of Nursing (DON) who revealed the Nurse managers would read over the physician orders and treatments from the Discharge Summary orders and put the orders into the record. She revealed if there were no physician orders the nurse manager should call the physician or hospital to get their discharge orders. She indicated Resident #82 should have orders for tracheostomy care and suctioning.

Based on observations, staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 1/14/22 complaint and recertification survey. This was for a recited deficiency on the current recertification survey in the area of respiratory/tracheostomy care and suctioning and dispose garbage and refuse properly. The continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F814 Based on observations and staff interviews, the facility failed to maintain the area surrounding the grease bin free of grease buildup and debris. This included 1 of 1 grease bin observed. During the recertification and complaint survey on 1/14/22 the facility was cited for failure to maintain the area around the dumpster free of debris. F695 Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to obtain physician orders for supplemental oxygen (Resident #74) and tracheostomy care and suctioning (Resident #82) for 2 of 5 residents reviewed for respiratory care. During the recertification and complaint survey on 1/14/22 the facility was cited for failure to obtain a Physician's order for use of supplemental oxygen. An interview was completed on 3/29/23 at 1:45pm with the Director of Nursing (DON) and Administrator. The DON indicated the QAA committee meets monthly to discuss the facility's ongoing performance improvement plans. The DON revealed there were no ongoing performance improvement plans regarding respiratory care or maintaining the cleanliness of the area surrounding the dumpster. The DON and Administrator stated it was their expectation that the facility identify deficient practice and create performance improvement plans to correct the deficient practice.

Based on record review and staff interviews, the facility failed to develop a comprehensive, individualized care plan that addressed Hospice services for 2 of 2 sampled residents reviewed for Hospice services (Resident #102 and Resident #56). Findings included: 1. Resident #102 was admitted to the facility on [DATE]. A review of Resident #102's medical record revealed the Resident's family signed the consent for hospice services to begin on 12/19/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was coded as receiving Hospice services. A review of the Resident #102's comprehensive care plan most recently reviewed on 3/27/23 revealed no identification or incorporation of Hospice services. An interview was completed on 3/29/23 at 8:40am with the MDS Coordinator. She confirmed Resident #102 was receiving hospice services. The comprehensive care plan was reviewed with the MDS Coordinator, and she confirmed there was no inclusion of the Resident's hospice services in her care plan. The MDS Coordinator stated hospice services should have been included in Resident #102's comprehensive care plan. An interview was completed on 3/29/23 at 12:22pm with the Director of Nursing (DON). The DON indicated Resident #102's comprehensive care plan included a terminal illness care plan, and it should have been customized to include hospice services. 41772 2.Resident #56 was admitted to the facility on [DATE]. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was admitted to Hospice care. A review of Resident #56's comprehensive care plan last reviewed 3/10/23 did not reveal a care plan related to Hospice services. During an interview with MDS Coordinator on 3/29/23 at 9:40 AM she confirmed Resident #56 was receiving hospice services. A review of the comprehensive care plan with the MDS Coordinator revealed there were no hospice services included in Resident #56's care plan. The MDS Coordinator stated hospice care should have been included in the Resident's care plan. An interview was conducted with the Director of Nursing (DON) on 3/29/23 at 1:30 PM. The DON stated Resident #56's comprehensive care plan should have included a hospice care plan. She further stated the care plan should have been customized to include hospice services.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately for 2 of 27 residents whose MDS was reviewed (Resident #67 and Resident #107). Findings included: 1. Resident #67 was admitted to the facility on [DATE] with diagnoses which included stroke and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #67 was coded as comatose, and he required oxygen, suctioning, and tracheostomy (surgical airway to assist with breathing) care. Resident #67's cognition was not assessed related to him being rarely/never understood. An observation on 3/26/23 at 2:00 pm revealed Resident #67 was awake and alert, did not have oxygen in use, and did not have a tracheostomy. An interview on 3/26/23 at 2:30 pm Nurse #2 revealed Resident #67 was awake and alert with periods of confusion but was able to make his needs known. She stated he did not have a tracheostomy, use oxygen, or require suctioning. Nurse #2 stated she reviewed Resident #67's previous physician orders and documentation and confirmed he was awake and alert since admission and never had a tracheostomy, he never required suctioning, and had not been on oxygen. During an interview on 3/27/23 at 2:53 pm the MDS Nurse reviewed Resident #67's health record and confirmed Resident #67 was not comatose, he did not have a tracheostomy or require oxygen and suctioning. The MDS Nurse stated she coded Resident #67 in error. An interview was conducted on 3/29/23 at 11:26 am with the Director of Nursing (DON) who revealed Resident #67 was never comatose, he never had a tracheostomy, and he did not require suctioning. The DON stated the MDS Nurse was responsible to complete an accurate assessment for Resident #67 based on observation and record review. 2. Resident #107 was admitted to the facility on [DATE] with an unstageable pressure ulcer injury to his sacrum. The Skin/Wound/Treatment note dated 1/25/23 revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum. A physician order dated 1/25/23 for sacrum cleanse with wound cleaner, apply silver alginate (wound treatment) and cover with folded pad secured with tape every evening shift and as needed for unstageable pressure ulcer. The Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed Resident #107 had an unstageable pressure ulcer injury which was present upon admission to the facility. The Weekly Wound Observation Tool dated 2/01/23 revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum. A nursing progress note dated 2/01/23 revealed Resident #107 was sent to the hospital for hematuria (blood in urine) and was admitted . a. The MDS discharge return anticipated assessment dated [DATE] revealed Resident #107 did not have an unstageable pressure ulcer injury. The Skin/Wound/Treatment note dated 2/07/23 revealed Resident #107 returned to the facility and had an unstageable pressure ulcer injury to his sacrum/left buttock. b. The MDS 5-day admission assessment dated [DATE] revealed Resident #107 did not have an unstageable pressure injury. The Weekly Wound Observation Tool dated 2/17/23 revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum/left buttock. The Weekly Wound Observation Tool dated 2/23/23 revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum/left buttock. The Skin/Wound/Treatment note dated 2/28/23 revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum/left buttock. A Physician Progress note dated 3/02/23 revealed Resident #107 was sent to the hospital for declining respiratory status and sacral pressure ulcer infection and was admitted . c. The MDS discharge return anticipated assessment dated [DATE] revealed Resident #107 did not have an unstageable pressure ulcer injury. During an interview on 3/27/23 at 3:00 pm the MDS Nurse revealed she completed the wound section based on the weekly wound report provided by the Wound Nurse. The MDS Nurse confirmed Resident #107 had an unstageable pressure ulcer injury on 2/01/23, 2/13/23, and 3/02/23 when she completed the assessments based on the weekly wound report. The MDS Nurse stated she must have just missed it and coded Resident #107 incorrectly regarding his unstageable pressure ulcer injury. An interview was conducted on 3/28/23 at 9:54 am with the Wound Nurse who revealed Resident #107 had an unstageable pressure ulcer injury to his sacrum when he admitted to the facility and received treatment daily. The Wound Nurse stated she provided the MDS Nurse with a weekly wound report and Resident #107 was included on the weekly wound report. During an interview on 3/29/23 at 11:26 am the Director of Nursing (DON) revealed the MDS Nurse was responsible to ensure the assessments were accurate for Resident #107. The DON stated the MDS Nurse was to physically see each resident to confirm the assessment was accurate and if any question regarding the resident status she was able to ask questions before submitting the assessments for Resident #107.

Based on record review and staff interviews, the facility failed to provide written notification for reason of discharge to hospital to the Resident and/or Responsible Party (RP) for 6 of 6 residents reviewed for hospitalization (Resident #69, Resident #82, Resident #3, Resident #96, Resident #74, and Resident #46). The findings included: 1. Resident #69 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated dated dated [DATE] revealed Resident #69 was cognitively intact. Review of Resident # 69's medical record revealed hospital stays from 1/17/23 through 1/21/23 and 2/5/23 through 2/9/23. No written notice of transfer was documented to have been provided to the resident or her responsible party. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Resident Party (RP). The DON stated the bed hold and transfer/discharge to hospital form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP. 2. Resident #82 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident # 82 was severely cognitively impaired. Review of Resident #82's medical record revealed she was transferred to the hospital on 11/24/22 through 11/28/22. No written notice of transfer was documented to have been provided to the resident or her responsible party. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Responsible Party (RP). The DON stated the bed hold and transfer/discharge to hospital form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP. 41772 3. Resident #3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. A Health Status Note dated 9/3/22 revealed Resident #3 was transferred to the emergency department for further evaluation. The medical record indicated Resident #3 was discharged to the hospital on 9/3/22 and returned to the facility on [DATE]. Review of the medical record revealed no evidence that Resident #3 and his Responsible Party received written notification of the reason for transfer to the hospital. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Responsible Party (RP). The DON stated the bed hold policy and discharge/transfer form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP. 4. Resident #96 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had severe cognitive impairment. A Health Status Note dated 1/24/23 revealed Resident #96 was sent to the emergency department for further evaluation. The medical record indicated Resident #96 was discharged to the hospital on 1/24/23 and he returned to the facility on [DATE]. Review of the medical record revealed Resident #96 revealed no evidence the Responsible Party received written notification of the reason for transfer to the hospital. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Responsible Party (RP). The DON stated the bed hold policy and discharge/transfer form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP. 45045 5. Resident # 74 was admitted to the facility on [DATE]. A Nursing Progress Note dated 2/5/23 revealed Resident #74 was sent to the emergency department for further evaluation. The medical record revealed Resident #74 was discharged to the hospital on 2/05/23 and returned to the facility on [DATE]. Review of the medical record revealed no evidence that Resident #74 and/or his Responsible Party (RP) received written notification of the reason for transfer to hospital. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Responsible Party (RP). The DON stated the bed hold policy and discharge/transfer form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP. 6. Resident #46 was admitted to the facility on [DATE]. A Nursing Progress Note dated 1/20/23 revealed Resident #46 was sent to the emergency department for further evaluation. The medical record revealed Resident #46 was discharged to the hospital on 1/0/23 and returned to the facility on [DATE]. Review of the medical record revealed no evidence that Resident #46 and/or his Responsible Party (RP) received written notification of the reason for transfer to the hospital. During an interview with the Director of Nursing on 3/28/23 at 11:49 AM, she stated when a resident was sent out to the hospital the facility notified the physician and Responsible Party (RP). The DON stated the bed hold policy and discharge/transfer form were sent to the hospital with the resident. She stated that the facility notified the RP by phone but there was no written notification sent to the resident or RP.

Based on observations and staff interviews the facility failed to maintain the area surrounding the dumpster free of debris for 2 of 2 dumpsters observed. The findings included: During an observation of the dumpster area on 1/11/22 at 10:46 AM, 2 disposable gloves were observed behind dumpster # 1, assorted papers, and a jelly cup were between dumpster #1 and dumpster # 2. Broken glass from a fluorescent light bulb was observed between dumpster #2 and the grease disposal container. During a second observation on 1/13/22 at 9:54 AM 2 disposable gloves were behind dumpster # 2, a jelly cup and clear broken glass were between dumpster #1 and dumpster # 2. Broken glass from a fluorescent light bulb was observed between dumpster #2 and the grease disposal container. A third observation of the dumpster area on 1/14/22 at 9:26 AM 4 disposable gloves and assorted papers were observed on the ground behind dumpster # 2. a jelly cup and clear broken glass were between dumpster #1 and dumpster # 2. Broken fluorescent light bulb was observed between dumpster #2 and the grease disposal container. An observation of the dumpster area was conducted with the regional dietary manager on 1/14/22 at 10:17 AM revealed the dumpster area to be in the same condition. During an interview 1/14/22 at 10:19 AM the regional dietary manager stated all departments, including dietary used the dumpster every day and the kitchen staff did their part to keep the area clean. She indicated she would get the area cleaned up. In an interview on 1/14/22 at 10:22 AM the housekeeping manager stated the garbage truck driver should have cleaned up the area. He indicated they would no longer rely on the garbage truck driver and his staff would sweep and clean the area daily. In an interview on 1/14/22 at 12:01 PM the administrator indicated staff would begin making daily rounds to check and clean the dumpster area.

Based on record review, observation, resident interview, and staff interviews, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38 ' s Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was on oxygen. Record review of care plan dated 10/23/18 with revisions on 3/4/19, 8/23/19, and 2/6/20, revealed care plan for ineffective breathing pattern related to chronic [CONDITION(S)] and obstructive sleep apnea. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 1/11/22 at 3:10 PM Resident #38 with oxygen via nasal cannula at 2 Liters and oxygen in use sign on resident door. Record review of Oxygen Saturation Summary Report for the month of January revealed resident had oxygen saturation levels between 96%-99% with oxygen via nasal cannula. During an interview on 1/13/22 at 8:33 AM Nurse #1 revealed that Resident #38 was on oxygen and that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She was unable to state why the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/13/21 at 8:36 AM Nurse Aide (NA) #2 revealed that Resident #38 was on oxygen. During an interview on 1/13/22 at 1:39 PM NA #1 revealed that Resident #38 was on oxygen, and he would put on and take off as he wanted. During an interview on 1/13/22 at 9:56 AM the Director of Nursing (DON) revealed that Resident #38 required a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/14/22 at 11:15 AM the Administrator revealed the DON or unit nurse were responsible to confirm orders were entered. She stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to clarify code status orders for 1 of 2 residents reviewed for advanced directives. (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the advanced directive care plan dated 10/6/21 and revised on 10/25/21 revealed Resident #21 was a full code. Record review of hard copy code status book revealed Resident #21 had a full code order dated 10/6/21. Resident #21 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitively impairment. Record review of MDS Discharge Return Anticipated assessment dated [DATE] revealed Resident #21 was discharged from the facility to an acute hospital. Record review of MDS Entry Tracking assessment dated [DATE] revealed Resident #21 returned to the facility from an acute hospital. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/13/22 at 8:33 AM Nurse #1 revealed that the Social Worker was responsible to obtain and enter Resident #21 ' s code status in the electronic record and place a paper copy in code status book located at the nursing station. Nurse #1 stated that if a discrepancy of code status orders were found the resident would be a full code until the order was clarified. During an interview on 1/13/22 at 9:26 AM the Social Worker revealed she confirmed code status with the resident or responsible party (RP) if resident was cognitively impaired upon admission to the facility or when a code status change was requested while a resident. She stated she entered the code status order in the electronic medical record and placed a written copy in the code status book at the nurse station. The Social Worker reported she reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Worker was unable to state how she missed the full code order for Resident #21. During an interview on 1/13/22 at 9:59 AM the Director of Nursing (DON) revealed the Social Worker was responsible for confirmation and electronic order entry of code status. She stated Resident #21 ' s RP had considered hospice care and a DNR order was discussed but RP decided not to pursue hospice care and the code status was not changed. The DON was unable to state how Resident #21 ' s conflicting code status orders were missed. During an interview on 1/14/22 at 11:19 AM the Administrator revealed the Social Worker was responsible to obtain the code status order and enter in electronic medical record. She stated the Social Worker was expected to ensure the code status was correct and if discrepancy to clarify before entering a new code status order.

Based on record review, staff and Resident Representative (RR) interviews, and Nurse Practitioner interview, the facility failed to treat and monitor multiple pressure ulcers and did not implement measures to address a resident's refusals of treatment for 1 of 3 residents reviewed for pressure ulcers (Resident #3). The facility did not treat and change pressure ulcer dressings as ordered and did not monitor a pressure ulcer to prevent maggots from developing in the wound. When the resident refused treatment the facility did not contact the resident's representative as specified in the resident's care plan to elicit their input. Failure to treat and check Resident #3's pressure ulcers allowed maggots to be present in one of the resident's wounds. Resident #3 was transferred to the hospital for evaluation and treatment. Findings included: A review of the medical record revealed Resident #3 was re-admitted to the facility on [DATE] from an acute long term care hospital with active [DIAGNOSES REDACTED]. A review of Resident #3's medical record revealed no assessment of the resident's pressure ulcers on admission to the facility on [DATE]. A review of Resident #3's physician orders [REDACTED]. Apply duoderm (a type of dressing), every Monday and Friday and when necessary (prn). The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #3 was severely impaired for cognition, rejected care 1-3 days out of 7 days and needed total assistance for all Activities of Daily Living (ADLs) with the physical assistance of two persons. The MDS indicated Resident #3 had multiple pressure ulcers and had a pressure reducing device for the bed and chair, and that nutrition interventions to manage skin problems were in place. The Care Area Assessment (CAA) for Pressure Ulcers dated 7/13/18 indicated a focus on pressure ulcers and the facility would address the area of pressure ulcers on the residents' plan of care. Review of Resident #3's current plan of care (dated 5/1/18) revealed it contained a Focus area of pressure ulcers related to chronic [MEDICAL CONDITION] and a goal of: pressure ulcers will show positive healing with reduction in size/stage of pressure ulcer through next review. The care plan interventions included; Treatment as ordered by physician. Weekly assessment of wound/ulcer. Notify physician of changes as indicated. Further review of Resident #3's current care plan (dated 5/31/18) revealed it contained a Focus area which address the resident's refusals of all treatments at all times. The goal specified Resident #3 will receive care within resident's choices and preferences through next review. The interventions included: Document care being resisted per facility protocol and notify physician of patterns in behavior. Discuss with resident implications of not complying with therapeutic regimen. Elicit family input for best approaches to resident. Allow for flexibility in routines. If resident refuses care, try again later. A review of Resident #3's Treatment Administration Record (TAR) from 7/6/18 to 7/16/18 revealed the pressure ulcer on his right upper leg and his other pressure ulcers were documented as being treated only on one occasion which was on 7/11/18. The TAR specified Resident #3 refused treatment to all of his other pressure ulcers or would not allow staff to check any of his pressure ulcers on the following dates; 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18 and 7/16/18. The reverse side of the resident's TAR noted the initials and signature of Treatment Nurse #1 and documentation that all treatments were refused on the dates noted above and that the Resident's Representative and Physician were notified of all of the resident's refusals. A review of the progress notes revealed a note written on 7/11/2018, by Treatment Nurse #1, as a Skin/Wound/Treatment Note, which was a list of Resident #3's pressure ulcers and other wounds. The documentation included: Right leg (upper) unstageable; 2.5 cm (centimeters) x 1.5 cm with 100% brown slough (a layer of dead tissue surrounded by living tissue); peri wound intact; no signs/symptoms (s/s) of infection at this time; cleanse area with wound cleanser and apply santyl foam and absorbent dressing every other day and when necessary. This was the only wound assessment found in the resident's electronic health record system from 07/06/18 (his readmission). A progress note dated 7/14/2018, written by Treatment Nurse #1, specified Treatment Nurse #1 discussed the importance of receiving dressing changes with Resident #3, and he verbalized understanding, however, Resident #3 refused and stated maybe tomorrow. The note continued with the RR was made aware of the resident's refusals via telephone and indicated she would come talk to Resident #3. A progress notes dated 7/17/18, written by the Director of Nurses (DON) revealed Resident #3 was transferred to the local hospital for possible wound debridement and the Resident's Representative was notified. A review of hospital records revealed Resident #3 was transported to a local hospital Emergency Department (ED) on 7/18/2018. The resident's ED records revealed the Emergency Medical Services (EMS) that transported Resident #3 to the ED reported the facility indicated there were maggots found in one of the resident's pressure ulcers. Resident #3 was admitted to the hospital with [REDACTED]. On 7/27/2018 at 9:10 AM, the Quality Improvement (QI) Nurse was interviewed and stated she and Treatment Nurse #2 went into Resident #3's room on 7/17/2018 to do his treatments because Treatment Nurse #1 was not at the facility. The QI Nurse indicated she took the dressing off of Resident #3's right upper leg (the QI Nurse indicated the area to be on the outer upper area of the thigh/leg). The QI Nurse stated the dressing was loose and soiled heavily with wet, brown drainage. The QI Nurse stated I pulled off the dressing on his right upper leg and saw about 15 maggots in the wound. The QI Nurse stated she knew what maggots looked like and she covered the wound and she and Treatment Nurse #2 went out and called the Director of Nursing (DON). The QI nurse stated no other wounds had maggots in them and no other wounds had drainage or loose dressings, but all of the wounds were treated as ordered. In an interview on 7/27/2018 at 9:30 AM, Treatment Nurse #2 stated on 07/17/18 she and the QI nurse went to Resident #3's room and told him why she was there and he agreed to the treatment. Treatment Nurse #2 stated she had not taken care of Resident #3 because she worked the upper halls of the facility. Treatment Nurse #2 stated all of the dressings on Resident #3's body were dated 7/11/18. Treatment Nurse #2 indicated the right upper leg dressing was soiled and loose. Nurse #1 stated the pressure ulcer did have an odor but did not appear to be infected. Nurse #1 also noted she observed maggots in the wound, the DON was notified and she and a Nurse supervisor came and cleaned and re dressed all of the resident's pressure ulcers. A telephone interview was attempted with the Treatment Nurse #1 on 7/27/2018 at 11:00 AM. The Treatment Nurse answered and then stated she no longer worked at the facility, she had been fired and ended the call. On 7/27/2018 at 1:25 PM, in an interview, Nursing Assistant (NA) #3 stated she had cared for Resident #3 multiple times since his readmission to the facility on [DATE]. NA #3 stated she usually gave the resident a bed bath at about 9:30 AM each day. NA #3 indicated she would take the bathing supplies in and tell him she was going to do his bath and he was always agreeable when she would let him know before she started providing the bath. NA #3 stated while giving Resident #3 his bed bath on Monday 7/16/18 she noticed the dressings on his body were still dated 7/11/18. NA #3 stated she was working on 7/17/18 and Resident #3 refused his bath that morning and she went back in the afternoon and he refused and stated he did not feel good. NA #3 stated she had told Nurse #2 on 7/16/18 the dressings were dated 7/11/18. In a telephone interview on 7/27/2018 at 3:40 PM, Nurse #2 stated NA #3 did tell her about the dates on Resident #3's dressings on 7/16/18. Nurse #2 stated she was not sure, but thought that she told the Treatment Nurse #1, who was there that day. On 7/27/2018 at 4:00 PM, the Administrator was interviewed and stated the Treatment Nurse #1 had been terminated relating to falsifying documents that were unrelated to Resident #3. The Administrator stated she could not verify the documentation for Resident #3 was valid for the care Treatment Nurse #1 provided or the resident's refusals to allow staff to perform dressing changes or check the resident's pressure ulcers. The Administrator stated her expectations were all treatments would be completed as ordered. In an interview on 7/27/2018 at 4:05 PM, the Resident Representative (RR) stated since the resident's readmission to the facility on [DATE] she had only received one phone call from staff, which was on 7/14/2018, to inform her that Resident #3 had refused his wound treatments. The RR stated she had filed a grievance on 7/16/18 because Resident #3's wounds were not being treated. The RR indicated she was told if Resident #3 refused his treatment, the staff could educate him, but could not force him. On 7/27/2018 at 4:20 PM, in an interview, the Nurse Practitioner (NP) stated she had referred Resident #3 for management of his pressure ulcers to the wound clinic and Infectious Disease physician when he was admitted . The NP did not recall if she was notified about his Resident #3's refusals of treatment, but did say she spoke to Resident #3 on 7/16/2018 about his refusing treatment. The NP stated she spoke to the MD about Resident #3 having an elevated temperature on 07/16/18 and the physician agreed the resident would be started on an antibiotic. The NP stated she did not look at the pressure ulcers on 07/16/18. On 7/28/2018 the facility provided the following plan of correction with a compliance date of 7/22/2018: On 7/17/18 at 2:55 PM Treatment nurse #2 and the QI nurse entered Resident #3's room to change Resident #3's dressings. Treatment nurse #2 and the QI nurse began to undress Resident #3 wounds. Dressing to Resident #3 right upper thigh noted to be secure at the base of the dressing but not secured at the top of the dressing. Upon removing Resident #3 dressing to right upper thigh, white larvae approximately 0.5 cm in length in the wound was noted. The QI nurse exited Resident #3's room and notified the DON of the larvae. On 7/17/2018 the DON notified RR and physician and assessed and measured the wound by 8:15 pm and order was received by the physician to send to the emergency room for evaluation. On 7/18/18 Resident #3 was admitted to the local hospital with a [DIAGNOSES REDACTED]. A thorough investigation was initiated on 7/17/2018 to identify the root cause of fly larva in the residents wound. During the investigation it was found that Resident #3's wounds were not assessed on admission and wound care was only provided once in eleven days by treatment nurse #1 prior to larvae being discovered in a wound. It was determined by the Administrator that the cause was the failure of treatment nurse #1 to continuously seek alternatives to aide in the alternate treatment options due to a systematic failure of educating the licensed nurses on the process of actions to take when a resident refuses care or treatments. Treatment Nurse was terminated on 7/24/18 for other reasons. Corrective Actions All current residents with wounds were physically assessed on 7/18/2018 and completed on 7/20/18 by the Quality Improvement nurse, West Wing Treatment nurse and Registered Nurse to ensure wounds care had been completed and no signs or symptoms of worsening of wounds. All wounds were measured and documented in each resident's electronic record. No issues were identified. On 7//20/18 a 100% audit of all current residents progress notes x 30 days was completed by the wound Consultant to determine if any resident had been refusing wound care. There were no other residents identified in the progress notes that refused wound care. On 7/21/18 a 100% audit of all current residents Treatment Administration Records for the month of (MONTH) and July, was completed by the Director of Nursing to identify any refusals of wound care. There were three other residents identified that refused wound care at times in the progress notes. The care plan was updated on 7/21/18 by the MDS nurse to address alternatives to aide in the encouragement of residents allowing wound care. A head to toe assessment was completed on 100% of all residents on 7/21/18 by the Assistant Director of Nursing and RN supervisor to identify all residents with wounds. There were two residents identified with wounds that had not been addressed. The two identified wounds were assessed, documented, measured, treatment initiated and the physician and resident representative was notified on 7/21/18 by the treatment nurse. On 7/21/18, a questionnaire was initiated by the SF with 100% of all licensed nurses and medication aides to validate knowledge and understanding of steps to take when a resident refuses wound care. Retraining was completed by the SF during the time of the questionnaire for any identified areas of concerns. On 7/19/18, the facility revised the Nursing Admission Assessment form to ensure the admitting nurse assess, document and measure all residents with wounds on admission. On 7/19/18 an in-service was initiated by the Wound Nurse Consultant for the Administrator, the DON, and Staff Facilitator in regard to the revised Nursing Admission Assessment to include: 1. Upon admission, the admitting nurse will do a full skin assessment of all wounds to include location, description, and measurements. 2. The treatment nurse will complete a second skin assessment to validate or clarify location, description and measurement of all wounds and document on the applicable flow sheet. This in-service was completed by 7/19/18. The in-service in regards to the revised Nursing Admission assessment was initiated with all other licensed nurses to include agency nurses on 7/19/18 by the Staff Facilitator. This in-service was completed by 7/22/18. On 7/18/18 a 100% in service for all licensed nurses to include agency nurses was initiated by the DON in regards to Notification of refusals to include: 1. Each time medications, treatments, or any form of care is refused by a resident it must be reported to the RR and the provider. 2. Nurses must document all refusals of care to include notification of RR and MD This in-service was completed by 7/22/18. On 7/21/18 an in-service was initiated with all license nurses and Medication Aides regarding Alternatives for residents that resist wound care. This in-service was completed by 7/22/18. This in-service included: People may refuse help from some but not others Give clear explanations and repeat ourselves as necessary Work at building a closer relationship with the individual, showing that they are valued as a person and not just seen as a focus for a care task Ensure that we are going at a pace with which the person feels comfortable and safe, and are respecting their modesty as much as possible. When necessary seek a staff member that resident trust to encourage wound care Family involvement-notify family and get family involved to come and encourage the resident. Ask family for ideas that will motivate the resident to agree to wound care. Explain the risk factors of not allowing wound care to residents Explore if resident is fearful and reason why Be patient, allow the resident time to process requests or tasks to be complete or questions to answer Assess for pain and ensure resident has adequate pain control prior to treatment/care Notify MD for pain orders if resident complains of pain not relieved with prn pain medication. Psych consult Wound clinic referrals ***Note: Most of these alternatives can be utilized for resistance to other types of care as appropriate. The decision to monitor the system for wound care was made on 7/22/2018 by the Administrator and Director of Nursing. 25% of residents with wounds will be physically assessed and documentation on the TAR, progress notes and wound ulcer flow sheet will be reviewed by the ADON, SF, RN Supervisor, or Quality Improvement Nurse 3 x per week x 4 weeks, weekly x 4 weeks, then monthly x 1 month utilizing a Wound Care Audit Tool. This audit is to ensure all wounds have been identified, wound care has been completed per physician's orders [REDACTED]. Any areas of concern identified during the audits will be addressed during the audit by the ADON, SF, RN Supervisor, or Quality Improvement Nurse to include providing additional staff training. The DON will review and initial the Wound Care Audit Tools weekly x 12 weeks for completion and to ensure all areas of concern were addressed. The DON will present the findings of the Wound Care Audit Tools to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review the Wound Care Audit Tools to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. The decision to review the monitoring of wound care during the quality assurance committee meeting was made by the Administrator and Director of Nursing on 7/22/2018. Final date of compliance is 7/22/18. The Administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the plan of correction. Validation of the above referenced plan of correction was completed on 7/28/2018 during an extended survey. Validation included staff interviews regarding residents refusing care and residents refusing treatments. In-services regarding Admission Assessments were reviewed. In-service for staff regarding notification of refusals. Staff were interviewed regarding in-service for residents that resist wound care. Wound care audit tools were reviewed that will be and are used 3 x per week for 4 weeks, weekly x 4 weeks, then monthly x 1 month as stated in the plan of correction. The date of 7/22/2018 was validated as the facility's date of compliance.

Based on record review, staff and Resident Representative (RR) interviews, and Nurse Practitioner interview, the facility neglected to treat and monitor multiple pressure ulcers and neglected to attempt alternate measures to address a resident's refusals of treatment for 1 of 3 residents reviewed for pressure ulcers (Resident #3). The facility's failure to treat the wounds and address the resident's refusals to allow wound treatments as ordered resulted in maggots developing in one of the resident's wounds. Resident #3 was observed with maggots present in the pressure ulcer on his right upper leg and was transferred to the hospital for evaluation and treatment. Findings included: A review of the medical record revealed Resident #3 was re-admitted to the facility on [DATE] from an acute long term care hospital with active [DIAGNOSES REDACTED]. A review of Resident #3's medical record revealed no assessment of the resident's pressure ulcers on admission to the facility on [DATE]. A review of Resident #3's physician orders [REDACTED]. Apply duoderm (a type of dressing), every Monday and Friday and when necessary (prn). Further review of Resident #3's 07/06/18 readmission physician orders [REDACTED]. The frequency of treatment varied but all 22 were to be checked on the days they were not treated. The Admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #3 was severely impaired for cognition, rejected care 1-3 days out of 7 days and needed total assistance for all Activities of Daily Living (ADLs) with the physical assistance of two persons. The MDS indicated Resident #3 had multiple pressure ulcers and had a pressure reducing device for the bed and chair, and that nutrition interventions to manage skin problems were in place. The Care Area Assessment (CAA) for Pressure Ulcers dated 7/13/18 indicated a focus on pressure ulcers and the facility would address the area of pressure ulcers on the resident's plan of care. Review of Resident #3's current plan of care (dated 5/1/18) revealed it contained a Focus area of pressure ulcers related to chronic [MEDICAL CONDITION] and a goal of: pressure ulcers will show positive healing with reduction in size/stage of pressure ulcer through next review. The care plan interventions included; Treatment as ordered by physician. Weekly assessment of wound/ulcer. Notify physician of changes as indicated. Further review of Resident #3's current care plan (dated 5/31/18) revealed it contained a Focus area which address the resident's refusals of all treatments at all times. The goal specified Resident #3 will receive care within resident's choices and preferences through next review. The interventions included: Document care being resisted per facility protocol and notify physician of patterns in behavior. Discuss with resident implications of not complying with therapeutic regimen. Elicit family input for best approaches to resident. Allow for flexibility in routines. If resident refuses care, try again later. A review of Resident #3's Treatment Administration Record (TAR) from 7/6/18 to 7/16/18 revealed the pressure ulcer on his right upper leg and his other pressure ulcers were documented as being treated only on one occasion which was on 7/11/18. The TAR specified Resident #3 refused treatment to all of his other pressure ulcers or would not allow staff to check any of his pressure ulcers on the following dates; 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/12/18, 7/13/18, 7/14/18, 7/15/18 and 7/16/18. The reverse side of the resident's TAR noted the initials and signature of Treatment Nurse #1 and documentation that all treatments were refused on the dates noted above and that the Resident's Representative and Physician were notified of all of the resident's refusals. A review of the progress notes revealed a note written on 7/11/2018, by Treatment Nurse #1, as a Skin/Wound/Treatment Note, which was a list of Resident #3's pressure ulcers and other wounds. The documentation included: Right leg (upper) unstageable; 2.5 cm (centimeters) x 1.5 cm with 100% brown slough (a layer of dead tissue surrounded by living tissue); peri wound intact; no signs/symptoms (s/s) of infection at this time; cleanse area with wound cleanser and apply santyl foam and absorbent dressing every other day and when necessary. This was the only wound assessment found in the resident's electronic health record system after 07/06/18 (his readmission). A progress note dated 7/14/2018, written by Treatment Nurse #1, specified Treatment Nurse #1 discussed the importance of receiving dressing changes with Resident #3, and he verbalized understanding, however, Resident #3 refused and stated maybe tomorrow. The note continued with the RR was made aware of the resident's refusals via telephone and indicated she would come talk to Resident #3. A progress notes dated 7/17/18, written by the Director of Nurses (DON) revealed Resident #3 was transferred to the local hospital for possible wound debridement and the Resident's Representative was notified. A review of hospital records revealed Resident #3 was transported to a local hospital Emergency Department (ED) on 7/18/2018. The resident's ED records revealed the Emergency Medical Services (EMS) that transported Resident #3 to the ED reported the facility indicated there were maggots found in one of the resident's pressure ulcers. Resident #3 was admitted to the hospital with [REDACTED]. On 7/27/2018 at 9:10 AM, the Quality Improvement (QI) Nurse was interviewed and stated she and Treatment Nurse #2 went into Resident #3's room on 7/17/2018 to do his treatments because Treatment Nurse #1 was not at the facility. The QI Nurse indicated she took the dressing off of Resident #3's right upper leg (the QI Nurse indicated the area to be on the outer upper area of the thigh/leg). The QI Nurse stated the dressing was loose and soiled heavily with wet, brown drainage. The QI Nurse stated I pulled off the dressing on his right upper leg and saw about 15 maggots in the wound. The QI Nurse stated she knew what maggots looked like and she covered the wound and she and Treatment Nurse #2 went out and called the Director of Nursing (DON). The QI nurse stated no other wounds had maggots in them and no other wounds had drainage or loose dressings, but all of the wounds were treated as ordered. In an interview on 7/27/2018 at 9:30 AM, Treatment Nurse #2 stated on 07/17/18 she and the QI nurse went to Resident #3's room and told him why she was there and he agreed to the treatment. Treatment Nurse #2 stated she had not taken care of Resident #3 because she worked the upper halls of the facility. Treatment Nurse #2 stated all of the dressings on Resident #3's body were dated 7/11/18. Treatment Nurse #2 indicated the right upper leg dressing was soiled and loose. Nurse #1 stated the pressure ulcer did have an odor but did not appear to be infected. Nurse #1 also noted she observed maggots in the wound, the DON was notified and she and a Nurse supervisor came and cleaned and re dressed all of the resident's pressure ulcers. A telephone interview was attempted with the Treatment Nurse #1 on 7/27/2018 at 11:00 AM. The Treatment Nurse answered and then stated she no longer worked at the facility, she had been fired and ended the call. On 7/27/2018 at 1:25 PM, in an interview, Nursing Assistant (NA) #3 stated she had cared for Resident #3 multiple times since his readmission to the facility on [DATE]. NA #3 stated she usually gave the resident a bed bath at about 9:30 AM each day. NA #3 indicated she would take the bathing supplies in and tell him she was going to do his bath and he was always agreeable when she would let him know before she started providing the bath. NA #3 stated while giving Resident #3 his bed bath on Monday 7/16/18 she noticed the dressings on his body were still dated 7/11/18. NA #3 stated she was working on 7/17/18 and Resident #3 refused his bath that morning and she went back in the afternoon and he refused and stated he did not feel good. NA #3 stated she had told Nurse #2 on 7/16/18 the dressings were dated 7/11/18. In a telephone interview on 7/27/2018 at 3:40 PM, Nurse #2 stated NA #3 did tell her about the dates on Resident #3's dressings on 7/16/18. Nurse #2 stated she was not sure, but thought that she told the Treatment Nurse #1, who was there that day. On 7/27/2018 at 4:00 PM, the Administrator was interviewed and stated the Treatment Nurse #1 had been terminated relating to falsifying documents that were unrelated to Resident #3. The Administrator stated she could not verify the documentation for Resident #3 was valid for the care Treatment Nurse #1 provided or the resident's refusals to allow staff to perform dressing changes or check the resident's pressure ulcers. The Administrator stated her expectations were all treatments would be completed as ordered. In an interview on 7/27/2018 at 4:05 PM, the Resident Representative (RR) stated since the resident's readmission to the facility on [DATE] she had only received one phone call from staff, which was on 7/14/2018, to inform her that Resident #3 had refused his wound treatments. The RR stated she had filed a grievance on 7/16/18 because Resident #3's wounds were not being treated. The RR indicated she was told if Resident #3 refused his treatment, the staff could educate him, but could not force him. On 7/27/2018 at 4:20 PM, in an interview, the Nurse Practitioner (NP) stated she had referred Resident #3 for management of his pressure ulcers to the wound clinic and Infectious Disease physician when he was admitted . The NP did not recall if she was notified about his Resident #3's refusals of treatment, but did say she spoke to Resident #3 on 7/16/2018 about his refusing treatment. The NP stated she spoke to the MD about Resident #3 having an elevated temperature on 07/16/18 and the physician agreed the resident would be started on an antibiotic. The NP stated she did not look at the pressure ulcers on 07/16/18. On (MONTH) 28, (YEAR) the facility provided the following plan of correction with a compliance date of 7/24/2018: On 7/17/18 at 2:55pm Treatment nurse #2 and the QI nurse entered resident #3 room to change resident #3 dressings. Treatment nurse #2 and the QI nurse began to undress resident #3 wounds. Dressing to resident #3 right upper thigh noted to be secure at the base of the dressing but not secured at the top of the dressing. Upon removing resident #3 dressing to right upper thigh, white larvae approximately 0.5cm in length in the wound was noted. The QI nurse exited resident #3 room and notified the DON of the larvae. On 7/17/2018 the DON notified RR and physician and assessed and measured the wound by 8:15 pm and order was received by the physician to send to the emergency room for evaluation. On 7/18/18 Resident #3 was admitted to the local hospital with a [DIAGNOSES REDACTED]. A thorough investigation was initiated on 7/17/2018 to identify the root cause of fly larva in the residents wound. During the investigation it was found that resident #3 wounds were not assessed on admission and wound care was only provided once in eleven days by treatment nurse #1 prior to larvae being discovered in a wound. It was determined by the Administrator that the cause was the failure of treatment nurse #1 to continuously seek alternatives to aide in the encouragement of resident #3 compliance with wound care. The licensed nurse failed to seek alternate treatment options due to a systematic failure of educating the licensed nurses on the process of actions to take when a resident refuses care or treatments. Treatment Nurse #1 was terminated on 7/24/18 for other reasons. Corrective Actions On 7/23/18, all alert and oriented residents were interviewed regarding neglect by the Activity Staff and Social Workers. There were no negative findings. All current residents with wounds were physically assessed on 7/18/2018 and completed on 7/20/18 by the Quality Improvement (QI) nurse, West Wing Treatment nurse, and Registered Nurse (RN) to ensure wound care had been completed and no signs or symptoms of worsening of wounds. All wounds were measured and documented in each resident's electronic record. No issues were identified. On 7/20/18 a 100% audit of all current residents progress notes x 30 days was completed by the Wound Consultant to determine if any resident had been refusing wound care. There were no other residents identified in the progress notes that refused wound care. On 7/21/18 a 100% audit of all current residents Treatment Administration Records for the month of (MONTH) and July, was completed by the Director of Nursing to identify any refusals of wound care. There were three other residents identified that refused wound care at times in the progress notes. The care plan was updated on 7/21/18 by the MDS nurse to address alternatives to aide in the encouragement of resident allowing wound care. A head to toe assessment was completed on 100% of all residents on 7/21/18 by the Assistant Director of Nursing and RN Supervisor to identify all residents with wounds. There were two residents identified with wounds that had not been addressed. The two identified wounds were assessed, documented, measured, treatment initiated and the physician and resident representative was notified on 7/21/18 by the treatment nurse. On 7/21/18, a questionnaire was initiated by the SF with 100% of all license nurses and medication aides to validate knowledge and understanding of steps to take when a resident refuses wound care. Retraining was completed by the SF during the time of the questionnaire for any identified areas of concerns. On 7/23/18, an in-service was initiated for 100% of all staff to include license nurses, agency nurses, nursing assistants, housekeeping, dietary, therapy, maintenance, pay roll, book keeper, social workers, was initiated by the SF regarding Neglect to include examples of neglect, prevention of neglect, and notification. This in-service was completed by 7/24/18. On 7/19/18, the facility revised the Nursing Admission Assessment form to ensure the admitting nurse assess, document, and measure all residents with wounds on admission. On 7/19/18 an in-service was initiated by the Wound Nurse Consultant for the Administrator, the Director of Nursing (DON), and Staff Facilitator (SF) in regards to the revised Nursing Admission Assessment to include: 1. Upon admission, the admitting nurse will do a full skin assessment of all wounds to include location, description, and measurements. 2. The treatment nurse will complete a second skin assessment to validate or clarify location, description and measurement of all wounds and document on the applicable flow sheet. This in-service was completed by 7/19/18. The in-service in regards to the revised Nursing Admission assessment was initiated with all other licensed nurses to include agency nurses on 7/19/18 by the Staff Facilitator. This in-service was completed by 7/22/18. On 7/18/18 a 100% in service for all licensed nurses to include agency nurses was initiated by the DON in regards to Notification of refusals to include: 1. Each time medications, treatments, or any form of care is refused by a resident it must be reported to the RR and the provider. 2. Nurses must document all refusals of care to include notification of RR and MD This in-service was completed by 7/22/18. On 7/21/18 an in-service was initiated with all license nurses to include agency nurses and Medication Aides regarding Alternatives for residents that resist wound care. This in-service was completed by 7/22/18. This in-service included: People may refuse help from some but not others Give clear explanations and repeat ourselves as necessary Work at building a closer relationship with the individual, showing that they are valued as a person and not just seen as a focus for a care task Ensure that we are going at a pace with which the person feels comfortable and safe, and are respecting their modesty as much as possible. When necessary seek a staff member that resident trust to encourage wound care Family involvement-notify family and get family involved to come and encourage the resident. Ask family for ideas that will motivate the resident to agree to wound care. Explain the risk factors of not allowing wound care to residents Explore if resident is fearful and reason why Be patient, allow the resident time to process requests or tasks to be complete or questions to answer Assess for pain and ensure resident has adequate pain control prior to treatment/care Notify MD for pain orders if resident complains of pain not relieved with prn pain medication. Psych consult Wound clinic referrals ***Note: Most of these alternatives can be utilized for resistance to other types of care as appropriate. The decision to monitor the system for wound care was made on 7/22/2018 by the Administrator and Director of Nursing. 25% of residents with wounds will be physically assessed and documentation on the TAR, progress notes and wound ulcer flow sheet will be reviewed by the ADON, SF, RN Supervisor, or Quality Improvement Nurse 3 x per week x 4 weeks, weekly x 4 weeks, then monthly x 1 month utilizing a Wound Care Audit Tool. This audit is to ensure all wounds have been identified, wound care has been completed per physician's orders [REDACTED]. Any areas of concern identified during the audits will be addressed during the audit by the ADON, SF, RN Supervisor, or Quality Improvement Nurse to include providing additional staff training. The DON will review and initial the Wound Care Audit Tools weekly x 12 weeks for completion and to ensure all areas of concern were addressed. The Quality Improvement Organization was contacted by the administrator as witnessed by the Regional Vice President of Operations on 7/27/18 for assistance in evaluation of specific steps to be taken to address neglect and training, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan's success, and frequency of monitoring the effects of the plan initiation. The DON will present the findings of the Wound Care Audit Tools to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review the Wound Care Audit Tools to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. The decision to review the monitoring of wound care during the quality assurance committee meeting was made by the Administrator and Director of Nursing on 7/22/2018. Final date of compliance is 7/24/2018. The Administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the plan of correction. Validation of the above referenced plan of correction was completed on 7/28/2018 during an extended survey. Validation included staff interviews regarding residents refusing care and residents refusing treatments. In-services regarding Admission Assessments were reviewed. In-service for staff regarding notification of refusals. Staff were interviewed regarding in-service for neglect and for notification. Wound care audit tools were reviewed that will be and are used 3 x per week for 4 weeks, weekly x 4 weeks, then monthly x 1 month as stated in the plan of correction. The date of 07/24/18 was validated as the facility's date of compliance.