Every finding on record at The Gables of Marysville Health and Rehabilitation

Based on record review, observations, policy review, and staff interviews, the facility failed to ensure a resident received the appropriate mechanical soft diet and thickened liquids per physician orders. This affected one (#67) of four residents reviewed for diets. The facility census was 85.Findings include:Review of the medical record for Resident #67 revealed an admission date of 02/20/25. Diagnoses included dementia, severe protein-calories malnutrition, and dysphagia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had moderate cognitive impairment. Resident #67 required a mechanically altered diet which required change in texture of foods or liquids (e.g., pureed food, thickened liquids).Review of the care plan for Resident #67 revealed a focus of potential to alteration in nutrition and hydration related to body mass index (BMI) eighteen point five, underweight status, diagnosis of malnutrition, history of percutaneous endoscopic gastrostomy (PEG) tube and alterative nutrition, mechanically soft diet, and weight loss. inventions included to monitor consistency of diet offer meal substitutes when foods are refused, and thickened liquids as ordered.Review of the meal ticket for Resident #67 on 06/03/26 revealed a diet of mechanical soft, honey thickened liquids, and no bread.Observation and interview on 06/03/26 at 8:41 A.M. revealed Resident #67 was drinking orange electrolyte drink which was not thickened. Registered Nurse (RN) #10 verified the electrolyte drink was not thickened and RN #10 placed three packets of thickener in the electrolyte drink before returning it to Resident #67. RN #10 stated somebody must not have put a whole lot of thickener in the electrolyte drink.Interview on 06/03/26 at 8:44 A.M. with Certified Nursing Assistant (CNA) #55 verified she did not put thickener in the electrolyte before giving it to Resident #67.Observation on 06/03/26 at 12:00 P.M. revealed Resident #67 received his lunch which included cooked broccoli. Resident #67 did not eat his broccoli.Interview on 06/03/26 at 12:39 P.M. with CNA #25 verified the broccoli served to Resident #67 was too hard and the broccoli could not be cut with a fork. Review of the facility's Mechanical Soft Guidelines dated spring/summer 2026 revealed these regular food items are omitted on mechanical soft diet but can be changed per Speech Language Pathologist (SLP) guidance: regular broccoli cuts, broccoli florets (not in blends); mechanical soft food items should be provided instead were carrots, spinach, greens, stewed tomatoes.This deficiency represents non-compliance investigated under Complaint Number 3030730.

Based on record review and staff interview, the facility failed to provide required the Skilled Nursing Facility Advance Beneficiary Notices ( SNF ABNs) to residents who remained in the facility with Medicare benefit days remaining when skilled therapy services were discontinued. This affected four (#03, #59, #62, and #65) out of five residents reviewed. The facility census was 92Findings Included:1.Review of the medical record revealed Resident #03 admitted to the facility on [DATE] and remained in the facility after therapy services were discontinued. Review of a Notice of Medicare Non-Coverage (NOMNC) was issued with a cut date of 12/05/25. No Advance Beneficiary Notice (SNF ABN) was present in the medical record.2.Review of the medical record revealed Resident #62 admitted to the facility on [DATE] and remained in the facility after therapy services were discontinued. Review of a Notice of Medicare Non-Coverage (NOMNC) was issued with a cut date of 12/06/25. No Advance Beneficiary Notice (SNF ABN) was present in the medical record.3.Review of the medical record revealed Resident #59 admitted to the facility on [DATE] and remained in the facility after therapy services were discontinued. Review of a Notice of Medicare Non-Coverage (NOMNC) was issued with a cut date of 12/15/25. No Advance Beneficiary Notice (SNF ABN) was present in the medical record.4. Review of the medical record revealed Resident #65 admitted to the facility on [DATE] and remained in the facility after therapy services were discontinued. Review of a Notice of Medicare Non-Coverage (NOMNC) was issued with a cut date of 01/28/26. No Advance Beneficiary Notice (SNF ABN) was present in the medical record.Review of the above clinical records in the electronic medical record (EMR), Point Click Care (PCC) revealed no evidence that an Advance Beneficiary Notice (SNF ABN) had been issued to any of the identified residents at the time therapy services were discontinued.Interview on 02/25/26 at 3:49 P.M. with Social Services #107 verified that the above residents who were discontinued from therapy services remained in the facility with Medicare benefit days remaining. She verified that the facility issued Notices of Medicare Non-Coverage (NOMNCs); however, residents did not receive an Advance Beneficiary Notice (ABN). She further verified that the facility had no documentation identifying which specific therapy services were discontinued or the amount or frequency of the services. She stated there was no additional documentation available regarding Skilled Nursing Facility Advance Beneficiary Notices ( SNF ABNs).

Based on observation, staff interview, and review of facility policy, the facility failed to ensure staff performed hand hygiene during meals service and when feeding residents. This had the ability to affect 15 Residents (#06, #09, #12, #13, #14, #18, #40, #46, #48, #50, #52, #70, #74, #81, and #97) that were served and fed meals in the 100/200/300 halls dining room. The census was 92.Findings include: Observation of the meal service in the 100/200/300 halls dining room on 02/23/26 from 12:15 P.M. through 12:37 P.M., revealed one Certified Nursing Assistant (CNA) #217 served all of the residents in the dining room. CNA #217 served meal trays to residents and removed plates and silverware from the trays and opened lids. CNA #217 opened various food items, drinks, condiment packages, soda cans and poured soda into cups of ice. CNA #217 was observed passing a total of 15 meal trays. Continued observation on 02/23/26 at 12:20 P.M., revealed CNA #217 fed Resident #09 a portion of her meal. CNA #217 then moved to Resident #52 and fed her a portion of her meal at 12:22 P.M. CNA #217 did not perform any hand hygiene before feeding Resident #09 or Resident #52. CNA #217 continued to pass meal trays to other residents. At no time during the meal service on 02/23/26 from 12:15 P.M. through 12:37 P.M. was CNA #217 observed performing any hand hygiene. During an interview on 02/23/2026 at 12:39 P.M., CNA #217 verified she had not performed hand hygiene while passing any meal trays and before feeding Resident #09 and Resident #52. The facility identified 15 Residents (#06, #09, #12, #13, #14, #18, #40, #46, #48, #50, #52, #70, #74, #81, and #97) as being served meal trays by CNA #217 on 02/23/26 from 12:15 P.M. to 12:37 P.M. Review of the facility's policy titled Hand Hygiene dated revised 11/28/17 hand hygiene will be properly performed to assist in the prevention of spreading infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR).

Based on medical record review and staff and resident interview, the facility failed to provide follow up care related to audiology services. This affected one (Resident #64) out of two residents reviewed for hearing/vision. The facility census was 92. Findings included:Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, generalized anxiety disorder, spinal stenosis and paroxysmal atrial fibrillation.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 was cognitively intact, required supervision for eating, substantial assistance for toileting, substantial assistance for bathing, and partial assistance for personal hygiene.Review of the medical record for Resident #64 revealed no documentation of an audiology visit in the past three months.Interview on 02/23/26 at 2:20 P.M. with Resident #64 revealed someone came in several weeks ago to check his ears due to having hearing issues. Resident #64 stated this person said she was going to order ear drops for his left ear and he has not had any ear drops since she was here.Interview on 02/25/26 at 9:34 A.M. with Licensed Social Worker (LSW) #107 verified Resident #64 had consented for all ancillary services including audiology and Resident #64 was not on the list for January 2026 audiology visits. A follow-up interview on 02/25/26 at 10:31 A.M. LSW #107 verified Resident #64 had an audiology visit on 01/29/26 and the facility had not received the provider note from that day and there were no notes in Resident #64 medical record regarding the audiology visit. The audiology notes had been requested today, 02/25/26. Review of Resident #64 audiology progress note dated 01/29/26 for Resident #64 provided today, revealed an exam revealed deeply impacted cerumen left ear. Debrox (drops for earwax removal) was recommended for the left ear and/or follow facility protocol for cerumen management. Review of the medical record for Resident #64 revealed no order for Debrox or any other cerumen management for the left ear.Interview on 02/25/26 at 11:20 A.M. with the Administrator revealed the facility does not have a policy related to ancillary services. A follow-up interview on 02/25/26 at 11:23 A.M. the LSW #107 verified the Audiologist left after the visit and had not informed anyone of the recommendations for Resident #64. LSW #107 verified she checked with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and both said they were not notified by the audiologist of the recommendation and visit on 01/29/26. Interview on 02/25/26 at 12:00 P.M. the DON stated she received the audiology note via email for Resident #64 but would not provide the email.Interview on 02/26/26 at 7:45 A.M. with the Medical Director #300 verified if audiology recommends Debrox, the providers would have followed the recommendation and ordered it for the resident.

Based on medical record review, staff interview, and policy review, the facility failed to ensure discrepancies in a resident code status was identified and corrected timely. This affected one resident (#80) out of 36 residents reviewed for advance directives. The facility census was 92.Findings include:Review of the medical record for Resident #80 revealed an admission date of 11/27/19 with diagnoses including Alzheimer's disease, delusional disorder, vascular dementia, type II diabetes mellitus, hypertension, and adult failure to thrive.Review of a physician order with a start date of 04/23/20 and a discontinuation date of 02/02/26 revealed an order for Do Not Resuscitate - CC Arrest, which permits life saving measures until the resident's heart or breathing stops.Review of the Do Not Resuscitate (DNR) order form dated 11/28/25 revealed Resident #80's guardian elected DNR Comfort Care (DNRCC), which refuses resuscitation measures.Review of the care plan dated 12/01/25 revealed Resident #80 received hospice services with a terminal diagnosis of early onset Alzheimer's disease.Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was severely cognitively impaired.Review of the physician order dated 02/02/26 revealed an order for DNR Comfort Care.Interview on 02/25/26 at 9:55 A.M. with the Director of Nursing (DON) revealed an audit identified the resident's code status in the electronic record did not match the paper documentation. The DON confirmed the intention was to change the resident's code status to DNRCC when the resident transitioned to hospice on 11/28/25. The DON confirmed a DNRCC order was placed on 02/02/26.A follow-up interview on 02/26/26 at 10:25 A.M. with the DON verified all licensed nursing staff are responsible for ensuring a resident's physician ordered code status matches the corresponding paper record.Review of a policy titled Resident Rights: Treatment and Advance Directive, dated 11/22/16 revealed decisions regarding advanced directives and treatment will be addressed with significant change.

Based on observation, staff interview, record review, review of online resources from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) with residents in enhanced barrier precautions (EBP) (infection control measures in Skilled Nursing Facilities requiring gowns and gloves during high-contact resident care to reduce multidrug-resistant organism [MDRO] transmission). This affected two (Residents #01 and #74) observed during personal care. The facility census was 92.Findings include:Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included anoxic brain damage, metabolic encephalopathy, other heart failure, and ischemic cardiomyopathy. Review of the medical record revealed Resident #74 had physician orders dated 11/19/25for EBP every shift. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition, supervision for eating, dependent for toileting, dependent for bathing, and partial assistance for personal hygiene. Observation on 02/23/26 at 11:28 A.M., revealed Licensed Practical Nurse (LPN) #169 went in Resident #74's room to give medication via gastrostomy tube (GT) and LPN #169 did not have a gown on. Observation on 02/23/2026 at 11:30 A.M., revealed LPN #169 left the resident's room and stated she forgot her stethoscope. Observation on 02/23/2026 at 11:31 A.M., revealed LPN #169 came back in Resident #74's room and did not have a gown on. Observation on 02/23/2026 at 11:32 A.M., revealed LPN #169 performed administration of medications via GT without a gown in place Observation on 02/23/2026 at 11:37 A.M., revealed LPN #169 left Resident #74's room again for a cup and reentered again with no gown on and administered a 30 milliliter (ml) flush. Interview on 02/23/2026 at 11:45 A.M., LPN #169 verified Resident #74 was in EBP. LPN #169 verified she did not wear a gown during GT medication administration. Interview on 02/26/26 at 8:10 A.M., Certified Nursing Assistant (CNA) #266 stated she was not aware of what PPE to wear for which type of resident care. CNA #266 verified there were no signs on the resident's doors who were in EBP to instruct staff on what PPE to don. 2. Review of the medical record for Resident #01 revealed an admission date of 01/16/25 with diagnoses of atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the care plan dated 03/21/25 revealed Resident #01 had alteration in elimination related to obstructive and reflux uropathy, benign prostatic hyperplasia, chronic kidney disease stage three, and indwelling suprapubic catheter use. Interventions included maintaining enhanced barrier precautions, providing suprapubic catheter care every shift, and changing the catheter and emptying the catheter bag every shift. Review of the physician order for Resident #01 dated 12/07/25, revealed the resident was ordered to be EBP related to an indwelling catheter. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #01 was cognitively intact, had an indwelling catheter, and required substantial/maximal assistance with toileting. Observation of Resident #01's room on 02/25/26 from 10:25 A.M. to 10:32 A.M., revealed a small sign on the door frame indicating the resident was in EBP. LPN #18 performed catheter care for resident #01 without donning a gown. Interview on 02/25/26 at 10:32 A.M., LPN #18 verified Resident #01 was in EBP due to a suprapubic catheter and verified there was an EBP sign posted on the resident's door. LPN #18 verified there were PPE supplies located directly outside of the resident's room. LPN #18 verified she didn't wear a gown and should have when providing direct resident care. Interview on 02/26/26 at 10:25 A.M., the Director of Nursing (DON) verified a gown, and gloves should be worn by staff when they were providing direct care on residents who were in EBP. Review of standard and transmission-based precautions (TBP) dated 07/24/24, revealed EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. Review of online resources from CDC (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html) dated 06/28/24, revealed EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involves at minimum gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical device. EBP expands the use of gowns and gloves beyond anticipated blood and body fluid exposures. Review of the policy titled, Standard and Transmission Based Precautions, dated 03/24/24 revealed, information regarding the particular type of precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and acted upon. This affected one resident (Resident #72) out of five residents reviewed for pharmacy recommendations. The facility census was 92.Findings include:Review of the medical record for Resident #72 revealed an admission date of 09/20/23 with diagnoses of Alzheimer's disease, dementia, senile degeneration of the brain, bipolar disorder, insomnia, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was severely cognitively impaired, received an antipsychotic and an antidepressant, and last underwent a gradual dose reduction (GDR) on 12/28/23.Review of a pharmacy recommendation dated 02/26/25 revealed the resident had taken Trazodone (an antidepressant) 50 milligrams nightly since September 2023. The resident's Celexa (an antidepressant) was reduced in January, and the resident also received Seroquel (an antipsychotic). The pharmacy noted the resident was due for a gradual dose reduction GDR evaluation. The prescriber selected other, documenting the resident was followed closely by psychiatry and nursing should advise psychiatry regarding GDR recommendations.Review of a pharmacy recommendation dated 05/12/25 revealed the resident received Seroquel 25 mg every morning and 50 mg twice daily and had been on that dosage since November 2024. The pharmacy noted no adverse effects, no psychiatric service notes, and that the resident was due for a GDR. The physician response stated disagree with a directive to follow up with psychiatry.Review of the care plan dated 07/16/25 revealed the resident had a history or diagnosis of depression and/or anxiety, persistent anger toward others, and repetitive physical movements. Interventions included assisting the resident in working through anxieties.Review of a pharmacy recommendation dated 11/11/25 again revealed Seroquel 25 mg every morning and 50 mg twice daily with no adverse effects, no psychiatric notes, and that the resident was due for a GDR. The physician response documented disagree and other, with a note to consult the psychiatry nurse practitioner.Review of a psychiatric note dated 01/08/26 revealed the resident was being seen for an initial comprehensive psychiatric evaluation and medication management.Review of the quarterly MDS dated [DATE] revealed Resident #72 was severely cognitively impaired, received an antipsychotic and antidepressant, and last received a GDR on 11/05/24.Interview on 02/25/26 at 2:32 P.M. with the Director of Nursing (DON) revealed the DON could not locate any psychiatric visit prior to the initial evaluation on 01/08/26 and would need to confirm whether the resident had been seen by an alternate provider.Interview on 02/26/26 at 8:45 A.M. with the DON revealed psychiatric notes prior to 01/08/26 had not be located.Interview on 02/26/26 at 10:25 A.M. with the DON confirmed the resident was not seen by psychiatry until the initial evaluation on 01/08/26. The DON also confirmed that while the nurse practitioner reviewed the pharmacy recommendations, the pharmacy statements indicating the psychotropic regimen was being managed by psychiatry were not accurate at the time, and orders were not placed to obtain a psychiatry consult. As a result, the pharmacy recommendations dated 02/26/25, 05/12/25, and 11/11/25 were not addressed timely when issued.Review of the facility's Medication Regimen Review (MRR) policy dated 11/28/17 revealed the MRR is a thorough evaluation of the resident's medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences. The policy states the physician will document in the medical record that any identified irregularities have been reviewed and what, if any, action has been taken.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure appropriate infection control practices were followed during tracheostomy care for one (Resident #111) of one resident reviewed for tracheostomy care. The facility census was 92.Findings include:Review of the medical record for Resident #111 revealed an admission date of 01/29/26. Diagnoses included chronic respiratory failure with hypoxia, encounter for palliative care, unspecified severe protein-calorie malnutrition, and tracheostomy status.Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had impaired cognition with a Brief Interview for Mental Status score of seven and required extensive to total assistance with activities of daily living.Review of the plan of care dated 02/09/26 revealed the resident was at risk for infection related to tracheostomy status, chronic respiratory failure with hypoxia, and severe protein-calorie malnutrition. Interventions included monitoring for signs and symptoms of infection and providing care per physician orders.Review of physician orders dated 01/29/26 revealed the resident required ongoing tracheostomy care and monitoring. Review of physician orders dated 02/09/26 and 02/18/26 continued to reflect tracheostomy status requiring nursing care and monitoring.Observation on 02/25/26 at 11:12 A.M. of tracheostomy care for Resident #111 revealed Registered Nurse #199 washed her hands in the bathroom sink, donned a gown, gloves, and mask, and gathered tracheostomy supplies. The Registered Nurse did not disinfect the bedside table prior to placing tracheostomy supplies on the surface. The Registered Nurse touched the bed controls with gloved hands and then handled gauze at the tracheostomy site with the same gloves. The Registered Nurse opened sterile supplies, removed her gloves, performed hand hygiene with sanitizer, and donned sterile gloves. While wearing sterile gloves, the Registered Nurse touched the outside of the non sterile saline bottle and then touched sterile cleaning swabs. The Registered Nurse touched the tracheostomy site with gloves that had contacted the outside of the non sterile saline bottle. After cleaning the tracheostomy site, the Registered Nurse touched the outside of new tracheostomy ties that had been placed on the bedside table and touched the television remote control, and then used the same gloves to apply the new tracheostomy ties. When removing the old tracheostomy tie, the Registered Nurse handled the soiled ties with sterile gloves. The Registered Nurse then removed the sterile gloves, performed hand hygiene, donned new gloves, touched the outside of the opened gauze package, and applied new gauze to the resident using the same gloves.Interview on 02/25/26 at 11:39 A.M. with Registered Nurse #199 confirmed the tracheostomy care was performed as observed.Review of the facility policy titled, Tracheostomy Care, Tube Changes and Suctioning dated 04/17/23, revealed tracheostomy care was to be performed consistent with physician orders and infection prevention and control practices. The policy specified that infection prevention and control practices were to be followed throughout the procedure. The policy further specified that tracheostomy suctioning was a sterile procedure, that hand hygiene was to be performed, personal protective equipment was to be applied, sterile gloves were to be donned using sterile technique, and sterile supplies were to be handled in a manner that maintained sterility.

Based on medical record review, observation, and staff interview, the facility failed to implement a pressure ulcer/injury prevention intervention. This affected one (Resident #13) out of four residents reviewed for pressure ulcer/injury. The census was 92.Findings Included:Review of Resident #13's medical record revealed an admission date of 02/03/24. Diagnoses included chronic respiratory failure, severe protein-calorie malnutrition, heart failure, muscle weakness, peripheral vascular disease, and dementia. Review of Resident #13's care plan dated 01/09/26 revealed a focus area stating the resident was at risk for alteration in skin integrity related to falls, impaired mobility, and prolonged pressure to bony prominences. Intervention for this focus was to encourage and assist resident to elevate heels when in bed as need/tolerated. Review of a Braden Scale assessment for Predicting Pressure Ulcers/Injuries dated 01/27/26 revealed a score of 11.0, which indicated a high risk for developing pressure ulcers/injuries. Review of the current physician's orders list revealed the following active order with a start date of 10/08/24: Encourage/assist resident to float heels off bed as tolerated.Observation on 02/23/26 at 10:56 A.M. revealed a laminated paper sign hung above Resident #13's bed that read Please float my heels.Observation and interview on 02/25/26 at 9:42 A.M. revealed Resident #13's heels lying flat on the mattress while lying in bed. At the time of observation, interview with License Practical Nurse (LPN) #169 stated that the expectation was when Resident #13 was in bed their heels are floated off the bed with a pillow underneath their knees. LPN #169 verified Resident #13's heels were lying flat on the bed and subsequently placed a pillow underneath the resident's knees to float their heels.

Based on medical record review, observation, and staff interview, the facility failed to ensure staff fed dependent residents in a dignified manner. This affected two (#09 and #52) out of six residents observed during dining. The facility census was 92.Findings include: 1.Review of Resident #09's medical record revealed an admission date of 05/08/24. Diagnoses included dysphagia, chronic pain, dementia, and hearing loss. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #09 had severely impaired cognition and was dependent on staff for eating. 2.Review of Resident #52's medical record revealed an admission date of 08/09/18. Diagnoses included Parkinsonism, major depressive disorder, and psychotic disturbance. Review of a quarterly MDS dated [DATE] revealed Resident #52 had severely impaired cognition and required substantial to maximum assistance eating. Observation on 02/23/26 at 12:20 P.M. Certified Nurse Aide (CNA) #217 was observed feeding Resident #09. CNA #217 was standing beside a resident who was seated at the table in a tilt wheelchair. CNA #217 fed Resident #09 one spoonful of food and moved on to Resident #52 who was seated in a tilt wheelchair at the same table. CNA #217 fed Resident #52 one spoonful of food while standing then moved on to pass more resident meals trays. During an interview on 02/23/26 at 12:39 P.M. CNA #217 verified she had stood while feeding Resident #09 and Resident #52. CNA #217 verified Resident #09 and Resident #52 had not been fed any more of their meal since 12:20 P.M.

Based on observation, staff interview, and policy review, the facility failed to ensure the dishwasher was maintained in working order. This had the potential to affect all 95 residents who reside in the facility. The facility census was 95. Findings include: Observation on 06/10/24 at 9:27 A.M., with Executive Chef #744 revealed the dishwasher had an electronic read out that states ERR too hot when it was running. Also, the gauges on the dishwasher were not moving while the machine was on. Interview on 06/10/24 at 9:27 A.M., with Executive Chef #744 revealed the facility has a high temperature sanitizing dishwasher. Executive Chef #744 also said he is looking for a high temperature of 185 to 190 degrees Fahrenheit (F). Observation on 06/10/24 at 9:31 A.M., revealed Executive Chef #744 used a temperature test sticker to test the hot water sanitizer of the machine. The temperature test sticker stated Square turns black as temperature is reached 160 F. After running the sticker through the machine, the sticker was white. Observation on 06/10/24 at 9:33 A.M., revealed the temperature test sticker was ran through the dishwasher again by Executive Chef #744. Interview on 06/10/24 at 9:33 A.M., with Executive Chef #744 revealed the second test strip did not reach appropriate temperature either. When questioned what is the process if the dishwasher isn't working, Executive Chef #744 revealed they handwash everything then. Interview on 06/11/24 at 3:45 P.M., with Executive Chef #744 revealed the dishwasher is not fixed. Executive Chef #744 revealed someone from GFS came to look at the dishwasher last night. Executive Chef #744 revealed he was under the impression the dishwasher was fixed as no one called or told them about it. Executive Chef #744 revealed he put a temperature sticker through the machine after breakfast and the machine was still not working. Executive Chef #744 said they have been handwashing since breakfast. Executive Chef #744 called the company and they said they had to order a part because they didn't have it on hand. When asked if they are still using the dishwasher, Executive Chef #744 said they are running large items through the dishwasher that do not fit in the three compartment sink. Executive Chef #744 said they still do not have correct sanitizer test strips. When asked how are you making sure dishes and utensils are being sanitized, Executive Chef #744 said that is a good question and he hopes that the sanitizer is right. Interview on 06/11/24 at 4:35 P.M., with Executive Chef #744 confirmed the dishwasher is a high temperature sanitizer dish machine. Executive Chef #744 revealed he ordered the proper sanitizer test strips and a dishwasher thermometer because the gauges on the dishwasher do not move and the electronic read out is an error message. Interview on 06/13/24 at 10:49 A.M. ,with Executive Chef #744 revealed they do not keep a temperature log of each dish machine cycle, but he does keep a log of daily test stickers. The test sticker log starts 01/01/24 and ends 05/04/24. Executive Chef #744 revealed he ran out of stickers at that time. Review of the policy titled, Dishwashing Machine Use, dated April 2020 stated dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than: 165 F for stationary rack, single temperature machines. The policy also stated corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the super-visor and corrected immediately. Lastly, the policy stated if hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted.

Based on observations, staff interviews, cleaning schedule review, and policy reviews, the facility failed to date food items in the walk-cooler, dispose of out of date food items, maintain the kitchen in a clean condition, obtain the correct sanitizer test strips, and properly sanitize dishware and utensils. This had the potential to affect all 95 residents who reside in the facility. The facility census was 95. Findings include: Observation on [DATE] at 8:58 A.M., with Executive Chef #744, of the soda dispenser revealed the machine was dirty on the inside and the holder was also dirty. Interview on [DATE] at 8:58 A.M., with Executive Chef #744 revealed the soda dispenser unit didn't get cleaned this weekend. Observation on [DATE] at 9:00 A.M., with Executive Chef #744 of the coffee station revealed the coffee machine had a brown powder under and around the dispensers and dried liquid drippings on the lids next to the dispenser. Interview on [DATE] at 9:00 A.M., with Executive Chef #744 revealed the coffee station is not clean. Observation on [DATE] at 9:06 A.M. to 9:08 A.M., with Executive Chef #744, of the the walk-in cooler revealed a container of macaroni salad did not have a date on it; a container holding a white pudding substance and orange slices did not have a date on it; and two unmarked and unlabeled plastic shopping bags containing food items were stored on a food storage cart next to a container of mushrooms, a container of cream of mushroom soup, a container of mashed potatoes, and a bag of leftover salad. Interview on [DATE] at 9:06 A.M., with Executive Chef #744 revealed there was not a date on the container and the macaroni salad was made last Thursday, The container holding the white pudding substance and orange slices as orange fluff. Executive Chef #744 confirmed it does not have a date and does not remember having it on the menu. Executive Chef #744 revealed the unmarked bags were stuff someone brought from home. Observation on [DATE] at 9:18 A.M., with Executive Chef #744 revealed the floor between the steam table and wall had a straw, sour cream container, and napkins on the ground; the floor between the ovens and grill and the wall had a burger and can of soda on the ground. Interview on [DATE] at 9:18 A.M. and 9:20 A.M., with Executive Chef #744 confirmed the debris and that they clean behind equipment once a week. Observation on [DATE] at 9:20 A.M. with Executive Chef #744 revealed the floor between the ovens and grill and the wall had a burger and can of soda on the ground. and revealed Sous Chef #834 dropped a burger behind the grill yesterday. Observation on [DATE] at 9:23 A.M. with Executive Chef #744, of the three compartment sink revealed the test strips used to measure the sanitizer concentration are pH test strips. Interview on [DATE] at 9:23 A.M., with Executive Chef #744 revealed the facility uses quat sanitizer in the sanitizer compartment of the three compartment sink. When questioned if the facility has quat test strips, Executive Chef #744 stated No, these are what I got in. Executive Chef #744 revealed the supplier gave him these test strips this past Thursday. Observation on [DATE] at 9:27 A.M., with Executive Chef #744, of the dishwasher revealed the readout read ERR too hot. Also, the gauges on the machine did not move when the dishwasher was on. Observation on [DATE] at 9:31 A.M., revealed Executive Chef #744 used a temperature test sticker to test the hot water sanitizer of the machine. The temperature test sticker stated Square turns black as temperature is reached 160 F After running the sticker through the machine, the sticker was white. Observation on [DATE] at 9:33 A.M., revealed the temperature test sticker was ran through the dishwasher again by Executive Chef #744. Interview on [DATE] at 9:33 A.M., with Executive Chef #744 revealed the second test strip did not reach appropriate temperature either. When questioned what is the process if the dishwasher isn't working, Executive Chef #744 revealed they handwash everything then. Observation on [DATE] at 9:43 A.M., with Executive Chef #744, of the dry storage revealed three outdated bags of [NAME] big white bread amongst many other bags of bread stored on the bread rack in the kitchen. There were bags dated [DATE]; [DATE]; and [DATE]. Interview on [DATE] at 9:43 A.M., with Executive Chef #744 revealed the bread must have gotten mixed up. Executive Chef #744 stated they get bread twice a week. Observation on [DATE] at 3:24 P.M., revealed the soda can and debris is still on the ground behind the ovens and grill and there are still napkins, a sour cream container, and a straw on the ground behind the steam table. Interview on [DATE] at 3:45 P.M. with Executive Chef #744 revealed the dishwasher is not fixed. Executive Chef #744 revealed someone came to look at the dishwasher last night. Executive Chef #744 revealed he was under the impression the dishwasher was fixed as no one called or told them about it. Executive Chef #744 revealed he put a temperature sticker through the machine after breakfast and the machine was still not working. Executive Chef #744 said they have been handwashing since breakfast. Executive Chef #744 called the company and they said they had to order a part because they didn't have it on hand. When asked if they are still using the dishwasher, Executive Chef #744 said they are running large items through the dishwasher that do not fit in the three compartment sink. Executive Chef #744 said they still do not have correct sanitizer test strips. When asked how are you making sure dishes and utensils are being sanitized, Executive Chef #744 said that is a good question and he hopes that the sanitizer is right. Interview on [DATE] at 4:35 P.M. with Executive Chef #744 confirmed the dishwasher is a high temperature sanitizer dish machine. Executive Chef #744 revealed he ordered the proper sanitizer test strips and a dishwasher thermometer because the gauges on the dishwasher do not move and the electronic read out is an error message. Executive Chef #744 revealed they currently do not have the appropriate test strips for the three compartment sink. Interview on [DATE] at 4:44 P.M., with Executive Chef #744 revealed there is still trash behind equipment on both walls. Executive Chef #744 picked up the soda can. Interview on [DATE] at 10:35 A.M., with the Administrator revealed the facility does not have a policy for where employees are to store their food. Interview on [DATE] at 10:49 A.M., with Executive Chef #744 revealed they do not keep a temperature log of each dish machine cycle, but he does keep a log of daily test stickers. The test sticker log starts [DATE] and ends [DATE]. Executive Chef #744 revealed he ran out of stickers at that time. Review of undated cleaning schedule revealed the coffee machine table and floors under equipment on the line are cleaned monthly. Review of the policy titled, Food and Nutrition Services, dated [DATE], stated the facility will dispose of garbage and refuse properly, garbage and refuse containers will be maintained in good condition, and garbage receptacles will be covered when transported to the dumpster from the kitchen. Review of the policy titled, Dishwashing Machine Use, dated [DATE], stated dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than: 165 F for stationary rack, single temperature machines. The policy also stated corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the super-visor and corrected immediately. Lastly, the policy stated If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. Review of the policy titled, Refrigerators and Freezer,dated [DATE] revealed all food shall be appropriately dated to ensure proper rotation by expiration dates. The policy also stated supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Review of the policy titled, Food Receiving and Storage Policy, dated [DATE] stated all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Review of the undated policy titled, Multi-Quat Sanitizer, revealed Keystone multi-quat sanitizer is a concentrated, no rinse quat sanitizer that is effective across a dilution range of 0.26 - 0.68 oz per gallon of water. The policy also revealed that the quat range for use is ,d+[DATE] parts per million.

Based on medical record review, policy review, staff interviews, and review of email communications, the facility failed to ensure pharmacy recommendations were retained and provided to the physician for Gradual Dose Reductions (GDRs) and laboratory recommendations. This affected one (#22) of five residents reviewed for unnecessary medications. The facility census was 95. Findings include: Record review revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, unspecified, dementia, and vascular dementia, unspecified severity, with other behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated ,d+[DATE] revealed the resident had severe cognitive impairment. Review of the Care Plan dated 05/18/23 revealed resident has impaired cognitive function/impaired thought processes r/t unspecified dementia with psychotic disturbances. Resident requires partial assistance with eating, bed mobility, and wheelchair mobility and was dependent with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfers. Review of the Care Plan dated 04/29/22 revealed interventions include encourage to take medication stating: the doctor wants you to take this and completing medication regimen review. Review of physician orders revealed an order dated 06/04/23, for QUEtiapine Fumarate Tablet 25 milligram (mg), give 0.5 tablet by mouth two times a day for dementia with behavioral disturbances and an order dated 07/08/23, for Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for dementia in other diseases classified elsewhere, unspecified with behavioral disturbance. Review of the Monthly Pharmacy Review received via email 06/12/24 at 9:01 A.M., revealed a pharmacy recommendation was made on 09/06/23. Per the email, the spreadsheet from the pharmacist, the pharmacy asked for a dose reduction on the Quetiapine 12.5 mg two times daily. The pharmacist recommended a depakote level be drawn. The pharmacist indicated there was no follow up on the recommendation. Interview on 06/12/24 at 4:05 P.M., with the Director of Nursing (DON) revealed the physician was in the building and advised she should not order a Depakote level due to medication being used for behaviors, not seizures. DON also advised GDR request from pharmacy dated 09/06/23, for QUEtiapine Fumarate Tablet 25 mg is not available but they would keep looking. Review of an email received on 06/13/24 at 11:02 A.M., to the DON from the pharmacy, advising the facility was not able to locate the GDR request from pharmacy dated 09/06/23 for QUEtiapine Fumarate Tablet 25 mg give 0.5 tablet by mouth two times a day. The DON verified the pharmacy made recommendations but the facility was unable to locate the recommendations. Review of the undated policy titled Pharmacy Services Overview, revealed Memorial [NAME] shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: Help the facility to establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility.

Based on medical record review, infection control log review, and staff interview, the facility failed to ensure there was no unnecessary medications administered to residents. This affected two (#13 and #72) of five residents reviewed for unnecessary medications. The current census is 95. Findings include: Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #13 include epilepsy, diabetes type two, obesity, heart disease, kidney disease, and osteoarthritis. Review of Resident #13's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident has intact cognition, was receiving an antibiotic, and is fall risk. Review of Resident #13's care plans dated 07/11/17, with a revision on 01/20/22, revealed a focus for urinary tract infections. Interventions include administer antibiotics per order, monitor laboratory results, and monitor for signs and symptoms of infection. Review of Resident #13's physician orders dated 06/23/23, revealed the resident was to receive Macrobid 100 milligram (mg) (antibiotic) one time a day for recurrent urinary tract infections. Review of the infection control log from May 2023 to May 2024 revealed Resident #13 was not on the infection control log for a urinary tract infection. Interview on 06/13/24 at 1:30 P.M., with the Director of Nursing (DON) revealed Resident #13's physician had prescribed the Macrobid antibiotic as a prophylactic medication to prevent further urinary tract infections. Per the DON, Resident #13 did not have any signs or symptoms of infection which would justify the use of the antibiotic. The DON verified the physician's prescribed antibiotic did not meet the criteria for administration in regards to the antibiotic stewardship protocols. 2. Record review of Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #72 included dementia, kidney disease, diabetes type two, failure to thrive, and urgency of urine. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a person assist for Activities of Daily (ADL). Review of Resident #72's care plans dated 10/20/23 revealed a focus for urinary tract infections. Interventions include administer antibiotics per order, monitor lab results, and monitor for signs and symptoms of infection. Review of Resident #13's physician orders dated 12/23/23 revealed the resident was to receive Cephalexin 500 (mg) (antibiotic) one time a day for recurrent urinary tract infections. Review of the facility's infection control log from January 2024 to May 2024 revealed Resident #72 was not on the infection control log for a urinary tract infection. Interview on 06/13/24 at 1:30 P.M., with the Director of Nursing (DON) revealed Resident #72's physician had prescribed the Macrobid antibiotic as a prophylactic medication to prevent further urinary tract infections. Per the DON, Resident #72 did not have any signs or symptoms of infection which would justify the use of the antibiotic. The DON verified the physician's prescribed antibiotic did not meet the criteria for administration in regards to the antibiotic stewardship protocols.

Based on medical record review and staff interview, the facility failed to ensure all pharmacist recommendations were completed in regards to antipsychotic medication assessments. This affected one (#21) of three residents reviewed for antipsychotic medication use. The current census is 95. Findings include: Review of the medical record for Resident #21 revealed the resident was admitted to facility on 06/30/21. Diagnoses for Resident #21 include polymyalgia, spinal stenosis, bipolar disorder, degeneration of brain, and heart failure. Review of Resident #21's care plans dated 11/05/21 revealed a focus for use of antipsychotic medications related to bipolar disorder. Interventions include consult pharmacy for medication recommendation, monitor and report side effects, and monitor and record target behaviors. Review of Resident #21's prescribed medications revealed on 09/14/22 the resident is to receive Risperidone 1 milligrams (mg) (antipsychotic) daily for bipolar disorder. Review of the pharmacy's recommendations dated 08/08/23 and 11/10/23 revealed the pharmacist communicated to the nursing staff the resident was to have an Abnormal Involuntary Movement Scale (AIMS) assessment completed for the Risperidone. Review of the assessments for Resident #21 revealed on 12/20/23 and 01/17/23 an AIMS assessment had been completed for the use of antipsychotics. Interview on 06/12/24 at 3:30 P.M., with the Director of Nursing (DON) revealed per pharmacy recommendations and standards of practice AIMS assessments are to be completed quarterly for all residents on antipsychotic medications. The DON verified there was only one AIMs assessment completed for the first quarter of 2023 and one AIMS assessment completed in the fourth quarter for Resident #21. The DON verified the nursing staff did not follow the pharmacist's recommendations for the AIMS to be completed in August 2023 and November 2023. The DON verified there was no actual policy for the AIMS but stated it was a standard of practice.

Based on observation, medical record review, review of the incident log, review of fall investigation, resident interview, and staff interview, the facility failed to safely transport a resident resulting in a fall. This affected one (#13) of five residents reviewed for falls. The current census is 95. Findings include: Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #13 included epilepsy, diabetes type two, obesity, heart disease, kidney disease, and osteoarthritis. Review of Resident #13's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident has intact cognition, requires a wheelchair for ambulation, and is fall risk. Review of Resident #13's care plans dated 07/11/17, with a revision on 06/21/23, revealed a focus for falls characterized by multiple risk factors. Interventions include education for resident to not transfer to a golf cart, educate resident to ask for assistance, non-skid footwear at all times, educate resident to use handrails, ensure adaptive equipment in place when resident in wheelchair, and transfer or change position slowly. Review of the incident log dated from January 2024 to June 2024 revealed there was no documented fall for Resident #13 on 05/30/24. Review of the facility's fall investigation dated 05/30/24 revealed Resident #13 reported to the staff she fell forward out of the wheelchair during transport and scraped her knees. Per the investigation the driver of the vehicle was interviewed and stated the seatbelt was not secured properly due to the resident falling onto her knees and the floor of the vehicle when the driver put on the brakes of the vehicle. Per the investigation the driver claimed he hit his head on the back hitch of the vehicle just prior to transporting the resident. The driver was educated to not drive if injured and to notify the facility for assistance. No notification of the family representative was documented in the investigation. Review of Resident #13's skin assessments dated 05/30/24 revealed the resident had scrapes on bilateral knees. Per the skin assessment dated [DATE] the injuries to the knees have healed. Observation on 06/11/24 at 3:00 P.M., of Resident #13's bilateral knees revealed no injuries were visible. Interview on 06/11/24 at 3:00 P.M., with Resident #13 revealed the resident was alert and oriented and able to recall details of past events. Resident #13 reported during a transport to an outside physician appointment the resident claimed the staff did not secure her in the transportation vehicle properly. Resident #13 stated she fell twice during the transport. Resident #13 stated she started to fall forward and was able to catch herself the first time and she yelled at the transport driver to help her since she was not 'buckled in'. Resident #13 stated the driver ignored her requests for help. Resident #13 stated the second time she fell she landed in front of her wheelchair on the floor of the transport vehicle. Resident #13 stated she hurt her knees and she again started yelling for help to the driver. Resident #13 stated when she arrived back to the facility she reported the fall in the bus to her nurse and the Director of Nursing (DON). Resident #13 state the DON offered her to have a x-ray of her knees but the resident declined stating she didn't think anything was broken just 'bruised'. Resident #13 denied any pain from the injuries and stated she had no further concerns regarding the fall. Interview on 06/12/24 at 11:05 A.M., with the DON verified Resident #13 reported she had fallen out of her wheelchair during transport. DON verified the driver claimed he hit his head prior to driving the resident to her appointment in the facility's vehicle. The DON stated the driver had not ensured the seatbelt was buckled due to him hitting his head prior to driving. The DON stated the driver was educated not to drive if injured. Per the DON, Resident #13's family was not notified as she is her own person and first contact for emergencies. Per the DON no other education had been provided to the driver or other staff to prevent another incident. Interview on 06/13/24 at 11:10 A.M., with State tested Nurse Aide (STNA) #854 revealed he was driving the bus on 05/30/24, when Resident #13 had her fall. STNA #854 stated he was securing the resident into the vehicle to transport her back to the facility when he struck his head on a bar in the bus. STNA #854 stated he could not recall buckling the resident's seatbelt. STNA #854 denied hearing Resident #13 yell to him before she had fallen out of the wheelchair. STNA #854 confirmed the resident had fallen out of her wheelchair as he was pulling into the parking lot and stated he parked the vehicle at the front door and ran to get help for Resident #13. STNA #854 stated he has been educated to not drive the vehicle if he has struck his head but stated he felt he was able to continue the transport back to the facility. STNA #854 stated it is procedure to ensure all residents are secure in the vehicle prior to transporting them.

Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a care plan was updated to include dental needs after teeth extractions. This affected one (#23) of one resident reviewed for dental. The facility census was 95. Findings include: Review of medical record for Resident #23 revealed admitted [DATE], with diagnoses including osteoarthritis, spondylolisthesis cervical region, insomnia, restless leg syndrome, senile degeneration of brain, and hypertension. Review of nursing oral assessment dated [DATE] revealed Resident #23 had her own teeth and the resident recently had all her top teeth removed. Some scant bleeding and swelling remained. Bottom teeth intact in fair condition. Review of progress note dated 05/11/24 revealed Resident #23 complained of pain post dental teeth extraction. Bruises noted to face/bilateral cheeks and bruises under nose were noted. New order received to monitor bruises to face and right side until resolved. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed a brief interview of mental status (BIMS) score of 15, which indicated the resident was cognitively intact. No chewing or swallowing difficulty, weight loss, or mouth/facial pain noted during the look back period. Resident #23 was set up assist for meals. Review of care plan dated 05/29/24 revealed no care plan related to dental issues was noted. Review of oral intake for the past 14 days (05/27/24-06/10/24) revealed the resident ate on average 76-100 percent of meals. Interview on 06/10/24 at 10:59 A.M., with Resident #23 revealed the dentist took all her teeth out on the top and she had not received her dentures yet. Resident #23 stated it would be sometime in July when the fit her for dentures. Interview on 06/13/24 at 12:44 P.M., with Director of Nursing (DON) verified the care plan for Resident #23 did not include anything regarding the residents top teeth being pulled or that the residents top teeth had started breaking and they needed to be pulled. DON stated that multiple nurses did the care plans. DON verified no specific care plan regarding the resident's teeth after the teeth were pulled. Review of policy titled Comprehensive Person-Centered Care Plans revised August 2019, revealed an individualized comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The comprehensive, person-centered care plan will incorporate identified problem areas, aid in preventing or reducing decline in the resident's functional status or functional levels. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. The Interdisciplinary Team must review and update the care plan at least quarterly, and when there has been a significant change in the resident's condition.

Based on record review and staff interview, the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) was completed when a new qualifying diagnosis was received. This affected one (#16) of one resident reviewed for PASARR. The facility census was 95. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia, and unspecified dementia, unspecified severity, with psychotic disturbance. Further record review revealed a diagnosis of bipolar disorder was received on 12/27/23. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of the Care Plan dated 05/18/23 revealed the resident has impaired cognitive function/impaired thought processes related to unspecified dementia with psychotic disturbances. Review of the PASARR determination from the Ohio Department of Mental Health dated 06/09/23 revealed the resident had no indication of serious mental illness and / or developmental disabilities with effective date of 06/09/23. Review of the care plan dated updated on 06/12/24 revealed no evidence of the PASARR recommendations included in the care plan. Interview on 06/12/24 at 10:21 A.M., with Admissions - Discharge Coordinator #642 confirmed a new PASARR was not completed when resident received a new diagnosis of Bipolar on 12/27/23. Interview on 06/12/24 at 3:57 P.M., with the Director of Nursing confirmed the facility does not have a policy on PASARR completion.

Based on medical record review, staff interview, review of the facility policy, and review of an online medication resource, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #10) of three residents reviewed for medication administration. The census was 87. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including malignant neoplasm of endometrium, heart disease, chronic kidney disease, and anemia. Review of physician's orders for Resident #10 revealed an order dated 11/29/23 for Afinitor (an anti-cancer drug) 7.5 milligrams (mg) one tablet by mouth once daily for treatment of malignant neoplasm of the endometrium. Review of the complete blood count (CBC) laboratory test results for Resident #10 dated 02/01/24 revealed the resident's hemoglobin (a lab value which indicates the level of red blood cells in the body) level was 6.5 grams per deciliter (g/dL). A normal level was 12.1 to 15.1 g/dL for females. Per review of the progress note for Resident #10 dated 02/01/24 per Agency Nurse (AN) #110 revealed the resident's physician called an order to the facility to withhold Afinitor 7.5 mg until notified by the office to resume. The physician also gave an order to draw a CBC laboratory test on 02/05/24 and call the physician's office with the results so they could determine if it was appropriate to restart the Afinitor. Review of the CBC laboratory test results for Resident #10 dated 02/05/24 revealed the resident's hemoglobin level was 6.4 g/dL. Review of the Medication Administration Record (MAR) for Resident #10 dated February 2024 revealed the resident's Afinitor was withheld on the following dates: 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/06/24. The medication was signed off as administered on the following dates: 02/07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24. Review of the CBC laboratory test results for Resident #10 dated 02/13/24 revealed the resident's hemoglobin level was 5.6, and the resident was sent to the hospital for an evaluation due to the low hemoglobin level. Review of the hospital notes for Resident #10 revealed the resident was admitted to the hospital on 02/13/24 with a diagnosis of acute on chronic anemia and her hemoglobin level was 5.6 g/dL. The hospital physician recommended a blood transfusion to treat the anemia related to the low hemoglobin level, but the resident refused for religious reasons. The resident returned to the facility on [DATE] and was admitted to hospice for end stage endometrial cancer, and the Afinitor was discontinued in the hospital. Review of the readmission physician's orders for Resident #10 revealed an order dated 02/16/24 for resident to receive hospice services for endometrial cancer. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 02/20/24 revealed the resident was cognitively intact and required one to two person assistance with activities of daily living (ADLs.) Interview on 03/20/24 at 12:04 P. M. with the Director of Nursing confirmed Resident #10's physician gave an order on 02/01/24 to withhold Afinitor until further notice. The DON confirmed Resident #10's hemoglobin level on 02/01/24 was 6.5 which was considered low. The physician also gave an order to recheck the resident's hemoglobin level on 02/05/24 and call the results to the physician, because the medication Afinitor could contribute to anemia (low hemoglobin levels in the blood.) The DON confirmed the facility rechecked Resident #10's hemoglobin level on 02/05/24 and it was 6.4. Further interview confirmed the order to withhold Resident #10's Afinitor was not properly implemented, and the resident received the medication on the following dates even though the physician had not given an order to restart the medication: 02/07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24. The DON confirmed Resident #10's hemoglobin level on 02/13/24 was 5.6, and the physician gave an order to send the resident to the hospital for an evaluation. The DON confirmed Resident #10 was admitted to the hospital with acute on chronic anemia. The DON confirmed Resident #10 refused a blood transfusion to treat the low anemia level due to religious reasons and the resident returned to the facility on [DATE] on hospice care for endometrial cancer and Afinitor was discontinued. Interview on 03/21/24 at 8:45 A. M. with Licensed Practical Nurse (LPN) #105 confirmed she transcribed the verbal order dated 02/01/24 to hold Resident #10's Afinitor into the electronic medical record but the medication should have been discontinued until the physician had given an order to resume it. LPN #105 confirmed Resident #10 received the medication in error on the following dates: 02/07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24. Interview on 03/21/24 at 10:49 A.M. with Registered Nurse (RN) #115, who worked at the physician's office, confirmed the physician gave an order on 02/01/24 to withhold Resident #10's Afinitor until further notice. RN #115 confirmed the physician had not given an order to resume the Afinitor. Review of the facility policy titled Medication Orders August 2017 revealed medications must be administered in accordance with physician's orders. Review of online resource Medscape on 03/21/24 at https://reference.medscape.com/drug/afinitor-zortress-everolimus-999101#4 revealed anemia was a potential adverse effect of Afinitor and the CBC should be monitored in conjunction with administration. This deficiency represents noncompliance investigated under Complaint Number OH00151631.

Based on medical record review, staff interview, review of the Self-Reported Incident investigation, review of the daily staff schedule, and policy review, the facility failed to ensure enough direct care staff were available to ensure residents were not left in the bathroom for an extended period of time and the required number of staff were used when residents were transferred with the use of mechanical lifts. This affected one resident (#134) of three reviewed for assistance with toilet use. The facility identified 28 residents who required assistance with toilet use and 12 residents who required two staff member assistance for transfers. The facility census was 77. Finding include: Review of the medical record for Resident #134 revealed an admitted of 05/05/21. Diagnosis included Alzheimer's disease, dementia, chronic kidney disease, major depressive disorder, anxiety, history of falls and repeated falls, and need for assistance with personal care. Review of the plan of care dated 05/06/21 and revised on 12/07/21 revealed Resident #134 had bowel incontinence characterized by inability to control bowel movement, dementia. Interventions include to apply a protective barrier cream with each incontinent episode. Assess any complaints or signs of pain or discomfort. Cleanse perineal area well with each incontinence episode. Record bowel movement and monitor frequency and consistency. Review of Resident #134' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating a severely impaired cognition for daily decision making abilities. Noted to experience a long and short term memory problem, and disorganized thinking that fluctuated. Resident #134 required extensive assistance from two staff members for bed mobility, transfers, dressing and toilet use. Had no impairment to the bilateral upper and lower extremities and required the use of a wheelchair for mobility. Resident #134 was always incontinent of bladder function and frequently incontinent of bowel function. Review of the Self-Reported Incident Number 232923, dated 03/13/23 at 9:38 A.M. revealed an allegation of Neglect/Mistreatment Abuse. Summary of the incident included: On Monday 03/13/23 Licensed Nursing Home Administrator (LNHA) received a phone call from Resident #134's daughter who stated she felt her mother was neglected on Saturday 03/11/23. The daughter stated she visited her mother on Saturday around 1:15 P.M. and stated her mother was in the bathroom. The daughter stated State tested Nursing Assistant (STNA) #165 entered the residents room/bathroom and assisted her off of the toilet at 2:00 P.M. The daughter stated her mother was on the toilet for too long and alleged neglect. The LNHA immediately suspended STNA #165 and the Unit Manager #77 completed a head-to-toe assessment of resident with Resident #134 with no injuries noted. The resident's Physician was notified with no new orders. Resident #134 does have a medical diagnosis of/but not limited to Alzheimer ' s disease, Dementia without behavioral disturbances, Pseudobulbar affect, major depressive disorder, anxiety disorder, mental disorder, insomnia, and constipation. STNA #165 was interviewed with no negative findings. STNA #165 stated Resident #134 was incontinent of bowel and bladder, however when toileted, she will have a bowel movement, but needed a lot of time to do so. STNA #165 stated resident had a large bowel movement and was cleaned up and assisted back to her wheelchair to visit with her daughter. STNA #165 stated the resident's daughter seemed upset on 03/11/23 about Resident #134 being on the toilet. Staff in the facility were interviewed with no negative findings. Several staff who worked on the resident's unit stated Resident #134 would have a bowel movement on the toilet, but does require a lot of time to do so. Residents on the unit of the allegation that were not able to be interviewed, received head to toe assessments with no negative findings. Social Service Director (SSD) followed up with Resident #134 on 03/14/23 and resident's mood and behavior remained within normal limits. SSD stated Resident #134 was in a pleasant mood with no change in baseline of mood or behavior. Facility Conclusion/Disposition Section revealed this allegation was unsubstantiated, Evidence indicates abuse, neglect or misappropriation had not occurred. The facility had found no evidence to conclude that neglect occurred with Resident #134. Interview on 03/31/23 at 3:02 P.M. with Unit Manager #77 who indicated he was the unit manager for the unit where Resident #134 resided and Admissions/Discharge Coordinator #61 revealed he had worked here for about [AGE] years. Unit Manager #77 indicated he was not in the room when the incident with Resident #134 occurred, but completed a head-to-toe assessment on the resident when she was supposedly left in the bathroom for a extended period of time The head to toe assessment revealed no concerns regarding any form of injury and the resident appeared to be at her baseline regarding mood and behaviors. He spoke with STNA #165 who was providing care and was told the resident was placed on the toilet to have a bowel movement with the use of a mechanical sit to stand lift and was left there for a little while due to it taking her a little while to have a bowel movement, which Resident #134 ended up having a bowel movement. STNA #165 claimed she had left Resident #134 in the bathroom with the door closed to attend to another resident and to give Resident #134 time to use the bathroom and ended up getting tied up in an incident where another resident had to be transferred out to the hospital and had not realized how long Resident #134 had been on the toilet, but that she did not plan for her to be on the toilet for a long period of time. Interview on 03/31/23 at 3:19 P.M. with STNA #165 revealed she was the STNA who was providing care to Resident #134 on the day the incident occurred where she was in the bathroom for an extended period of time. STNA #165 claimed there was only two STNAs, herself and another STNA, there that day to care for all the residents on the Special Care Unit and most of the residents required two staff assistance for care. STNA #165 claimed she liked to try to get all of her residents onto the toilet, if she could because it helps them use the bathroom easier if they are sitting on the toilet. Resident #134 required some time on the toilet to be able to actually use the bathroom. Since there was only two STNAs to provide care, she used this time to provide care for other residents and to allow some privacy for Resident #134. Resident #134 had a sit-to-stand mechanical lift placed in front of her which is a mechanical lift like machine that has a sling that goes back behind the resident and then up under their arms and then attached to two extended metal arms of the machine. The resident was also able to hold onto the extended metal arms when the lift is in use. The Resident would then place their feet on the foot plate section of the lift and their knees and shins placed on the patted part of the lift that is intended to keep the residents' knees from buckling when the lift was assisting to raise the resident. STNA #165 claimed when Resident #134 was left on the toilet the sit-to-stand was still placed in front of her with the extended metal arms lowered into the lowest position, so they were down beside the residents sides keeping her from falling from side to side, the residents feet were still placed on the foot board and her knees were placed up against the padded part intended for her legs and knees. The machine was locked in place, so it was not able to slide or roll away from the resident. Resident #134 was secured while on the toilet with this lift from both sides and the front. There was no way for her to fall and STNA #165 felt she was safe to be left on the toilet alone with the lift secured in place. STNA #165 claimed she really meant no harm for the resident, only wanted to provide her enough time and privacy to use the bathroom. STNA #165 also claimed that she knows she was supposed to use two staff members for a mechanical lift but due to there only being two STNAs to care for the unit, most of the time she had to use the lift alone and she did transfer Resident #134 by herself on that day. Interview on 03/31/23 at 3:30 P.M. with STNA #17 who was working on 03/11/23 with STNA #165, verified she had not assisted STNA #165 at any point during the day to transfer Resident #134 and STNA #165 had used the sit-to-stand lift alone. Review of the daily posted staffing scheduled dated 03/11/23 from 6:00 A.M. through 2:30 P.M. there was one nurse and three STNAs where one STNA was noted to only be scheduled until 11:00 A.M., after that leaving only two STNAs on the Special Care Unit until the next shift was scheduled to arrive at 2:00 P.M. Review of facility policy titled Using a Mechanical Lifting Machine, undated revealed all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's care plan. General Guidelines. 2) At least two (2) trained staff members are needed to safely move a resident with a mechanical lift. Staff should review the resident's care plan prior to care/treatment to assess for any special needs. This deficiency represents non-compliance investigated under Complaint Number OH00141425.

Based on medical record review, family, and staff interviews the facility failed to adequately supervise and initiate fall preventions interventions. This affected one Resident (#149) out of three residents identified by the facility as having a fall with injury within the past three months. This resulted in actual harm to Resident #149 who sustained a hip fracture after a fall, resulting in a severe decline in his activities of daily living (ADL). The census was 99. Findings include: Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care dated 06/25/15 for falls initiated upon admission indicated the resident was at risk for falls. Interventions included ensure the environment was free of clutter, keep commonly used items within reach, and wear proper foot wear. On 11/27/15 the plan of care was updated to include keeping his wallet locked up when not in use so he did not put it in his shoe. The plan of care indicated the resident required assistance to restore function to maximum self sufficiency. Interventions included to not allow the resident to ambulate without assistance and one person assist with ambulation, transfers, and bed mobility. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was a 9 indicating the resident had moderate cognitive deficits. He required limited assistance of one staff member for bed mobility and ambulation. He required extensive assistance of one staff member for dressing, toileting, and personal hygiene. He used a wheeled walker to ambulate. He required set up and supervision for eating. Review of Interdisciplinary Care Conference Summary dated 12/19/16 indicated an invitation was sent to the family concerning the care conference date and time and there was no response from the family. The family did not attend the care conference. The summary noted the resident fell on [DATE]. No other information concerning the fall or discussion of fall risk and current interventions in place was documented. Review of the nurses progress notes dated 12/19/16 indicated the resident was up in his room without assistance and fell . There were no injuries. The intervention to prevent further falls was a physical therapy screening. Review of the Fall risk Assessment, dated 12/19/16, indicated the resident was at a high risk for falls. Review of the Rehabilitation Screening, dated 12/21/16 indicated the resident was status [REDACTED]. The therapy recommendation was for the resident to be provided with a touch call light and nursing was to monitor for further decline in cognition. Review of the Fall Investigation dated 12/21/16 indicated a touch call light was explained to the resident and he seemed to be more confused by the new call light and the original push call light was left in place. No other interventions were put into place to prevent falls. Review of the nurses note dated 02/03/17 indicated Resident #149 was up unassisted twice and was found in the bathroom of his room. Review of nurses notes dated 02/06/17 at 4:46 A.M. indicated the resident was found in bathroom by staff. He had self transferred. Review of a nurses notes entitled Monthly Note dated 02/10/17 at 12:46 P.M. indicated the resident was alert and oriented with periods of confusion. He transferred and ambulated with a walker and one assist. He transferred himself at times without requesting assistance. He requires one assist with ADL's and was able to feed himself independently after set-up. Review of the nurse notes dated 02/15/17 at 3:09 P.M. indicated staff heard another resident calling for help. Resident #149 was found lying on the floor with both knees bent. The resident was noted to be ambulating without assistance with his walker trying to grab snacks from the snack cart. Review of the fall investigation dated 02/16/17 regarding the 02/15/17 fall and fracture indicated on 02/15/17 at 2:05 P.M. staff was alerted by another resident that Resident #149 was on the floor at the nurses station. Resident #149 stated he was trying to get a snack. This fall resulted in a left hip fracture. He was noted to be ambulating using a walker trying to grab a snack from the cart. Upon assessment of the resident there was an internal rotation of his left leg and he complained of left hip and leg pain . The family and the physician were notified. He was sent to the emergency room for evaluation and treatment. The resident was confused, oriented to place and person only. He had a gait imbalance and impaired memory and was ambulating without assistance using a wheeled walker. There was no witnesses. Review of the Discharge Summary from the local hospital dated 02/22/16 indicated the resident was admitted to the hospital on [DATE] with a fractured left hip following a fall at the nursing home. He underwent surgery for [REDACTED]. Review of the Fall Risk assessment dated [DATE] indicated the resident was at high risk for falls. Review of the 14 day medicare MDS assessment dated [DATE] indicated the resident was unable to complete the brief interview for mental status. He had short and long term memory loss with expressive aphasia. The resident required extensive assistance of two staff members for bed mobility and transfers. He was non ambulatory. He required extensive assistance of one staff member for eating. Review of the plan of care dated on 03/08/17 remained unchanged from the plan of care dated 06/25/15. Review of the Interdisciplinary Care Conference Summarydated 03/21/17 stated an invitation was sent to the family concerning the care conference date and time and there was no response from family. The family did not attend the care conference. The summary noted the resident fell on [DATE] with a hip fracture. No other information concerning the fall or discussion of fall risk and current interventions in place was documented. During an interview with Resident #149's family member on 04/24/17 at 2:57 P.M. he stated the resident had not been the same since he returned from the hospital following his hip fracture. He received physical, occupational and speech therapy following his return to the facility on [DATE]. He was no longer able to walk and required two staff to assist him with all of his mobility. He was wheelchair bound. He could speak but he would only say a very few words and he needed assistance to eat. During an interview with Registered Nurse (RN) #120 on 04/26/17 at 2:00 P.M. indicated she worked with Resident #149 frequently. She verified he required extensive assistance of two staff members for bed mobility and transfers and he no longer ambulated since his return from the hospital. He could feed himself if his food was in a bowl; however, he required assistance of one at times to eat certain foods and prevent choking. During an interview with LPN #55 on 04/26/17 at 2:15 P.M. stated she worked with Resident #149 frequently. She verified he required extensive assistance of two staff members for bed mobility and transfers and he no longer ambulated since his return from the hospital. He could feed himself if his food is in a bowl; however. he required assistance of one at times to eat certain foods and prevent choking. She verified he had significantly declined from his status prior to the fall and fracture. During an interview with the Director of Nursing on 04/26/17 at 2:30 P.M. she verified Resident #149 was observed up without assistance multiple times and had experienced a fall without injuries prior to the fall and fracture on 02/15/17. She verified the resident had confusion and did not use his call light. She verified the fall prevention interventions were to remind the resident to use his call light, keep common things within his reach, keep his wallet locked up and staff to check on him frequently and not to allow him to ambulate without assistance. She stated his family did not want any restrictions to keep him from ambulating without assistance. During an Interview with Licensed Practical Nurse (LPN) Quality Assurance Coordinator #11 on 04/27/17 at 11:10 A.M. verified the staff caring for the resident prior to the fall on 02/15/17, was not interviewed during the fall investigation. She stated the resident always sat in the common area after lunch and visited with another resident, who has since been discharged . She verified the time of the incident was 2:05 P.M. She verified the resident had been been sitting there for approximately two hours as lunch began at 11:30 A.M She verified no staff was present at the time of the fall. During an interview with RN #45 on 04/27/17 at 2:00 P.M. he stated he was working on 02/15/17 at the time Resident #149 fell . He stated there was no staff who witnessed the residents fall, they just heard another resident, who no longer resided in the facility, yelling for help. He verified the resident liked to sit in the common area and talk to another resident he had known in the past. He verified the resident had been sitting in the common area since lunch. He verified the resident was not the same as he was prior to the fall and fracture. .

Based on observation, medical record review, resident, staff, and physician interview, and review of policy on pressure ulcers, the facility failed to accurately assess, implement interventions, and develop a plan of care to prevent the development of multiple avoidable in-house acquired pressure ulcers. This resulted in actual harm for one (#144) of two residents reviewed for pressure sores, when Resident #144 acquired an avoidable unstageable pressure ulcer and three avoidable in-house acquired stage one pressure ulcers. The facility census was 99 . Findings include: Review of Resident #144's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive Minimum Data Set (MDS) assessment dated [DATE], identified the resident as having good memory and recall, required supervision for bed mobility with one person physically assisting, requiring set up assistance to walk in room, was at risk for skin breakdown, without current skin breakdown, and had pressure relieving devices for the chair and bed. Review of the predicting pressure sore risk scale assessment completed on 08/25/14, indicated the resident was not at risk for a pressure ulcer. Review of the medical record revealed on 10/06/14, the resident developed reddened areas on the bony prominence of the bilateral feet and a dark red, nonblanchable area on the right great toe. Skin prep and band aid for protection was ordered by the physician for the skin areas. Review of the wound assessment notes dated 10/17/14, revealed the resident was identified to have an avoidable unstageable (full thickness tissue loss in which the base of the ulcer is covered in slough and /or eschar in the wound bed) pressure ulcer area to the right lateral foot. The unstageable pressure area measured 0.7 centimeters (cm) by 0.9 cm and described as unable to see the wound bed, clear drainage noted on top of the wound. The area was previously noted to be red from the residents old black shoes. On 11/02/14, the unstageable pressure ulcer wound increased in size to 1.4 cm x 1.5 cm and the intervention was to inform social services of need for podiatry consult. There was no change in treatment nor was the physician notified of the increase in size of the pressure ulcer on 11/02/14. A review of the medical record revealed there were not any weekly assessments on the three stage one pressure ulcers. Review of the treatment orders revealed on 10/18/14, there was an order to cleanse the open area to the right small toe with wound cleanser, pat dry, and apply a cleansing agent named "polymem", cover toe with band aid on shower days, change every shower day and as needed until resolved. Review of the admission care plan for skin, dated 03/05/13, indicated the resident was at risk for skin breakdown due to chronic progressive [DIAGNOSES REDACTED]. The three interventions on the care plan dated 03/05/13 indicated to record percentage of meal consumed, ensure special mattress is in place, and if skin has reddened, has open areas or has new open areas to report to the nurse and wound nurse. Review of all Resident #144's care plans revealed there was no pressure ulcer care plan developed and/or revised after the pressure ulcers developed. Observations were made on 11/04/14 and 11/05/14 of Resident #144 wearing shoes. On 11/04/14 at 1:53 P.M. and 4:07 P.M., and on 11/05/14 at 8:58 A.M., 2:02 P.M., and 2:20 P.M., revealed Resident #144 was observed wearing her diabetic shoes. An observation of Resident #144's pressure ulcers was made on 11/05/14 at 2:20 P.M. The observation revealed an unstageable tan scabbed area on the right lateral side of the right foot that measured 1.0 cm length by 1.3 cm width. Further observations revealed the right medial side of the right foot has a stage one pressure ulcer which measured 1.1 cm length by 1.3 cm width with no open areas, the left lateral side of the left foot had a stage one pressure ulcer which measured 0.3 cm length by 0.4 cm width with no open areas, and the left medial side of the left foot had a stage one pressure ulcer which measured 0.9 cm length by 1.1 cm width with no open areas. After observations of the pressure ulcers, Registered Nurse #171 was observed to place the diabetic shoes back on the resident's feet. Interview with Resident #144 on 11/04/14 at 1:53 P.M., revealed she recently got the new diabetic shoes and stated the podiatrist came in one day and told her she had to wear the diabetic shoes and left the room. The resident stated she was upset because the facility would not let her wear her eighty dollar shoes and the new shoes do not fit her. She said her toes are "slamming" into the end of the shoe because they do not fit her. The resident stated she required more assistance with ambulation because she felt "wobbly" in the diabetic shoes because they didn't fit her. An additional interview with Resident #144 on 11/05/14 at 2:30 P.M., revealed she got the other three new pressure areas about a week ago and has told staff that the diabetic shoes are uncomfortable and her feet slide in them. Interview with Licensed Practical Nurse (LPN) #93 on 11/04/14 at 2:52 P.M., revealed the resident received new diabetic shoes to wear on 10/14/14. Interview with LPN #106 on 11/04/14 at 4:07 P.M., verified the resident was wearing her diabetic shoes and stated she is wearing the diabetic shoes because the resident's old shoes gave her pressure areas and since she got the new diabetic shoes on 10/14/14 her pressure areas had really healed well. Interview with Social Worker #154 on 11/04/14 at 4:26 P.M., revealed the podiatrist would be in to visit Resident #144 in five to six weeks. Interview on 11/05/14 at 10:00 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #55, verified the lack of assessment and reassessment of the pressure ulcers, no pressure ulcer care plan, and the physician was not notified of the increase in pressure ulcer on 11/02/14. Interview with Physician #200 on 11/05/14 at 4:00 P.M., revealed the resident had a long history of bunions and stated bunions were pressure ulcers and the resident had never broken down like this before. Physician #200 verified the diabetic shoes caused the pressure areas and he was not aware the unstageable pressure ulcer had increased in size on 11/02/14. Physician #200 also verified there was not a change in treatment when the unstageable pressure ulcer increased in size and was unaware of a care plan for the pressure ulcers. Interview with Resident #144 on 11/06/14 at 9:00 A.M., revealed the facility finally listened to her and they took away the diabetic shoes and are allowing her to wear her black shoes to go to the bathroom only. She indicated the staff have been instructed to take off her shoes when not ambulating, in which she said she does not ambulate very often anyway. The resident stated the registered dietitian (RD) #202 also saw her the night before and talked to her about increasing protein in her diet due to the pressure ulcers. An observation at this time, revealed she was not wearing shoes and was sitting in her recliner. Review of a progress note from RD #202 dated 11/05/14 at 4:30 P.M., revealed nursing had alerted the RD that the resident had a pressure ulcer area to the the right foot, which was healing. The RD documented she talked with the resident about increasing protein in her diet to aide in wound healing and the resident agreed to drink milk with all her meals, include protein foods with meals, and try to eat protein snacks, and would start a protein powder supplement named Promod at 30 milliliters at morning medication pass. Interview with RD #202 on 11/06/14 at 10:18 A.M., revealed she found out on 11/04/14, that the resident had a pressure ulcer and confirmed the resident required more protein due to the pressure ulcers. RD #202 stated she tries to put nutritional interventions in place as soon as she knows about the pressure ulcers and that it usually takes one to two days at the most. Review of the facility's undated policy titled "Pressure Ulcers/Skin Breakdown" indicated the physician would assist the staff to determine etiology and characteristics of the skin alteration. The physician would help identify medical interventions related to wound management. Review of the facility's undated policy titled "Wound Guidelines" indicated the policy is to provide documentation of a systematic approach and monitoring for skin integrity and wound care. Prevent/reduce pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate documentation reflecting preventative measures. A complete wound assessment/progress note would be completed weekly on all pressure ulcers until healed.