Every finding on record at The Kings Daughters and Sons

Based on facility policy review, personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Registered Nurse (RN) using another RN's (RN C) Tennessee license. Imposter Nurse A worked at the facility from 06/12/2024 to 11/24/2024The findings include: Review of an undated policy Employment revealed, .Form I-9 [Employment Eligibility Verification].the second section, Steps 5 and 6 must be completed by the HR [Human Resource] Director.Background Investigations.Should the background investigations (s) disclose any material misrepresentation or omission on the employment application form(s) or disclose information indicating that the individual is not suited for hire.the applicant will not be employed, or, if already employed, will be terminated.License/Abuse Registry Verifications.Each individual applying for a position must present to the HR Director, or other designee, a copy of his/her registration number and/or social security number. The HR Director, or other designee, is responsible for contacting the state registry to determine the validity of the individual's certification/license status and the status of the individual on the state abuse registry. Review of Imposter Nurse A's undated employment application revealed a social security number scratched out and another number written in. This SSN did not match the SSN listed on the background check. Review of the background check dated 05/29/2024, revealed the Social Security (SSN) used was not the SSN submitted on the Social Security Card or the I-9 form. The background check had both Imposter Nurse A's name as well as Nurse C's name listed on the form. The background check showed Nurse C's Registered Nurse License number listed on the form. Review of the I-9 form used to verify the identity and legal authorization of individuals hired for employment in the United States dated 06/12/2024, revealed Imposter Nurse A's legal first and last name, along with a copy of her Social Security Card issued on 04/22/2022 and a valid Driver's license from the State of Tennessee. The birthdate listed on the I-9 form was different than the birthdate listed on the background check for Imposter Nurse A. The second section of the I-9 form was not signed by the HR Director as stated in the Employment policy. Review of an Abuse Registry Search dated 06/18/2024, revealed the search was done using the SSN that was listed on the copy of the Social Security card submitted with the I-9 form, but a search was not run on the SSN listed on the background check. Review of the undated Separation Notice revealed Imposter Nurse A's real first and last name with a SSN that did not match the SSN listed on the background check. The separation form showed her employment dates from 06/12/2024 to 11/24/2024 with the reason for the termination listed as Quit.prn [as needed].has not picked up shifts for 3+ [plus] months- voluntary termination. Review of the Employee Time Entrees for Imposter Nurse A for June 2024, revealed she worked in this facility on June 18, 19, 20, 21, 24, 25, and 26, 2024. Review of the Employee Time Entrees for Imposter Nurse A for July 2024, revealed she worked in this facility on July 15, 2024. During an interview on 10/01/2025 at 11:30 AM, the Director of Nursing (DON) confirmed Imposter Nurse A used (Named Artificial Intelligence online website) for charting that stood out to me. The DON confirmed Imposter Nurse A only had access to patients for 1 day on 07/15/2024. During an interview on 10/01/2025 at 12:45 PM, the Administrator confirmed that Imposter Nurse A was employed from 06/12/2024 to 11/24/2024 and Imposter Nurse A was not fired or quit, just fell off because zero (0) shifts were picked up in three (3) months. There was no evidence that the facility questioned the differences in names, birth dates, or Social Security Numbers on the pre-employment forms submitted by Imposter Nurse A. Imposter Nurse A was hired as a Registered Nurse to render nursing services, and she was only terminated for a voluntary termination. The facility employed an unqualified person.

Based on Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019, policy review, medical record review, observation, and interview, the facility failed to provide skin and wound assessments, and wound treatments for residents' pressure ulcers for 2 of 4 residents (Resident #7 and #8) reviewed for pressure ulcers. The facility's failure to perform treatments and conduct assessments in accordance with facility policy contributed to the development and deterioration of pressure ulcers/injury for Resident #7 and #8 resulting in harm. The findings include: 1. Review of the Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019, revealed .Stage 3 Pressure Injury .Full-Thickness loss [deep and beyond the first 2 layers of the skin and may reveal fatty tissue, muscle, tendon, or even bone] of skin, in which adipose (fat) is visible in the ulcer and granulation tissue [new tissue forming during healing] and epibole (rolled wound edges) are often present. Slough [form of dead tissue that appears tan or yellow] and/or eschar may be visible .Unstageable Pressure Injury .Obscured full-thickness skin and tissue loss .within the ulcer cannot be confirmed because it is obscured by slough or eschar [dead skin] .If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . 2. Review of the facility's policy titled, Skin Assessment, dated October 2022, revealed .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission and weekly .The assessment may also be performed after a change of condition .Documentation of skin assessment .Document observation ( .skin conditions .) .Document the type of wound .Describe wound (color, type of tissue in wound bed, drainage, odor, pain) . Review of the facility's policy titled, Documentation of Wound Treatment, dated October 2022, revealed .the facility completes accurate documentation of wound assessments .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .The following elements are documented as part of a complete wound assessment .Type of wound .(pressure injury .) .Measurement .height, width, depth, undermining [erosion under the wound edges, resulting in a large wound with a small opening], tunneling [a wound that has progressed to form an opening underneath the surface of the skin] . Description of wound characteristics .Type of tissue in the wound bed ( .granulation, slough, eschar .) . Review of the facility's policy titled, Pressure Injury Prevention Guidelines, dated 2016, revealed .Interventions will be implemented in accordance with physician orders .When physician orders are present, the facility will follow the specific physician orders .Intervention will be documented in the care plan and communicated to all relevant staff . Review of the Treatment Nurse Job Description revealed .Major Duties and Responsibilities .Identifies, manages, and treats specific skin conditions, such as pressure injuries .Provide wound care on assigned residents, in accordance with physician orders .Completes a thorough and accurate wound assessment upon notification of wound. Completes the follow-up assessments weekly and as needed. Document all assessments in the medical record .Provides status reports to Director of Nursing weekly . 3. Review of medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Multiple Sclerosis, Paraplegia, Heart Failure, and Hypertension. Review of the Care Plan dated 12/21/2020, revealed .has the potential for skin breakdown r/t [related to] impaired mobility . Review of the physician's orders dated 2/14/2022 revealed .BARRIER CREAM TO SACRAL AREA AS PREVENTIVE MEASURES Order Date .FLOOR NURSE .TO APPLY BARRIER CREAM TO SACRAL AREA EVERY SHIFT AS PREVENTIVE MEASURES . Review of the WEEKLY SKIN ASSESSMENT [a full body skin assessment as part of our systematic approach to pressure injury prevention and management per facility policy] dated 2/18/2023, revealed .No new skin issues . There was no documentation the weekly skin assessment was completed for the week of 2/20/2023 Review of the Physician's Orders dated 2/22/2023, .Clean Wound to (R) ischial c [with] Wound Cleanser pat dry & [and] apply Santyl [medication to remove dead tissue and aid in wound healing] & Wound gel [gel used to hold sufficient moisture in the superficial layer of the wound site] .Cover . QOD [every other day] . Review of the Care Plan dated 2/22/23, revealed .wound tx [treatment] r [right] ischial area .Observe skin for reddened areas daily when providing care, notify nurse if present . There was no documentation the weekly skin assessment was completed for the week of 2/20/2023 - 2/25/23 in accordance with the facility policy titled Skin Assessment. Review of the Wound Assessment Report [documentation per policy of a wound] dated on 2/27/2023, revealed .Pressure Ulcer . [right side] Ischial [near the ischium, which is the lower and back region of the hip bone] .Unstageable due to slough/eschar .Length-2.60 cm [centimeters] .Width - 2.20 cm .Depth - 0.00 cm .Physician notified . Review of the Physician's Progress Note, dated 2/27/2023, revealed .Patient with new right ischial pressure ulcer .Skin .Unstageable right ischial pressure ulcer with thick tan and dark slough noted which measures 2.6 [centimeters] by 2.2 cm [centimeters] .Plan .Will continue Santyl ointment and hydrogel . Review of the Wound Assessment Report, dated 3/6/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.60 cm [centimeters] .Width - 2.50 cm .Depth - 0.00 cm . Review of the Wound Assessment Report, dated 3/13/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.10 cm [centimeters] .Width - 1.80 cm .Depth - 0.00 cm . Review of the Physician's Progress Note, dated 3/13/2023, revealed .Patient with worsening of right ischial pressure ulcer .Unstageable right ischial pressure ulcer with thick tan and dark slough noted which measures 2.1 by 1.8 cm . Review of the Physician's Progress Note, dated 3/20/2023, revealed .Patient continues Santyl ointment mixed with wound gel for ischial pressure ulcer .Skin .Unstageable right ischial pressure ulcer with thick tan and dark slough noted . Review of the Wound Assessment Report, dated 3/20/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.80 cm [centimeters] .Width - 2.00 cm .Depth - 0.00 cm . Review of the Wound Assessment Report, dated 3/27/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-3.10 cm [centimeters] .Width -2.50 cm .Depth - 0.00 cm . Review of the Physician's Progress Note, dated 3/27/2023, revealed .Patient with enlarged of right ischial pressure ulcer .unstageable .with dark slough .measures 3.1 by 2.5 cm . Review of the Weekly Skin Assessments revealed the facility failed to complete skin assessments for week of 3/26/2023 to 4/1/2023 in accordance with the facility policy. Review of the Wound Assessment Report, dated 4/3/2023, revealed .Pressure Ulcer .Ischial .Stage 4 .Length- 2.00 cm .Width - 3.50 cm .Depth - 1.00 cm .Granulation 50.00 % [percent] .Slough 50.00% . Review of the 4/3/2023 wound assessment showed the wound had deteriorated with an increase in size to 3.5 cm with a depth of 1.0 cm. There was no description of the wound bed tissue. Review of the Wound Assessment Report, dated 4/10/2023, revealed .Pressure Ulcer .Ischial .Stage 3 . Length- 3.70 cm .Width - 2.80 cm .Depth - 1.10 cm .Granulation Tissue 100.00% .Tunneling 0.50 .Undermining 2.0 .Wound Vac [Vacuum] . [Vacuum-assisted closure of a wound] . The wound deteriorated with an increase in length, developed tunneling and undermining. There was no documentation of the wound bed tissue description. The ischial wound was back staged by the wound care nurse from a stage 4 on 4/3/2023 to a stage 3 on 4/10/2023. Review of the Wound Assessment Report, dated 4/17/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 3.50 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 100.00% .Wound Vac . There was no documentation the weekly skin assessments were completed for the week of 4/24/2023 through 4/29/2023 in accordance with the facility policy. Review of the Wound Assessment Report, dated 5/1/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.30 cm .Width - 1.60 cm .Depth - 1.00 cm .Undermining 1 .Wound Vac . Review of the Wound Assessment Report, dated 5/15/2023, revealed .Pressure Ulcer .Ischial .Stage 3 . Length- 3.70 cm .Width - 2.60 cm .Depth - 1.20 cm .Granulation 95.00% .Slough 5.00% .Tunneling 2.00 .Undermining 10 . [Named Medical Director] visited on 05-15-23 [5/15/2023], the wound has deteriorated some, now has dark slough in the wound bed, and had foul odor . The wound measurements showed the wound deteriorated in size and developed a foul odor. Review of the Wound Assessment Report, dated 5/22/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.50 cm .Width - 2.40 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 5/29/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.00 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 6/12/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.00 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 6/19/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 3.00 cm .Width - 2.20 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.00 .Undermining 10 .Wound Vac . The wound measurements sowed the wound to have deteriorated in length. There was no documentation the weekly skin assessments were completed for the weeks of 5/22/2023 - 5/27/2023, and 6/5/2023 - 6/18/2023 in accordance with the facility policy. Review of the 6/19/2023 skin assessment documented a dressing to the sacrum and a wound vac to ischial pressure ulcer. Review of the Care Plan dated 6/19/23, revealed .new sacral pressure ulcer . Review of Physician's Orders dated 6/19/2023 revealed .Sacral Pressure. There was no other information was included in the order. Review of the Physician's Progress Note dated 6/19/2023, revealed .Development of sacral pressure ulcer noted. Improvement of right ischial pressure ulcer appreciated .Skin .new unstageable sacral pressure ulcer with tan and dark slough noted which measure 7 by 4.2 cm. Moderated drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measure 3 by 2.2 cm by 1 cm deep. It undermines up to 1 cm at 10 o'clock .no drainage noted . Review of the Wound Assessment Report, dated 6/19/2023, revealed .Pressure Ulcer .Sacrum .Unstageable due to slough/eschar .length - 7.00 cm .Width - 4.20 cm .Depth - 0.00 cm . The sacral pressure ulcer was identified as unstageable with slough/eschar on 6/19/2023 and there was no physician's order for treatment until 7/28/2023. The only treatment in place was to apply barrier cream every shift as a preventative measure that was ordered on 2/14/2022. Review of the Treatment Administration Records (TAR) dated June 2023 and July 2023, revealed no pressure ulcer treatments were documented as being administered for the sacral pressure ulcer that was identified on 6/19/2023 for the following dates: 6/19/2023. 6/20/2023, 6/21/2023, 6/22/2023, 6/23/2023, 6/24/2023, 6/25/2023, 6/26/2023, 6/27/2023, 6/28/2023, 6/28/2023, 6/29/2023, 6/30/203, 7/1/2023, 7/2/2023, 7/3/2023, 7/4/2023, 7/5/2023, 7/6/2023, 7/7/2023, 7/8/2023, 7/9/2023, 7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, 7/14/2023, 7/15/2023, 7/16/2023, 7/17/2023, 7/18/2023, 7/19/2023, 7/20/2023, 7/21/2023, 7/22/2023, 7/23/2023, 7/24/2023, 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, and 7/29/2023. Review of the Wound Assessment Report, dated 6/26/2023, revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 7.00 cm .Width - 4.20 .Depth - 0.00 . There was no documentation for the ischial pressure ulcer. Review of the Physician's Progress Note, dated 7/3/2023, revealed .Unstageable sacral pressure ulcer with tan and dark slough noted which measures 6.3 by 2.8 cm. Moderate drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.6 by 2 cm by 0.7 cm deep. It undermines up to 2.4 cm at 6 o'clock . Review of the Physician's Progress Note, dated 7/10/2023, revealed .Treatment of sacral pressure ulcer changed to Santyl ointment once a day .Unstageable sacral pressure ulcer with tan and dark slough and stage 3 right ischial pressure ulcer noted . Review of the Wound Assessment Report, dated 7/10/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.60 cm .Width - 2.00 cm .Depth - 0.70 cm .Granulation Tissue - 1000.00% [percent] .Tunneling 2.40 .Undermining 6 . Review of the Wound Assessment Report, dated 7/10/2023, for the sacral pressure ulcer revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 6.30 cm .Width - 2.80 .Depth - 0.00 . Review of the Wound Assessment Report, dated 7/17/1012, revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 5.30 cm .Width - 3.10 .Depth - 1.00 . Review of the Physician's Progress Note, dated 7/17/2023, revealed .Stage 3 sacral pressure ulcer with little tan slough noted which measures 5.3 by 3.1 cm by 1 cm deep Moderate drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.8 by 2.6 cm by 0.6 cm deep. It undermines up to 1.2 cm at 6 o'clock . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated she was cognitively impaired, and was totally dependent for all activities of daily living (ADLs). Resident #7 had one unstageable and one stage 3 pressure ulcer. Review of the Physician's Orders, dated 7/28/2023, revealed .CLEAN SACRAL WOUND WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE [intended for the management of exudating [draining] wounds, COVER WITH DRY DRESSING .EVERY OTHER DAY .CLEAN WOUND TO RIGHT ISCHIAL WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE, COVER WITH DRY DRESSING. CHANGE EVERY OTHER DAY . The sacral pressure ulcer was identified on 6/19/2023 as unstageable pressure ulcer with slough/eschar. There was no physician's order for treatment of the sacral ulcer when it was identified on 6/19/2023, and no documented treatments to the sacral ulcer from 6/19/2023 - 7/29/2023. There was a previous entry for a physician order dated 6/19/2023, but it was not complete. There was an order dated 7/28/2023for treatment to the sacral pressure ulcer but was not started until 7/30/2023. Review of the July 2023 TAR revealed an order dated 7/28/2023 with a start date of 7/30/2023 .CLEAN SACRAL WOUND WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE, COVER WITH DRY DRESSING, CHANGE EVERY OTHER DAY . Review of the Physician's Progress Note, dated 7/31/2023, revealed .Stage 3 sacral pressure ulcer with little tan slough noted which measures 6.2 by 3.2 cm by 0.6 cm deep. Moderated drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.8 by 2.5 cm by 1 cm deep. It undermines up to 1 cm at 12 o'clock . The progress note revealed the sacral pressure ulcer deteriorated in length, width, and depth from the 7/17/2023 measurements. Observation in the resident's room on 10/4/2023 at 9:28 AM, revealed Resident #7 had a pressure injury to the sacrum and right ischial. During an interview on 10/5/2023 at 12:34 PM, the Wound Care Nurse was asked should Resident #7's wound, identified on 2/22/2023, have a completed wound assessment. The Wound Care Nurse stated, .I was waiting for doctor [Named Medical Director] to get here .it had slough and eschar tissue .unstageable . In summary, Resident #7 developed a pressure ulcer to the right ischial/buttock area on 2/22/2023 and to the sacral pressure ulcer on 6/19/2023, both as unstageable when identified. The facility failed to perform weekly skin assessments in accordance with the facility policy, failed to ensure complete weekly wound assessments that included measurements, description in accordance with the facility policy, failed to consistently stage the pressure ulcer, and failed to perform wound care treatments. 4. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Diabetes, Depression, and Multiple Sclerosis. Review of the facility's Skin Assessments revealed Resident #8 had redness to the buttocks on 10/5/2021, 10/12/2021, 10/19/2021, and 10/24/2021 with no other description. Review of the Treatment Administration Record for 10/2021, revealed there was no interventions implemented for the redness to Resident #8's buttocks. Record review revealed there were no weekly skin assessments conducted for Resident #8 from 11/1/2021 through 11/22/2021. Review of the facility's Weekly Skin Assessments, dated 11/23/2021, revealed Resident #8 had ulcers to the buttocks, with no other description in the assessment. Review of the Care Plan with a revision date of 11/23/2021, revealed Resident #8 had .Stage IV [four] left buttock . The facility failed to conduct skin assessments from 11/1/2021 through 11/22/2021, prior to the identification of the Stage IV pressure ulcer to Resident #8's left buttock. Review of the facility's Wound Assessment Report, dated 11/24/2021, conducted by the Wound Nurse revealed .Pressure Ulcer .Left Buttock .Date Wound Identified 11/23/2021 .Stage 3 [the care plan dated 11/23/2021 documented the pressure ulcer was a Stage 4] . Review of the Physician Orders dated 11/23/2021, Clean open area to left buttocks with wound cleanser, apply AG [Alginate] to wound bed, and cover with foam dressing every other day. Review of the Physician's Progress Note dated 11/29/2021, 6 days after the stage 4 pressure ulcer was identified, revealed .initial wound assessment . developed a pressure ulcer .left ischium .unstageable .thick tan and dark slough noted which measures 4.5 by 3.1 cm . heavy drainage noted . Review of the facility's Wound Assessment Report, dated 11/29/2021, revealed .Pressure Ulcer .Left Buttock; left ischial .Date Wound Identified 11/23/2021 .unstageable due to slough, eschar .Length 4.5cm . Width 3.1 cm . Depth 0 cm . Review of the Physician Order dated 11/29/2021, revealed Clean left ischial wound with wound cleanser, apply Santyl to open, then apply Calcium Alginate over Santyl, and cover with foam dressing QOD [every other day] Review of the Physician Order dated 11/30/2021, revealed Juven one packet by mouth twice per day X[times] 60 days. There was no documentation the Weekly Wound Assessment Report was completed the week of 12/6/2021. Review of the Physician's Progress Note, dated 12/13/2021, revealed .A lot of slough is gone from the left ischial pressure ulcer .unstageable .7.5 by 4.4 cm . heavy drainage noted . Review of the facility's Wound Assessment Report, dated 12/13/2021, revealed .Pressure Ulcer .Left Buttock .left ischial .unstageable .7.50 cm .4.40 cm . The resident's wound to the left ischial/buttock increased in size from 11/29/2021 to 12/13/2021. There was no documentation the Weekly Wound Assessment Report was completed on 12/20/2021 and 12/27/2021. Review of the Physician Order dated 12/22/2022, revealed Clean wound to left ischial with wound cleanser, apply Santyl and Alginate and cover with foam dressing daily. Review of the Physician Order dated 12/29/2021, revealed Prostat 30 cc [cubic centimeter] by mouth daily. Review of the facility's Wound Assessment Report, dated 1/3/2022, revealed .Pressure Ulcer .Left Buttock .left ischial .Stage 4 .7.9 cm .3.9 cm .3 cm . undermining .2 [o'clock] . The resident's wound increased in height and had undermining from 12/13/2021 to 1/3/2022. Review of the Physician Order dated 1/3/2022, revealed Clean left ischial with wound cleanser, lightly pack are of depth with Silver Alginate and cover with foam dressing daily. Review of the Physician's Progress Note, dated 1/3/2022, revealed .Slough is gone from the left ischial pressure ulcer .Stage 4 .palpable bone noted .6.9 by 3.9 by 3 cm with up to 1 cm undermining at 2 o'clock .heavy drainage . Review of the facility's Wound Assessment Report, dated 1/17/2022, revealed .Pressure Ulcer .Left Buttock .left ischial .Stage 4 .6.8 cm .4.6 cm .1.40 cm . tunneling 2.5 .undermining . There was no documentation the Weekly Wound Assessment Report was completed the week of 1/10/2022. The width of the resident's wound increased in size from 1/3/2022 to 1/17/2022. There was no documentation the Weekly Wound Assessment Report was completed the week of 1/24/2022. Observation in the resident's room on 10/5/2023 at 7:43 AM, revealed Resident #8 had a pressure ulcer to the left ischial. In summary, Resident #8 had redness to the buttocks on 10/5/2021, 10/12/2021, 10/19/2021, and 10/24/2021. The facility failed to conduct skin assessments from 11/1/2021 through 11/22/2021 in accordance with facility policy for a systematic approach to pressure injury prevention and management. On 11/23/2021, the facility documented Resident #8 had Stage 4 pressure ulcer to the left buttock. 5. During a Telephone interview on 10/5/2023 at 2:15 PM, the Medical Director was asked who was responsible for monitoring, assessing, and providing wound care treatments in the facility. The Medical Director stated, .I thought it was [Named Wound Care Nurse] .not sure if the nurses [floor nurses] are signing off on the treatment administration records .I don't know why that is happening [the charge nurses are completing the wound care and not the wound care nurse] . The Medical Director was asked if the Wound Care Nurse was certified, should she document the measurement and stage the wound when identified. The Medical Director stated, Yes .she can .I'm not sure what the policy says .they should document the assessment at the time it [wound] is found .there should be no delay . The Medical Director was asked if a wound is identified as a stage 4 can you backstage a wound to a stage 3 and would that be an accurate assessment. The Medical Director stated .No . The Medical Director was asked at what stage should the wounds be identified. The Medical Director stated, .Preferably at a stage 1 . The Medical Director was asked if it was acceptable to identify a wound that's unstageable with slough and eschar. The Medical Director stated No . The Medical Director was asked should there be missed skin assessments, wound assessments, and missed treatments. The Medical Director stated, .No . staff should follow the orders for treatments . During an interview on 10/5/2023 at 3:25 PM, the Director of Nursing (DON) confirmed there should not be any missed weekly skin assessments or wound assessments. The DON stated, The Unit Manager and myself make sure they are being done. The DON was asked at what stage should a pressure injury be identified. The DON stated, .At a stage one . The DON was asked who stages the wounds when identified. The DON stated, . [Named Medical Director] comes in and does the assessments and the measurements . [Named Wound Care Nurse] does not stage the wounds .she should describe the wound in a nurse note when identified . The DON confirmed that a Registered Nurse and the DON could stage and measure the wounds. The DON was asked when she attended the Quality Assurance (QA) meeting was she informed Resident #7's wounds (sacrum and ischial) were identified as unstageable. The DON stated, No . she just said they were unstageable [did not specify they were identified as unstageable] .

Based on policy review, observation, and interview the facility failed to ensure infection control practices to prevent the spread of infection when 2 of 4 (Licensed Practical Nurse (LPN) #2 and #3) and when 1 of 1 (Wound Care Nurse) staff members failed to perform hand hygiene during medication administration and wound care. The findings include: 1. Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so .as ordered by the physician and in accordance with the professional standards of practice, in a manner to prevent contamination or infection .Compliance Guidelines .Wash hands prior to administering medication per facility protocol . Review of the facility undated policy titled, Clean Dressing Change, revealed .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination .Wash hands and put on clean gloves .Place a barrier cloth .remove the existing dressing .remove gloves .Wash hands and put on Clean gloves .Cleanse the wound as ordered .Pat dry with gauze .Wash hands and put on clean gloves .dress the wound as ordered .Secure dressing .Discard disposable items and gloves .wash hands . Review of the facility's policy titled, Hand Hygiene, dated October 2002, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene technique when using soap and water .Wet hands with water .Apply to hand the amount of soap .Rub hands together vigorously for at least 20 seconds .Rinse hands with water .Dry thoroughly with a single-use towel .use clean towel to turn off the faucet .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Observation in resident's room on 10/3/2023 at 5:34 PM, revealed LPN #2 entered Resident #61's room and failed to perform hand hygiene before checking the residents blood glucose. Observation in the resident's room on 10/4/2023 at 8:25 AM, revealed LPN #3 entered Resident #24's room and failed to performed hand hygiene before donning and after removing her gloves, before administering medications, and before checking the residents blood glucose. 3. Review of medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Multiple Sclerosis, Paraplegia, Heart Failure, and Hypertension. Observation outside Resident #7's room on 10/2/2023 at 10:04 AM, 10/2/2023 at 4:11 PM, 10/3/2023 at 7:45 AM, 10/4/2023 at 7:48 AM, and 9:40 AM, revealed signage for enhanced barrier precaution and there was no isolation cart provided for the resident in enhanced barrier precaution. Observation in the resident's room on 10/2/2023 at 4:11 PM, revealed Certified Nursing Assistant (CNA) #1 provided direct care, which included a bed bath and incontinent care to Resident #7, without donning the personal protective equipment. Resident #7's door had signage indicating she was in enhanced barrier precaution and there was no isolation cart outside the resident's room. During an interview on 10/2/2023 at 4:11 PM, CNA #1 confirmed there was not an isolation cart containing PPE outside of Resident #7's room. Observation in Resident #7's room on 10/4/2023 at 9:40 AM, the Wound Care Nurse entered Resident #7's room, donned her gloves, cleaned the over bed table with a bleach wipe, removed her gloves, and failed to perform hand hygiene. The Wound Care Nurse exited Resident #7's room to gather her supplies, reentered the resident's room, placed a barrier on the over bed table with the supplies, and entered Resident #7's bathroom to wash her hands. The Wound Care Nurse turned off the faucet with the same wet paper towel she dried her hands with. The Wound Care Nurse exited Resident #7's room, reentered the resident's room with a red biohazard bag, went into the bathroom, washed her hands for 8 seconds, and turned off the faucet with the same wet paper towel. The Wound Care Nurse exited Resident #7's room, obtained gown, reentered the resident's room, and went into the bathroom. The Wound Care Nurse washed her hands for 11 seconds and turned off the faucet with the same wet towel she dried her hands with. The Wound Care Nurse donned her gown and gloves, adjusted the resident's bed with the remote, pulled the covers back exposing the resident from the waist down, and removed the dressings from the sacrum [a triangular bone in the lower back between the hip bones of the pelvis] and the ischium [the curved bone forming the base of each half of the pelvis]. The Wound Care Nurse removed her gloves, entered the bathroom, washed her hands for 6 seconds, and turned off the faucet with the same wet towel she dried her hands with. The Wound Care Nurse donned a new pair of gloves, cleaned the ischium, removed her gloves, and donned a new pair of gloves without performing hand hygiene. The Wound Care Nurse cleaned the sacrum, removed her gloves, and donned a new pair of gloves without performing hand hygiene. The Wound Care Nurse dried ischium and sacrum and removed her gloves. The Wound Care Nurse entered the bathroom and washed her hands for 8 seconds and turned off the faucet with the same wet towel she dried her hands with. The Wound Care Nurse donned a new pair of gloves, applied Promagran Alginate (medication indicated for the management of draining wounds) at each site, removed her gloves, donned a new pair of gloves without performing hand hygiene, and applied a dressing to the ischial and sacrum. 4. Review of medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses of Atrial Fibrillation, Coronary Heart Disease, Renal Insufficiency, Diabetes, and Anxiety. Observation in the resident room on 10/4/2023 at 10:42 AM, revealed the Wound Care Nurse entered Resident #49's room donned her gloves, without performing hand hygiene, adjusted the resident's bed, removed her gloves, donned a new pair of gloves and gown, without performing hand hygiene. The Wound Care Nurse pulled the covers back exposing the lower extremities, removed the Geri-sleeve (protect the resident arms and legs), removed the dressing from each foot with a pair of clean scissors, placed the scissor on the over bed table, removed her gloves and washed her hands for 8 seconds. The Wound Care Nurse donned a new pair of gloves, cleaned the right heel, removed her gloves and gown, and exited the resident's room to get the skin prep (liquid film skin protectant). The Wound Care Nurse entered the resident's room, went into the resident's bathroom, washed her hands for 10 seconds, and donned her gloves and gown. The Wound Care Nurse applied skin prep to the right heel, applied an abdominal pad (large gauze pad) over the skin prep, and wrapped the heel with a Kerlix (wound bandage) gauze. The Wound Care Nurse removed her gloves, entered the bathroom and washed her hands for 10 seconds. The Wound Care Nurse donned new gloves, cleaned the left heel, applied ointment to the left heel with her gloved hands, applied Santyl (a debriding ointment to remove dead tissue) to the wound bed with a tongue blade, covered the wound with an abdominal pad, and wrapped it with Kerlix. The Wound Care Nurse failed to remove her gloves and wash her hand before applying the Santyl to the wound bed. The Wound Care Nurse applied the Geri-sleeves, applied the nonskid socks, applied the heel boots, disposed of the dirty supplies in the biohazard bag, place the dirty scissors in her front pocket, and removed her gown and gloves. During an interview on 10/4/2023 at 11:09 AM, the Wound Care Nurse was asked if she should have placed the scissor in her scrub pocket. The Wound Care Nurse stated, No, I should have cleaned them . During an interview on 10/4/2023 at 2:18 PM, the Wound Care Nurse was asked how long she should wash her hands. The Wound Care Nurse stated, .some people say 15 second .some people say 20 seconds. The Wound Care Nurse was asked if she knew what the facility policy stated. The Wound Care Nurse stated, .I'm not sure . The Wound Care Nurse was asked after washing her hands how should she turn off the faucet. The Wound Care Nurse stated, .I use the one [paper towel] I dry my hands with . 5. During an interview on 10/5/23 at 09:56 AM, the Infection Preventionist was asked should the facility have personal protective equipment (PPE) outside of the residents' rooms who are in enhanced barrier precautions. The Infection Preventionist stated, Yes, ma'am .on the green hall had new staff and they had not been in-serviced on the enhanced barrier precautions . The Infection Preventionist was asked should staff members wear appropriate PPE when providing direct care to residents in enhanced barrier precautions. The Infection Preventionist stated, Yes. During an interview on 10/5/2023 at 3:25 PM, the Director of Nursing (DON) was asked how long the staff members should wash their hands. The DON stated, Twenty seconds . The DON was asked should the staff members turn off the faucet with the paper towel they dried their hands with. The DON stated, No . During an interview on 10/5/2023 at 3:29 PM, the Director of Nursing (DON) confirmed staff should wash hands before and after removing their gloves.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and enhance resident's dignity and respect when 1 of 1 (Wound Care Nurse) nurse failed to provide privacy for 1 of 2 (Resident #7) residents observed during wound care. The findings include: 1. Review of the facility's policy titled, Dignity dated October 2022, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains or enhances resident's quality of life by recognizing each resident's individuality .Maintain resident privacy . Review of the facility's undated, NURSING HOME RESIDENTS' RIGHTS, revealed .Right to Privacy .During treatment and care of personal needs . 2. Review of medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Multiple Sclerosis, Paraplegia, Heart Failure, Adult Failure to Thrive, and Hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Metal Status (BIMS) score of 3, which indicated she was cognitively impaired, and was totally dependent for all activities of daily living (ADLs). Resident #7 had one unstageable and one stage 3 pressure ulcer. Observation in the resident's room on 10/4/2023 at 9:40 AM, revealed the Wound Care Nurse entered Resident #7's room and placed a barrier on over bed table with her supplies. The Wound Care Nurse exited the room to get a red biohazard bag from the Wound Care Cart, returned to the room, closed the door, and donned her Personal Protective Equipment (PPE). The Wound Care Nurse pulled the covers off Resident #7 and exposed her buttock, which was facing the window. There was a resident sitting outside the window in the courtyard in his wheelchair. The Wound Care Nurse failed to provide privacy to Resident #7 by closing the blinds. During an interview on 10/4/2023 at 2:18 PM, the Wound Care Nurse confirmed she should have closed the blinds to provide privacy during wound care.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 4 (Resident #285) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's undated policy titled, Compliance with Reporting Allegations of Abuse /Neglect/Exploitation, revealed .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes .The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required .When suspicion of abuse .or reports of abuse .The Administrator or designee will .Notify the appropriate agencies as soon as possible, In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion .Obtain statements from direct care staff .Suspend the accused employee pending completion of the investigation .Follow up with appropriate agencies, during business hours, to confirm the report was received .Within 5 days of the incident, report sufficient information to describe the results of the investigation, and indicate corrective actions taken, if the allegation was verified . 2. Review of medical record revealed Resident #285 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, Dementia, Hypertension, and Atrial Fibrillation. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #285 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition, and required extensive, one person assistance from staff for bed mobility, transfers, dressing, and toileting. Review of the facility's investigation dated 4/3/2023, revealed Family Member #1 reported to the Director of Nursing (DON) that Resident #285 called her and told her Certified Nurse's Assistant (CNA #2) talked to him without respect. Resident #285's Family Member #1 reported they felt like Resident #285 was being spoken to like a 6-year-old when she overheard the CNA #2 ask the resident why he urinated on himself and who put those clothes on him. Family member #1 reported there was a time when CNA #2 must have been hasty when he (CNA #2) removed Resident #285's shirt and hurt the resident's eye. Further review revealed there was no documentation the allegation of abuse related to Resident #285 was reported to the State Survey Agency. During an interview on 10/5/2023 starting at 9:00 PM, the Administrator was asked what the process was when someone reports an allegation of abuse to the facility. The Administrator stated, If they report it as abuse, then we report it to the state and we investigate. The Administrator was asked did you obtain statements from all staff who worked that shift when Resident #285's Family Member #1 reported CNA #2 had disrespectfully spoken to Resident #285 and roughly handled Resident #285. The Administrator stated, She [Resident #285's Family Member #1] did not report it [the statement] to us as abuse. The Administrator and DON was asked did she [Resident #285's Family Member #1] report that CNA #2 was being rough. The DON stated, When I did talk to the [named CNA #2] about that, the resident had taken the shirt off himself. The DON confirmed she did not report an allegation of abuse to the state, after being notified by Family Member #1 on 4/3/2023 of an allegation of abuse. The DON was asked should she have reported it to the state. The DON stated, Yes, I just didn't think it was abuse. The Administrator and DON were asked who all do you report an allegation of abuse to. The Administrator stated, State of Tennessee, the ombudsman, depending on the situation we have to report it to the police, some situations we have to report to APS [Adult Protective Services]. The facility failed to report an allegation of abuse to the appropriate agencies.

Based on policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 4 (Resident #285) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .It is the policy of the facility to provide protection for the health, welfare, and rights of each resident .Abuse .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated .Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Written procedures for investigation include .Identify staff responsible for the investigation .Exercising caution in handling evidence .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge or the allegations .Focusing the investigation on determining if abuse, neglect, exploitation .has occurred, the extent, cause .Providing complete and thorough documentation of the investigation . 2. Review of medical record revealed Resident #285 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Dementia, Hypertension, and Atrial Fibrillation. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #285 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition, and required extensive, one-person assistance from staff for bed mobility, transfers, dressing, and toileting. Review of the facility's investigation dated 4/3/2023, revealed Family Member #1 reported to the Director of Nursing (DON) that Resident #285 told her a Certified Nursing Assistant (CNA #2) talked to him without respect and was hasty when he removed Resident #285's shirt and hurt the resident's eye. Review of the facility's investigation dated 4/3/2023, revealed the facility failed to obtain witness statements from the staff, failed to complete a skin assessment of Resident #285 and other residents in CNA #2's care, and failed to complete an incident report. During a telephone interview on 10/5/2023 at 2:40 PM, Family member #1 confirmed she informed the DON of concerns she had related to CNA #2 and the resident. Family member #1 alleged CNA #2 had spoken to Resident #285 disrespectfully on two different occasions and once when CNA #2 had been rough when pulling off the resident's shirt. During an interview on 10/5/2023 at 9:00 PM, the Administrator confirmed a thorough investigation included interviewing all employees that may have been witnesses. The Administrator and DON were asked what your investigation includes. The Administrator stated, Interview the person being accused, the person that is accusing, any other employees that may have been witnesses in the area .any other residents that may have been working with the employee or that are interviewable . The DON confirmed that she completed the investigation into Resident #285's allegation of abuse. The DON was asked did you interview any of the staff. The DON stated, I only asked the other [staff] on 3-11 could he take his own clothes off .can't think of who it was now . The DON confirmed she did not obtain staff statements. The DON confirmed she did not complete skin audits on any other residents. The DON was asked did she perform a skin assessment on Resident #285. The DON stated, No. The DON confirmed she did not complete an incident report or a thorough investigation. The facility failed to complete a thorough investigation after an allegation of abuse for Resident #285.

Based on policy review, Family/Staff Conference form, medical record review, and interview, the facility failed to conduct quarterly Interdisciplinary Care Plan Meetings for 2 of 24 (Resident #8 and #19) residents reviewed for Care Plan Meetings. The findings include: 1. Review of the undated facility's policy titled, Comprehensive Care Plans, revealed .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to .The attending physician or non-physician practitioner designee involved in the resident's care .A registered nurse .A nurse aide .A member of food and nutrition services staff .The resident and the resident's representative, to the extent practicable .Other appropriate staff or professionals .as determined by the resident's needs or as requested by the resident .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [minimum data set] assessment . 2. Review of the facility's undated family communication form titled, FAMILY / STAFF CONFERENCE, revealed .It is essential that we give attention to individual needs and to the adjustment which comes as a result of illness or injury. Through the Interdisciplinary Planning Conference, the staff and family members have the ability to achieve a common purpose and to better understand the goals and objectives of the care which is specified for individual residents .These conferences are held the first available Tuesday or Thursday after admission and then quarterly. We strongly encourage a family representative to attend the conference and to take an active part in the evaluation and formulation of the plan of care . 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnosis of Diabetes, Depression, Multiple Sclerosis, and Hemiplegia. Review of the quarterly MDS dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status Interview (BIMS) score of 10, which indicated she was moderately cognitively impaired. Review of the Resident #8's CARE PLAN MEETING signature sheets revealed the following: a. A Care Plan Meeting signature sheet dated 7/22/2021. b. A Care Plan Meeting signature sheet dated 10/19/2022. c. A Care Plan Meeting signature sheet dated 7/20/2023. The facility was only able to provide documentation one Care Plan Meeting occurred in 2021, 2022, and 2023. During an interview on 10/3/2023 at 11:00 AM, the MDS Coordinator stated Resident #8's last care plan meeting was 7/20/2023, and the Care Plan Meeting Signature Sheets that she provided were the only documentation of Care Plan Meetings for Resident #8 in 2021, 2022, and 2023. The MDS Coordinator confirmed that she was unable to provide documentation that letters were sent inviting Resident #8's family to attend her Care Plan Meetings. The MDS Coordinator confirmed they could not provide a calendar of MDS meetings for 2021, 2022, and 2023. 4. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Hypertension, Osteoporosis, Anxiety Disorder, and Parkinson's Disease. Review of the quarterly MDS dated [DATE], revealed Resident #19 had a BIMS score of 15, which indicated she was cognitively intact. The facility was unable to provide documentation that a Care Plan Meeting occurred in the first two quarters of 2023. Review of the CARE PLAN MEETING signature sheet dated 9/19/2023, revealed an interdisciplinary team Care Plan Meeting was conducted and Resident #19's daughter attended the Care Plan meeting, but Resident #19 was not present. During an interview on 10/3/2023 at 8:23 AM, Resident #19 was asked was she or a person of her choice invited to participate in Care Plan meetings. Resident #19 stated, .we had 1 or 2 when I first came in. That's been it. 5. During an interview on 10/3/2023 at 9:47 AM, the MDS Coordinator was asked how often Care Plan meetings were held. The MDS Coordinator stated, [We] Offer every quarter at a minimum . The MDS Coordinator confirmed that the only documentation she had of a Care Plan meeting for Resident #19 in 2023 was on 9/19/2023. The MDS Coordinator was asked how often Care Plan meetings should be conducted. The MDS Coordinator stated, We should offer them every quarter . The MDS Coordinator confirmed she did not have documentation that notification for the care plan meetings had been sent to Resident #19's Responsible Party. During an interview on 10/5/2023 at 12:24 PM, the Director of Nursing (DON) confirmed that Care Plan Meetings should be held quarterly and with each significant change for all residents.

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for medication administration and failed to obtain a physician's order to apply a foot strap to a resident's wheel chair for 2 of 24 (Resident #35 and #44) sampled residents reviewed for physician orders. The findings include: 1. Review of the facility's undated policy titled, Provision of Physician Ordered Services revealed .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .Professional Standards of Quality .means that care and services are provided according to accepted standards of clinical practice .Qualified nursing personnels will submit timely requests for physician ordered services .to appropriate entity . Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered .in accordance with professional standards of practice .Administer medications as ordered [by practitioner] . 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses of Polymyositis, Depression, Anxiety Disorder, and Osteoporosis. Review of the Physician's Order dated September 2023, revealed .Alprazolam [anxiety medication] 0.25 MG [milligram] BY MOUTH THREE TIMES DAILY . Review of the MISSING DRUG ORDER FORM [a form completed when a resident drug is not available/missing] dated 9/4/2023 at 9:23 PM, . [Named Resident #35] ALPRaZolam 0.25 mg . Review of the Medication Administration Record (MAR) dated September 2023, revealed Alprazolam was not administered to Resident #35 on 9/4/2023 at 8:00 PM and 9/5/2023 at 8:00 AM and 2:00 PM. Resident #35 missed 3 scheduled doses of Alprazolam for anxiety in September. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated she was moderately cognitively impaired, and was coded for anti-anxiety medication. During an interview on 10/2/2023 at 4:52 PM, Resident #35 confirmed that she took Alprazolam three times daily. Resident #35 stated, .Since I've been a resident here, they've run out of it [Alprazolam] .within the last month . During an interview on 10/5/2023 at 12:08 PM, the Director of Nursing (DON) confirmed the facility ran out of Resident #35's Alprazolam on 9/4/2023 and did not send a request for it to the pharmacy until 9:23 PM that night. The DON stated, .pharmacy should have been called and asked for a STAT [urgent or rush] delivery .don't see it documented where she [the nurse] did . The DON confirmed Resident #35 should not have missed the doses of Alprazolam. 3. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE], with diagnoses of Traumatic Subdural Hematoma, Osteoporosis, Mood Disorder, and Cerebral Infarction. Review of the MDS dated [DATE], revealed Resident #44 had a BIMS of 13, which indicated she was cognitively intact, required extensive assistance for most activities of daily living (ADLs), had range of motion impairment in both arms and her right leg, and required a wheelchair for mobility. Resident #44 was not coded for restraints. Review of the Physician's Orders for Resident #44 dated July 2023, revealed there was no order for a Velcro strap on the right leg footrest of her wheelchair. Review of the Care Plan dated 11/27/2020, with a target date of 11/28/2023, revealed Resident #44's Care Plan did not reflect the Velcro strap attached to the right leg footrest of her wheelchair. During observation in the resident's room on 10/2/2023 at 10:48 AM and 3:37 PM, 10/3/2023 at 8:19 AM, 10/4/2023 at 7:42 AM, and 10/5/2023 at 8:35 AM, revealed Resident #44 was in a wheelchair, her right leg was on the footrest, and a Velcro strap attached to the right leg footrest was strapped around her right lower leg/ankle. Observation and interview with the Therapy Director on 10/5/2023 at 4:48 PM, revealed the Therapy Director was not aware of a Velcro strap on the right leg footrest of Resident #44's wheelchair. The Therapy Director was asked should facility staff have been aware of the Velcro strap on the wheelchair. The Therapy Director stated, Yes ma'am . The Therapy Director stated, .I don't know [how it got there] .it's not something we would have installed . The Therapy Director confirmed the strap was anchored to the wheelchair using a nut and a bolt. During an interview on 10/5/2023 5:01 PM, Certified Nursing Assistant (CNA) #2 confirmed she was familiar with Resident #44. CNA #2 was shown the Velcro strap on the footrest and asked did she know anything about the strap. CNA #2 stated, It goes across her to keep her leg stable. CNA #2 was asked how long the strap had been on the wheelchair. CNA #2 stated, I can't say . CNA #2 confirmed that she did not know who placed the strap on Resident #44's wheelchair. During an interview on 10/5/2023 at 5:12 PM, Unit Manager #1 was asked do you know anything about the Velcro strap around Resident #44's wheelchair leg. Unit Manager #1 stated, .it's been there for I don't know how long, but I never put an order in. Unit Manager #1 confirmed she was aware the Velcro strap was on Resident #44's wheelchair leg. Unit Manager #1 was asked should Resident #44 have been care planned for the Velcro Strap. Unit Manager #1 stated, She should, anything that's put on [the wheelchair]. During an interview on 10/5/2023 at 5:29 PM, the Therapy Director stated, I talked to [named Resident #44's son] and he said he installed it [Velcro strap to prevent the resident's foot from falling off the foot rest] late July, early August. The Therapy Director confirmed that Resident #44 did not have functional or purposeful movement of the right leg and could express her wants and needs. The Therapy Director stated, I knew immediately [when she observed the Velcro strap] my supplier didn't install [Velcro strap] . During an interview on 10/5/2023 at 6:08 PM, the Director of Nursing (DON) was asked was she aware Resident #44 had a Velcro strap that staff strapped around her lower leg/ankle area attached to her wheelchair footrest. The DON stated, I was just notified, and I don't know how I missed it because I pick her leg up every day .have such a good relationship with her son, can't believe he didn't say something . The DON confirmed that she frequently observed Resident #44 in her wheelchair but had never noticed the Velcro strap around her leg. The DON was asked should she have been aware of the Velcro strap on Resident #44's wheelchair. The DON stated, I should have been notified and yeah aware. The DON confirmed there should have been an order for the strap, it should have been on Resident #44's Care Plan, and assessments should have been completed. The DON was asked what should have been done with a device of this type. The DON stated, We would have parameters on when to put it on and we would check skin integrity depending on how long she was wearing it for the parameters. The DON confirmed the parameters would have been on the physician's order.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 16 medication storage areas (One South Nurse Station Medication Room and One North Medication Cart #1) where an expired medication was found a medication cart was left unlocked and unattended. The findings include: 1. Review of the facility's undated policy titled, Medication Storage, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication cart according to the manufacturer's recommendations .all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated .medications . 2. Observation in the One South Nurse's Station Medication Room refrigerator on 10/5/2023 at 5:48 PM, revealed an opened bottle of Pantoprazole (medication for acid reflux) 40 mg/ml (milligram/milliliter) with an expiration date of 9/30/2023. During an interview on 10/5/2023 at 5:48 PM, Licensed Practical Nurse (LPN #4) confirmed expired medications should be discarded. 3. Observation at the One North Medication Cart #1 on 10/5/2023 at 7:19 PM, revealed the medication cart was left unlocked and unattended. During an interview on 10/5/2023 at 8:00PM, LPN #5 confirmed the medication cart should not be left unlocked and unattended. During an interview on 10/5/2023 at 9:00 PM, the Director of Nursing (DON) was asked should expired medications be in the medication storage areas. The DON stated, No.

Based on policy review, Facility Reported Incident (FRI) review, medical record review, and interview, the facility failed to report an allegation of abuse and neglect within 2 hours for 1 of 3 (Resident #1) sampled residents reviewed. The findings include: Review of the undated facility Abuse Prevention Policy documented, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment revealed Resident #1 scored a 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively intact for decision making. Review of the Event Report dated 7/8/19 documented, .Administrator was notified of allegation of abuse on 7/8/19 at approximately 12 PM by (named person) MDS Coordinator .Ms. (Resident #1's) daughter reported that on 6/24/19 a certified nursing assistant (CNA) had come into her mother's room to put her to bed and grabbed her by the arm and the back of the pants, attempting to transfer her without a lift. She stated that in doing this she dropped her on the floor. She stated the certified nursing assistant then roughly picked her mother up off the floor and put her back in the bed and never told anyone the incident occurred . Review of the FRI revealed the incident was reported to the State Agency on 7/9/19 at 5:44 PM. Interview on 7/17/19 at 10:30 AM in the conference room, the MDS Coordinator confirmed her witness statement. She stated, .( (Resident #1's daughter) came to me on 7/8/19 at approximately 12 noon and informed me that (Resident #1) had been abused on 6/24/19 by a CNA because she was yanked on the arm and put in the bed .I immediately informed the Administrator there was an allegation of abuse . Interview on 7/17/19 at 2:00 PM with the Assistant Director of Nursing (ADON) in the conference room, the ADON confirmed the abuse allegation was reported to the State Agency by the Administrator on 7/9/19, 24 hours after the facility received the allegation of abuse. The ADON stated, .The Administrator said she thought she had 24 hours .

Based on policy review, observation, and interview, the facility failed to ensure the recent survey results were readily accessible for all residents residing in the facility. The facility has a census of 104 residents. The findings included: 1. The facilities policy's Resident Rights documented the following .The resident has a right to .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors . Observation in the reception area on 2/13/18 at 3:45 PM, revealed a white binder with 9/4/14, 10/21/15, and 12/7/16 survey results. The reception area was behind a closed door, not readily available to residents and family. Interview with Resident Council attendees (Resident #14, 20, 28, 33, 36, who were identified as alert and oriented by the facility) on 2/13/18 at 3:04 PM, in the dining room, attendees stated they did not know where the results of the last survey were located. Interview with the Administrator on 2/13/18 at 3:41 PM, in the Admission office, the Administrator was asked if residents had free access to survey results. The Administrator stated, They can always ask to see them.

Based on policy review, observation, and interview the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by wet nesting of plates, failure of staff to perform proper hand hygiene, and placement of soiled items on a cart used for serving food. This had the potential to affect 101 residents that received meal trays from the kitchen of the 104 total residents at the facility. The findings included: 1. The facility's Ware Washing policy documented, .The Food Services Director ensures that all dishware is air dried and properly stored . The facility's Hand Washing policy documented, .When Should You Wash Your Hands? .Before putting on gloves or after removing them . 2. Observations in the kitchen on 12/6/16 at 8:50 AM, revealed the Dietary Aide removed clean dishes from the dish washer, and stacked the wet plates in the plate warmer. Interview with the District Manager (DM), on 12/6/16 at 8:55 AM, in the kitchen, the (DM) was asked if it was appropriate to store plates wet. The (DM) stated, .No, Ma'am . 3. Observations in the kitchen on 12/6/16 at 4:50 PM, revealed the Cook removed gloves and donned another pair of gloves without performing hand hygiene while checking tray line temperatures. Observations in the kitchen on 12/6/16 at 5:07 PM, revealed the Cook picked up 3 used alcohol wipes from the floor with gloved hands, removed the gloves, and then placed the used alcohol wipes and gloves on the cart that was being used to serve sandwiches, rolls, and pureed bread. Interview with the Cook on 12/6/16 at 4:55 PM, in the kitchen, the Cook was asked what she was supposed to do after she removed her gloves, and before she donned new gloves. The Cook stated, I am supposed to wash my hands. Interview with the DM on 12/6/16 at 5:15 PM, in the kitchen, the DM was asked if it was appropriate to place dirty gloves and alcohol wipes that had touched the floor on a cart with food that was served to the residents. The DM stated, .No .She should be more tidy .

Based on policy review, medical record review, and interview, the facility failed to ensure physician's orders and care plans were followed for 1 of 11 (Resident #5) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The care plan dated 3/23/16 documented Resident #5 was at risk for complications associated with Hyper or [DIAGNOSES REDACTED] with approaches to administer medications per physician's orders and perform accuchecks as ordered. The physician's orders dated 5/18/16 documented, .ACCUCHECK BEFORE MEALS AND HOUR SLEEP *NO SLIDING SCALE* . The EMAR (Electronic Medication Administration Record) dated June 2016 did not document accuchecks were performed per physician's orders on June 2, 4, 5, 7, 9, 11, 12, 14, 16, 18, 19, 21, 23, 25, 26, 28, or 30. The EMAR dated July 2016 did not document accuchecks were performed per physician's orders on July 2, 3, 5, 7, 9, 10, 12, 14, 16, 17, 19, 21, 23, 24, 26, 28, 30, or 31 The EMAR dated August 2016 did not document accuchecks were performed per physician's orders on August 2, 4, 6, or 7. Interview with the Director of Nursing (DON) on 12/7/16 at 4:19 PM, in the conference room, the DON was asked if the accuchecks were done according to the physician's orders. The DON stated, .It clearly says accuchecks before meals and hour of sleep daily .they (staff) are not following the physician's orders . The DON was asked if the staff was following the care plan. The DON stated, .No, and I would like to say they (blood sugars) were stable, but they are high .

Based on medical record review, observation and interview, the facility failed to ensure proper treatment and assistive devices were obtained or maintained for visual impairment for 1 of 3 (Resident #17) sampled residents reviewed of the 27 residents with visual impairment. The findings included: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], and the quarterly MDS dated [DATE], documented Resident #17 had moderate cognitive impairment, had no corrective lenses, and had moderately impaired-limited vision, indicating could not see newspaper headlines, but could identify objects. The care plan dated 8/10/16 addressed visual impairment with interventions including staff was to read her mail for her. The care plan documented, .Staff will assist resident to clean and apply glasses daily/prn (as needed) . The EYE DOCTOR APPOINTMENTS sheet dated 1/14/11 documented, .Eye exam per family request .no change in Rx (prescription) needed. Pt (patient) may wear glasses as needed . Review of the list To be seen by (Named Optometry) for 10/17/16, revealed Resident #17 was on the list, but was not seen that day. Observations on 12/05/16 at 11:27 AM and 4:26 PM, and 12/6/16 at 10:51 AM and 5:52 PM, revealed Resident #17 had no glasses on. Interview with the Social Services Director (SSD), on 12/07/16 at 8:27 AM, in the Social Service Office, the SSD stated, .She was seen by eye doctor 1/13/2011 .She was probably not seen .for over a year . Interview with Resident #17 on 12/07/16 at 2:04 PM, in Resident #17's room, the resident was asked if she had any problems with her vision, and if she had glasses. Resident #17 stated, .No, I don't have glasses. I do have problems seeing .Yes, I would like to see the eye doctor . Interview with the SSD on 12/08/16 at 9:35 AM, the SSD was asked when Resident #17 had an eye exam. The SSD stated, .the last one was February, 2011 .

Based on medical record review and interview the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment related to hospice for 1 of 11 (Resident #125) sampled residents reviewed of the 24 residents in the stage 2 review. The findings included: Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ADMIT TO (named) HOSPICE WITH [DIAGNOSES REDACTED]. There was no documentation of hospice services on the significant change MDS assessment dated [DATE]. Interview with the MDS Coordinator on 12/7/16 at 6:46 PM, in the conference room, the MDS Coordinator was asked if the significant change MDS documented hospice care. She stated, No.

Based on policy review, observation, and interview, 5 of 21 staff members (Certified Nursing Assistant (CNA) #2, 3, 4, 1, and Licensed Practical Nurse (LPN) #5) failed to prevent the potential spread of infection during dining observations; the facility failed to ensure food was prepared, stored and served in a safe and sanitary manner as evidenced by carbon build-up on pans and floor of the freezer was dirty with ice build-up on the ceiling and on the floor. The facility had a census of 97, with 92 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Hand Washing policy documented, .The purpose of this procedure is to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents, and visitors . Compliance Guidelines . All facility personnel must wash their hands for 15 seconds under the following conditions . 2. Between resident contacts. 3. After handling contaminated objects . 9. Before performing resident care procedures . a. Dining observations in the purple hall on 10/19/15 beginning at 12:03 PM, CNA #2 entered Resident #120's room, placed the meal tray on the bedside table, raised the head of the bed, took the lid off of the plate of food, donned gloves and cut up the meat, touched the resident's phone, touched the top of the straw when opening it, and then removed her gloves, without performing hand hygiene. CNA #2 touched her shirt and pants, touched the a resident's hand, and touched her jacket, then took a meal tray to Resident #62 in the dining area in front of the purple nurses' station, touched the wheelchair handles, locked the wheelchair, and touched the tip of the straw without performing hand hygiene. b. Dining observations in the dining area in front of the purple nurses' station on 10/19/15 beginning at 12:03 PM, revealed CNA #3 delivered a meal tray to Resident #103, pulled a chair up to the table, and then touched the tip of the straw when opening it, without performing hand hygiene. c. Dining observations in the yellow hall on 10/19/15 at 12:39 PM, revealed CNA #4 entered Resident #9's room, placed a meal tray on the overbed table, walked into the bathroom, took a paper towel from the rack with her hands that had not been washed, tucked the towel under her armpit, washed her hands and then dried her hands with this towel. CNA #4 set up Resident #9's tray, touched a roll with her bare hand, cut the roll, touching the roll with her bare hand and applied butter to the roll. d. Dining observations in the purple hall on 10/20/15 beginning at 5:35 PM, revealed CNA #1 entered Resident #120's room, placed a meal tray on the overbed table and touched the bed control to raise the bed, opened two containers on the resident's tray without performing hand hygiene. CNA #1 entered Resident #95's room, placed the meal tray on the overbed table, and touched the tip of the straw with her hand and opened containers without performing hand hygiene. CNA #1 delivered a meal tray to Resident #7 in the dining area in front of the purple nurses' station, placed opened containers and touched the bottom of the straw barehanded, without performing hand hygiene, and placed the straw in a cup of coffee, added thickner to the cup of coffee and stirred the cup of coffee with the end of the straw that was touched by her bare hand. CNA #1 obtained a chair from the nurses' station, did use hand sanitizer, then continued to carry the chair to the dining area in front of the purple nurses' station, and touched the handle of a resident's wheelchair, then started feeding Resident #111, without performing hand hygiene. e. Dining observations in the dining area in front of the purple nurses' station on 10/20/15 beginning at 5:35 PM, LPN #5 sat down to assist in feeding of Resident #37, without performing hand hygiene. Interview with the Assistant Director of Nursing (ADON) on 10/21/15 at 6:15 PM, in the ADON office, the ADON was asked if you would expect staff to wash their hands after touching items while passing trays or feeding residents. The ADON stated, Yes. The ADON was asked if it is acceptable to touch straws without proper hand hygiene. The ADON stated, No. 2. Observations in the kitchen on 10/19/15 at 9:15 AM, revealed a large stove top pan, a saute pan, and a baking pan with carbon build-up on them. Observations in the kitchen on 10/20/15 at 9:40 AM, revealed a frying pan with carbon build-up. Interview with the Dietary Manager (DM) on 10/20/15 at 9:40 AM, in the kitchen, the DM was asked what was on the frying pan. The DM stated, Looks like carbon as well. 3. Observations in the walk in freezer on 10/19/15 at 9:15 AM, on 10/20/15 at 9:40 AM, and on 10/21/15 at 6:35 PM, revealed the floor was dirty with ice build-up on the ceiling and on the floor. Interview with the DM on 10/19/15 at 9:15 AM, in the walk in freezer, the DM was asked how often the walk in freezer was cleaned. The DM stated, Monthly.

Based on policy review, observation, and interview, 5 of 21 (Certified Nursing Assistant (CNA) #2, 3, 4, 1, and Licensed Practical Nurse (LPN) #5) facility staff failed to prevent the potential spread of infection during dining and 2 of 4 nurses (LPNs #4 and 3) nurses failed to prevent the potential spread of infection during medication administration. The findings included: 1. The facility's Hand Washing policy documented, The purpose of this procedure is to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents, and visitors . Compliance Guidelines .All facility personnel must wash their hands for 15 seconds under the following conditions . 2. Between resident contacts. 3. After handling contaminated objects . 7. Before preparing or handling medications . 9. Before performing resident care procedures . 15. After removing gloves . Additional Considerations . The use of gloves does not replace hand washing. Wash hands after removing gloves . 2. Dining observations in the purple hall on 10/19/15 beginning at 12:03 PM, CNA #2 entered Resident #120's room, placed the meal tray on the bedside table, raised the head of the bed, took the lid off of the plate of food, donned gloves and cut up the meat, touched the resident's phone, touched the top of the straw when opening it, and then removed her gloves, without performing hand hygiene. CNA #2 touched her shirt and pants, touched the a resident's hand, and touched her jacket, then took a meal tray to Resident #62 in the dining area in front of the purple nurses' station, touched the wheelchair handles, locked the wheelchair, and touched the tip of the straw without performing hand hygiene. 3. Dining observations in the dining area in front of the purple nurses' station on 10/19/15 beginning at 12:03 PM, revealed CNA #3 delivered a meal tray to Resident #103, pulled a chair up to the table, and then touched the tip of the straw when opening it, without performing hand hygiene. 4. Dining observations in the yellow hall on 10/19/15 at 12:39 PM, revealed CNA #4 entered Resident #9's room, placed a meal tray on the overbed table, walked into the bathroom, took a paper towel from the rack with her hands that had not been washed, tucked the towel under her armpit, washed her hands and then dried her hands with this towel. CNA #4 set up Resident #9's tray, touched a roll with her bare hand, cut the roll, touching the roll with her bare hand and applied butter to the roll. 5. Dining observations in the purple hall on 10/20/15 beginning at 5:35 PM, revealed CNA #1 entered Resident #120's room, placed a meal tray on the overbed table and touched the bed control to raise the bed, opened two containers on the resident's tray without performing hand hygiene. CNA #1 entered Resident #95's room, placed the meal tray on the overbed table, and touched the tip of the straw with her hand and opened containers without performing hand hygiene. CNA #1 delivered a meal tray to Resident #7 in the dining area in front of the purple nurses' station, placed opened containers and touched the bottom of the straw barehanded, without performing hand hygiene, and placed the straw in a cup of coffee, added thickner to the cup of coffee and stirred the cup of coffee with the end of the straw that was touched by her bare hand. CNA #1 obtained a chair from the nurses' station, did use hand sanitizer, then continued to carry the chair to the dining area in front of the purple nurses' station, and touched the handle of a resident's wheelchair, then started feeding Resident #111, without performing hand hygiene. 6. Dining observations in the dining area in front of the purple nurses' station on 10/20/15 beginning at 5:35 PM, LPN #5 sat down to assist in feeding of Resident #37, without performing hand hygiene. 7. Interview with the Assistant Director of Nursing (ADON) on 10/21/15 at 6:15 PM, in the ADON office, the ADON was asked if you would expect staff to wash their hands after touching items while passing trays or feeding residents. The ADON stated, Yes. The ADON was asked if it is acceptable to touch straws without proper hand hygiene. The ADON stated, No. 8. The facility's Administration of Eye Drops policy documented, .Policy Explanation and Compliance Guidelines . 1. Cleanse hands before and after administration (gloves may be worn per facility policy or according to standards of practice) . The facility's [MEDICATION NAME] DRUG DELIVERY SYSTEM (PATCH) APPLICATION policy documented, .Purpose . To administer medication through the skin through proper placement of the patch and care of the application sites . Procedures . C. Remove old patch from body . D. Cleanse area of old patch with wet gauze pad and pat dry with another gauze pad. E. Cleanse area where new patch will be placed using wet gauze pad and pat dry with another gauze pad . a. Observations in front of Resident #25's room on 10/19/15 at 4:25 PM, revealed LPN #4 touched the cart, prepared medications at the medication cart, entered Resident #25's room, and administered a medication by mouth to this resident. LPN #4 applied gloves, and administered 1 eye drop to each eye of this resident without hand hygiene prior to applying the gloves or between the eye drop administration to each eye. b. Observations in Resident #61's room on 10/20/15 at 9:36 AM, revealed LPN #3 applied gloves, administered medicines by mouth to this resident, removed the old patch from the left upper posterior shoulder, with the same gloves, and applied the new [MEDICATION NAME] to the right upper posterior shoulder blade. LPN #3 did not cleanse the skin. LPN #3 removed her gloves and then washed her hands. LPN #3 applied gloves, administered 1 eye drop to Resident #61's right eye, removed her gloves, without performing hand hygiene, applied new gloves and administered an inhaler to this resident. LPN #3 removed her gloves without performing hand hygiene, applied new gloves, and assisted this resident in putting on her jacket. Interview with the Director of Nursing (DON) on 10/21/15 at 2:10 PM, the DON was asked what should be done between glove use. The DON stated, Wash hands. The DON was asked what should be done between each eye when administering eye drops. The DON stated, Wash hands. The DON was asked what should be done to the skin when applying a medication patch. The DON stated, Should wipe the skin off where old patch removed, and wipe off skin where the new patch is going.

Based on review of menus, observation, and interview, the facility failed to honor 1 of 34 (Resident #57) resident's choice during dining observations. The findings included: Review of Resident #57's choice menu dated 10/19/15, revealed the following items were circled by Resident #57 for lunch preferences: chicken salad plate, saltine crackers, green beans, fresh fruit, and sweet tea. Observations and interview in Resident #57's room on 10/20/15 at 12:20 PM, revealed Resident #57's lunch tray had a barbeque pork riblette, oatmeal raisin cookie, fruit, and sweet tea. Resident #57's family member stated, This is not what was ordered. Interview with the Dietary Manager (DM) on 10/21/15 at 6:40 PM, in the kitchen, the DM was shown Resident #57's daily menu preference choices for lunch dated 10/19/15 and the meal ticket (what was delivered) for lunch dated 10/19/15. The DM was asked if Resident #57 should have received the food listed on the dietary preference sheet. The DM stated, Yes ma'am, it doesn't match it.

Based on medical record review and interview, the facility failed to accurately assess residents for anticoagulant medication, weight loss program, antibiotic usage, and/or pressure ulcers for 2 of 12 (Residents #46 and 57) sampled residents reviewed of the 34 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/15 documented Resident #46 was on a physician - prescribed weight loss regimen, and no anticoagulant medication was received in the last 7 days. Review of Resident #46's medical record revealed there was no weight loss program ordered. The physician's orders [REDACTED].QD (daily) . XARELTO (an anticoagulant) 20 MG (milligrams) BY MOUTH AFTER DINNER (with a start date of 8/18/15) . The august 2015 Medication Administration Record (MAR), documented Xarelto was administered daily from 8/18/15 to 8/31/15, which would have included the look back period of 8/20/15 through 8/26/15 for the MDS dated [DATE]. Interview with MDS Coordinator #1 on 10/21/15 at 3:40 PM, in the conference room, MDS Coordinator #1 was asked if Resident #46 was on a physican-prescribed weight-loss regimen. MDS Coordinator #1 looked at Resident #46's chart and stated,No, the wrong box was marked incorrectly by looking at this, there is no reason for her to be on a physican-prescribed weight-loss diet regimen. Interview with MDS Coordinator #1 on 10/21/15 at 6:12 PM, in the conference room, MDS Coordinator #1 was asked about Resident #46's anticoagulant medication administration. MDS Coordinator #1 confirmed the admission MDS assessment was inaccurate in regard to anticoagulant therapy. 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS with an ARD of 6/4/15 documented Resident #57 received antibiotics 5 of 7 days of the look back period. The May 2015 MAR, documented [MEDICATION NAME] was administered on 5/28/15 and 5/2915, which was only 2 days during the 7 day look back period. Interview with Director of Nursing (DON) on 10/21/15 at 2:30 PM, in the DON office, the DON was asked if Resident #57 had received antibiotics for 5 of 7 days of the look back period as documented on the MDS. The DON confirmed there were only 2 days of antibiotics documented on the MAR. The quarterly MDS with on ARD of 9/3/15 documented the oldest date for a stage 2 pressure ulcer was 6/5/15. The Wound Assessment Report dated 9/21/15 documented, .Pressure Ulcer . Stage 2 . the date wound identified was 9/29/14 . Interview with the DON on 10/21/15 at 2:30 PM in the DON office, the DON was asked if the 9/3/15 MDS that documented date of 6/5/15 as the oldest stage 2 pressure ulcer was correct. The DON stated, No, it's older than that.

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention quick reference guide, medical record review, observation and interview, the facility failed to document weekly skin assessment with a description with stage, size depth, length, width or presence or absence of drainage for 2 of 5 (Residents #23 and 57) sampled residents reviewed with pressure ulcers. The findings included: 1. The NPUAP quick reference guide documented, .Ongoing assessment of the skin is necessary to detect early signs of pressure damage . Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if necessary . Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals . 2. Medical record review revealed Resident #23 was admitted to facility on 5/8/15 with [DIAGNOSES REDACTED]. The resident data collection admission assessment dated [DATE] documented, .reddened area to sacrum . Nurses note revealed the following documentation: a. 5/14/15 - .late entry for 5/11/15 skin assessment admission note . red sacral/coccyx noted . md (medical doctor) present with new orders noted . b. 6/5/15 - .late entry . wound care team made rounds with measurements and assessment . open are (area) noted to buttock with tx (treatment) impleemnted (implemented) . c. 6/8/15 - .late entry 6/8 . wound care . (team) made rounds with measurements and assessment completed stage 2 sacral r/t (related to) IAD (incontinence associated damage) noted . d. 6/17/15 - .late entry 6/15 . wound care team made rounds with measurements and assessments taken rash of prineal (perineal) [MEDICAL CONDITION] noted with noted right buttocks noted. 1.4 cm (centimeter) x (by) 0.8 cm x 0.1 cm noted . Physician's progress notes documented the following: a. 5/18/15 - .open area to sacrum . b. 5/29/15 - .[DIAGNOSES REDACTED]. Pressure ulcer, stage II (2) . The weekly skin assessments dated 5/24/15, 6/7/15, and 7/4/15, revealed skin assessments were performed with no wound measurements documented. No other weekly skin assessments or wound assessment reports were provided by the facility for Resident #23. Interview with the Director of Nursing (DON) on 10/21/15 at 5:52 PM, in the hallway outside of the Assistant Director of Nursing's (ADON) office, the DON was asked if weekly skin assessments were performed for Resident #23. The DON stated, No, not that I can see. 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the wound assessment reports, departmental notes, wound care notes, weekly pressure ulcer records, and physican progress notes dated from 6/1/15 to 10/19/15 revealed no weekly assessments or wound measurements for the sacral and the left posterior thigh pressure ulcers for the weeks of 6/22/15, 8/3/15 and 8/17/15. Interview with the DON and the Minimum Data Set (MDS) Coordinator on 10/21/15 at 4:45 PM, in the MDS office, the DON was asked how often wound assessments should be done. The DON stated, Weekly. The DON was asked if the wound assessments should include measurements. The DON stated, Yes. The DON was shown the notes given to the surveyor for missing assessments. The DON was asked if she could find measurements for the dates of 6/22/15, 8/3/15 and 8/17/15. The DON stated, Have not located them yet.