Every finding on record at Towers Nursing Home

Based on observation, interview and record review, the facility failed to ensure residents was provided the required assistance with eating resulted in poor intake, however, the resident met identified weight services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 6 residents ( Resident # 1 ) reviewed for nutrition. The facility failed to provide Resident #1 with supervision and assistance during meal service on 06/11/2026. This failure could place residents at risk of dehydration and malnutrition. Findings include: Record review of Resident #1's face sheet, dated 06/11/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included unspecified severe protein-calorie nutrition (a condition caused by a deficiency of both protein and energy , leading to loss of weight , muscle mass, and fat stores it is not specified the exact clinical subtype in the medical record), cognitive communication deficit ( an impairment in communication skills caused by disruptions in the brain's thinking processes, rather than a primary speech or language issue), and dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety ( dementia involves the damage or death of nerve cells in the brain, which prevents a person from communication properly. Symptoms includes memory loss, confusing and impaired reasoning. A doctor has diagnosed a patient with dementia, but the specific cause wasn't identified, and the patient does not have behaviors.)Record review of Resident #1's Quarterly MDS Assessment, dated 03/11/2026, reflected Resident #1 had a BIMS score of 00, which indicated Resident #1 cognition was severely impaired. Resident #1 required supervision or touching assistance with eating ( helper provides cues and/or touching/steadying and/ or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or as needed). She was assessed in section I under additional active diagnosis to have a diagnosis of malnutrition.Record review of Resident #1's Comprehensive Care Plan, revised on 03/18/2026, reflected the following:*Resident # 1 had a desired weight gain related to BMI ( Body Mass Index - a medical screening tool that uses your height and weight to estimate your total body fat). Intervention: Continue with interventions: Resident #1 had ( on 06/05/2026) 16 pounds weight gain in the past 90 days. Give supplements as ordered by physician. Offer snacks as ordered by physician. Pureed Diet with house supplement 2.0 twice a day.*Resident #1 had an ADL Self- Care performance deficit related to generalized weakness ( loss of physical strength across multiple muscle groups, such as both arms and legs, rather than just a single area of the body) secondary to unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing ( when the fracture [small partial cracks to complete breaks of a bone] was healing normally and no complications are present Interventions: Functional Performance of Eating- Resident #1 required supervision or touching assistance for eating.* Resident #1 had an ADL self-care performance deficit related to generalized weakness secondary to unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing. Interventions: Eating- Resident #1 required supervision assistance by one staff to eat. Review of Resident #1's weight record reflected the following:Resident #1 weighed 67.1 pounds on 03/01/2026.Resident #1 weighed 82.0 pounds on 06/09/2026.Observation on 06/11/2026 at 7:20 a.m. revealed Resident #1 received her breakfast meal tray in the secure unit dining room. CNA C set up Resident #1's meal tray and continued to pass out meal trays to other residents.Observation on 06/11/2026 at 7:30 a.m. Resident #1 was sitting staring at her meal tray. She was drinking her juice. Resident #1 did not attempt to pick up a fork or spoon to eat her meal. CNA C and LVN D continued to pass out meal trays to other Residents. CNA C and LVN D were the only staff in the secure unit dining room.Observation on 06/11/2026 from 7:30 a.m. until 8:23 a.m. revealed Resident #1 stared at her food and did not attempt to eat. The staff did not cue Resident #1 or assist her with feeding.Observation on 06/11/2026 at 8:04 a.m. the ADON E entered the secure unit dining room and began to ask the residents if they needed more coffee. She spoke to Resident #1 and other residents sitting at the same table as Resident #1. ADON E did not cue Resident #1 with eating her breakfast or offer assistance with feeding Resident #1. Observation on 06/11/2026 at 8:23 a.m. LVN D asked Resident #1 if she wanted him to warm up her food. He exited the dining room and the secured unit. He returned with another meal tray for Resident #1, and he began to assist feeding Resident #1.Interview on 06/11/2026 at 8:50 a.m. CNA C stated Resident #1 sometimes does not prefer staff to feed her. She stated Resident #1 did require staff to cue her to eat her meals most of the time. CNA C stated, I was feeding another resident and did not notice Resident #1 was not eating. She stated all staff was responsible to ensure the residents were cued to eat their meals or assist the residents with feeding as needed. CNA C stated she had been in-service on feeding residents , cueing residents when they are not feeding themselves. She did not recall the date or time of the in-service.Interview on 06/11/2026 at 2:46 p.m. LVN D stated he was feeding another resident, and he was sitting across from Resident #1. He stated, I did not cue Resident #1 to eat or try to get another staff to attempt to feed Resident #1. LVN D stated he was expected to cue Resident #1 to eat or have another staff to assist her if he was busy feeding another resident. He stated ADON E could have fed or cued Resident #1 when she came into the secure unit dining room. He stated he had been in-service on dining room service, cueing residents, and feeding residents. LVN D stated he did not remember the date of the in-service. Interview on 06/11/2026 at 4:25 p.m. ADON E stated Resident #1 did require to be cue when she was eating her meals. She stated there are times Resident #1 needs assistance with feeding, however, Resident #1 sometimes will refuse assistance. LVN D stated all staff was expected to attempt to assist Resident #1 with feeding if she was not feeding herself and cue Resident #1 to eat her meals. She stated there was a possibility if a meal tray sat uncovered on the dining room table from 7:20 a.m. until 8:23 a.m. the food was cold and the resident may not eat. She stated for a resident to wait approximately one hour to eat was too long and it could affect the Resident's appetite if she was drinking all of her fluids and not eating her meals. She stated her expectation was that all residents be offered assistance and be cued to eat their meals as soon as possible. ADON E stated there was a risk of Resident #1 not getting the nourishment she needed and possibility of weight loss. In an interview on 06/11/2026 at 5:25 p.m. The Nurse Consultant stated her expectations for dining room meal service was all residents to be served and their meal tray set up for the resident. She stated the residents needed cueing and/ or assistance with feeding was expected to be fed as soon as their meal tray was set in front of the resident. She stated after the staff set up the meal tray, the staff was expected to assist the resident with eating or cue the resident to eat. The Nurse Consultant stated if a resident refused assistance with feeding, she expected the staff to observe the resident and offer to assist feeding the resident for the 2nd time if the staff observed the resident not eating or to cue the resident as many times as the resident needed to be cued to eat. She stated if a resident was not eating and no one was cueing the resident or offered to assist with feeding there was a potential the resident may not eat if the food becomes cold or the resident was drinking all the fluids at one time and not eating their meal. She stated there was a potential a resident may lose weight if the resident was high risk for weight loss. In an interview on 06/11/2026 at 5:54 p.m. The Administrator stated she expected all staff to assist resident with setting up their meals. She stated if a resident needed assistance with eating, she expected the staff to sit with the resident and assist with feeding immediately after setting up the resident's meal tray. She stated if a resident refused the assistance, she expected the staff to attempt to assist resident again. The Administrator stated all the staff was expected to cue the residents to eat if the resident was staring at their food and not eating. She stated waiting almost an hour for a resident to eat their meal was too long and this was not acceptable. The Administrator stated the staff had been in-service and trained on dining room service and this training will be continued. She did not recall the date or time of the in-service. The Administrator stated there was a possibility a resident may not eat their meal after it becomes cold and if they were drinking all their fluids especially if they had a health supplement. She stated there was a potential for weight loss if a resident was not eating their meals and needed cueing to eat.Record review of the Facility's Policy on Meal Service, dated 10/01/2018, reflected The facility believes that all residents should be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. Residents will be properly groomed, and their needs attended to during the meal service. Procedure:Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining.

Based on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in response to one (Resident #1) of three Residents with unknown COVID 19 status. The facility failed to appropriately screen and test Resident #1 for signs, symptoms, and exposure of COVID-19. This failure placed residents at risk of exposure to COVID-19, which could result in illness, and hospitalization.Findings included:Record review of Resident #1's face sheet, dated 06/11/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included COVID-19 with onset 01/11/2026 (an infectious respiratory illness).Record review of Resident #1's admission MDS Assessment, dated 02/25/2026, reflected Resident #1 had a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. She was assessed to have poor short- and long-term memory recall. Her decision-making abilities was severely impaired.She was assessed in section I under additional active diagnosis to have a diagnosis of COVID-19.Record review of Resident #1's Quarterly MDS Assessment, dated 03/11/2026, reflected Resident #1 had a BIMS score of 00, which indicated Resident #1 cognition was severely impaired. Resident #1 was dependent on staff for showers, and toileting hygiene. She required substantial/maximal assistance ( helper does more than half the effort) with the following:Personal HygieneUpper and Lower Body dressingOral hygienePutting on /taking off footwearShe was assessed in section I under additional active diagnosis to have a diagnosis of COVID-19. Record review of Resident #1's Comprehensive Care Plan, revised on 03/18/2026, reflected the following:*Resident #1 had high risk for communicable respiratory infections- influenza/pneumonia ( influenza- a highly contagious respiratory illness) , (pneumonia- an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid). Interventions: Monitor facility for trends in respiratory infections, Administer flu/pneumonia vaccines in accordance to CDC guidelines after consent received from resident or responsible party. *Resident #1 was at risk for deterioration of medical condition due to positive results of COVID-19 test. *Resident #1 was at risk for psychosocial well-being related to medically imposed restrictions related to COVID -19 precautions ( date initiated on 1/11/2026 and revised on 1/13/2026). Interventions: Contact/droplet precautions in place due to positive COVID-19 test ( date initiated on 1/13/2026). Educate staff, resident, family, and visitors of COVID -19 signs, symptoms and precautions ( date initiated on 1/13/2026), and maintain in private room or cohort with other COVID-19 positive residents if applicable ( date initiated 01/13/2026).Record review of Resident #1's Nurses Notes, dated 01/07/2026 at 5:38 p.m. reflected Resident continues being monitored for meal intake, Breakfast - 0 Percent, Lunch- less than 25 percent, dinner - less than 25 percent. Resident encouraged to increase PO intake for nutritional support, encouraged to increase hydration for overall health. Signed by LVN A.Record review of Resident #1' Nurses Note, dated 01/08/2026 R/P called and requested to add Vitamin C ( an essential water-soluble nutrient that the body cannot produce itself), Vitamin K ( a group of fat-soluble vitamins that are essential for blood clotting, wound healing, and building healthy bones), Zinc ( an essential trace mineral and a bluish-white metallic chemical element), and Elderberry ( it is a nutrient-dense fruit packed with antioxidants, vitamin c, and dietary fiber) to resident's Medication Administration Record NP ok'd. Notified R/P that we did not carry elderberry and R/P stated she would bring some in. MAR updated. Charge nurse notified. Signed by DON.Review of Resident #1's R/P text messages with the Director of Nurses, dated 01/08/2026 at 1:54 p.m. reflected Hi (DON) being that [ Resident #1] can't be tested and can't be moved, thank you for putting a mask on her at my request. Can you see if you can get the doctor to prescribe vitamin c , k and Elderberry. Review of Resident #1's R/p text messages with the Director of Nurses, dated was not on the text sent to surveyor, reflected New orders for [Resident #1] : Zinc 50 mg daily , Vitamin C 500 mg daily , and Vitamin K 100 mg. We don't care Elderberry. Doctor said it would be fin if family wanted to bring it in and we can add it to her [Resident #1] MAR. Record Review of Resident #1's Nurses Note, dated 01/11/2026 at 4:19 p.m., reflected Resident #1 had a cough ( signs and symptoms was not described when the note stated describe S/S ( signs and symptoms). Notified Responsible Party on n 01/11/2026 at 5:18 p.m. Signed by RN B.Record Review of Resident #1's Change of Condition Nurses Note, dated 01/11/2026 at 6:50 p.m., reflected Resident #1 tested positive for COVID, started on 01/11/2026. Things that make the condition worse: ( this was documented in the note but did not specify ). Things that make the condition better: ( this was documented in the note but did not specify). History: Primary Diagnosis ( did not specify). Vitals:Blood Pressure: 108/64 lying down 0/11/2026Pulse: 71 Regular 01/11/2026Resp ( Respiratory) : 16 on 01/11/2026Temp ( Temperature): 99 on 01/11/2026O2 SAT : 97 on 01/11/2026Functional Status: Functional Status Changes : 1 ( she had changes)Mental Status Changes: 1 ( she had changes). Signed by RN BRecord Review of Resident #1's Nurses Notes dated 01/12/2026 at 12:38 p.m. , reflected Resident #1 had poor PO ( orally - by mouth) for nutritional support, current COVID infection diagnosis, physical decline, new order received:Start - Lactated Ringers Intravenous Solution ( used to replace lost fluids and to help correct acid-base imbalances in the body) use 1 liter intravenously one time only for 1 day Administer 1,000 ml at 65 ml/hr until complete, related to poor intake PO intake/ COVID infection, may administer via IV( intravenous) or hypodermoclysis ( the administration of fluids or medications directly int the layer of fat just beneath the skin) to LUE ( left upper extremity), resident tolerated procedure without complications. Family notification at 8:21 p.m. Called and spoke with Responsible Party provided update of Resident #1 current condition and new MDS order, R/P thanked charge Nurse. Signed by LVN A.Record review of the facility's COVID positive log, dated January 2026, reflected the following:Resident #2 tested positive for COVID-19 on 01/06/2026.Resident #3 tested positive for COVID -19 on 01/07/2026.Resident #4 tested positive for COVID -19 on 01/07/2026.Resident #5 tested positive for COVID-19 on 01/08/2026.Resident #6 tested positive for COVID-19 on 01/08/2026.Resident #7 tested positive for COVID-19 on 01/08/2026.Resident #8 tested positive for COVID -19 on 01/09/2026.Resident #1 tested positive for COVID -19 on 01/11/2026.Resident #9 tested positive for COVID-19 on 01/11/2026.Resident #10 tested positive for COVID-19 on 01/11/2026.Resident #11 tested positive for COVID-19 on 01/11/2026.Resident #12 tested positive for COVID -19 on 01/12/2026.Review of Resident #1's R/P text message dated 01/20/2026 at 10:12 a.m., reflected Good morning [ Director of Nurses] I hope you're well. Is there a specific policy governing why [ Resident #1] was denied a COVID test when I requested one due to us initially not being aware of COVID because there was no sign on the door to memory care until I said something. [ Resident #1] and I were exposed so I need to know why she was denied testing. Also, with my request to keep her [ Resident #1] in her room and keep other residents out of her room during this COVID time, also requested her door be kept closed. Why was a resident sitting in her room with the door opened but the resident was sitting in the chair in the same corner and side of [ Resident #1's] room. I would like an explanation. Thank you.Interview on 06/11/2026 at 7:52 a.m. Resident #1 was not interview able. She did not respond to questions or conversation. Interview on 06/10/2026 at 4:10 pm Resident #1's R/P stated she contacted the Director of Nurses via phone on 01/07/2026 with a concern of Resident #1 having some symptoms of COVID-19. She stated I explained to the DON ( Resident #1) had been exposed to COVID-19 from Resident #2 on the hall where Resident #1)lives on 01/6/2026. She stated Resident #2 was sitting by her and Resident #1in the dining room. I asked if ( Resident #1) could be moved to another hall and was explained Resident #1could not be moved related to being exposed to COVID and Resident #1could impact others health if she was moved. The DON told me that COVID should not be tested because only residents with symptoms could be tested. She stated Resident #1had a running nose and this was not her normal for her. The Director of Nurses stated Resident #1 could not be tested. I sent a text on 01/08/2026 at 1:54 p.m. and asked since that my mother cannot be tested and cannot be moved, I thanked the Director of Nurses for placing a mask on my mother at my request. In the text I asked if the Director of Nurses could get the doctor to prescribe the following: vitamin C, Vitamin K, and elderberry . I received a text from the Director of Nurses, and the text stated Resident #1received new orders of zinc 50 mg daily, Vitamin C 500 mg daily and Vitamin K 100 mg. I was told in the text from the Director of Nurses that the facility did not carry Elderberry, but the Physician was fine if the family wanted to bring Elderberry to the facility and the staff could add it to her MAR ( Medical Administration Record) . I sent a text to the Director of Nurses on 01/20/2026 at 10:20 a.m. requesting information about a specific policy governing why my mother [ Resident #1] was denied a COVID test when I requested one due to us initially not being aware of COVID because there was not sign on the door to memory care unit until I mentioned it to the staff. I stated Resident #1and I were exposed to COVID, and I needed to know why Resident #1was denied testing. I also asked if my Resident #1could be kept in her room during covid and keep other residents out of her room during the COVID time. I also requested for Resident #1's door to her room be kept closed due to there was another resident in Resident #1's room sitting in a chair near her. I never received a response from the Director of Nurses via Phone or text. I sent the Director of Nurses another text on 01/30/2026 at 9:26 a.m. requesting a response from my 01/20/2026 text. I explained in the text a concern of Resident #1's health had been severely impacted due to COVID and among other things. I asked the Director of Nurses to respond. I finally received a response from the Director of Nurses stating that the Director of Nurses was in the facility Monday- Friday 9 am to 5 pm and she could also schedule a meeting anytime during the week. I responded to the Director of Nurses it was not possible at this time for her to come to the facility due to having to go to hospital every day . I asked her if she was available for a phone appointment or even on electronic face to face meeting. The Director of Nurses stopped communicating with me via text or phone. I am not going to ever meet with the Director of Nurses in person I do not trust her, and she has lied about a lot of things. I will meet with the Nurse Consultant and the Administrator. I am fine if the Director of Nurses is in the meeting, but I will not meet with the Director of Nurses alone and this is why I prefer to communicate with her via text or email due to not trusting her and she has lied to me so many times. She stated she had a meeting last week of May with the Nurse Consultant and the DON. R/P stated the Nurse Consultant stated in their meeting she would have given my mother a COVID test. In an interview on 06/11/2026 at 12:28 p.m. The Director of Nurses stated Resident #1 did not have symptoms until 01/11/2026. Her symptoms on this date was a cough. She stated Resident #1 was tested for COVID on 01/11/2026 and she tested positive for COVID. The Director of Nurses stated Resident #1 was placed on precautions ( she did not specify what type of precautions), isolation and her R/P and Medical Doctor was notified. She stated Resident #1's R/P communicated with her via text messages. She stated Resident #1's R/P asked about the facilities policy on COVID testing, and I explained to her the facility followed the CDC guidelines. The Director of Nurses stated she did receive a text from Resident #1's R/P asking why was her mother denied a COVID test. She stated I did not respond via text. I attempted to call her, and she did not answer the phone. The Director of Nurses stated, I did not attempt to call her any more except that one time. She stated she did not have any documentation of her communicating with Resident #1's R/P about testing for COVID. She stated she did respond via text referring R/P [ Resident #1's R/P] requested for Resident #1 receive Vitamin C, Vitamin K, Zinc, and Elderberry. She stated she contacted the physician and he approved for the vitamins and stated it was ok for the family to bring in the Elderberry due to the facility did not have Elderberry in the facility. She stated she communicated via text with this information. The Director of Nurses stated it was difficult to document everything a family requested from the staff. The Director of Nurses stated she did speak with Resident #1's R/P about CDC guidelines and she did not document this conversation. The Director of Nurses became annoyed and a little agitated with the questioning about the situation and the interviewed was stopped. In an interview with a former employee on 06/11/2026 at 1:40 p.m. She stated I did work at the facility during the month of January 2026. I do recall when Resident #1 was on the secure unit at the facility. She stated Resident #1 was having a runny nose and did not feel very well. She stated Resident #1's R/P voiced concern about Resident #1 and was worried she had COVID. She stated Resident #1's R/P, wanted her to be tested for COVID and Resident #1 was not tested when the R/P requested the test. She stated she knew she had requested the test due to hearing R/P talking to the ADON ( no longer works at the facility) with her concerns of the resident having COVID and refusing to test her for COVID. She stated Resident #1 was around the first resident who tested positive for COVID. She stated I do not recall the dates of when any of the conversations occurred or when the first Resident on the secure unit tested positive for COVID. In an interview on 06/11/2026 at 5:25 p.m. The Nurse Consultant stated anytime there was telephone correspondence with a family member concerning the medical condition of the resident, she expected for the nurse to document the conversation in medical records. She stated if there was not any documentation of any correspondence with a family member about anything there was no proof the conversation had occurred with the family. She stated if Resident #1's R/P requested a covid test for her mother, she stated she would have called the physician and received an order for the COVID test. The Nurse Consultant stated Resident #1's R/P was in the facility every day for several hours. If she was attempting to call the family and was unable to reach R/P via phone she would have talked to the R/P in the facility. She stated her expectations was all communication with families concerning a resident's health to be documented and to follow-up with the family of any request a family may have asked or needs information. The Nurse Consultant stated she did have a meeting with the DON and the R/P at the end of May 2026, and she did inform the R/P if she had of asked her for the COVID test she would have given to Resident #1. She stated if Resident #1 had a runny nose this was a symptom of COVID. In an interview on 06/11/2026 at 5:54 p.m. The Administrator stated her expectations whenever a family member had requested a COVID test the Director of Nurses was expected to call the physician and get an order for the COVID test. She stated the facility staff should not deny a resident a COVID test if the family requests one and the resident has some symptoms of COVID. She stated the facility followed CDC guidelines now and during the month of January 2026 as well as their own infection control protocol. The Administrator stated anytime a family member was calling staff about concerns of their family she did expect the nursing staff to document it in the electronic medical records under nurses notes, especially if it pertained to anything related to the residents medical condition. She stated anytime a family member voiced concern about COVID the nursing staff was expected to document this in the residents electronic medical record. The Administrator stated unless the staff documents any conversations about a residents medical care voiced by a family member or by anyone there was no proof the conversations occurred between the staff and the family member or others. Record review of the most recent CDC guidelines of COVID -19 symptoms , dated 3/10/2025,the following list does not include all possible symptoms of COVID-19. Symptoms may change with new COVID-19 variants and can vary depending on vaccination status. Possible symptoms include the following:1. Fever or chills2. Cough3. Shortness of breath or difficulty breathing4. Sore throat5. Congestion or runny nose6. New loss of taste or smell7. Fatigue8. Muscle or body aches9. Headache10. Nausea or vomiting11. Diarrhea Record review of the Facilities Infection Prevention and Control Program, dated 05/13/2023 reflected, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary , and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. COVID-19 testing:Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS -CoV-2 ( the highly contagion coronavirus responsible for causing COVID-19) as soon as possible.Asymptomatic residents with close contact with someone with SARS- CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 ( where day of exposure is day 0), day 3 , and day 5.

Based on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or promote wound healing for one (Resident #1) of three residents reviewed for pressure ulcers. The facility failed to provide treatments on 03/19/2026 and 03/25/2026 to a pressure ulcer on Resident #1 buttocks. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Record review of Resident #1's face sheet, dated 03/31/2026, reflected Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] and readmitted on [DATE] with a diagnosis muscle wasting and atrophy, not elsewhere classified, multiple sites ( a significant decrease in muscle mass and strength that cannot be attributed to a more specific diagnosis- atrophy is defined by shrinking muscles often due to immobility or aging), iron deficiency anemia ( a common condition where the blood lacks sufficient healthy red blood cells due to lack of iron), and muscle weakness ( a reduced capacity to exert force with one or more muscles, often presenting as difficulty performing daily tasks like lifting, walking, or grasping objects). Record review of Resident #1's admission MDS Assessment, dated 02/25/2026, reflected Resident #1 had a BIMS score of 99 (she was unable to respond to any questions) which indicated her cognition was severely impaired. She had short- and long-term memory recall. She had was admitted with a stage 2 pressure ulcer. Resident #1 had pressure reducing device for bed. She received pressure ulcer/injury care. Record review of Resident #1's Comprehensive Care Plan revised on 03/03/2026, reflected Resident #1 had an alteration in skin integrity related to the presence of stage 2 pressure ulcer/injury on the buttocks. Interventions:Apply treatment as ordered. Assess and document on status of pressure ulcer/ injury weekly and as needed.Assess complications, including signs and symptoms of infection (drainage, redness, increased warmth, odor, tenderness, etc.). Notify Doctor with identification of skin integrity impairments. Turn and reposition as needed. Review of Resident #1's physician orders, dated 3/18/2026 reflected wound care: cleanse with wound cleanser and pat dry. Apply zinc oxide to wound bed and leave open to air once daily until resolved. Review of Resident #1's Treatment Administration Record dated, March 2026, revealed Resident #1 had the following order: Wound Care: Cleanse with wound cleanser and pat dry. Apply zinc oxide to wound bed and leave open to air once daily until resolved (every day shift for wound care). Resident did not receive wound care on 03/18/2026 and on 03/25/2026- According to the Treatment Administration Record dated March 2026. Review of Resident #1's Skin Assessment Nurses Notes, dated 03/17/2026, reflected Resident had Stage 2 pressure ulcer/injury with partial thickness, skin loss with exposed dermis to buttocks. Wound was present on admission. No undermining (a serious complication where the tissue under the wound edges separates from the underlying structure, creating a hidden pocket) or tunneling (a serious, deep wound where tissue destruction creates a narrow channel or passageway beneath the skin's surface, extending from the main wound bed). Review of Resident #1's Skin Assessment Nurses Notes, dated 03/24/2026, reflected Resident #1 had Stage 2 pressure ulcer/injury with partial thickness, skin loss with exposed dermis to buttocks. Wound was present on admission. There is no undermining or tunneling. Interview on 03/31/2026 at 2:30 pm, the Nurse Practitioner stated Resident #1's overall health is improving. She stated a few weeks ago we were not expecting her to live. The Nurse Practitioner stated she was sitting up in wheelchair, eating better and her skin concerns has not deteriorated they have improved. She stated there was no negative outcome of Resident #1 not receiving treatment to her skin concerns on 03/18/2026 and 03/24/2026. She stated Resident #1's overall cognition and physical condition have improved above her baseline. The Nurse Practitioner stated it was a miracle she had recovered physically and mentally from a few weeks ago. She stated Resident #1 is doing great and there was no issues with her skin concerns deteriorating. She stated the nurses calls her of any changes with Resident #1 and she stated I am very pleased of Resident #1's care and her physical condition at this time. I have no concerns of her care at the facility. Interview on 03/31/2026 at 3:30 pm, the Director of Nurses stated Resident #1's skin concerns did not deteriorate from missing 2 treatments on 03/18/2026 and 03/24/2026. She stated she did not know why she missed those treatments; however, she would investigate and complete in services the importance of completing treatments to skin concerns. She stated a full investigation would be completed. She stated she had in-service staff on wound treatments recently. The Director of Nurses stated she could not recall the date. Interview on 04/01/2026 at 1:45 pm, the Nurse Consultant stated she reviewed Resident #1's medical record and her skin concerns did not deteriorate from missing treatment to her buttocks on 03/19/2026 and 03/24/2026. She stated her wound remained the same. The Nurse Consultant stated there was a possibility if a resident was not receiving treatment on a regular basis the wound may increase in size. She stated an investigation was in process of why these 2 treatments on Resident #1 were missed. She stated there was no evidence according to Resident #1's medical record of any deterioration of her wound from 03/19/2026 to 03/25/2026. The Nurse Consultant stated in-services were in the process with all nurses related to skin concerns and treatments. She stated at this time the treatment nurse was on leave of absence; however, he was present at the time when the treatments to Resident #1 were missed. She stated the infection control preventionist, Director of Nurses or Charge Nurse was completing wound care at this time. Interview on 04/01/2026 at 3:00 pm, the Administrator stated the treatment nurse was on leave of absence at this time. She stated she expected the nurses to follow each resident's physician orders and follow any type of treatment plan for skin concerns. The Administrator stated if treatment was not completed as ordered there was a potential the wound may deteriorate. She stated Resident #1's wound did not deteriorate when she did not receive treatment on 3/19/2026 and 3/24/2026. The Administrator stated a full investigation would be conducted of why the treatments to Resident #1 were missed. Record review of Nursing Inservice on Nursing Education, dated 08/19/2025 and 08/20/2025, reflected skin concerns and wound treatment documentation was discussed. Record review of Facility Policy on Pressure Injury Prevention and Management, dated 08/15/2022, reflected This facility is committed to the prevention of avoidable pressure injuries and promotion of healing of existing pressure injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including assessment and treatment.

Based on observation, interview, and record review, the facility failed to ensure a resident with indwelling catheter received the appropriate care and services to prevent urinary tract infections for 1of 3 residents (Resident #2) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #2's urinary drainage bag tubing and bag were kept from touching and resting on the floor. This failure could place residents with indwelling catheters at risk of developing infections. Findings included: Record review of Resident #2's face sheet reflected Resident #2 was admitted to the facility on [DATE] with diagnosis which included need for assistance with personal care ( a person required help from a caregiver to safely manage daily ADLs), unspecified dementia ( a diagnosis used when a patient exhibits clear symptoms of cognitive decline in memory loss, but a specific cause cannot yet be determined), and displaced intertrochanteric fracture of left femur, initial encounter for closed fracture ( a severe break in the upper thighbone, where the bone fragments have shifted out of alignment - initial encounter for closed fracture signified this is the first medical assessment for a broken bone that has not broken through the skin). Record review of Resident #2's admission MDS was in progress, dated 3/30/2026. Record review of Resident #2's Baseline Care Plan revised on 03/28/2026, reflected Resident #2 had an indwelling suprapubic catheter (a tube inserted into the bladder through a small abdominal incision): 16 foley with 10 ml balloon. Intervention: Resident #2 had 16 French foley with 10 ml balloon. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Check tubing for kinks once each shift. Monitor and document intake and output as ordered. Monitor/ document for pain/discomfort due to catheter. Monitor/record/ report to Medical Doctor for signs and symptoms of UTI ( an infection in any part of the urinary system): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. Resident #2 had a behavior problem related to hitting staff secondary to pain. Interventions: Administer medications as ordered. Monitor and document for side effects and effectiveness. Caregivers to provide opportunity for positive interaction and attention. Stop and talk with Resident #2 when passing by her. If reasonable, discuss Resident #2's behavior. Explain/ reinforce why behavior is inappropriate and/ or unacceptable to the resident. (There was not a care plan of resident throwing things such as catheter when the care plan was printed prior to 9:45 am on 3/31/2026). Observation and interview on 03/31/2026 at 9:04 am reflected, Resident #2 was sitting up in her bed. Her bed was in low position; she had fall mat beside her bed. Resident #2 had indwelling catheter. Her catheter bag had kinks in the tubing, and the bag was lying on the floor halfway underneath the bed. Resident refused to be interviewed. Observation on 03/31/2026 at 9:20 am reflected Resident #2 was lying in bed. Her bed was in low position. Resident #2's indwelling catheter continued to be kinked and was lying on the floor in a covered bag partially under the bed. Interview on 03/31/2026 at 9:23 am MDS Coordinator LVN stated Resident #2 had behavior problems and would hit staff during care and would throw things in the room. She stated her behaviors were care planned. The MDS Coordinator LVN stated the catheter bag could not on the floor and it was not to be kinked. She stated urine could back up into the bladder and Resident #2 could develop a UTI, or any type of infection such as sepsis (a life - threatening medical emergency caused by the body's extreme, dysfunctional response to an infection). MDS Coordinator LVN stated the bag should not be kinked related to it could affect the urine from not flowing into the bag. She stated the catheter bag was to be hung on side of the bed and below the bladder. She stated it was unacceptable for catheter bag to be lying flat on the floor. She stated she had been in-service on catheter bags but could not recall the date. Interview on 04/01/2026 at 11:00 am, LVN A stated anytime a resident had an indwelling catheter it was to be hanging below the bladder with tubing on top of the resident's leg. She stated a catheter was never to be lying flat on the floor. She stated there was a possibility urine could back up into the bladder and the resident could develop a UTI or sepsis. LVN A stated it was not best practice to have kinks in the tubing and catheter lying on the floor. She stated she had been in-service on catheters but did not recall the date. She stated she had not given care to Resident #2. Interview on 04/01/2026 at 11:25 am, CNA B stated she had given care to Resident #2 maybe 2 times since her admission to the facility. She stated she was not aware of Resident #2 throwing anything. CNA B stated she was aware of Resident #2 not being cooperative sometimes during ADL care but not throwing her catheter or other things from her bed. She stated catheters was never to be on the floor. CNA B stated all catheters were to be hung on the bed below the bladder. She stated if the catheter tubing had a kink and the catheter was flat on the floor there was a possibility the resident could develop a UTI or any type of bladder infection. She stated CNAs or nurses could hand the catheter bag on side of the bed and ensure it was in the correct position. She stated if a CNA was uncertain about catheter bags, the CNA could always ask the nurse for guidance. CNA B stated she had been in-service on catheters; however, she did not recall the date. Interview on 04/01/2026 at 11:40 am, LVN C stated he had been assigned to Resident #2 approximately 3 or 4 times since her admission. He stated no one had reported to him Resident #2 throwing her catheter or anything from her bed. LVN C stated it had been reported to him Resident #2 was not being cooperative during ADL care, especially showers. He stated it was reported to him she would hit staff during showers. LVN C stated all catheters were to be hung on side of bed and below the bladder. He stated the tubing was to be straight and without any kinks. LVN C stated if the catheter was lying flat on the floor and the tubing was twisted there was a possibility the urine could back up into the bladder, and the resident could develop sepsis or an UTI. He stated it was not safe for the resident's catheter to be lying on the floor and tubing to have kinks in it. LVN C stated if any staff observed a catheter on the floor and the person was not a nurse or CNA, it was expected the staff to report it immediately to the nurse supervisor. He stated he had been trained on catheters but did not recall the date. Interview on 04/01/2026 at 12:00 pm, CNA D stated she had given care to Resident #2 twice over the past 2 weeks. CNA D stated she was not aware of Resident #2 throwing things from her bed or throwing anything in her room. She stated she was aware Resident #2 could be uncooperative with staff during showers. CNA D stated she had not observed Resident #2 throwing anything in her room or outside her room. She stated all catheters were to be hanging on the bed and below the bladder. CNA D stated if the catheter was lying flat on the floor and the tubing had a kink in it would not be very good for the resident. She stated the resident could develop a UTI or any type of infection in their bladder. She stated the resident may need to be admitted to the hospital with severe infection. Interview on 04/01/2026 at 1:45 pm Nurse Consultant stated her expectation was for catheters to be hanging below the bladder. She stated no catheter needed to be lying flat on the floor. Nurse Consultant stated if the tubing had a kink there was a possibility a resident may develop catheter associated UTI (an infection involving any part of the urinary system- bladder, urethra, or kidneys- that develops in a patient with an indwelling urinary catheter - a tube in the bladder) or other infection such as sepsis. She stated all catheters tubing was not to have a kink or twisted. She stated catheters was never to be lying on the floor. She stated if catheter was not hanging correctly there was a potential for complication such as: urine not flowing from the bladder. Facility Policy on Indwelling Urinary Catheter, not dated, reflected Keep the catheter and drainage tubing free from kinks to allow the free of flow of urine. Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of catheter UTI. Do no place the drainage bag on the floor, to reduce the risk of contamination and subsequent catheter UTI.

Based on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 (Resident #01) reviewed care plans. The facility failed to update the comprehensive care plan to reflect Resident #01 received IV fluids for dehydration. This failure could have placed residents at risk of not having their needs identified and met.Findings included: Record review of Resident #1's admission Record documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia in other diseases classified elsewhere, severe, without behavioral disturbance (a medical diagnosis indicating severe dementia occurring in a patient whose dementia is caused by an underlying physiological condition), dysphagia pharyngeal stage (difficulty swallowing), and severe protein-calorie malnutrition (A condition where the body does not receive enough nutrients to maintain its normal functions. Record review of Resident #1's care plan dated 12/25/2025, and 01/12/2026 did not indicate the care plan had been updated to reflect the IV fluids. Record review of Resident #1's physician's orders, dated 01/12/2026, indicated an order for Lactated Ringers Intravenous Solution. Record review of Resident #1's MDS dated [DATE] and 01/13/2026 indicates K0520 A, parental/IV fluids were provided during the look-back period. During an interview with the DON on 01/29/2026 at 1:45pm, she stated an IV is a significant change and should be in the care plan. She was unable to tell me how soon it should be placed in the care plan. During an interview with the MDS Coordinator on 01/29/2026 at 2:00pm, she stated the intravenous fluids for dehydration were not in Resident #2's care plan. The MDS Coordinator stated the care plan should have been updated immediately. She stated the MDS does indicate the use of IV fluids. Record review of the facility's undated policy titled Comprehensive Care Plans dated implemented 10/24/2022 documented .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All care Assessment Areas triggered by the MDS will be considered in developing the plan of care.

Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 27 and Resident #30) out of 8 residents reviewed for call lights. The facility failed on 07/29/2025 to ensure Resident # 27 and Resident #30's call light was within reach to use. This failure could affect all residents who needed assistance and could result in needs not being met.Findings included: Review of Resident #27's face sheet, dated 07/30/2025, reflected [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included unspecified dementia, mild, with psychotic disturbance ( memory and thinking problems that are mild and not specifically identified and includes behaviors such as delusions- a false belief of reality), unsteadiness on feet (a lack of stability or coordination while walking or standing), need assistance for personal care ( a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming), and age related physical debility (characterized by decreased in strength, endurance, and balance, often leaing to a higher risk of falls, disability, and hospitalization). Review of Resident #27's Quarterly MDS, dated [DATE], reflected the resident BIMS assessment was completed by staff. Resident #27 had poor short- and long-term memory recall (having difficulty remembering things that have just happened or been learned). She required partial /moderate assistance (helper does less than half the effort) with personal hygiene, dressing, showers, transfers, and toileting. Resident #27 did not reject care. Review of Resident #27's Comprehensive Care Plan, with a completion date 06/29/2025, Resident #25 had an ADL self-care performance deficit. Interventions: Resident required partial/moderate assistance with transfers, dressing, personal hygiene, and picking up objects. Resident #25 was high risk for falls related to impaired cognition with poor safety awareness, inability to bear weight without assistance. Intervention: Ensure Resident #27's call light was within reach and encourage the resident to use the call light for assistance as needed. She required prompt response to all requests for assistance. Resident #27 needed a safe environment with a working and reachable call light. Observation and interview on 07/29/2025 at 7:15 AM, revealed Resident #27 was lying in bed. Her call light was approximately 8 feet from her bed lying on the over the bed rolling table. Resident #27 was unable to reach her call light. She stated yes when asked if she knew how to use a call light. Resident #27 stated leave my room. Interview on 07/29/2025 at 7:18 AM CNA C entered Resident #27's room and stated Resident #27's call light was on the floor and Resident #27 was unable to reach the call light. She stated Resident #27 did use the call light. CNA C stated all residents call light was required to be within reach of all residents when a resident was in their room. She stated if a resident was unable to reach their call light and needed assistance, there was a possibility a resident may need nursing assistance. She stated a resident may attempt to assist self out of bed and fall trying to get assistance. She stated Resident #27 was a fall risk. She stated she had been in-serviced on placing call lights within resident's reach. CNA C stated she did not recall the date of the in-service. She stated if the nursing staff was not near the resident's room, it was a possibility the staff would not hear a resident yell for help. CNA C stated any staff entered a resident room was responsible to ensure the call light was within reach of the resident. Review of Resident #30's face sheet, dated on 07/29/2025, reflected a 88- year-old- female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia ,unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (memory and thinking problems that are mild and not specifically identified without behaviors), unsteadiness on feet (a lack of stability or coordination while walking or standing), and need assistance for personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming). Review of Resident #30's Quarterly MDS Assessment, dated 06/06/2025, reflected Resident #30 had a BIMS score of 1, which indicated her cognition was severely impaired. Resident #30 did not reject care. She required partial/moderate assistance (helper does less than half the effort) with personal hygiene, showers, toileting and lower body dressing. She required supervision/or touching assistance (helper provides verbal cues and/ or touching assistance) with the following: upper body dressing, and oral hygiene. Review of Resident #30's Comprehensive Care Plan, with a completion date 06/28/2025, reflected Resident #30 had an ADL self-care performance deficit. Interventions: Encourage Resident #30 to use call light for assistance. She required assistance with personal hygiene, showers, dressing, and toileting. Resident #30 was a high risk for falls related to generalized weakness and poor safety awareness. Intervention: Resident #30 needs a safe environment including a working and reachable call light. Observation and interview on 07/29/2025 at 7:28 AM, revealed Resident #27 was lying in bed. Her call light was on the floor approximately 6 feet from her bed. Resident #27 was not interviewable. Interview on 07/31/2025 at 9:20 AM CNA D stated all residents call lights were expected to be placed within reach of the resident when a resident was in their room. She stated if a resident was sitting in a wheelchair the call light was expected to be attached to the wheelchair. CNA D stated i a resident was lying in bed the call light was expected to be attached to the pillowcase, the sheet or the bedspread where the resident was able to reach it when they needed assistance from nursing staff. She stated if a call light was on the floor or lying on bedside table and the resident was not able to reach the call light, there was a possibility a resident may fall trying to stand up from wheelchair or from the bed when they needed assistance. She stated it was everyone's responsibility to ensure the residents call light was within reach. CNA D stated if a CNA was in the shower and a nurse was in a resident's room, the nursing staff may not be able to hear a resident yell for help. Interview on 07/31/2025 at 10:20 AM ADON stated if a resident was in their room lying in bed or sitting in a wheelchair, the call light was expected to be within reach of the resident. She stated if a resident was unable to reach their call light there was a potential a resident may fall from the bed or wheelchair if the call light was not within reach and the resident needed assistance. The ADON stated any staff who entered a resident's room was expected to check the call lights of the residents and if the call light was not in reach, any staff could place the call light within reach of the resident's wheelchair or bed. She stated in-service had been given to staff on placing call lights within reach of residents when they are in their room. The ADON stated she did not recall the date of the in-service. Review of the facility's Policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022 reflected, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. Staff will ensure the call light is within reach of resident and secured, as needed. 2. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.3. Special accommodations will be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.)4. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 30 and Resident # 65) reviewed for ADL care. The facility failed on 07/29/2025to ensure Resident #30, and Resident #65's fingernails were cleaned. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Review of Resident #30's face sheet, dated on 07/29/2025, reflected a 88- year-old- female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety (memory and thinking problems that are mild and not specifically identified without behaviors), lack of coordination (the inability to smoothly and precisely control movements), and need assistance for personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming). Review of Resident #30's Quarterly MDS Assessment, dated 06/06/2025, reflected Resident #30 had a BIMS score of 1, which indicated her cognition was severely impaired. Resident #30 did not reject care. She required partial/moderate assistance (helper does less than half the effort) with personal hygiene, showers, toileting and lower body dressing. She required supervision/or touching assistance (helper provides verbal cues and/ or touching assistance) with the following: upper body dressing, and oral hygiene. Review of Resident #30's Comprehensive Care Plan, with a completion date 06/28/2025, reflected Resident #30 had an ADL self-care performance deficit. Interventions: required assistance with personal hygiene, showers, dressing, transfers and toileting. Observation and interview on 07/29/2025 at 7:28 AM, revealed Resident #30 was in her lying in bed. She had a blackish/ brownish substance underneath the middle and ring fingernails on her right hand. Resident #30 was not interview able. Record review of Resident # 65's face sheet dated 07/31/2025 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included unspecified dementia with mood disturbance (memory and thinking problems that are mild and not specifically identified and includes behaviors), need for assistance with personal care (a person needs assistance with daily living activities such as: bathing, dressing, toileting, and grooming), and muscle weakness (a reduced ability to generate force in one or more muscles, impacting physical performance and daily activities). Record review of Resident #65's Quarterly MDS Assessment, dated 06/28/2025, reflected Resident #65 reflected the resident BIMS assessment was completed by staff. Resident #65 had poor short- and long-term memory recall (having difficulty remembering things that have just happened or been learned). Resident #65 required substantial/maximal assistance (helper does more than half the effort) with the following: personal hygiene, dressing, showers, toileting, oral hygiene, and transfers. Record review of Resident #65's Comprehensive Care Plan, with completion date of 07/02/2025, reflected Resident #65 had an ADL self-care performance deficit related to weakness. Intervention: Resident #65 required substantial/maximal assistance with personal hygiene, dressing, transfers showers, toileting and oral hygiene. Observation and interview on 07/29/2025 at 7:40 AM, revealed Resident #65 was in her room lying in bed. She had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #65 was not interview able. In an interview on 07/29/2025 at 7:18 AM, CNA C stated the CNAs (Certified Nurse Assistant) were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes (a disease occurs when blood sugar is too high). She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA C stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. CNA C stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 30 and Resident #65, and they did not refuse nail care. In an interview on 07/31/2025 at 9:45 AM, LVN E stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. CNA C stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. She stated she was in- serviced on nail care, however, she did not recall the date. She stated she would need to ask staff questions for the reason nail care was not completed on Resident #30 and Resident #65. In an interview on 07/31/2025 at 9:20 AM, CNA D stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA D stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA D stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 30 and Resident #65, and they did not refuse nail care. CNA D stated she did not know the last time these residents' nails were trimmed or cleaned she would need to check the medical records. In an interview on 07/31/25 at 10:20 AM, ADON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The ADON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON was responsible for monitoring the nurse supervisors. Review of the facility's Policy on Activities of Daily Living (ADLs), dated 05/26/2023, reflected The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for two of six residents (Resident #10 and Resident #93) reviewed for infection control practices. The facility failed to ensure: MA B followed good nursing practices when preparing medications to prevent cross contamination of oral medications for Resident #93 on 07/30/2025 when MA B failed to perform hand hygiene and don gloves prior to touching Resident #93's medications with contaminated, ungloved hands. RN A used sanitary supplies during medication administration via g-tube (a tube inserted into the stomach) for Resident #10 when on 07/30/2025 RN A did not sanitize a tray table prior to use supplies and medications on while administering medications to Resident #10 via gastrostomy tube. This failure could place the resident at risk for cross contamination and infection. Findings included: 1. Review of Face sheet for Resident #93 reflected a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (dementia that damages the brain), Congestive Heart Failure (heart disease that affects pumping action of the heart muscles), Legal Blindness (visual impairment limiting everyday tasks), and Gastro-esophageal reflux disease (acid from the stomach frequently backs up into the esophagus). Review of Annual Assessment MDS for Resident #93 dated 06/26/2025 reflected a BIMS score of 5 (severe cognitive impairment). Section B- Hearing, Speech, and Vision section indicated she was able to understand others and is able to make her ideas and wants known to others. Review of Care Plan for Resident #93 reflected a Problem section stating, [Resident #93] has impaired cognitive function or impaired thought processes r/t Alzheimer's. Date Initiated: 04/10/2018, with related Interventions stating, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 04/10/2018 and [Resident #93] needs supervision with all decision making. Date Initiated: 09/07/2020. Review of Physician Orders for Resident #93 reflected an order for, Regular diet, Regular texture, Regular Liquids consistency started on 03/05/2019. Observation of Medication administration for Resident #93 on 07/30/2025 at 7:54AM revealed that MA B performed hand hygiene prior to dispensing medications. She then touched the medication carts, medication cards, and computer keyboard prior to using ungloved hands to remove two pills from the medication cup for Resident #93. In an interview with MA B on 07/30/2025 at 8:00AM, she stated that she should have cleaned her hands and put on gloves before taking the pills out of the cup. She stated that the potential risk to the resident was that they, could get sick. 2. Review of Face sheet for Resident #10 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Aphasia (difficulty using or comprehending language), Dysphagia (difficulty swallowing), and Gastrostomy status (gastrostomy tube in place, a tube inserted into the stomach). Review of Quarterly Assessment MDS for Resident #10 dated 05/05/2025 reflected a BIMS score of 12 (moderate cognitive impairment). Section B-Hearing, Speech, and Vision indicated that Resident #10 is usually able to understand others and usually able to make his ideas and wants known to others. Review of Care Plan for Resident #10 reflected a Problem area stating [Resident #10] has the need for Enhanced Barrier Precautions due to a feeding tube Is at risk for infection, depression, feelings of isolation, and decline in physical activity Date Initiated: 05/10/2024 and a related Intervention stating, Administer medication as ordered. Date Initiated: 05/10/2024. Review of Physician Orders for Resident #10 reflected and order for, NPO (nil per os-nothing by mouth) diet, NPO texture, Nectar Thickened Liquids consistency with a start date of 07/04/2025 and medication orders are all noted to be administered via G-Tube or PEG-Tube (percutaneous gastrostomy tube-a type of gastrostomy tube that is inserted into the stomach). Observation of medication administration for Resident #10 on 07/30/2025 at 10:49AM with RN A revealed that she asked another staff member to bring her a tray table from the resident room directly across the hall from Resident #10. She then used the tray table from the other room to set all of her supplies and medications on while administering medications to Resident #10 via gastrostomy tube. In an interview with RN A on 07/30/2025 at 12:11PM, who stated that she should have cleaned the tray table before she used it for Resident #10. She stated that the risk of sharing un-sanitized equipment between residents is the potential for infection. In an interview on 07/31/25 at 1:00PM, the ADMIN who stated that she expected staff to follow the infection control practices for the facility. She stated she would not expect staff to touch medications with their bare hands. She stated that she expected staff to disinfect items that are used between residents. She stated that the risk to the residents of not following the infection control guidelines is the possibility of infection. In an interview on 07/31/25 at 1:02PM, the DON stated that staff are not supposed to touch pills with their bare hands. She stated that she expected staff to wash their hands prior to preparing the medications also. She stated that they should also observe any special instructions with medications regarding need for PPE (Personal Protective Equipment). She stated that any equipment used between residents should be sanitized between use. She stated the risk to the residents of not following the facility infection control guidelines is the possibility of infection. Review of facility policy for Infection and Prevention and Control Program dated 5/13/23 reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.e. Environmental cleaning and disinfection shall be performed according to facility policy. Review of facility policy for Medication Administration dated 10/01/19 reflected: Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to do so. B. Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. Examination gloves are worn when necessary.

Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors. The facility failed to ensure Resident #1's glucose was monitored, and insulin was administered regularly from 07/21/24 - 08/02/24. She was sent to theER on [DATE] with a glucose level of 649 and a diagnosis of DKA. The noncompliance was identified as PNC. The IJ began on 08/02/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end-stage renal disease , dependence on renal dialysis, type I diabetes, long-term (current) use of insulin, and history of DKA (a serious complication of diabetes that happens when the body does not have enough insulin, causing the body to break down fat for energy). Review of Resident #1's admission MDS assessment, dated 07/22/24, reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section N (Medications) reflected she received insulin injections. Section O (Special Treatments, Procedures, and Programs) reflected she required dialysis. Review of Resident #1's admission care plan, dated 07/17/24, reflected she had chronic renal failure related to end-stage renal disease with an intervention of monitoring vital signs as ordered or as needed and monitoring for changes in mental status. Review of Resident #1's physician order, dated 07/17/24, reflected Insulin Glargine Subcutaneous Solution Pen-Injector - 100 unit/ML - Inject 8 unit subcutaneously one time a day (9:00 AM) for diabetes. Review of Resident #1's MAR, July 2024, reflected she was not administered the Insulin Glargine Solution on 07/25/24, 07/29/24, and 07/30/24. Review of Resident #1's MAR, August 2024, reflected she was not administered the Insulin Glargine Solution on 08/02/24. Review of Resident #1's physician order, dated 07/21/24, reflected Insulin Lispro Injection Solution - Inject as per sliding scale: If 71 - 149 = 0 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; Greater than 399 = 12 units and notify Provider Three times a day for Diabetes before meals Review of Resident #1's MAR, July 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection on 07/25/24 (11:00 AM and 4:00 PM), 07/26/254 (4:00 PM), 07/29/24 (7:00 AM and 4:00 PM), and 07/30/24 (11:00 AM and 4:00 PM). Review of Resident #1's MAR, August 2024, reflected her BS was not checked and she was not administered the Insulin Lispro Injection 08/02/24 (7:00 AM). Review of Resident #1's Change of Condition Communication form, dated 08/02/24, reflected the following: Signs/Symptoms: high blood sugar greater than 300, low blood pressure, change in mental status .increased confusion . slurred speech . decreased appetite. Review of Resident #1's progress notes, dated 08/02/24 at 1:15 PM and documented by LVN B, reflected the following: At 11:45 (AM) [Resident #1]'s [FM D] called inquiring about [Resident #1]. Stated her blood sugars were elevated, didn't feel good and was not going to dialysis. Shortly after the phone call, [LVN A] came and informed me that [Resident #1]'s BS was high . I notified the NP which was present in the facility. 12:10 PM - NP gave an order to administer 12 units of insulin, hydrate with water, and to recheck in 30 minutes. 12:35 PM - BS rechecked - still elevated - NP provided another order of 12 units per sliding scale to be administered. [Resident #1] had been exhibiting changes in mental status. 12:40 PM - NP assessed [Resident #1] and decided to send her to the hospital for evaluation and management. 1:15 PM - [Resident #1] loaded on stretcher and left facility by Ambulance to (hospital). Review of Resident #1's progress notes, dated 08/02/24 at 11:44 PM and documented by LVN B, reflected the following: Around 12:00 (PM), [LVN A], LVN charge nurse came and informed me that [Resident #1]'s BS was reading High (glucometer unable to read) VS 102/42, 90, 99.1. [Resident #1] in bed with [FM D] at bedside - had been exhibiting changes in mental status. [LVN A] rechecking her blood sugars while I went and notified the NP. Review of Resident #1's NP assessment, dated 08/02/24, reflected the following: [Resident #1] is seen today to follow up accucheck reading of high and refusing dialysis d/t not feeling well. This was reported to this provider and orders were given to [LVN A] to admin 12 units of SSI now, vital signs, encourage water, recheck blood sugar in apx 30 mins, monitor closely and report changes/concerns. I am here now to follow up with [Resident #1] after interventions administered above, nurse rechecked accucheck s/p insulin, result reads high, therefore new orders given to nurse to administer 12 additional units of SSI. On exam, [Resident #1] appears more confused than baselined, oriented to self, unable to follow commands, notable leg jerking, she endorses headache and dizziness. D/t hx of diabetes with DKA and ESRD , recommend transfer to ED to eval and treat. Review of Resident #1's hospital medical records, dated 08/02/24, reflected the following: .BIBEMS after reportedly altered at nursing home earlier this afternoon. Nursing home reports that [Resident #1] is usually AOx4, but found confused and altered, only oriented to self. .[Resident #1] with recent admission on 7/15/24, briefly: . [Resident #1] was altered/not oriented on arrival, found to be in DKA and admitted to (hospital) .admitted w/DKA w/significant acidosis. Reported missed insulin dose while at SNF, which was likely precipitation factor for DKA.Found altered in nursing home by staff; given 24 lispro in nursing home, 500 mL in EMS and 1 L LR in ED. BG 574 -> 649 . Started on DKA protocol . During an interview on 08/20/24 at 10:34 AM, the ADM stated it was the DON's responsibility to ensure the MARs were completed and medication doses were not being missed. He stated she had been working closely with LVN E because she was new to long-term care. He stated once he was made aware of the medication discrepancies and lack of oversight by the DON, both LVN A and the DON were terminated. During an interview on 08/20/24 at 11:24 AM, LVN B stated Resident #1's FM D had called the nurses station on 08/02/24 around 12:00 PM. She stated FM D was upset because Resident #1 did not feel well and did not want to go to dialysis. She stated she located LVN A who told her the glucometer was reading high when she tested Resident #1's blood sugar. She stated the glucometer stops reading blood sugar levels when they are above 500. She stated she asked LVN A what her levels were that morning and LVN A stated, I did not do them. She stated she asked her why she had not checked her blood sugar, but LVN A had no answer for her. She stated missing doses of insulin repeatedly could lead to DKA. She stated it was hard to say if the missing dose of insulin on 08/02/24 was what caused Resident #1 to go into DKA, but she did have a history of it, so it was likely. She stated the importance of checking blood sugar levels and not missing insulin doses was to avoid situations like that one. She stated it was important when someone's body was not producing insulin that insulin gets administered. She stated the nurses were recently in-serviced on glucometer checks and administering insulin. During an interview on 08/20/24 at 11:55 AM, LVN C stated she worked with Resident #1 and had heard about her requiring hospitalization for DKA. She stated Resident #1 was a type I diabetic which made it more imperative that her blood sugar levels were checked regularly, and no doses of her insulin were missed. She stated with type I diabetics, they were unable to produce insulin, so no matter what they ate, the sugar levels would always spike high. She stated it was a life-or-death situation and missed doses could lead to coma, DKA, or death, especially for someone like Resident #1 who had a history of DKA. She stated the nurses had recently been in-serviced on accuchecks and insulin administration. During an interview on 08/20/24 at 1:14 PM, the NP stated when the nursing staff alerted her on 08/02/24 that Resident #1's blood sugar was reading high, she ordered 12 units of insulin, asked them to push fluids, and to re-check her levels in an hour. She stated when it was still high, she gave orders for more insulin. She stated that along with Resident #1's comorbidities and her being altered for her baseline, she made the decision to send her to the hospital at that time. She stated that there were multiple risk factors for DKA and did not believe missing the insulin doses was what caused her to go into DKA. During an interview on 08/20/24 at 1:37 PM, the MD stated if a resident was missing multiple doses of insulin, it would concern him as it could cause blood sugar to be unstable. He stated Resident #1's blood sugar was controlled until that day (08/02/24), so he would not say the missed dose that morning was what had caused DKA. He stated individuals with type I diabetes go into DKA a lot. During an interview on 08/20/24 at 4:15 PM, LVN E stated the nursing staff had recently been provided in-serviced on accuchecks, insulin, following physician orders, and administering medications timely. She stated they also did check-offs with the DON. She stated it was important for insulin to get administered as ordered because it could lead to coma or death. During an inteview on 08/20/24 at 4:33 PM, the Interim DON stated she reviewed a report of missed medications the prior day that was generated by their EMR system every morning to investigate the reasoning for the missed doses. On 08/20/24, several attempts were made to contact LVN A. A returned call was not received prior to exiting . Review of the facility's QAPI Meeting Agenda, dated 08/02/24, reflected the ADM, the DON, the MD, the ADON, and the RNRCS were in attendance to discuss diabetics, accuchecks, physician orders, changes in condition, and medication administration. Review of the DON an LVN A's termination documents, dated 08/04/24, reflected both were terminated. Review of a statement, dated 08/02/24 and documented by the ADM, reflected the following: [Pharmacist] consultant was notified via phone by the Administrator regarding the medication error that occurred on 08/02/24. Administrator request a pharmacist visit to review all resident in facility with orders for accuchecks and or insulin orders/antidiabetic medications. Visit was scheduled for 08/09/24. Review of an audit conducted by the Pharmacist, dated 08/09/24, reflected no recommendations were made. Review of an audit conducted by the DON/clinical team, dated 08/02/24, reflected no residents with orders for accuchecks and insulin had been affected and had been receiving treatments according to physician orders. Review of in-services entitled AccuChecks/Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration: Importance of Timely Accuchecks and Medication Administration - Resident Safety: Consistent and timely blood glucose checks and medication administration are vital to managing chronic conditions like diabetes, preventing adverse events such as hypo- or hyperglycemia. - Compliance with Physician Orders: Adherence to prescribed schedules ensures that residents receive their treatments as intended by their healthcare providers. - Legal and Regulatory Compliance: Accurate and timely documentation is necessary to meeting regulatory requires and avoid potential legal liabilities. Review of in-services entitled Accu Checks/Medication Administration, from 08/02/24 - 08/03/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on timely accuchecks and medication administration. Review of in-services entitled Medication Administration, from 08/02/24 - 08/06/24 and conducted by the DON and the ADON, reflected all nurses were in-serviced on their Medication Administration Policy. Review of the facility's Medication Administration Policy, dated 10/01/19, reflected the following: Medications are administered as prescribed in accordance with good nursing principles and practices only by persons legally authorized to do so. Review of Medication Pass and Obtaining Blood Sugar Readings checkoffs, dated 08/02/24 - 08/07/24, reflected all nurses and medication aides completed competency checkoffs with no concerns. The noncompliance was identified as PNC. The IJ began on 08/02/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began.

Based on interview, observation, and record review the facility failed to ensure that the residents environment remained as free of accident hazards as was possible for one (Resident #45) of thirty-three residents reviewed for hazards. The facility failed to ensure that Resident #45 was assisted by two care providers during peri-care resulting in her rolling out of the bed onto the floor and sustaining facial lacerations. This failure could place residents at risk of accidents and injury. Findings Include: Review of Resident #45's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Cerebral Infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it resulting in lack of oxygen and vital nutrients which CAN cause parts of the brain to die off), Parkinson (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), and Morbid (Severe) Obesity (complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions). Review of Resident #45's MDS Admission Assessment, dated 05/09/2024 revealed Resident #45 had a BIMS Score of 15, which indicates cognition is intact. Resident #45's MDS revealed in Section GG - Functional Abilities and Goals - Admission A. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed indicated 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity , or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident #45's Comprehensive Care Plan revealed a problem area [Resident #45] has an ADL self-care performance deficit r/t muscle weakness, contracture, pain and decreased mobility Date Initiated: 05/02/2024 with an intervention for BED MOBILITY: [Resident #45 requires total assist by 2 staff to turn and reposition in bed as necessary. Date Initiated: 05/13/2024. Review of Occupational Therapy OT evaluation & Plan of Treatment, start of care date 05/03/2024 revealed, Resident #45 Assessment Summary: Clinical impressions: Resident #45 presents with multiple impairments that have contributed to decline in independence with functional ADLs and safety that will be addressed by skilled OT services in order to facilitate pt return to PLOF. Impairments include: decreased strength and flexibility, impaired coordination, activity tolerance, balance reactions, and decreased Independence with ADLs. Review of Transfer Related Incident Report, prepared by RN A, dated 05/10/2024 at 12:00 PM. Resident #45 was found after fall lying on the floor parallel to her bed, lying face down, hollering and crying. Description: Complete head to toe skin assessment. NVS initiated. Wound care provided. PRN pain medication administered. Physician notified. Orders to send to ER for evaluation and treatment if indicated. Resident taken to Hospital? Y. Witnesses: CNA H, Relation: Staff, Date 5/10/2024, Statement: I was changing resident, resident was capable of talking to this CNA, helping this CNA and acknowledged that she knew what she need to do during peri care. This CNA asked resident, CAN you please turn your body to the right? resident said, Yes, I will help as much as I can. Then this CNA said, CAN you allow yourself to go to the side of the bed to hold on the edge of the bed? and resident said, Yes. As she held on to the edge of the bed, she proceeded to put more force with her own body, and that allowed her to tip more weight to her right side, allowing her to go from the bed to the floor. Resident was on floor parallel to her bed, face down, and then nurse was notified to come to resident's room. Notes: 5/10/2024 Resident sent to hospital for x-rays returned with no acute injuries, education provided to staff that she is a 2 person assist with all aspects of care. Review of [Medical Facility Emergency Department Record dated 5/10/24 revealed, Patient Complaint: Facial Lacerations, Triage Assessment: Facial Lacerations. Review of [Medical Facility] Emergency Physician Record dated 5/10/2024 revealed, Adult Injury lac to nose. Review of facility's progress notes in their electronic records system for Resident #45 revealed the following: 5/10/2024 19:30 (7:30 PM) NURSING - Nurse Note Late Entry (unidentified staff): Note Text: resident brought to room per wheelchair per two staff members. Transferred to bed. was awake and able to make needs known. v/s 96.4 t, 20r, 96o2 at room air, 70 hr., 138/74. Status post injury to face and bruising to left hand. Stated some pain to face. Call light within reach, bed on low. 5/11/2024 17:03 (5:03 PM) NURSING - Nurse Note Text (unidentified staff): S/P witnessed fall day 1, resident with small steri-strips to nose and small band aid to upper lip CDI, mentation at baseline, up per normal routine, currently sitting in wheelchair in main dining room for dinner, resident taking Ibuprofen prn for pain and is effective. 5/11/2024 20:32 (8:32 PM) NURSING Nurse Note Text (unidentified staff): 2nd day status post fall. resident lying in bed and awake. able to answer questions appropriately at this time. v/s: 96.2 forehead, 18r, 93O2 sat on RA, 67 hr., 116/64. face continues with steri-strips to bridge of nose and band aid to upper lip. is able to make needs known. call light within reach, bed on low. 5/13/2024 19:51 (7:51 PM) NURSING - Nurse Note Text (unidentified staff): resident had a fall out of bed on 05/10/24 which she ended up in the ER for evaluation for trauma to face. resident does c/o pain to face. resident requested ibuprofen 400mg, which was effective. she is a 2-person assist with transfers and changes. Observation and interview on 06/05/2024 at 8:09 AM, Resident #45 was observed lying in her bed and had some discoloration under both of her eyes, which appeared to be diminishing. Resident #45 stated that approximately one month ago she requested that an add assist her with peri-care. Resident #45 stated a CNA assisted her and as she started to roll her to her side she was not able to stop her momentum and rolled off the bed onto the floor. Resident #45 stated when she fell it caused bruising to her face. Resident #45 stated the CNA was provided the care by herself and that her rolling off the bed was an accident. Resident #45 was observed to be heavy set and did not appear to have much core strength or the ability to assist with her care. Interview on 06/05/2024 at 3:19 PM, RN A stated she was at work on 5/10/24, when Resident #45 fell from her bed. RN A stated she was at the nurse's station when CNA G came and told her that Resident #45 had fallen. RN A stated that when she entered the room of Resident #45 she observed CNA G and CNA H present and believed the bed was in the low position. RN A stated she observed Resident #45 on the floor between her bed and the wall and observed she was bleeding and possibly injured in the area of her nose and eyes. RN A stated she did a full assessment of Resident #45, who stated she was alright. RN A stated she then used the mechanical lift with the assistance of the CNAs to place Resident #45 back in her bed. RN A stated she notified the DON, Administrator, RP, and both ADONs were present. RN A stated after assessment and contact with NP, Resident #45 was sent to the emergency room due to contact with her head and face to ensure no head trauma or fractures. RN A stated she spoke with and obtained a statement from CNA H, who told her Resident #45 asked to help her clean up (peri-care). RN A stated CNA H told her she was rolling Resident #45 to her side by herself, and she just continued to roll over and out of the bed. RN A stated she would assume Resident #45 was a 2 person assist for bed mobility / peri-care due to her weight. RN A stated in her opinion if peri-care was being performed on Resident #45 she should have been assisted by 2 CNAs. Interview on 06/05/2024 at 3:30 PM, CNA H was contacted by phone and stated that she was at work. CNA H stated she could not speak due to being in the presence of patients and would call back at approximately 5:30 PM when she left work. Interview on 06/05/2024 at 3:44 PM, CNA G stated he was at work on 05/10/2024 and was in the area of Resident #54 when he heard what he described as desperate screaming. CNA G stated he entered the room of Resident #45 and saw CNA H standing by the bed with a look of shock on her face. CNA G stated he saw Resident #45 on the floor on the other side of her bed and observed that she was bleeding. CNA G stated he asked CNA H what happened, and she did not respond. CNA G stated he went quickly and got RN A to come to the room. CNA G stated he moved Resident #45's bed out of the way and stated he believed it was in the mid position, which would be standard for peri-care. CNA G stated RN A assessed Resident #45 and then they placed her back in the bed using a mechanical lift to do so. CNA G stated he heard RN A ask CNA H what happened, and she told her she was trying to change Resident #45 and she rolled out of the bed. CNA G stated he worked 7 AM to 1 PM on the day of the fall and left shortly after but did see EMS arrive and knew the AIT was on location. CNA G stated when he returned to work after the fall that Resident #45 was back in the facility. CNA G stated he and all staff were trained and instructed that Resident #45 was to be a 2 person assist for all care and transfers. CNA G stated he had never attempted peri-care on Resident #45 by himself prior to or after the fall and did not know of anyone other than CNA H during this incident who had. CNA G stated common sense should have been enough for CNA H to know that she should not have attempted peri-care on Resident #45 by herself. CNA G stated he does not believe CNA H wanted this to occur and is a very caring person. CNA G stated he knew after the incident that CNA H was removed from the hallway and did not provide further care for Resident #45. Interview on 06/05/2024 at 4:09 PM, ADON B stated she was in the facility on 05/10/2024, when Resident #45 fell out of the bed. ADON B stated she was notified of Resident #45's fall from the bed and went to the room. ADON B stated CNA H stated she was providing peri-care for Resident #45 and when she rolled her on her side she continued to roll and fell off the bed. ADON B stated it was not appropriate for CNA H to have been performing peri-car on Resident #45 without assistance. ADON B stated Resident #45 had blood coming from her mouth and nose and was transported by EMS. ADON B stated after Resident #45's fall they trained all staff on 2-person transfers / assist and ensured that staff knew that Resident #45 was a 2-person assist. Interview on 06/05/2024 at 4:33 PM, the DON stated she was not in the facility on 05/10/2024 but was notified by the Administrator of Resident #45's fall. The DON stated after the incident all staff were in-serviced that Resident #45 was a 2-person assist with all care. The DON stated she went and spoke to Resident #45 after the fall, and she stated she felt safe in the facility. The DON stated she knew Resident #45 was a 2-person assist after this incident but was unsure if that was the case prior due to her limited time in the facility before the fall. At 4:49 PM, the DON stated she checked the records and that Resident #45 was in fact a two person transfer at the time of the fall and that CNA H should not have been provided peri-care on Resident #45 by herself. Interview attempted on 06/05/2024 at 7:04 PM with CNA H, who had not called as she stated she would. CNA H did not answer, and the call was sent to voicemail. Follow-up interview on 06/06/2024 at 8:03 AM, CNA G stated they are trained to review the kardex before providing care to ensure patients' needs are bed and proper assistance is provided. CNA G stated if they ever go to another hallway to assist they CNA look at the kardex but are also informed verbally of assist requirements by the CNAs regularly assigned to the hall. CNA G stated during the in-service they were instructed that Resident #45 was to be a 2-person full assist and that they received specialized training to include interactive participation and demonstration. CNA G stated during the in-service training they were also instructed on proper brief size for residents during peri-care. CNA G stated since Resident #45's fall and the staff in-service that he has never seen or heard of anyone attempting care on Resident #45 by themselves and does not believe Resident #45 would allow them to do so if they did try. Interview on 06/06/2024 at 8:15 AM, the Administrator stated Resident #45 was sent to the emergency roiagnom on the day of the fall for a CT-Scan to rule out any bleeds / fractures, or any other injuries received during the fall. The Administrator stated no treatments were required and that the fall resulted in bruising to the area of both eyes and her nose. The Administrator stated he was working to obtain her medical records to provide as confirmation of no further injuries. Interview on 06/06/2024 at 8:50 AM, the AIT stated he was in the facility on 05/10/2024 when Resident #45 fell from her bed. The AIT stated he spoke by phone with the Administrator and notified him of Resident #45's fall. The AIT stated he met with Resident #45 after the fall, and she stated she felt safe in the facility. The AIT stated he never spoke directly with CNA H about the incident. The AIT stated he could not state whether it was appropriate for CNA H to have performed 1-person peri-care due to his current limited role as a trainee in the facility and the matter being handled by the Administrator. Interview on 06/06/2024 at 9:20 AM, the Therapy Director stated Resident #45 would obviously need 2-person assistance because she requires mechanical lift. Therapy Director stated due to Resident #45's size and lack of truck control there should not be less than two assisting her with bed mobility / peri-care. Therapy Director stated in his professional opinion CNA H should not have attempted peri-care on Resident #45 by herself. Interview on 06/06/2024 at 9:40 AM, the ADON stated she was in the facility on 05/10/2024 when Resident #45 fell . The ADON stated she went to Resident #45's room after notification and observed that Resident #45 was back in her bed. The ADON stated she observed blood on the floor by Resident #45's bed and observed she was bleeding from her nose and mouth. The ADON stated she told RN A to contact the Administrator and physician. The ADON stated Resident #45 need to be sent to the emergency room for a CT-Scan due to contact with her head and to ensure she had no other injuries. The ADON stated CNA H should not have performed peri-care on Resident #45 by herself. The ADON stated after the fall they immediately put interventions in place to prevent further occurrences. The ADON stated all staff were in-serviced that Resident #45 was a 2-person total care. The ADON stated Resident #45 was changed to a bariatric bed, which was wider to minimize risk of recurrence. The ADON stated when she spoke with Resident #45 after the fall that she told her that it was an accident. The ADON described CNA H as approximately five foot seven and one hundred and sixty pounds. The ADON stated CNA H walked out during a shift approximately two weeks after this incident and was no longer in the facility. Interview on 06/06/2024 at 9:56 AM, CNA I stated she was new to the facility and was currently on her second day of training in the 300 hallway. CNA I stated the facility trained their CNA staff by each individual hallway before being assigned to ensure they know the residents and their needs. CNA I stated she has been trained to review the kardex to ensure proper care and assistance is provided to residents. CNA I stated assistance for peri-care was provided under the continence tab. CNA I stated in addition to the electronic files she was walked down the 300 hallway by staff on the first day and verbally advised of each residents level of assistance with bed mobility and transfer. CNA I stated she has been trained and believed that even if a resident was indicated for 1-person assist that she would only provide the care by herself if she was sure that she could safety and correctly do so. CNA I stated they have to consider everything from how heavy the resident was, to their fragility. CNA I stated failure to ensure adequate assistance with task for residents could result in injury. Follow-up interview on 06/06/2024 at 3:00 PM, Resident #45 was seated in her wheelchair in the lobby. Resident #45 stated she had always had care provided by at least two staff members prior to his incident. Resident #45 stated since her fall she has never had care provided by less than two staff members. Resident #45 stated the injury to her mouth must have occurred when she accidentally bit herself during the fall. Resident #45 stated she did not believe this was an intentional act and stated she loves it at this facility and does not believe anything like this would ever happen again. Interview on 06/06/2024 at 3:08 PM, the Administrator stated he investigated the fall during peri-care involving Resident #45 and CNA H. The Administrator stated staff were in-serviced on transfers and ensured that all knew Resident #45 was a 2-person assist. The Administrator stated he interviewed Resident #45 after the fall and she indicated to him that this was an accident that took place during care. The Administrator stated Resident #45 was upset because she did not like that CNA H did not stop her from falling and then did not immediately react after her fall. The Administrator stated he interviewed Resident #45 a second time and she again indicated that this incident was an accident that occurred during her peri-care. The Administrator stated during peri-care / transfers that it is his expectation that, a resident is never put in a situation that could cause harm. Review of Imaging Services Report from [Medical Facility] with an indicated film date of 5/10/2024 revealed, Impression: No acute infarction, hemorrhage, or mass effect. Review of personal / training file for CNA H revealed, Restorative Nursing Assistant Competencies Checklist, Areas of Skill 3. Bowel & Bladder 11/06/2023 Pass, 6. Bed Mobility 11/06/2023 Pass. Candidate Clinical Card for CNA H indicated initials by Pericare F and Pos on side. Review of Form 5497 Texas Nurse Aide Performance Record revealed Section VII, Personal Care Perineal Care / Incontinent Care - Female (With or Without Catheter), Classroom / Online 10/23/23, Skill Lab 11/28/2023, Clinical 11/20/2023. Certificate of Completion from [Nursing Facility] to CNA H in recognition of completion of the requirements for [Nursing Facility] Nurse Aide Training Program #TX44989 completed on 12/06/2023. The facility did provide documentation of all mandatory background checks within the past calendar year. Review of undated [Nursing Facility] In-Service Training Report for All Staff, Topic [Resident #45], Summary of Training Session: Resident is a 2 person care at all times with all aspects of care. Review of the facility's Activities of Daily Living (ADLs) policy dated 05/26/2023 revealed, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 2. Transfer and ambulation; Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to date a box of bananas in the dry storage area which contained a banana that was open and rotted. The facility failed to ensure that no food products or food product boxes were stored on the floor in the facility's walk-in refrigerator and freezer. The facility failed to ensure that a food product in the freezer was in a sealed bag to prevent direct exposure to air. The facility failed to discard of food products that were past indicated use by dates per facility policy. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness. Findings included: Observation on [DATE] at 6:25 AM, of the facility's walk-in refrigerator revealed the following: *a bag of lettuce on the floor, *1 metal tray covered in plastic wrap that was labeled, Cake [DATE] to [DATE], *1 covered metal container marked ground beef [DATE] 10:00 AM use by [DATE], *1 sealable plastic bag with hot dog [NAME] in it that only had a date of [DATE], and *one 16-ounce container of strawberries on the shelf of which one strawberry had visible signs of mold growth on it. Observation on [DATE] at 6:33 AM, of the facility's walk-in freezer revealed the following: *two boxes of mild Italian pork sausage on the floor, with boxes stacked on top of them. * an open box of biscuit dough on a shelf that had an open bag allowing direct air exposure in the freezer to the product. Observation on [DATE] at 6:38 AM, of the facility dry storage area revealed an undated open box of bananas, one of which was busted open and rotten. Interview and observation on [DATE] at 10:45 AM, the FSS stated that all items placed in the refrigerator should have the date they are placed in it and then a use by date of no more than four days. The FSS stated in the dry storage area she expected items to be labeled, clearly identified, and date with the received-on date. The FSS stated failure to date food products could result in a lack of knowledge for how long the product has been in the kitchen. The FSS stated no food products or boxes should be stored at any time on the floor of the dry storage area, or the walk-in refrigerator / freezer. The FSS stated storage of food products on the floor could result in possible contamination. The FSS conducted a walk through and stated she discarded the bag of lettuce that was on the floor in the refrigerator due to possible contamination. The FSS stated the boxes found in the freeze should not have been on the floor and were placed more than six inches off the floor. The FSS had discarded all the food product was past the use by date in the refrigerator except for the plastic bag of hot dog [NAME]. The FSS stated they should not have been on the shelf and added there should have been a use by date recorded on the bag. The FSS stated failure to removed expired / out of date food products could result in food borne illness. Interview on [DATE] at 11:03 AM, DA stated all food products should be dated as soon as they are received. DA stated once opened and placed in the refrigerator they are supposed to record the date opened and then a use by date for three days later when placed in the refrigerator. DA stated failure to label and date items could result in expired food being served leading to possible foodborne illnesses. DA stated no food products should be stored on the floor anywhere in the kitchen to prevent contamination. DA stated items that are placed in the freezer are to be in sealed bags our bags that are tied closed to prevent air exposure. DA stated exposed food products in the freeze could lead to freeze burn resulting in poor taste and loss of nutritional value. Follow-up interview on [DATE] at 11:08 AM, the FSS stated service of expired food products could lead to contamination and sickness for residents. The FSS stated food exposed in the freezer could result in freezer burn affecting the quality of the food and taste. The FSS stated all staff should be checking for quality and expiration dates but ultimately the responsibility falls on her to ensure that nothing is out of stated or stored improperly. Interview on [DATE] at 11:12 AM, the Administrator stated his expectation was for all food products to be labeled, dated, and removed from the refrigerator within seventy-two hours if not used. The Administrator stated no food products should be stored on the floor and should always be at least six inches off the ground. The Administrator stated failure to follow these guidelines could lead to bacteria and contamination. Review of the facility's Food Storage Policy dated [DATE] reflected, Policy: The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Guidelines: 1. Dry Storage rooms d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. f. Where possible, items are left in the original cartons placed with the date visible. 2. Refrigerators a. All refrigerated foods are stored per state and federal guidelines. b. Fresh meat, poultry, seafood, dairy products and most fresh fruit and vegetable are kept in the refrigerator at an internal temperature <41 F. c. All food is stored on racks or shelves off the floor. e. All refrigerated foods are dated, labeled and tightly sealed, including left overs, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 72 hours. Items that are over 72 hours old are discarded. 3. Freezers c. All foods are stored on racks or shelves off the floor. e. Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated. Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on interview and record review the facility failed to establish an infection prevention and control program that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 (Residents #94 and Resident #28) of 3 residents reviewed for infection control A) The facility failed to follow the antibiotic stewardship recommendations for Resident #94. B) The facility failed to follow the antibiotic stewardship recommendations for Resident #28 This deficient practice could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use and increased antibiotic-resistant infections. Findings include: A) Review of Resident #94's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include chronic systolic (congestive) heart failure, anemia (low levels of healthy red blood cells to carry oxygen throughout the body), hyperlipidemia (high levels of fat particles in the blood), depression, anxiety, chronic pain, retention of urine, muscle spasms. Review of Resident #94's MDS Assessment, dated 03/29/2024, reflected a BIMS score of 09 which indicated moderate cognitive impairment. Review of Resident #94's Comprehensive Care Plan reflected resident was on antibiotic therapy related to Urinary Tract Infection (UTI) prophylaxis, initiated 03/26/2024. Interventions included Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Monitor/document/report PRN adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat). Monitor/document/report PRN signs/symptoms of secondary infection r//t antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus. Review of Resident #94 orders, written by NP K, start date of 3/26/2024 for cephalexin oral 250mg with an end date of indefinite. The order reflected an indication for use as UTI prophylaxis. Review of Resident #94's Medication Administration Record for the months of March, April, May and June of 2024 reflected she has received cephalexin 250mg daily at 0900 (9:00AM) starting on 03/26/2024. Review of the Antimicrobial Stewardship Recommendation for Resident #94, dated 03/28/2024, reflected a recommendation by the consultant pharmacist to amend the cephalexin order to include an end date and states the prophylactic use of anti-microbials was contra-indicated. Review of the Consultant Pharmacist's Medication Regimen Review for Resident #94, dated 03/28/2024, reflected a recommendation by the consultant pharmacist to amend the cephalexin order to include an end date and states the prophylactic use of anti-microbials is contra-indicated. In an interview on 06/06/24 11:00 AM the DON stated the use of antibiotics for UTI prophylaxis was not acceptable and she has spoken with the providers regarding this practice. She stated it was an ongoing issue that has been addressed before and she will continue to communicate with the providers regarding this. She stated the potential consequence of over prescribing could be development of antibiotic resistance and superbugs. B) Review of Resident #28's face sheet reflected a [AGE] year-old female admitted to the facility 08/16/2022 with the following diagnoses dementia(A group of symptoms that affects memory, thinking and interferes with daily life.), osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.) and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.). Review of Resident #28's Quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a 00 BIMS score indicating severe cognitive impairment. Resident #28 was assessed to require substantial/ maximal assistance with all ADLs. Resident #28 was assessed to be incontinent of bladder. Resident #28 was assessed to not be on antibiotics during the assessment period or to have a UTI in the past 30 days. Review of Resident #28's comprehensive care plan reflected a problem dated 08/16/2022 and revised on 04/25/2024 Resident #28 always has bladder incontinence r/t decreased mobility, muscle weakness, HX of UTI and impaired cognition. Interventions included Monitor/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident #28's nursing progress notes reflected an entry dated 5/30/2024 Caregiver requesting UA, states resident was not acting herself. New order for UTI panel/reflex received. Review of Resident #28's nursing progress notes reflected an entry dated 05/31/2024 indicating Rocephin 1 gm was administered IM after urine was collected. Review of Resident #28's urinalysis and UTI panel dated 06/05/2024 reflected Resident #28's UA C&S was negative for infection. In an interview on 06/06/2024 at 10:00 AM the DON stated the nurses called Resident #28's physician and got orders for the UA C&S. The DON stated Resident #28 should not have been given antibiotics prior to her lab results coming back. She stated she has been having trouble with the physicians not following the antibiotic stewardship policies of the facility. The DON further stated the residents should not be placed on antibiotics unless the PCR test comes back and the resident has a high bacterial load. Review of a statement dated 05/03/2020 from the facility's Medical Director reflected .As discussed in multiple previous mandatory provider meetings, most recently last month April 2024, has recommended all providers consider getting UpToDate to help with keeping up with the latest guidelines along with the use of policies, procedures, and medical director recommendations. Antibiotic stewardship is of optimal importance in order to collaboratively maintain and align processes for assessing, planning, evaluating, and implementing evidence-based and patient centered antimicrobial stewardship practices, including new drugs, patient care strategies, policies and procedures, treatment guidelines, systems and processes, and antimicrobial stewardship practices integrated into the community. As always, we should all follow evidence-based practice and use all your resources to make the best decision for our patients. To support your stewardship practice, we will work on incorporation and consistency methods to include antibiogram, resident and family information materials, and Loeb and McGeer Criteria for initiation of antibiotics in long-term care residents. Review of the facility's policy Antibiotic Stewardship Program dated 10/24/2022 reflected It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .a. Antibiotic use protocols: 1.Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR form prior to notifying the physician. Laboratory testing shall be in accordance with current standards of practice. The facility uses the updated McGeer criteria to define infections. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized .Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families . 32452 49851

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 of 8 residents, in that: Resident 29 was not provided fingernail care. This failure affected one resident and could place her at risk of infection and diminished self-esteem. Findings include: Record review of resident's 29 face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of: type 2 diabetes with diabetic neuropathy, dementia, hypertension, hypokalemia, overactive bladder, atrial fibrillation, hypothyroidism, gastro esophageal reflux disease, restless leg syndrome, and osteoarthritis. Record review of the quarterly minimum data set (MDS) assessment for resident 29 dated 04/25/24 reflected a brief interview for mental status (BIMS) score of 00 indicating impaired cognitive function. Her physical assessment for functional abilities and goals reflected she required supervision for eating, maximum assistance for all other ADLs, always incontinent of bladder, and frequently incontinent of bowel. Record review of the care plan for resident 29 dated 04/25/2024 reflected she had an ADL self-care performance for personal hygiene deficit related to impaired cognition, muscle weakness, pain, and lack of coordination. Interventions: Requires extensive assistance by one staff with personal hygiene. Care plan reflected resident was at risk for signs or symptoms of covid 19 and an intervention included assisting resident in practicing hand hygiene. Note: Care plan reflected resident 29 is resistive to care at times. No documentation reflected or staff interviews stated resident 29 refused personal hygiene or nail care. Care plan did not address resident 29 digging in brief with her hands. Record review of resident 29 medication administration record (MAR) and TAR (treatment administration record) reflected no records of nail care being provided. Record review of task list for resident 29 in point click care (PCC) reflected nail care is scheduled to be provided by CNA on days. Record review of order summary for resident 29 did not reflect any order for nail care. Observation on 6/04/2024 at 10:22 am revealed resident 29 seated in her wheelchair in the dining room drinking coffee with other residents. Resident 29 had her hands placed under the table. Surveyor asked resident 29 if she could show her hands to surveyor. Resident 29 lifted her hands up and resident 29 was observed with a brown substance under her nails of both hands. Observation on 06/05/2024 at 2:54pm revealed resident 29 resting in bed and her fingernails had a brown substance under nails of both hands. Observation on 06/06/24 at 9:45 am revealed resident 29 seated in her wheelchair in the hallway outside of her room with brown substance under nails of both hands. In an interview on 06/06/24 at 9:20am with LVN D she stated direct care staff know what kind of care residents need based on their kardex and care plan. She stated nail care is the CNA's and nurses' responsibility. She stated if a resident is diabetic the nurses do nail care. She stated resident 29 does not refuse nail care and the reason her nails get dirty is because resident 29 scratches at her pants and also digs her fingers into her brief. In an interview on 06/06/24 at 9:36am with CNA G he stated staff know what kind of care a resident need based on their kardex, information passed during report or shift change, common sense, and will ask nurse or therapy. He stated resident 29 tends to dig her fingernails into her brief. He stated CNAs are responsible for fingernail care but not toenails if a resident is diabetic. He stated nail care is done on Sundays. In an interview on 06/06/24 at 10:20am with DON, she stated staff know what care residents need by looking at the kardex and pocket care plans especially for staff that have moved to another hall. She stated they try and not use the pocket care plans. She stated the facility has a lead CNA that floats and two CNA instructors in building. She stated everyone is responsible for nail care. She stated resident 29 scratches and digs at her brief and they clean her nails throughout the day. She stated resident 29 needs nail care throughout the day because she has periods of diarrhea. In an interview on 06/06/24 1240pm with ADM he stated staff refer to a resident's kardex or pocket care plan to find out about a resident's ADLs. He stated staff are also given education and in-services. ADM stated he does role play for in services where he is the resident, and they practice and train for ADLs. He stated he tells staff do not be afraid to ask for help because this protects the resident and staff as well from injury. He stated he tells staff it is better go up in care instead of going down. For example, if a resident is a one person assist and a staff member feels they cannot provide aid by themselves to ask for help. He stated nurses take care of nail care for residents who are diabetic and if the resident is not diabetic the CNAs provide nail care. He stated nails are trimmed as needed. Review of facility policy dated 05/26/2023 titled Activities of Daily Living reflected the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of in-services for 2023 and 2024 revealed there were no in-services about nail care.

Based on record review and interviews the facility failed to complete preadmission screening for a resident with a mental disorder. The facility failed to review and correct a PASSR evaluation for Resident #45 . This failure could result in the resident not receiving correct and approved treatments, medications and quality of life enhancements. Findings include: Review of the Face Sheet for Resident #85 reflected she was admitted on [DATE] with diagnosis of: Myocardial Infarction, Dementia, and bipolar Disorder unspecified. Review of the entry MDS for Resident #85 dated 5/17/24 reflected no cognitive assessment, a 00 BIMS score. Her physical assessment reflected she needed assistance or supervision with all ADL's, she ambulated via wheelchair and walker. She was assessed as having an indwelling catheter. She was assessed as frequently incontinent of bowel and bladder. Review of the Care Plan for Resident #85 reflected interventions were in place for: ADL performance deficit, Impaired cognitive function, High risk for falls, Psychotropic medications, Indwelling catheter for urinary retention, impaired visual function. In an interview on 6/05/24 at 2:25 PM the MDS nurse stated the facility had received an incorrect PASSR for Resident #85 on admission (5/13/24) and was submitting a Form 1012 to have it corrected (not completed on 6/05/24). The MDS nurse stated Resident #85's primary diagnosis should be changed from Myocardial Infarction to Dementia. She stated the change might be made if or when she was changed to long term care. The MDS nurse stated it had been approximately two weeks since Resident #85's admission and the physician should have signed it by now. The MDS nurse stated it was her responsibility to check the PASSER forms were accurate. In an interview on 6/06/24 at 10:20 am LVN M stated Resident #85 had not displayed any manic or depressive behaviors in her time at the facility. She stated daily monitoring for behaviors was ordered. In an interview on 6/06/24 at 10:35 am LVN P stated she had observed Resident #85 daily since she was admitted . She stated Resident #85 liked to sit with other residents and was normally quiet and calm. In an interview on 6/06/24 at 11:00 am the DON stated Resident #85 had arrived with an incorrect PASSR evaluation and the facility should have corrected it immediately. She stated it was not known if Resident #85 would be staying long term and there was no way to know if her primary diagnosis could be changed to Dementia. She stated Resident #85 was diagnosed with Bipolar. In an interview on 6/06/24 at 11:40 am the administrator stated the facility policy was not followed for Resident #85. The administrator stated the PASSR for Resident #85 was incorrect and should have been resubmitted for correction. He stated the MDS normally reviews and refers to the source of the assessment when a correction was needed. He stated the correction for the diagnosis of Bipolar disorder unspecified should have been clarified, such as Bipolar Depressive or Bipolar Manic. The administrator stated the facility followed state guidelines to complete and submit PASSR evaluations.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Resident #65 and Resident #81) of 8 residents reviewed for respiratory care. A) The facility failed to ensure that Resident #65's oxygen tubing with nasal cannula was changed out every seven days. The facility failed to ensure that Resident #65's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days and bagged. The facility further failed to ensure that the air filter on Resident #65's air concentrator filter was free of dust and debris. B) The facility failed to ensure that Resident #81's oxygen tubing and nasal cannula was changed out every seven days and failed to date the tubing and failed to ensure that Resident #81's air concentrator filter was free of dust and debris. These failures could place residents at risk for respiratory compromise and infection. Findings Included: A) Review of Resident #65's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Unspecified Dementia, Moderate (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain), Chronic Respiratory Failure with Hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and Heart Failure (heart does not pump enough blood for your body's needs). Review of Resident #65's MDS Quarterly Assessment, dated 03/06/2024 revealed Resident #65 had a BIMS Score of 12, which indicated moderate cognitive impairment. Resident #65's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy and further indicated under Section I that she had active diagnosis for Pulmonary (relating to lungs). Review of Resident #65's Comprehensive Care Plan revealed [Resident #65] has potential for ineffective breathing pattern and air way clearance related to chronic lung disease with respiratory failure with an intervention for OXYGEN as ordered with revision date of 03/30/2023. Review of Resident 65's Order Summary Report dated 06/05/2024 reflected the following start dates / orders: 06/20/2023 for Oxygen 2L NC prn sats<92% and 05/23/2024 for Ipratropium-Albuterol Inhalation Solution0.5-2.5 (3) MG/3ML(Ipratropium-Albuterol) 1 vial inhale orally every 8 hours for SOB/Wheezing. Further review revealed Resident #65's orders did not reflect any order in reference to care of her oxygen tubing or equipment. Observation on 06/04/2024 at 8:31 AM, Resident #65 was in her bed receiving oxygen via nasal cannula from an oxygen concentrator at 2L. The tubing was dated in fine print at the connection point with the concentrator which either displayed 5-21-24 or 5-26-24, both of which would have been past the seventh day. The air filter on the back of the concentrator was found to be dirty with built-up particles stuck to it. There was a nebulizer present on the nightstand to the side of Resident #65's bed that had oxygen tubing connected to it that lead to a mask with an in line nebulizing chamber. The mask was exposed to the air, not bagged, resting on paperwork, and was dated 5-26-24. Interview and observation on 06/04/2024 at 1:47 PM, Resident #65 was in her bed receiving oxygen via nasal cannula. Resident #65's nebulizer mask was now in a plastic bag on the nightstand and the outside of the bag was dated 6/4/24. The mask inside the bag was the same mask dated 5-26-24 that was observed earlier and had not been changed. Resident #65's oxygen tubing at the port of the concentrator now displayed a date of 5-28-24 and it was obvious that the 21 or 26 had been wrote over to place the 28 on the tubing. Resident #65 stated that a staff member did come in her room after the initial observation but stated that no one changed out her tubing / nasal cannula and that she was using the same one she had at 8:31 A.M. Resident #65 had a trash can beside her bed that had a dirty air filter in it and the concentrator now had no filter on the back of it. B) Review of Resident #81's Face Sheet dated 06/05/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain), Chronic Respiratory Failure with Hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and Heart Failure (heart does not pump enough blood for your body's needs). Review of Resident #81's MDS Quarterly Assessment, dated 04/19/2024 revealed Resident #81 had a BIMS Score of 7, which indicated severe cognitive impairment. Resident #81's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy and further indicated under Section I that she had active diagnoses for Pulmonary (relating to lungs). Review of Resident #81's Comprehensive Care Plan revealed a problem area [Resident #81] has oxygen therapy r/t chronic respiratory failure with an intervention for OXYGEN SETTINGS: O2 via NC @ 2LPM continuously with revision date of 05/03/2024. Review of Resident #81's Consolidated Orders last reviewed on 05/21/2024 reflected the following start date / order: 04/14/2024 for Oxygen at 2 LPM via NC. Resident #81's orders did not reflect any order in reference to care of her oxygen tubing or equipment. Observation on 06/04/2024 at 8:12 A.M, Resident #81 was in her bed receiving oxygen via nasal cannula from at concentrator at 2.75 L. Observed that the tubing from the concentrator to her cannula had no date displayed anywhere. The air filter on the back of the concentrator was found to be dirty. Interview and observation on 06/04/2024 at 2:18 PM, Resident #81 was in her bed receiving oxygen via nasal cannula from a concentrator. Resident #81's concentrator now had a plastic bag attached to it with her name and a date of 6/4/24. Resident #81's oxygen tubing now had a date present on it at the port for the concentrator, which displayed 6/3/24. The filter on the back of the concentrator was found to still be dirty and unchanged. Resident #81 stated a nurse did come in earlier, but that they did not change out her oxygen tubing / nasal cannula that had been in use. Interview and observation on 06/06/2024 at 11:19 AM, LVN D stated respiratory tubing and mask are to be changed out every seven days and dated. LVN D stated they normally place an orange identification sticker on the tubing, which they were to record the date and time of change on. LVN D stated the nebulizer mask was also to be changed every seven days and have the date recorded on them. LVN D started the concentrator filters are to be cleaned weekly and all oxygen mask and Cannulas are to be in a dated bag when not in use. LVN D stated all oxygen checks / changes are to be performed by the night nurse every Sunday. LVN D stated no one should ever record a date on top of another date because the tubing should be replaced, and a new date recorded. LVN D stated their procedures for oxygen equipment needed to be followed for infection control and to prevent respiratory infections. At 11:24 AM, LVN D entered the room of Resident #65, who was receiving oxygen via nasal cannula. LVN D checked the respiratory equipment for Resident #65 and stated nebulizer mask was past date and should not have been placed in a plastic bag with today's date. LVN D stated a new mask and tubing should have been installed and today's date placed on it before being placed in the bag. LVN D stated the date on the oxygen tubing at Resident #65's concentrator had been recorded over and that whoever did so should not have and should have replaced the tubing with cannula and recorded the new date. At 11:27 AM, LVN D entered the room of Resident #81, who was receiving oxygen via nasal cannula. LVN D checked the respiratory equipment for Resident #81 and stated it was not correct. LVN D stated if the oxygen tubing in fact was changed out on 6/3/24 as recorded that the bag on the concentrator should display the same date. LVN D stated the filter on the concentrator appeared to not have been cleaned in the past seven days. Interview on 06/06/2024 at 11:50 AM, the DON stated all respiratory tubing needed to be changed and dated every seven days. The DON stated respiratory equipment like mask and Cannulas should be bagged when not in use by the residents. The DON stated a date should never be recorded over and that to do so would not be their standard practice and could result in respiratory issues for the resident. The DON stated all respiratory tubing, mask, and Cannulas are to be changed every Wednesday but that she does allow staff until Sunday if it was not more than seven days. The DON observed evidence obtained in reference to Resident #65 and Resident #81's respiratory equipment and stated it was not within policy, should not have been done, and could lead to a respiratory infection for the resident. Interview on 06/06/2024 at 12:05 PM, the Administrator stated his expectation was for oxygen tubing / equipment to be replaced and dated every seven days or when soiled if less than seven days, stored in a bag at bedside when not in use, and replaced anytime it was found on the floor. The Administrator stated all oxygen tubing / equipment in to be replaced by a nurse every Wednesday night and that failure to do so could result in the resident having an adverse effect. The Administrator was requested to provide their policy in reference to oxygen equipment / care. Review of the facility's Oxygen Safety policy dated 01/26/2024, reflected, Policy: It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Further review revealed that he provided policy did not address respiratory care equipment in reference to dating and change of oxygen tubing, mask, cannulas, bagging of respiratory equipment when not in use, or cleaning of concentrator filters.

Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for Resident #6. The facility failed to assess and properly label Resident #6's peripheral intravenous catheter (PIV) This failure could place residents at risk of infection, infiltration, and not receiving appropriate PIV care. Findings include: Review of Resident #6's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included unspecified dementia, acquired absence of left leg above knee, atherosclerosis (a buildup of fats, cholesterol, and other substances in and on the artery walls), anemia (low levels of healthy red blood cells to carry oxygen throughout the body) and chronic pain. Review of Resident #6's MDS Assessment, dated 05/09/2024, reflected a BIMS score of 14 which indicted her cognitive function as intact. Review of Resident #6's Comprehensive Care Plan reflected IV therapy was not addressed. The care plan reflected the resident was at risk for infection and fluid volume deficit. Observation on 06/04/2024 at 09:45 AM revealed Resident #6 lying in bed with a PIV to her right wrist. A clear dressing was in place over IV site with tape to secure dressing and IV tubing. An empty bag of normal saline was connected to the IV. No date, initials or IV gauge (size) noted on the dressing. Observation on 06/04/2024 at 11:25 AM revealed Resident #6 sleeping. The IV tubing had been disconnected from the IV and discarded. Observation on 06/05/2024 at 10:00 AM revealed right wrist PIV still in place. Dressing intact with no label. In an interview on 06/05/2024 at 11:40 AM, LVN E stated peripheral IV maintenance should be done every shift to include cleaning the site, flushing to ensure patency and applying dressing with date and initials. She stated she was not sure if the current dressing for Resident #6 was dated or initialed. She stated not properly labeling the IV could put the resident at risk for infection. Observation on 06/06/2024 at 08:20 AM revealed Resident #6 sitting in bed. Right wrist PIV has been removed. In an interview on 06/06/2024 at 09:15 AM, LVN F stated the standard of practice for IV insertion and care would be to date and initial the IV dressing after insertion. He stated if it was not dated, then staff would not know when it was started or if it was changed. In an interview on 06/06/2024 at 09:50 AM the DON stated her expectation for IV care would be for the site to be dated, initialed, checked every shift and PRN. She stated the site should be discontinued if not needed. If it needs to stay in, she expected an order in place. She would expect the site to be checked by the nurse on each shift and was upset to find out that was not happening for Resident #6. Review of facility policy for IV catheter insertion and care, dated July 2016, reflected all IVs should be labeled to include the date and time of catheter insertion, initials, length and gauge of catheter on the label.

Based on observation, interview and record review, the facility failed to ensure nurse aides are competent in skills and techniques necessary to care for Resident's needs identified through assessments and described in the plan of care. The facility failed to utilize two caregivers to provide incontinent care for Resident #2 as described in her plan of care. The aide stated in an interview she performed incontinent care by herself for Resident #2, the resident had rolled off the bed and sustained injures on 8/01/23 two days earlier. This failure could result in falls or injuries for residents who require two person assistance for transfers and repositioning. Findings included: Review of the Face Sheet for Resident #2 reflected she was admitted to the facility on [DATE] with diagnosis of: Sequelae of Cerebral Infarction, Chronic Atrial fibrillation, Hemiplegia and Hemiparesis affecting right side , Dementia, Anxiety, Type 2 Diabetes, Congestive Heart Failure (CHF) and Osteoporosis . Review of the Annual MDS assessment for Resident #2 dated 5/30/23 reflected a BIMS score of 15 indicating normal cognitive functioning. Her functional assessment reflected she required extensive assistance for all ADLs except eating which required set up assistance . She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #2 dated 8/03/23 reflected interventions were in place for: post stroke care including physical weakness and deficits, Bilateral Hemiplegia, a High risk for falls, and an actual fall on 8/02/23 with major injury. Interventions for the fall included 2-person assist with repositioning and personal care (dated 8/03/23), Staff education on assisting with proper bed mobility when low air loss mattress is used. Resident #2 had interventions related to pain management and a pathological bone fracture-subchondral insufficiency fracture to the anterior latera tibial plateau r/t Vitamin D deficiency and Osteoporosis (dated 8/02/23). Review of a progress note for Resident #2 dated 8/01/23 reflected the nurse was notified by the CNA at 4:55 am the resident had rolled off the bed during a brief change. The nurse found the resident laying on the floor on her left side. Blood was noted by the nurse on the floor with skin tears to the left and right forearm. EMS was called for transfer to local emergency room and departed the facility at 5:17 am. The notes reflected hospital staff reported no damage found in a CT of the head and spine. A small 1 centimeter subchondral insufficiency fracture anterior lateral tibial plateau was found on x-ray. Resident #2 returned to facility at 1:35 pm. Review of the sign up sheet for Resident #2's updated Care Plan post fall dated 08/01/23 reflected CNA S was present for inservice on Resident #2 on 8/01/23. In an interview and observation on 8/03/23 at 12:05 pm, Resident #2 stated she had a fall two days ago. She stated she did not know how the fall occurred, but she woke up on the floor on her back and could not recall any details. Resident #2 was observed to have a blackened/bruised left eye and a bruise to the front of her left forehead. She stated she was on blood thinners since her heart surgery some time ago. She stated she had one sided weakness from a stroke. Resident #2 stated she had previously stayed at the facility after breaking her hip and insisted on coming back to Towers because she thought care was good. In an interview on 8/03/23 at 12:56 pm, Resident #2's son stated he was concerned after his mother rolled off the bed on 8/01/23. He stated interventions to remedy the fall risk was to have two persons providing her care and repositioning. He stated when he visited his mother on 8/02/23, he observed one staff member providing care . He stated he was upset about bruising to his mother's face and left eye and a fracture to the left knee bone. In an interview on 8/03/23 at 12:42 pm, CNA S stated on 8/02/23 she was assigned to the middle hall (300 hall). She stated the aide she was working with went on break and she was answering call lights. She stated she went into Resident Halls room and she requested pericare. She stated she was new and did not know all the resident's names and needs. She stated she did not receive the in-service about Resident #2 needing 2-person care at all times. She stated the son of the resident came in at the end of care, she covered the resident, and the son made no mention of any issues to her. She stated she did Resident #2's care slowly and carefully. No falls occurred and Resident #2 was not injured. She stated the Resident was moderately incontinent of urine and she had since received the in-service care. In an interview on 8/03/23 at 12:00 pm, LVN B stated he was charge nurse for the 300 hall. He stated Resident #2 was the only person who had experienced a fall on 300 recently. He stated she had bruising to her face and side and was to have two-person assist for all care. He stated fall prevention was in place. In an interview on 8/03/23 at 12:10 pm, RN H stated she normally worked on Hall 300 with Residents but today she was filling in. She stated most staff work the same halls daily. She stated Resident #2 had fall prevention and the falling star program in place for her safety. In an interview on 8/03/23 at 12:26 pm, the ADON stated Resident #2 went to theER on [DATE] and returned a few hours later. She stated an in-service education was held the same day and everyone was aware Resident #2 was to be a two person assist for all care and repositioning. The ADON stated the care plan was updated. She stated there was sufficient staff for a two person assist around the clock. She stated normal staffing was one nurse and 2 aides for each shift. In an interview on 8/03/23 at 2:50 pm, the Nurse Aide Trainer stated CNA S was present for the in-service on Resident #2's Care on 8/01/23. She stated she performed the in-service herself. She stated she did training for Group A and then group B right after, she stated the timing at change of shift worked out perfectly. She stated the PRN people and part timers have to sign off before they go to their areas. In an interview on 8/03/23 at 2:55 pm CNA U stated she received the in-service education on providing two-person assistance to Resident #2 for all care. In an interview on 8/03/23 at 3:05 pm, the ADON stated she expected all staff would provide care as prescribed in each Resident's care plan according to their needs . She acknowledged CNA S had signed the in-service education sheet dated 8/01/23. In an interview the Administrator stated he was working to resolve the complaints of Resident #2's son. He stated she had sustained a fall on 8/01/23 and was injured. He stated during pericare her low air loss mattress went flat and she rolled off the edge of the bed while one person (CNA T) was providing care. Resident #2 sustained injuries and as a result of the incident her interventions were updated to include that she must have two person assist for care at all times. The Administrator stated he received a report on 8/02/23 that the son entered the facility and one aide was changing his mom. The Administrator stated the aide (CNA S) may not have received the in-service education for Resident #2 as she had recently transferred to the facility. He stated CNA S had admitted she was performing care for Resident #2 by herself. He stated his expectation was all staff would receive the in-service education and provide two person assistance/care to Resident #2.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan which reflect interventions for each resident to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (four) of 26 (twenty-six) residents reviewed for care plans (Resident #95, Resident #105, Resident #109 and Resident #212). The facility failed to ensure Resident #95, Resident #105, Resident #109 and Resident #212's care plan was developed and implemented with appropriate interventions to reflect needed Activities of Daily Living assistance after completing comprehensive MDS. This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being. Findings included: Record review of Resident #95's face sheet, dated 02/13/2022, revealed that the resident was admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #95's admission MDS, dated [DATE], revealed a BIMS score 13 which indicated the resident was moderately cognitively intact. The record revealed the resident was indicated as needing assistance with personal hygiene with one-person physical assistance. Record review of Resident #95's Care Plan initiated on 01/26/2022, did not reveal a focus for his ADL care including nail and hair care. During an interview on 02/14/2022 at 09:00 AM with Resident #95, he stated that he has not had a shower in quite few days. It was observed nails on both his hands to be untrimmed and black underneath. Resident said that he wanted his nails and toenails trimmed and has asked several times but that the nurses would not trim them because he is diabetic. Resident went on to state that he needed a haircut as well. Resident stated that aides can't do it but that a nurse could. Resident stated that he really wanted to have this taken care of. It was observed that resident was dressed in gown. Record review of Resident #105's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #105's admission MDS, dated [DATE], revealed a BIMS score 15 which indicated the resident was cognitively intact. The record revealed the resident was indicated as having a type two pressure ulcer and diabetic [CONDITION(S)]. The record also revealed that resident required assistance or extensive assistance for ADL's. Record review of Resident #105's care plan initiated on 01/25/2022, did not reveal a focus plan for diabetic podiatry care or pressure ulcer care and prevention. During an interview with Resident #105 on 02/13/2022 at 10:26 AM, Resident stated that his shower days are on Monday, Wednesday and Friday. He stated that he needs to see a podiatrist and he has asked facility to arrange to see a specialist but has yet to see one. Resident has told the nurse aides numerous times. Resident stated that the nurse aide said about podiatry if I can remember it. Resident stated that he told the nurse aide that aide needed to get a notepad to write down tasks. PT and OT help him get up and dressed around noon. Record review of Resident #109's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #109's admission MDS, dated [DATE], revealed a BIMS score of 15 indicating that the Resident was cognitively intact. The record revealed that Resident needed assistance with personal hygiene, extensive assistance with dressing with two-person assistance as well as total dependence for bathing. Record review of Resident #109's Care Plan initiated on 01/25/2022, did not reveal a focus for his ADL care including nail care, showering/bathing and toileting. During an interview on 02/14/2022 at 8:45 AM with Resident #109, it was observed that her nails were still uncared for and there was a black substance under each nail at the nail bed. She stated that she didn't remember the last time that she had a shower and that she would like her nails taken care of and groomed. Record review of Resident #212's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #212's admission MDS, dated [DATE], revealed a BIMS score 10 which indicated the resident was cognitively intact. The record revealed the MDS was not signed by the MDS coordinator or RN. The record revealed resident was indicated as needing extensive assistance or total dependence on staff with personal hygiene with a one or two-person physical assistance. Record review of Resident #212's Care Plan initiated on 02/02/2022, did not reveal any interventions for ADL needs. During an interview on 02/14/2022 08:30 AM, Resident was observed her nails on left and right hand to be extremely overgrown, ragged and discolored. She stated that she would like to have someone take care of her nails, but no one had done this. It was noted that Residents nails on both hands were very long, some were had jagged edges and splitting down the middle of nails. She stated that she has had two showers since she's been there, but her facial hair care and nail care has not been done. She stated that she would like this taken care of and when she was at home, she had a safe razor that she would use to take care of it herself. It was observed facial hair white in color that was approximately 1/2 inch in length around her chin. During an interview on 02/15/2022 at 9:15 AM with the DON, she stated that the practice for both men and women's ADL's nail care and facial hair was as needed or if asked by resident. She stated that she was aware that nail care and facial hair care were not currently in the tasks they performed regularly and that these items needed to be tasked. She stated that facial hair care for women should be addressed as needed or as requested. She was not aware that Resident #212 had requested nail care and facial hair care. She stated that she knew that nails and facial hair care had fallen behind but the staff that had been performing these tasks moved from shower duty to the floor. She was not aware of the requests for podiatry and nail care from residents Resident #105 and #95. She stated that she was not aware of nail care needs for Resident #109. She stated that lack of care for facial hair when requested could lead to a dignity issue for residents and the lack of appropriate nail care could lead to infection control issues for residents. Interviews with MDS Care Management Specialist LVN A and MDS Care Management Specialist LVN B regarding the care plan timing were conducted on 02/15/2022 at 9:00 AM, MDS Specialist A stated that the care plans were completed seven days after the admission MDS is complete. She went on to state that if the Resident's care plan was not in compliance, orders for the resident's care should be in the system and all residents should still be receiving necessary care. She stated that for the residents in the 100 hallway, many of the care plans that had not been completed had been completed last night as they were updating care plans to address needed ADL's that had not been done. MDS Specialist B stated that she oversaw the skilled nursing care residents. She stated that there was a care plan completed at the 72 hours, after the OBRA 14 days and then at 7 days. She stated that first they do assessments, then the MDS and then have care planning meetings. She stated that the social worker sent out notices to families and that they try to get participation from residents. She stated that if the care planning date for compliance gets missed, this facility was in tune with its residents and there were other plans in place for resident care. An interview with the ADMIN on 02/15/2022 at 11:04 AM revealed that that the facility followed the care planning outlined by the RAI 3.0. He stated that he contacted other agency staff to look at care plans. Review of the facility's care planning policy (not dated) revealed that the facility has 7 (seven) days after completing the RAI assessment 3.0 to develop the resident's care plan. The 7 (seven) day policy for completion or modification of the care plan applies to the Admission, SCSA, SCPA and/or Annual RAI assessments. The care plan must include and electronic signature and a date.

Based on observation, interview and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for nine of thirty-nine residents (Residents #95, #105, #109, #212, #27, #162, # 80, #110 and # 47) reviewed for ADLs in that: A) Resident #95 required limited assistance with one-person assist for personal hygiene tasks and was not provided with nail care, podiatry care or hair care needs. B) Resident #105 required supervision with two-person assist for personal hygiene tasks and was not provided with podiatry care. C) Resident #109 required supervision with two-person assist for personal hygiene tasks and was not provided with nail care. D) Resident #212 required extensive assistance with two-person assist for personal hygiene tasks and was not provided with nail care or facial hair care. E) Resident # 27 required extensive assistance with one-person assist for personal hygiene tasks and was not provided with facial hair care. F) Resident # 162 required limited assistance with one-person assist for personal hygiene and was not provided with nail care. G) Resident # 80 required extensive assistance with one-person assist for personal hygiene tasks and was not provided with nail care. H) Resident # 110 required total dependence for personal hygiene and was not provided with nail care. I) Resident # 47 required supervision and one-person assist for personal hygiene and was not provided with nail care. This deficient practice could place all residents who are dependent on ADL care at risk for reduced self-worth and increased infections. Findings include: A) Record review of Resident #95's face sheet, dated 02/13/2022, revealed that resident was admitted to the facility on [DATE] with an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Non-insulin dependent diabetes) Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score 13 which indicated the resident was moderately cognitively intact. The record revealed the resident was indicated as needing assistance with personal hygiene with one-person physical assistance. Record review of Resident #95's Care Plan initiated on 01/26/2022, did not reveal a focus for his ADL care including nail and hair care. Observation and interview on 02/14/2022 at 09:00 AM with Resident #95, revealed he had long nails with black residue under them. He stated that he hasn't had a shower in quite few days and he wanted his nails and toenails trimmed. He stated he asked several times but that the nurse aides would not trim them because he is diabetic. Resident went on to state that he needs a haircut as well. Stated that aides could not do it but that a nurse could. Resident stated that he really wanted to have this taken care of. B) Record review of Resident #105's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #105's admission MDS, dated [DATE], revealed a BIMS score 15 which indicated the resident was cognitively intact. The record revealed the resident was indicated as having a type two pressure ulcer and diabetic [CONDITION(S)]. The record also revealed that resident required assistance or extensive assistance for ADL's. Record review of Resident #105's care plan initiated on 01/25/2022, did not reveal a focus plan for diabetic podiatry care or pressure ulcer care and prevention. Interview with Resident #105 on 02/13/2022 at 10:26 AM stated that his shower days are on M/W/F. He stated he needs to see a podiatrist and he has asked facility to arrange to see a specialist but has yet to see one. Resident has told the nurse aides numerous times and the nurse aide said about podiatry if I can remember it. Resident stated that he told the nurse aide that aide needed to get a notepad to write down tasks. PT and OT help him get up and dressed around noon. C) Record review of Resident #109's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #109's admission MDS, dated [DATE], revealed a BIMS score of 15 indicating that the Resident was cognitively intact. The record revealed that Resident needed assistance with personal hygiene, extensive assistance with dressing with two-person assistance as well as total dependence for bathing. Record review of Resident #109's Care Plan initiated on 01/25/2022, did not reveal a focus for his ADL care including nail care, showering/bathing and toileting. Observation and interview on 02/14/2022 at 8:45 AM with Resident #109, it was observed that her nails were uncared for and there was a black substance under each nail at the nail bed. She stated that she did not remember the last time that she had a shower and that she would like her nails taken care of and groomed. D) Record review of Resident #212's face sheet, dated 02/14/2022, revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #212's admission MDS, dated [DATE], revealed a BIMS score 10 which indicated the resident was cognitively intact. The record revealed the MDS was not signed by the MDS coordinator or RN. The record revealed resident was indicated as needing extensive assistance or total dependence on staff with personal hygiene with a one or two-person physical assistance. Record review of Resident #212's Care Plan initiated on 02/02/2022, did not reveal any interventions for ADL needs. Observation and interview on 02/14/2022 at 08:30 AM with Resident # 212 whose nails on her left and right hand were extremely overgrown, ragged, discolored and split down the middle. She had white facial hair approximately 1/2 inch in length around her chin. She stated that she would like to have someone take care of her nails, but no one had done this. She stated that she has had two showers since she had been there, but her facial hair care and nail care has not been done. She stated that she would like this taken care of and when she was at home, she had a safe razor that she would use to take care of it herself. E) Record review of Resident # 27's face sheet reflected she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 27's quarterly MDS dated [DATE] reflected a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident # 27's Care Plan initiated 06/18/2021 and revised on 10/14/2021 reflected she will maintain or develop clean and intact skin. Intervention: Avoid scratching and keep fingernails short. Observation and interview on 02/13/2022 at 1:35 PM with Resident # 27 who had 1/2 inch long white whiskers on her chin. She stated I have whiskers. I just want them cut off. F) Record review of Resident # 162's face sheet reflected he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 162's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognitive status. Review of Resident # 162's care plan initiated 11/04/2021 reflected he has an ADL self-care performance deficit and requires extensive assist by one person with personal hygiene. Observation and interview on 02/13/2022 at 10:57 AM with Resident # 162 who had long, jagged fingernails. He stated, My nails are too long. G) Review of Resident # 80's face sheet reflected he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 80's comprehensive MDS dated [DATE] reflected a BIMS score of 8 indicating moderate cognitive impairment. Review of Resident # 80's care plan dated 03/21/2019 reflected he has potential impairment to skin integrity related to kidney failure. Keep fingernails short. Observation and interview on 02/13/2022 at 1:05 PM of Resident # 80's nails which were long and jagged with a brown substance underneath. Resident stated that aides are ignoring him when he asks for personal care. If they don't want to do nothing, they don't do it. H) Review of Resident # 110's face sheet reflected he was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 110's annual MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident # 110's care plan dated 01/22/2022 reflected he has an ADL self-care performance deficit, requires extensive assist by one staff with personal hygiene. Observation and interview on 02/13/2022 at 11:27 AM of Resident # 110 nails and toenails which were long and jagged. He stated, I would like my fingernails and toenails trimmed. I) Review of Resident # 47's face sheet reflected she was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 47's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognitive status. Review of Resident # 47's care plan initiated 07/29/2021 and revised 10/27/2021 reflected she has an ADL self-care deficit r/t impaired cognition, hallucinations. Requires extensive assistance by one staff for personal hygiene. Observation and interview on 02/14/2022 at 10:16 AM of Resident # 47 revealed she was scratching her left arm and had long, jagged fingernails. ADON F/Treatment nurse asked her why she was scratching again and Resident # 47 stated, It's my jagged nails. Interview on 02/14/2022 at 2:29 PM with the DON Nail trimming is not documented in the computer system. The best practice is to do it on Sundays, but we ask that it's is done one day a week. When asked how she ensured it was completed, she stated I do walking rounds with the ADONs. When informed several residents had long, jagged nails and fingernails she stated, The system is not working. During an interview with the DON on 02/15/2022 at 9:15 AM, she stated ADL care for men and women included nail care and facial hair grooming as needed or if requested by a resident. She stated that she was aware that nail care and facial hair care were not currently being assigned and that these items needed to be assigned. She stated facial hair care for women should be addressed as needed or as requested. She was not aware that Resident #212 had requested nail care and facial hair care. She was not aware of the requests for podiatry and nail care from residents #105 and Resident #95. She stated that she was not aware of nail care needs for Resident #105. She stated that lack of care for facial hair when requested could lead to a dignity issue for residents and the lack of appropriate nail care could lead to infection control issues for residents. Interview on 02/15/2022 at 11:09 AM with the ADMIN, If a resident wants us to shave them, we will. If a woman has whiskers, we will shave her if she wants it. If nails are dirty, they get cleaned as needed. Nails need to be in good condition and not jagged. We do guardian angel rounds. Every manager has a hall and checks on the residents. This (nail care and shaving) should just be something that gets done.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for four of four residents (Resident #6, #26, #47 and #50) reviewed for pressure ulcers and wound care. A) The facility failed to ensure ADON F followed standard precautions during wound care for Resident #6's right heel and buttock pressure ulcers when she failed to perform hand hygiene, gloves changes or proper wound cleansing. B) The facility failed to ensure ADON F followed standard precautions during wound care for Resident #26's right buttock [CONDITION(S)] [CONDITION(S)] Vesicular [CONDITION(S)] (grouped pustules on a red base) and bilateral medial (inner) knee pressure ulcers. She failed to perform proper hand hygiene, contaminated clean wound care supplies with unwashed hands and failed to perform hand hygiene after contamination of her gloves. C) The facility failed to ensure ADON F followed standard precautions during wound care for Resident #47's open right ankle wound when she failed to perform proper hand hygiene, contaminated clean wound care supplies with unwashed hands, failed to perform hand hygiene after contamination of her gloves and failed to perform proper wound cleansing. D) The facility failed to ensure ADON F followed standard precautions during wound care for Resident #50's Stage 3 coccyx pressure ulcer when she touched clean wound care supplies with unwashed hands, and cleaned across the wound with gauze and normal saline, potentially contaminating it with peri-wound bacteria. (Bacteria on tissue surrounding a wound) These failures could place residents at risk for developing wound infections and hospitalization . Findings include: A) Review of Resident #6's face sheet reflected she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's quarterly MDS dated [DATE] reflected she did not have a BIMS assessment completed. Review of Resident #6's care plan initiated on 05/29/2021 and revised on 06/21/2021 reflected she had actual impairment to skin integrity of bilateral buttocks and right heel DTI. Observation on 02/14/22 at 9:02 AM of wound care for Resident # 6 revealed ADON F reached down to tie her shoes and then opened the treatment cart. She removed a bag of supplies from the cart. She did not sanitize her hands, grabbed plastic medicine cups for ointments and put her unwashed fingers in them. The tray table was not sanitized. She placed a clean drape on it and then touched the top of the drape with unwashed hands. She began working on the computer then with unwashed hands, placed gauze dressing in a package on the drape. She placed sterile Q-tips on top of the drape she touched with her unsanitized hands. She placed a handful of gloves on top of the drape. She touched the resident and her bedding, washed her hands then touched resident again and removed her foot holders. She put gloves on her unsanitized hands and removed the old dressing from Resident #6's right heel, did not wash her hands and re-gloved. She removed her gloves, did not wash her hands and then touched clean supplies in bag to be used for wound care. She then used the contaminated supplies to perform wound care. B) Review of Resident # 26's face sheet reflected she was admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (inflammation of the skin due to [CONDITION(S)] Virus) Review of Resident # 26's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. Review of Resident # 26's care plan reflected she has actual impairment to skin integrity of the right buttock r/t [CONDITION(S)] [CONDITION(S)] Vesicular [CONDITION(S)]. Intervention: Avoid scratching and keep hands and body parts from excessive moisture. Keep skin clean and dry. Observation on 02/14/22 at 9:44 AM of wound care for Resident #26 revealed ADON F did not wash her hands, placed gloves on and cleaned the tray table and computer. She took off her gloves and took supplies out of the cart and placed them on a clean drape. She touched gauze with unclean hands and placed it on the drape. She washed her hands then touched the computer key, tray table, opened the door to the room, grabbed a trash bag off the cart then put on gloves without sanitizing her hands. She touched the resident and her bedding, took her gloves off then touched the door, her keys in her pocket. She put gloves on without washing her hands, removed the dressing from the residents back, cleaned the wound with normal saline, and removed her gloves. She then used hand sanitizer, re-gloved and touched the residents bedding, bed controller and repositioned her. Without removing her gloves or sanitizing her hands, she grabbed gauze, placed wound cleanser on it and cleaned the left inner knee wound, took her gloves off, did not sanitize her hands and replaced her gloves. She put skin prep on the left inner knee, then re-gloved without washing her hands and cleaned the right inner knee with gauze and wound cleanser. C) Review of Resident # 47's face sheet reflected she was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 47's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognitive status. Review of Resident # 47's care plan initiated 07/29/2021 and revised 10/27/2021 reflected she has an ADL self-care deficit r/t impaired cognition, hallucinations. Requires extensive assistance by one staff for personal hygiene. Observation on 02/14/2022 at 10:16 AM of wound care for Resident # 47 revealed ADON F placed gloves on without sanitizing her hands, removed wound care supplies from the cart, took her gloves off, did not sanitize her hands and re-gloved. She placed a handful of gloves on a clean drape, took her gloves off, touched wound care instructions, removed supplies out of a plastic bag and touched gauze with unclean hands. She then touched the inside of two plastic medicine cups in which she placed an antibiotic ointment and Santyl. She then washed her hands and put on gloves, touched the residents brief and clean supplies on the drape. She sanitized her hands, re-gloved, placed a trash bag on the bed, touched wound care instructions, removed the resident's brief, touched the bedding, then cleaned the buttock wound with normal saline and gauze. She cleaned the right ankle and stated it was infected and required an antibiotic. She wiped across the wound from the peri-wound area potentially contaminating it with bacteria outside of the wound. D) Review of Resident #50's face sheet reflected she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's Comprehensive MDS dated [DATE] reflected she was unable to complete a BIMS due to being rarely or never understood. Review of Resident #50's care plan dated 09/18/21 reflected she has potential for pressure ulcer development due to recently healed stage 3. Observation on 02/14/2022 at 10:41 AM of wound care for Resident #50 revealed ADON F placed on gloves, sanitized the tray table and then reached into the bag of supplies touching the gauze to be used for wound care. She used the gauze to wipe across the wound from the peri-wound area potentially contaminating it with bacteria outside of the wound. Interview on 02/14/2022 at 2:00 PM ADON F stated, I hired on a charge nurse and did wound care for 4-5 months in 2020. The DON asked me to do the wound care today. We had a treatment nurse, but she quit. The charge nurses have been doing the wound care. I should sanitize before grabbing clean supplies and before putting gloves on. I could have been putting germs in the medicine cups. I shouldn't put my fingers in the cups. I should have sanitized the tray table. There could have been a contamination of everything. I don't do it (wound care) all the time. I should wash my hands, put on gloves, remove the dressing and then sanitize my hands and put on clean gloves. I could contaminate the wound by cleaning across it with the 4 X 4 's. (gauze) I did dirty to clean without sanitizing. On Resident #50, I was contaminating the wound with peri wound germs. I've not had training on wound care. Interview on 02/14/2022 at 2:34 PM Dr. C stated Anyone that does wound care should have training. By putting her dirty fingers in the medicine cups, that's breaking basic infection control When informed the ADON who did wound care was not sanitizing her hands, not using a clean technique by touching inside of medicine cups with her unclean fingers, used 4 X 4s that she had touched with unclean hands to clean the wound, she stated That's just basic infection control (to not do that) when informed Resident #50 was on [MEDICATION(S)] for her right malleolus ulcer, Yes, that (wound care) could cause problems with infection. I guess they don't think about those things if they don't do it (wound care) all of the time. Interview on 02/15/22 at 11:09 AM the ADMIN stated his expectations for wound care: I recently let go my wound care nurse. We are in the process of getting a new one. The ADONs are doing wound care. ADON F has been filling in. She should know proper nursing procedures and proper infection control. Our DON is ultimately responsible for the check off on wound care procedures and also our ICP. They sign them off. Through RELIAs, (facility computer training program) ADON F should have had courses on infection control and wound care. Interview and record review on 02/15/22 at 11:28 AM with the DON who was asked if there is any proficiency exam for nurses doing wound care. There is a check off list and I observe. When informed wound care was performed with hands not sanitized, touching inside of medicine cups with unwashed hands and touching 4 x 4s (gauze) with unwashed hands and then using them for wound care, My biggest expectation is infection control, that the wound heals and is free of infection. Yes, (the practices mentioned), can cause infection. We have a spot open for a treatment nurse. The DON stated they use the Lippincott Manual for wound care. An inspection of the manual reflected it did not contain a cohesive, step by step procedure for wound care. Interview on 02/15/22 at 11:55 AM with the DON, I don't have any documentation of doing wound care training with ADON F. Review of the facility Infection Control Manuel dated 01/2018 reflected Applying and removing gloves. Perform hand hygiene before applying non-sterile gloves. Review of the facility Infection Control Manual dated 01/2018 reflected The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs. Infection control training topics: standard precautions, including hand hygiene. Transmission based precautions (airborne, droplet, contact) sanitation procedures. Review of the Infection Control Manual dated 01/2018 reflected Infection Preventionist, The Infection Preventionist will provide education and training; and implement evidence -based infection prevention and control practices.

Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 6 residents reviewed for Medication Error. (Resident #1) The facility failed to administer Resident #1's physician ordered medication of [MEDICATION NAME] (Cardiac Drug) Tablet for two days resulting in Resident #1 having to be transported to the emergency room with elevated blood pressure and elevated heart rate. She required hospitalized from [DATE] - 08/01/2019. This was determined to be past non-compliance at a level of isolated harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility's failure to ensure that residents remained free of any significant medication errors could place residents not receiving medications at risk for decreased quality of life and eventually death. Findings include: Review of Resident #1's Face Sheet dated 08/13/2019 reflected an [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's - 5 Day Medicare MDS dated [DATE] reflected a BI[CONDITION] of 13 indicating Resident #1 was cognitively intact. Review of Resident #1's Comprehensive Care Plan dated 05/10/2019 reflected Resident #1 had [MEDICAL CONDITION]. Intervention included, Give cardiac medications as ordered. Review of Resident #1's current Consolidated Doctors Orders reflected an order dated 07/26/2019 for [MEDICATION NAME] Tab 125 MCG , give one tablet by mouth one time every Tuesday, Thursday, Saturday and Sunday. [MEDICATION NAME] Tab 250 MCG, give one tablet by mouth one time every Monday, Wednesday and Friday. Review of Facility's Medication Administration Record for Resident #1 reflected [MEDICATION NAME] Tablet 250 MCG Give 1 tablet by mouth two times a day for heart failure for 1 Day, [ENTITY]t date 07/26/2019 0900. The medication is marked as given but per interview with DON and MA A it was a documentation error. During an interview with MA A she stated she verbally notified Nurse B of the documentation error. Review of Facility's Skilled Administration Record for Resident #1 reflected [MEDICATION NAME] Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure. [ENTITY]t Date 07/27/2019 0900. D/C Date 08/01/2019 1245. [MEDICATION NAME] Tablet 250 MCG ([MEDICATION NAME]) Give 1 tablet by mouth on time only for elevated pulse related to UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION (148.91) until 07/28/2019 23:59 [ENTITY]t Date 07/25/2019 0945. Review of Facility's 24 Hour Summary Report reflected entry 07/25/2019 17:53 - Nursing - Nurse Note - Note Text Resident return from MD appointment with MD C with the following new orders: DC [MEDICATION NAME], increase [MEDICATION NAME] to 40 mg PO BID, DC [MEDICATION NAME] 20 mg, start [MEDICATION NAME] 0.25 mcg po bid x 1 day then 0.125 mcg po Qday. New orders for labs in two weeks need to be sent home with resident upon DC they are for 2 weeks from today on 08/08/2019. Also family will need to schedule an appointment for 08/25/2019 with MD in Smithville. Review of Facility's 24 Hour Summary Report reflected entry 07/26/2019 16:23 - Orders - Administration Note, Note Text [MEDICATION NAME] Tablet 250 MCG Give 1 tablet by mouth two times a day for heart failure for 1 Day. Review of Facility's 24 Hour Summary Report reflected entry 07/28/2019 09:36 - Nursing - Nurse Note - Noted res. diaphoretic, apical pulse 148, mostly regular, res. denies chest pain, has had cardiac med change from appt. on 07/25, phoned MD A, states to administered dig. 240mcg now and monitor for 1 hour, if condition has not changed inform Dr. Review of Facility's 24 Hour Summary Report reflected entry 07/27/2019 09:31 - Orders - Administration Note, Note Text: [MEDICATION NAME] Tablet 125 MCG Give 1 tablet by mouth one time a day for heart failure Review of Facility's 24 Hour Summary Report reflected entry 07/27/2019 11:14 - Nursing - Nurse Note, Note Text: no adverse reactions noted to new medication changes from cardiology apt. resident c/o feeling nauseous at start of shift, VS - 129/[AGE], [AGE] 22, 96.9, 95% on 2 lpm via NC. offered water and hot cereal with breakfast and accepted. after breakfast, resident stated she felt much better. after shower requested to lay in bed. Review of Facility's 24 Hour Summary Report reflected Late Entry 07/28/2019 09:36 - Nursing - Nurse Note - Note Text: Prior to phoning MD A about res. condition, confirmed with MA A, that no [MEDICATION NAME] had been given, MA A verified that [MEDICATION NAME] had not been given and that [MEDICATION NAME] was not on the medication cart and that [MEDICATION NAME]. was on nursing cart. Checked the nurse cart and found Resident #1's [MEDICATION NAME], noted that no medication had been removed from the card, then checked e-kit and noted that [MEDICATION NAME] was available, although no removal slip had been filled out and the container the medication was in was unopened, understanding that res. had not had ordered medication and was having [MEDICAL CONDITION] was diaphoretic, phoned MD A. for more instruction, informed of the above details. MD instructed to give medication as it had been ordered from cardiologist and to monitor for an hour, to consult Dr. if condition worsened. Review of Facility's 24 Hour Summary Report reflected entry 07/28/2019 09:40 - Orders - Administration Note, Note Text [MEDICATION NAME] Tablet 250 MCG Give 1 tablet by mouth one time only for elevated pulse related to UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION (148.91) until 07/28/2019 23:59 administered 1 dose per MA A instruction. Review of Facility's 24 Hour Summary Report reflected entry 07/28/2019 09:51 - Nurse Note, Note Text Correction to previous note, pulse was 158, and dig. dose was 250mcg., F/U on res. diaphoresis subsided, apical pulse 126, B/P 106/[AGE], will cont. to monitor. Review of notes, untitled, dated 07/25/2019, from MD C's office visit reflected, c/w rate control strategy: [MEDICATION NAME]. I will change [MEDICATION NAME] to low-dose [MEDICATION NAME]. Check BM, MG++, [MEDICATION NAME] level in 2 wks. Review of Emergency Department Nursing Record dated 07/28/2019 12:28 reflected E[CONDITION] Reports [AGE] F from NF with A-Fib with RVR. E[CONDITION] states that pt was taken off [MEDICATION NAME] on Wednesday and was to be on dig. Pt was not started on dig until today. 117/[AGE] HR 100-150's AO x 4, Nurses Notes at 15:00 NAD Noted. Tele cont to show afib with RVR rate 120's Review of Hospital's Discharge Summary dated 08/01/2019 reflected, .comes from NF, where she was found to be in [MEDICAL CONDITION] with rapid ventricular response. The patient was taken off [MEDICATION NAME] and put on [MEDICATION NAME] by he primary care physician, but then she did not get [MEDICATION NAME] for 2 days and she apparently went into [MEDICAL CONDITION] with rapid ventricular response. The patient was apparently going into heart failure as well at the same time. The patient initially had significant decrease perfusion in her digits and fingers which were a result of ongoing [MEDICAL CONDITION] and [MEDICAL CONDITION] with rapid ventricular response. During an interview on 08/13/2019 at 10:32 AM, LVN A stated she discovered the medication omission for Resident #1 on 07/28/2019 morning. She denied being aware of who was supposed to have given the Resident her medication. She stated she worked PRN for the facility and usually on the weekends. She stated the cardiologist discarded one medication, changed the dosage on another medication and added a new medication for Resident #1. The cardiologist started Resident #1 on [MEDICATION NAME] on 07/25/2019 after a visit so her first dose should have been 07/26/2019. Sunday, when Resident #1 complained of not feeling well she looked at the MAR and the medication card for the [MEDICATION NAME] and realized she had not received her medication. Prior to calling the doctor, she asked MA A if she had given Resident #1 her [MEDICATION NAME]. MA A told her [MEDICATION NAME] was only given by nurses so she did not give it. LVN A checked the E Kit to see if one was taken from there and it had not been. She called the doctor and notified him of the situation. The doctor directed her to give the initial dose of [MEDICATION NAME] and monitor for an hour. The resident appeared better initially but after an hour her pulse and blood pressure were elevated again. She notified the doctor and he directed her to have Resident #1 transported to the emergency room . During an interview on 08/13/2019 at 11:20 AM, family representative #1 for Resident #1 stated a nurse from the facility called and notified her Sunday morning that Resident #1 did not receive her newly prescribed heart medication since Friday and when her vitals were checked she had increased blood pressure and heart rate. She stated she was told her heart rate was 140 and they were sending her to the emergency room . During an interview on 08/13/2019 at 2:00 PM, family representative #2 for Resident #1 stated the facility admitted to missing the dose of [MEDICATION NAME]. She stated she was told by DON they did not order the medication so had to get a pill from the E Kit. She stated the emergency room doctor told them that Resident #1 was going into organ failure by the time she reached the hospital. She stated her heart was pumping so fast to compensate that her body was going into survival mode and that's the reason her extremities were turning purple from lack of circulation. During an interview on 08/13/2019 at 2:16 PM, LVN B stated the [MEDICATION NAME] for Resident #1 was not on her SAR to give. She assumed it would be on the MAR to give. The [MEDICATION NAME] should have been put on the SAR. 07/26/2019 would have been the initial dose. The nurse who originally put the order in should have put the medication on the SAR. She denied knowing anything about Resident #1's [MEDICATION NAME] until 07/28/2019 when she was contacted by the DON via phone. During an interview on 08/13/2019 at 2:35 PM, MA A stated Resident #1 did not return with any orders on 07/25/2019. When she came into work on 07/26/2019 the [MEDICATION NAME] for Resident #1 was on the MAR. She told LVN B that the [MEDICATION NAME] was on the MAR but Med Aides don't give [MEDICATION NAME] to residents. She stated the actual card of [MEDICATION NAME] was not on her cart on 07/26/2019. She stated she had given [MEDICATION NAME] in the past but policy changed and Med Aides were no longer allowed to give it. She stated she was aware Resident #1 was not feeling well on 07/27/2019. She stated the [MEDICATION NAME] was still on the MAR on 07/27/2019. The actual card of [MEDICATION NAME] was in her med cart 07/27/2019. She told LVN E she did not give Resident #1 her [MEDICATION NAME]. At the end of her shift on 07/27/2019 she gave the card of [MEDICATION NAME] with no medication popped out to LVN C. During an interview on 08/13/2019 at 2:43 PM, LVN C stated according to the report sheet (24 hour report) Resident #1 had a change in medication to [MEDICATION NAME]. LVN C denied anyone asking her about [MEDICATION NAME] for Resident #1. She stated [MEDICATION NAME] was given on the day shift and not the night shift so she assumed the medication had been given. LVN C works the night shift. She stated on 07/27/2019, MA A handed her the card of [MEDICATION NAME] for Resident #1 and she put the card in the Nursing Med Cart. She told LVN A the [MEDICATION NAME] was in the Nursing Med Cart. She stated she checked the [MEDICATION NAME] in on 07/25/2019 night and scanned it into the computer and placed it in the nurse med cart. When asked who was responsible for adding the medication to the MAR or SAR she stated whoever got the order from the doctor would be responsible for adding it to the MAR/SAR. During an interview on 08/13/2019 at 2:55 PM, LVN D stated she entered the orders for Resident #1's [MEDICATION NAME] into the system on 07/25/2019 in the afternoon. She stated the medication should have been put on the SAR but she had a habit of putting medications on MAR and staff would usually tell her, it's on the wrong MAR. She was on vacation from 07/26/2019 until 08/07/2019. The medication should have come in 07/25/2019 at the evening delivery so it would have been set to administer on 07/26/2019. During an interview on 08/13/2019 at 3:10 PM, LVN E stated she worked 07/27/2019 and found the card of [MEDICATION NAME] on her Nurse Med Cart but there was no order for it on the SAR. She denied anyone asking her about the medication. She gave the card of [MEDICATION NAME] to MA A and told her the medication was on the Nurse Med Cart in error. When asked if she was aware of the facility's policy for Medication Aides to not give [MEDICATION NAME] she stated she was not. She stated she only worked PRN at this facility and at the facility she usually worked at the Medication Aides were allowed to give [MEDICATION NAME]. During an interview on 08/13/2019 at 4:49 PM, DON stated MA A had clicked on the medication on the MAR to give then realized it was [MEDICATION NAME] and informed the nurse it was on her schedule but needed to be given by a nurse. MA A's signature on the MAR on 7/26/2019 is a documentation error. Per facility's investigation the nurse responded Ok but did not administer the medication. When asked about PRN staff being oriented and inserviced, she stated they were. She went on to say if we had to we call and complete the inservice via phone then we handled that way. She stated she spoke to LVN E via phone on 07/28/2019 to inservice her regarding nurses giving initial doses of [MEDICATION NAME] and moving forward only nurses would give [MEDICATION NAME]. She denied there being any changes to Resident #1's care plan as a result of her trip to the emergency room and subsequent hospital stay. Her expectation is that medication is administered as prescribed. During an interview on 08/14/2019 at 8:38 AM, MD A stated it was not only the absence of [MEDICATION NAME] that caused Resident #1 to have to go to the emergency room but the absence of the medication [MEDICATION NAME] that Resident #1's cardiologist had taken her off of 07/25/2019. Both Diltazem and Digoxen are prescribed to regulate heart rate and she did not receive either from 07/26/2019 to 07/28/2019. He stated his expectation for Resident #1 as well as all his patients at the facility is that medication is administered as prescribed. During an interview on 08/14/2019 at 12:38 PM MD B stated the absence of [MEDICATION NAME] could have been a contributing factor if she had [MEDICAL CONDITION]. During an interview on 08/14/2019 at 2:00 PM, ADM stated moving forward [MEDICATION NAME] has been removed from the MAR and placed on the SAR. His expectation is that medication is administered as prescribed. Review of Facility's Policy, Medication and Treatment Orders, dated Revised December 2017 reflected, Orders for medications and treatments will be kept in the electronic and/or paper chart, Medications shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state. It was determind past non-compliance existed and placed Resident #1 in an isolated harm situation from 07/26/2019 - 08/07/2019. The facility took the following action to correct the siutation of isolated harm on 07/28/2019 - 08/07/2019. 1. The day the incident was discovered, 07/28/2019, nurses and CMAs present at the facility were inserviced as well as staff directly involved were inserviced via phone calls. 2. Nurses and CMAs have been re-educated on following physician orders [REDACTED]. 3. The Cardiac Physician Assistant to MD #3 provided an inservice to nurses and CMAs regarding cardiac medication and signs and symptoms of cardiac events. 4. The facility initiated and policy to have nurses check that all medication had been administered at the end of each shift. Additionally, all orders are checked nightly 5. PRN staff will be educated and re-educated prior to working a shift at the facility.

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for one (1) of eleven (11) residents reviewed for neglect (Resident #3). Resident #3, who had standing physician orders [REDACTED]. Resident #3 choked on her food while eating lunch on [DATE]. The resident required EMS intervention to remove food that had lodged in the resident's throat and was transported by ambulance to a local hospital for assessment and treatment. While en-route to the hospital, the resident stopped breathing, necessitating resuscitation. This deficient practice could affect 19 residents identified with mechanically altered diet orders by placing them at risk for choking, aspiration, hospitalization , and death. Findings include: Review of Resident #3's Face Sheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE], reflected a BIMS score of 7 which indicated severe cognitive impairment. Eating was assessed as needing no setup or physical help from staff to needing setup help only. Swallowing/Nutritional Status was not assessed Review of Resident #3's Treatment Encounters Notes dated [DATE], reflected, Discussed diff (difficulty) w/meat- wrote order to chg diet, at least temporarily to try to up oral intake and lower aspiration. Review of Resident #3's Physician order [REDACTED]. Review of Resident #3's Diet Orders reflected the resident's diet changes: · [DATE] Change diet to mechanical soft meats. (SIC) Review of Resident #3's Care Plan dated [DATE] and edited [DATE], reflected no entry regarding type of diet. The Care Plan did reflect an ADL intervention of Nursing will make sure diet meets the needs of the body. Review of Resident #3's Care Plan dated [DATE], reflected a problem under the category of Communication Difficulty swallowing RT (related to) choking episode on [DATE]. (34 days after the choking incident.) Review of the Pre-Hospital Care Report (Ambulance Report) Summary Dated [DATE], reflected Resident # 3 was transported to a local facility. Narrative History Text revealed, Unit 925 responded emergent to an 82 y/o (year old) female who was choking on a piece of chicken, PT (patient) was found sitting in her wheelchair, staff report the PT was eating when another resident pointed at the PT and called for help, staff report they moved her to her room and attempted abdominal thrust but were unsuccessful, PT had difficulty breathing and had stridor (noisy breathing in general, and to refer specifically to a high-pitched crowing sound associated with croup, respiratory infection, and airway obstruction) and cyanosis (a physical sign causing bluish discoloration of the skin and mucous membranes. caused by a lack of oxygen in the blood) around her lips. Pt was assisted with standing and abdominal thrust were performed but were not successful. PT started to breathe on her own and started to talk. Pt was placed on O2 and the cyanosis started to disappear. Pt reported she felt dizzy and SOB. Pt denied any pain, weakness, nausea. Pt was lifted off the ground and placed on the stretcher. Pt's SOB started to worsen and she started to have stridor again staff report that this was how the Pt presented the first time. Pt's airway was looked in with laryngoscope and magill forceps were used to attempt to remove a second piece of chicken but was unsuccessful. Pt was move to the ambulance and secured. Pt lost consciousness and was unresponsive to painful stimuli. And turn Cyanotic while en route. Pt started to have agonal (Pertaining to death or extreme suffering) respirations and still had a pulse as we pulled into ambulance bay. Pt care was transferred to the nurse. The nurse was told about the Pt's condition and interventions. Crew was delayed at destination due to assisting ER staff with the Pt. Review of Resident #3's Nurses Progress Notes reflected: ·[DATE] 12:49 PM: 12:00 PM noted res (resident) to be choking on her lunch. RN immediately at res side. Noted to be breathing but wheezing. Pale in color. Able to talk softly. Shook head yes when asked if she was choking. Res taken to her room. Res became unresponsive, [MEDICATION NAME] preformed several times not effective. Oxygen applied via NC. EMS in facility for another res and come down to assist. EMS able to remove a piece of chicken from res. Throat via deep suctioning and tongs. Breathing then returns to normal and res becomes talkative and alert. Res put on stretcher to be taken to hospital. After on stretcher res has [MEDICAL CONDITION] activity. EMS transported res to hospital. Res RP (responsible party), was made aware. In an interview on [DATE] at 8:15 AM the Temporary Dietary Manager, stated I have been a temporary manager since last February. (SIC) I was not here the weekend Resident #3 had choked. I came back in the following Monday and was asked about the residents diet and Resident #3 was on a Mechanical soft diet. The Mechanical Soft diet was in the computer and on the printed food slip. I am not sure where the mess up was. I placed the change in the computer in February 2016 and posted for the shift cooks the same time the Dietary Manager passed away in a fatal car accident. Aides are held accountable for the resident's meal to be checked with the food slips. I think the time of the incident was the first time she was given Regular Diet instead of Mechanical Soft Diet. I don't know how she got a regular diet that day. It was not an issue prior because the resident was getting Mechanical Soft diet up until the time of the choking . (SIC) In an interview on [DATE] at 4:50 PM, CNA K stated, I take care of residents, I look at the tickets to make sure food is what each resident likes. If there is an error I let the Charge Nurse know and correct. I remember the Regular Diet for Resident #3 the day of the choking. I served Resident #3. The food was not cut up properly. Resident #3 was on Mechanical Soft diet up until that day. That day of choking Resident #3 was served a whole chicken leg. I took the meat off the bone for the resident. I did not get the meat small enough for her and she choked. It is normally CNA's job to cut food for Mechanical Soft. I know what Mechanical Soft food is by on the job training with co-workers. I have not had an in-service for it. In an interview on [DATE] at 9:47 AM, RN E stated, I work the weekends at (Name of facility). I am retired. I have worked there a couple of years as the weekend supervisor, 8 hours RN. I was working the Saturday that Resident #3 choked. I was sitting at the feeder table when a resident said we have a problem over here. I went to Resident #3 and she was barely talking and coughing. I told the CNA to get the nurse, she came and Resident #3 was still coughing. I decided to take her away from here in the wheel chair. Upon entering the resident's room the nurse tried to do the Heimleich with the resident in the wheel chair while I went to get EMS. EMS was in the building, they came, stood Resident #3 up to do another full Heimleich. When they stood her up she started having [MEDICAL CONDITION] symptoms. EMS put Resident #3 on the floor. A Laryngeal Scope and Tongs were used to pull the meat from the resident's throat. Once removed Resident said, Ah, that's better. EMS put Resident #3 on the stretcher and took her to the hospital. The reason I did not perform the Heimleich at the table was because I was taught that when the person is still coughing and talking to not do the Heimleich. Resident #3 did not stop coughing until we got her to the room. The incident happened at lunch time. In an interview on [DATE] at 1:30 PM, LVN A who was the residents Authorized Representative stated, I was not here the weekend (Resident #3) choked. I was off. I work on the opposite end of the facility from (Resident #3) because I am also the AR for (Resident #3). CNA's and groups of staff pass trays to residents daily. The trays are not checked all the time like it should be done. Checking trays is not something that is normally done. I normally see mechanical soft and puree come out of the kitchen but once in a while it will be wrong and I will go to kitchen to correct. The speech therapist is the one that put Resident #3 on the Mechanical Soft diet with thickening liquids. The swallowing study was done at the hospital and that is when she was put on a Puree diet. Observation of the kitchen on [DATE] at 12:00 PM, revealed that the kitchen served hot dogs and cabbage rolls for lunch. The staff was not observed cutting up food for any mechanical soft orders. In an interview on [DATE] at 9:45 AM the Administrator stated, There is no procedure on how to handle food and trays after the trays leave the kitchen. No procedure to check. In an interview on [DATE] 3:40 PM, the Administrator brought the Temporary Dietary Manager in the room to explain that she knew what a puree diet was. The Temporary Dietary Manager stated that the hot dogs would have been mashed but when asking why the cabbage roll was served whole she responded it should have been cut up. When asked if spot checking was efficient, the administrator stated, QA is not going over all the orders. I will put stronger guidelines in place and spot checking is not efficient. Review of the facility's Statement of Process for Dining Room Service (undated), provided by the Administrator, reflected, Nursing Department: the process for CNA's monitoring Dining Services. It is the process of this facility to review the resident's tray card against what is on the plate with the resident's food preferences. Process for Monitoring Dining Service: ·1 Licensed Nurse has visual from nurses' station for monitoring and assists C.N.A. as needed. ·2 C.N.A's look at tray card at time of service, if a discrepancy is noted, the Charge Nurse is notified. ·3 Charge Nurse takes appropriate action. In an interview on [DATE] at 2:55 PM, DON stated, The QA process is the Dining Experience there is no policy. Nursing Management goes out in the dining room on a rotation shift Monday thru Friday at each meal, each take a turn checking the meals to the tray cards. This has been in process for about 1 year. The system break down occurred where the QA Nurse did the comparing; there was a system break down. There was a system break down after the dietary manager was killed. We will have in-services with kitchen staff, CNA's and licensed staff as well. In an interview on [DATE] at 3:00 PM, the Administrator stated, The Dining Experience has been in place for 2 years. The Nursing Management goes out on in the dining room three times per week. The Dining Experience is discussed in the morning meetings. We discovered the system break down during our investigation. I don't know how it happened February to April MDS missed order in February, we found in [DATE]. Dietary has a weekly process. There was a Human Error. We will now highlight the changes to diets to each tray card. Check Nurses station for changes. We have had in-services. CNA's have been instructed to what a Regular diet, a Mechanical Soft and a Puree diet are. In an interview on [DATE] at 3:30 PM the Dietary Consultant stated The expectation is the Mechanical Soft diets come out of the kitchen Mechanical Soft . Review of the Addition to the Dining Room Experience policy provided by the Administrator with no letter head or signatures reflected, Beginning immediately [DATE], the charge nurse will be responsible for a full rack tray check at each meal. The charge nurse will need to look at every tray card and match the dietary card to the diet items on the tray. In an interview on [DATE] at 9:00 AM, Speech Therapist G stated, I worked there for 3 years. My last day was [DATE]. I worked with two or three residents on speech therapy. I worked with anybody, worked with residents and their swallowing. I observed meals which was common. I was not here the day that Resident #3 choked. There was no swallowing study done up to that point for Resident #3. Resident #3 was on a Mechanical Soft diet since February 2016. I recall Resident #3 receiving the Mechanical Soft diet up to the time of the incident. When I returned to work the diet was modified because of a study done while Resident #3 was at the hospital. The study recommended a Puree Diet. Resident #3 was scared of choking and was doing well on the Puree. The food normally comes from the kitchen Mechanical soft or Pureed. Normally, for example, meatloaf is soft but would be cut up by the CNA's. In an interview on [DATE] at 12:30 PM, Line Server L stated, The food tickets are printed by the Manager daily and provided to us. I don't know what food should be on the tickets. The Aides are the ones that touch the tray after we load the food onto the carts. They serve the trays to the residents. In an interview on [DATE] at 8:15 AM the AR (Authorized Representative) stated, Up until the day of the choking, I am not sure if she was getting Mechanical Soft diet or not. I was told there was a mess up on the computer and Resident #3 was given a Regular diet the day she choked. Since that day, Resident #3 is getting a Puree diet. I have been down there to check and once there was a regular coffee. I took the problem to the RN station. I talked to Resident #3 and said you know you're not supposed to have the regular coffee. (Resident #3) said, Sometimes I get this or that. It was corrected at that time and the RN took the coffee away. I have not seen mother (Resident #3) receive anything in error again but I am not always able to go check. When I received the call that mother (Resident #3) had been taken to the hospital, she received the wrong meal. I went down there. Mother (Resident #3) was put on a Vent in the ambulance because she had stopped breathing. Mother was on the Vent for about 8 hours. The EMS doctor said that he had her in one hand and the DNR in other hand and made the choice to save her, I said, thank you. When I explained to mother (Resident #3) that she had died from the choking incident, Mom (Resident #3) stated, I don't want to be brought back. I explained that this was different. There were no residual effects to mother (Resident #3) when she came back to the facility after the accident. She seems fine. I am not involved with her care planning, but I do attend the meeting as a family member. In an interview on [DATE] at 12:20 PM the Administrator stated, There was no Dietitian here at the time and the QA nurse had no one to communicate with, so the job was not done. We picked it back up in the 1st of May. The dietary personnel was killed in February and we did not start again until May when we caught the error. QA Nurse did not talk to supervisor to find out how to get the job done of reconciling dietary orders. Review of Resident #3's Patient Discharge Information dated [DATE] from local hospital reflected Findings: Interval placement of NG tube with tip extending below the film, but at least into the gastric body. ET tube remains well-positioned. Airspace disease at the left mid and left lower lung appears similar. Discharge Diagnosis: [REDACTED]. Patient Info: Full Code/Full Resuscitation-Category 1. Recent changes: [MEDICAL CONDITION] with [MEDICAL CONDITION], brief period of PEA arrest after choking on food. Review of Resident #3's Bedside Swallow Evaluation SLP Entered on [DATE] 13:27 CDT. Performed on: [DATE] 13:30 CDT reflected the recommendation of a Puree Diet for Resident #3. PT is 82 yo female adm (admitted ) from NH- had episode of choking at NH- attempted Heimleich there and was not successful. Brief PEA arrest. On intubation, retrieved large food bolus from oropharynx. Extubated same day, [DATE]. Bedside swallow eval completed. Review of Resident #3's Video Swallow Evaluation stated: Entered on : [DATE] 13:44 CDT Performed on [DATE] 13:35 CDT reflected [DATE] PT is 82 yo female adm from NH- had episode of choking at NH- attempted [MEDICATION NAME] there and was not successful. Brief PEA arrest. On intubation, retrieved large food bolus from oropharynx. Extubated same day, [DATE]. Bedside swallow eval completed. In an interview on [DATE] at 12:00 PM, the QA Nurse stated, I do not know how or why the system broke down; I was not here the day that Resident #3 choked. QA Nurse refused to respond to break down questions and stated, I take care of drug destruction, shots, labs and vaccinations. Review of the facility's policy Procedure for Dietary and Pharmacy Consult Reports, provided by the Administrator, with no dates or signatures reflected that the QA Nurse is responsible to ensure that the nurse updates the supplement/dietary care plan. In an interview on [DATE] at 12:10 PM, when asked why Resident #3's Care Plan was not updated to reflect a Pureed Diet, the MDS Coordinator stated, I did not think to do it. Observation of Resident #3's meal tray on [DATE] 5 PM, revealed the tray had been returned to the kitchen because Resident #3 had been provided with puree carrots, which was listed as a dislike.on her tray card. The Resident had requested fruit instead. Review of Resident # 11's meal card reflected Diet: MS (Mechanical Soft diet.) Observation of the Dining Room on [DATE] at 12:00 PM, revealed Resident #11's food tray was delivered to the Dining Room, where the DON caught the plate had a whole burger on it instead of a Mechanical Soft burger. The plate was returned to the kitchen for correction prior to it being served.to the resident. Review of Resident # 11's progress notes for [DATE] at 5:03 PM, reflected New order change in diet to mechanical soft. Review of Resident # 11's tray card reflected diet: Mechanical Soft. Review of Resident #11's Order Report by Category, reflected [DATE] Diet: Mechanical Soft. In an interview on [DATE] at 12:00 PM, when asked about the error in Resident #11's meal, Line Server M stated, I do not know how the mess-up happened, Sorry. I called the Mechanical Soft diet out, things move fast and we have to hurry to keep the food hot. Review of the Facility's policy and procedure for Care Plans dated ,[DATE]//2010 reflected the policy of to develop an initial plan of care for each resident: 1 To assure that the resident's immediate care needs are met and maintained, and initial care plan is developed upon admission. 2 The interdisciplinary team reviews the attending physician's orders [REDACTED]. diet, medications, treatments, etc) and implements a nursing care plan to meet the resident's immediate care needs. 3 Initial care plans are used until the comprehensive care plan has been completed. Review of the Facilities policy and procedure for Care Plans dated [DATE], reflected: It is the Policy of (Facility) that the care plan team develops a comprehensive care plan for each resident within seven (7) days of completing the resident assessment minimum data set. 1 A comprehensive care plan is developed within seven (7) days of completion of the resident assessment Minimum Data Set. 2 The care plan is developed by a team. Review of the facility's policy and procedure for Care Plans dated [DATE], reflected, It is the policy of (facility) that care plans incorporate goals and objectives which lead to the resident's highest obtainable level of independence. 1 Goals and objectives are defined as the desired outcome for a specific resident problem. 2 Goals and objectives are: A. Resident oriented; B. Behaviorally Stated; C. Measurable; and D. Within a specified time frame. 3 Goals and objectives are entered on the resident's care plan so that each discipline has access to such information. 4Goals and objective are reviewed and /or revised: A. When there has been a significant change in the resident's condition; B. When the resident has been readmitted to the ministry from a hospital stay; and C. at least quarterly. Review of the facility's policy: Procedure for Dietary and Pharmacy Consult Reports provided by the Administrator, reflected no date, signatures, or letter head and reflected: · The DON or designee will put the written recommendations in the proper provider's folders for review and either approval of the recommendation or new order. · Dietary recommendations will be immediately implemented by the nursing dietary staff. · If it is dietary change-you will need to fill out a dietary order modification form and bring that to the dietary manager, who is responsible for updating the care plan and dietary card. · QA and dietary manager will meet monthly to ensure that Matrix dietary order and Touch Point order system information matches. The facility's DON provided a list of 19 Residents on mechanically altered diets.

Based on observation, interview and record review, the facility failed to supervise and ensure the safety of 1 of 6 residents who smoke to prevent an incident that resulted in a fire and a burn injury to Resident #1. Resident #1 had a known history of cognitive impairment, functional decline, and tobacco abuse. Oxygen was being administered from an oxygen concentrator through tubing and nasal cannula. The nebulizer apparatus and nasal cannula tubing caught fire as she lit the lighter. The resident suffered first degree burns to her right wrist and smoke inhalation requiring emergency treatment. This resulted in an Immediate Jeopardy (IJ). The IJ was removed on 01/07/11 at 5:05 PM, following acceptance of the Plan of Removal and verification interventions were initiated. The facility remained out of compliance at a Severity level of actual harm at an isolated Scope. This deficient practice placed 42 of 91 residents residing on 1 of 2 wings (East) at risk of injury of burns and/or smoke inhalation from fire. Findings include: Review of Resident #1's Physicians' Orders dated 11/12/10 documented a [AGE] year old female admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #1's Physicians' Orders dated 11/12/10 documented Oxygen use at 2 liters per nasal Cannula continuous for COPD. The Resident also had a Physicians' Order for a Nicoderm patch topically daily every 24 hours. Review of Resident #1's Admission Assessment Form dated 11/12/10 indicated: Level of consciousness: The resident is Alert. Her long and short term memory is okay. The resident's cognitive skills for decision making are independent. The resident is able to make self understood, and understands others. Respiratory Function: The resident experiences difficulty breathing and shortness of breath. The Safe Smoking Evaluation indicated on the Admission Assessment Form lacked documentation and indicated, "Not Applicable". Review of the Resident #1's Updated Physician order [REDACTED]. No smoking assessment was found for Resident #1. Review of Resident #1's Care Plan dated 11/19/10 indicated: The resident has difficulty remembering new situations. Goal: The resident will be cued on new situations daily. Approach: The resident will be cued by staff. The resident will be assisted with decision making. The functional status of the resident Extensive; level of supervision: within eye sight for smoking; resident not ambulatory, resident interviewable but not reliable; the resident not capable of making informed decisions. Review of Nurses notes dated 12/7/10 indicated: 12/7/10 at 5:00 PM-Fire Alarm sounded. The Administrator and staff arrived to room and noted black smoke filing the room. The resident was removed from the room. Noted 3 ? inch in diameter soot (debris), on the back of the resident's right wrist, and a small burn noted on the resident's left thumb and forefinger. No burns noted to the resident's nose or soot (debris) on face. Oxygen was reapplied per nasal cannula after assessment. The emergency response System was contacted 12/7/10 at 5:30 PM-Emergency Medical System arrived. The resident's Oxygen Saturation was assessed at 67%. Oxygen was administered at 3 liters. The resident's Oxygen Saturation increased to 90% after several minutes. The resident was then taken to the emergency room via ambulance for evaluation and treatment. Review of the Hospital Discharge assessment dated [DATE] indicated: Diagnoses: [REDACTED]. Resident #1 on 12/7/10 at 9:00 PM returned to the facility. The resident was moved closer to the Nurses Station per family request. On 12/21/10 at 08:30 AM, Resident #1 was observed sitting in her wheelchair with her portable Oxygen tank secured in the back of her wheelchair. In an interview on 12/21/10 at 2:00 PM the Director of Nursing (DON) stated Resident #1 was admitted with an order for [REDACTED]. She further indicated an order was received from the physician which indicated the Resident could smoke 5 cigarettes per day. The DON further stated the Resident did not have a doctor's order allowing her to keep cigarettes and/or lighters with her. Therefore, both were kept at the nurse's station. The DON investigated the fire incident and interviewed the resident's son, who alleged the Resident's cognitively impaired brother left a lighter in the resident's room during a previous visit. He further alleged the Resident got a hold of the lighter and attempted to smoke a cigarette, which resulted in the fire. The DON further indicated she did not investigate the son's allegations or put systems in place to prevent family members from leaving items in the Resident's room that would compromise the Resident's safety. In an interview Licensed Vocational Nurse #A (LVN #A) on 12/21/10 at 2:15 PM stated at the time of the incident the fire alarms were being tested . She observed a lot of thick gray smoke coming out of the Resident #1's room. When she arrived on the scene it appeared the concentrator and the tubing of the nebulizer was on fire. She stated the Resident and roommate were immediately removed from their room; they were both taken outside and triaged along with all other residents on the unit at the time of the incident. She further indicated there were no other injuries, other than, Resident #1 wrist stained with black debris. In an interview on 12/21/10 at 2:45 PM LVN #B stated, "The problem with Resident #1's smoking was nothing new." The concern is not just one family member, but several. The Resident had six brothers, and lots of other the family members who visit. She stated any one of them could have left the lighter in her room. She further stated, prior to the fire incident she failed to report to the DON she witnessed family members taking Resident #1 outdoors to smoke with her oxygen concentrator or portable tank attached to her wheelchair. She also failed to report she learned from other staff prior to the fire incident that there is another resident who lends Resident #1 cigarettes. She further stated, "Residents who are allowed to keep lighters, probably shouldn't; and residents who smoke out doors are not always supervised for smoking safety, although they should be." In an interview on 12/21/10 at 3:00 PM the Administrator stated that he, all available staff and the physician responded immediately to remove Resident #1, her roommate, and all other residents who were on the unit from harm's way during the fire incident. He also indicated all affected residents were triaged by the physician and were determined to have no injuries. Resident #1 was found to have a first degree injury on her right wrist, and was treated with oxygen due to confusion and decreased oxygen saturation (amount of oxygen in the blood). She was sent to the local hospital for an evaluation and shortly thereafter returned to the facility with a small Band-Aid to her right wrist. He further stated, he is aware his staff failed to report important occurrences prior to the fire incident, and he is currently addressing the problems. Although the fire incident was investigated, much of the work involved was not documented. He further indicated, new policies, procedures, and Care Plans were in the process of being written, and would be effective as of 12/21/10 to ensure the safety of residents who smoke, as well as the safety of all residents. On 01/07/11 at 9:30 AM, the facility Administrator and DON were informed additional information regarding Resident #1's injury on 12/07/10 was required and the visit was re-opened. In an interview on 01/07/11 at 9:35 AM, Certified Nurse Aide (CNA) F stated Resident #1 was usually outside in the front or trying to go outside to smoke. She stated she observed Resident #1 with her own cigarettes. She was not sure if she had ever seen Resident #1 with a lighter, but she was sure she had seen her carrying her own cigarettes. She stated that Resident #1 was confused and had poor judgment. In an interview on 01/07/11 at 9:45 AM, CNA G stated that Resident #1 was a very sweet lady, but a little confused. She stated Resident #1 needed constant reminders to keep her oxygen on and also stated she observed Resident #1 with her own cigarettes. CNA G stated she observed Resident #1 several times, dragging her oxygen concentrator down the hall to go outside to the smoking area. In an interview on 01/07/11 at 10:15 AM, CNA H stated Resident #1 was confused and tried to take her oxygen out the back door. CNA H stated only certain smokers allowed to have their lighters on them, but that was supposed to happen, but did not always happen. CNA H stated the other Residents that were not supposed to have lighters were observed from time-to-time with lighters on them, including Resident #1. On 01/07/11 at 10:30 AM, the Administrator and DON were informed of the findings as well as the initial interviews, which placed the facility in "Immediate Jeopardy" (IJ). The Administrator and DON stated they had already started training the nurses and staff in the following areas: smoking policy, assessments, hazardous materials searches and reporting. On 01/07/11 at 2:10 PM the facility submitted the Plan of Removal. The Plan of Removal as submitted by the facility is as follows: 12/07/10, staff instructed by administration to search all rooms for any smoking paraphernalia and remove immediately (i.e. lighters, matches, cigarettes, etc.). All smoking paraphernalia removed. 12/07/10, Resident #1 immediately was triaged by a new doctor and DON. Lung sounds clear. Resident transported to (a local ER) for smoke inhalation. Resident #1 returned with no new orders. 12/07/10, Resident #1 quit smoking. 12/08/10, a sign was posted on the exterior doors for visitors to turn in all smoking products for Residents to the nurse's station. 12/08/10, DON placed a memo at nurse's station and instructed staff on safe use of oxygen (O2). 12/09/10, all staff in-serviced (attached), search, removal of all cigarette paraphernalia, hazardous materials, and continuing to removal all hazardous materials daily, including smoking paraphernalia (83% of staff attended). 12/21/10, all staff in-serviced on new smoking policy (regulations attached), emphasizing that no Resident is to have, in their possession, any smoking paraphernalia. All smoking paraphernalia needs to be kept locked in the medication room (med) at the nurse's station, only handed out by charge nurse, with direct supervision by staff, at designated times. Nursing rounds, by nursing staff, to search every Resident room for smoking paraphernalia, hazardous materials, every Sunday. All staff to remove any smoking paraphernalia and hazardous materials (70% of staff attended). Reviewed, as part of plan of removal, a new form to be used for Resident assessments, also reviewed a new smoking policy and safeties of oxygen. The memo dated 12/08/10 reads as follows: A. Make sure all Residents using O2 have a no smoking sign on the door. B. Continuing not having any smoking paraphernalia in room or on person and removed immediately. C. Staff to do rounds weekly to check for and remove any hazardous materials. D. Again, staff to do rounds to remove any lighters, matches, etc. E. All smoking should be in designated areas, smoking areas, or outside, as smoking is not allowed within 15 feet of oxygen use. Facility Smoking Policy Each Towers Nursing Home Resident has the right to be in a safe environment. Towers Nursing Home will inform Resident and staff if there is another affected party for smoking policies. Towers Nursing Home smoking policy includes the following provisions: 1. Smoking within the facility is prohibited, with the one exception that this policy would not in any way infringe on Resident rights. 2. Residents will be allowed to smoke only in designated smoking areas and only at designated smoking times. 3. Resident designated smoking areas: A. Station 2 designated smoking area near the DON office. B. Station 2, front porch. C. Station 2, garden patio. D. Station 1, front porch. 4. Resident designated smoking times will be limited to one cigarette or 15 minutes. 5. Resident designated smoking times are 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 2:30 PM, 4:30 PM, 7:00 PM, 9:00 PM, 12:00 AM, and 3:00 AM. 6. Employees will be allowed to smoke outside the facility in the designated smoking areas: A. Station 2, front porch. B. Station 2, garden patio. C. Station 1, front porch. 7. There will be no smoking for Residents with O2 use in progress. 8. There will be no O2 concentrators or cylinders allowed in any smoking areas. 9. All Resident smoking products must be kept at the nurse's station. 10. Resident will not be allowed to keep, in their possessions, smoking tobacco or products. 11. "No Smoking!" signs will be posted where flammable liquids, combustible gasses, or oxygen are used or stored in any of the other hazardous locations. 12. Do not use O2 concentrator in showers rooms. Only portable O2 cylinders are to be used. *This policy replaces all previous policies. In an interview on 01/07/11 at 1:00 PM, LVN B stated she recently received additional training on the safe use of oxygen and smoking materials. LVN B stated the new facility policy included specific smoking times, as well as supervision for all resident smokers. She also stated Resident #1 had signs on the door instructing the family to go to administration before going into the Resident's room. LVN B stated no Residents were to have, in their possession, lighters, matches, or any hazardous materials, and the nurses were responsible for handing out the lighters to the supervising staff. She also stated on Sundays the nurses and all staff were to do a search of the facility and resident rooms, specifically for fire materials. In an interview on 01/07/11 at 2:15 PM, CNA G stated she received training on a new smoking policy and reporting problems to nursing. CNA G stated the residents must be supervised by staff during the smoke break. She said, the residents now have scheduled smoke breaks and cannot hold smoking materials. CNA G stated a staff member must hold the lighter and light the residents' cigarettes. In an interview on 01/07/11 at 2:20 PM, CNA F stated she received training on the new smoking policy. CNA F also indicated the staff were now required to conduct scheduled and random searches for safety hazards. In an interview on 01/07/11 at 2:30 PM, CNA H stated she recently received training on the smoking policy and indicated the new policy included specific smoking times and staff supervision during smoking periods. The facility plan of removal was accepted and the IJ was removed on 01/07/11 at 5:05 PM. Although verification through observations of residents who smoke cigarettes and staff interviews indicated the facility Plan of Removal had been initiated, the facility remained out of compliance at a Severity level of actual harm at an isolated Scope due to lack of sufficient time to complete the Plan of Removal. The Administrator provided the Resident census of 91; Six (6) Residents smoked cigarettes and 42 Residents resided on the East Wing.

Based on observation, interview, and record review the facility failed to implement their written policy and procedure on completion of weekly head to toe skin assessments. A pressure sore developed on 1 of 3 sampled residents (Resident #1) reviewed for pressure sores. Two of three Licensed Vocational Nurses (LVNs) (LVN B and C) failed to remove Resident #1's right leg brace and complete the weekly head to toe skin assessment, per facility's policy and procedure, to prevent development of a Stage IV pressure sore. An infected Stage IV (four) pressure sore (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures), measuring 4 centimeters (cm) length x 3 cm width x 0.5 cm deep, was initially identified on the right popliteal (behind the knee area) by the Facility's Wound Care Physician on 11/23/10. This deficient practice could affect 2 residents. The facility's failure to provide necessary services to identify and prevent pressure sores resulted in Resident #1 developing an avoidable Stage IV pressure sore to the right popliteal area and suffering actual harm and could place residents with pressure sores, at risk for delay in treatment and deterioration of current pressure sores. The findings include: Review of undated Policy and Procedure titled Weekly Skin Assessment Nurse documented the following: Policy - All residents are minimally required to have a head to toe skin assessment upon admission, re-admission, with significant change of skin condition, transfer/discharge, and weekly. A weekly skin assessment nurse shall be designated to perform and work with other staff to see that all residents skin is assessed on a weekly basis. Observation on 12/01/10 at 9:40 AM revealed Resident #1 in a wheelchair, in her room, trying to propel herself around her room mate, to the room door. In an interview at that time, Resident #1 stated her right leg hurt a little. Resident #1 continued to talk at a low voice that was difficult to understand. Continued observation on 12/01/10 from 9:40 AM to 9:48 AM revealed Licensed Vocational Nurses (LVNs) LVNs A and B provide Resident #1 wound care to the Stage IV pressure sore, on her right popliteal leg. In an interview at that time, LVN B stated Resident #1 acquired the Stage IV pressure sore to her right leg at the facility. LVN B removed the dressing and measured the pressure sore. The pressure sore measured 5.5 cm length x 4.0 cm width. There was no drainage and the wound bed had pink tissue with a small amount of slough (dead tissue separated from living tissue). The pressure sore was cleaned with wound cleanser and an antibiotic cream was applied to the wound. A dressing was applied to the pressure sore by LVN B and she initialed and dated the dressing. During the wound care LVN A stated the Wound Physician was at the facility yesterday and debrided (removal of dead tissue from a wound) the pressure sore to the right leg. LVN B stated she could see a tendon (fibrous connective tissue serving for the attachment of muscles to bones) in the pressure sore last week. During the wound care Resident #1 made facial grimaces and told LVN A her right leg hurt. LVN A stated Resident #1 had a dose of [MEDICATION NAME] at 6:00 AM and would get her another dose for breakthrough pain. Review of Resident #1's Record of Admission sheet dated 08/18/10 documented she was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Sheet (MDS) Admission assessment dated [DATE] documented she had 3 Stage II pressure ulcers (sores) (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). Also documented was Resident #1's cognitive skills for daily decision making was severely impaired. She was verbally abusive and resisted care. Review of Resident #1's MDS Quarterly assessment dated [DATE] documented no pressure ulcers. Review of Resident #1's Quarterly Resident Care Risk assessment dated [DATE] documented Risk for Pressure Ulcers a score of 14 (Total score of 15 or below deems resident at risk). Review of Resident #1's Care Plan dated 05/20/10 and reviewed on 06/23/10 and 09/22/10 documented the following: At risk for skin breakdown related to limited self mobility due to general body weakness, incontinence, and history of breakdown. Approach was to assess skin for breakdown weekly, initiate protocol if breakdown occurs, notify Doctor and family of breakdown, implement treatment per protocol or Doctor's orders, ensure skin is clean and dry every two hours. Review of Resident #1's Care Plan dated 03/24/10, resolved 05/20/10 and reviewed 06/23/10 documented the following: Skin breakdown, actual - Stage II (two) to both buttocks and coccyx on 03/21/10 and resolved 05/20/10. Initiate protocol if breakdown occurs, monitor and report sign of infection, assess cause of skin breakdown, assess skin daily and document weekly. Review of the Wound Care Physician's Wound Care assessment dated [DATE] documented Resident #1 to have associated pain (pressure sore) at a pain score of 4 (pain scale 1 to 10, 10 being the worst). Pain addressed: Give [MEDICATION NAME] 30 minutes prior to wound dressing. Right popliteal area wound: Etiology-Pressure, Stage IV (Four) pressure sore, Description- 4 cm x 3 cm x 0.5 cm, Surface area-12 cm, Surrounding Tissue-purple/Maroon, Thick Adherent Devitalized Tissue- 100%. Additional Information documented: Pressure wound form leg brace. Has exposed tendon. Procedures: Surgical excisional debridement of muscle and expect to repeat debridement in 7 days to excise more necrotic tissue. [MEDICATION NAME] (antibiotic cream) and foam dressing twice a day and off load wound. Discontinue right leg brace. Review of Resident #1's Pressure Ulcer sheet dated 11/23/10 at 3:30 PM documented the following: Resident #1 complained of pain at location of pressure sore. Contributing factors included diabetes, pressure sore history, immobility and dementia. The pressure sore was located on the right popliteal with a width of 3 cm, length of 4 cm and classified as a Stage IV. The exudate (drainage) was purulent (contained pus), large amount, foul odor and the wound bed was red and yellow. Review of Resident #1's Medication Sheet dated November 2010 documented the following: [MEDICATION NAME] (anti-[MEDICAL CONDITION] drug given for mild to moderate pain) 400 milligrams (mg) (give with food) one tablet by mouth every 8 hours with a start date of 03/11/10. [MEDICATION NAME] ER (extended release) (narcotic given to manage moderate to severe pain) 15 mg one tablet by mouth three times a day (6 AM, 2 PM and 10 PM), that was discontinued and changed on 11/04/10 to [MEDICATION NAME] ER 15 mg one cap by mouth now, at 11:15 AM, then [MEDICATION NAME] ER 15 mg (2) caps by mouth every 12 hours (6 AM and 6 PM), that was discontinued and changed on 11/16/10 to [MEDICATION NAME] Solution (narcotic given for relief of moderate to severe pain) 20 mg per ml, give 0.5 ml every 6 hours (12 AM, 6 AM, 12 PM, 6 PM) by mouth sublingual (under the tongue). Also ordered on [DATE] was may have [MEDICATION NAME] Solution 20 mg per ml, 0.5 ml every hour for breakthrough pain as needed. The [MEDICATION NAME] 0.5 ml was given for breakthrough pain on 11/23/10, 11/26/10 and 11/28/10. In an interview on 12/01/10 at 9:50 AM LVN A stated Resident #1 finished her last dose of oral antibiotic, that morning, for the pressure sore infection to her right leg. LVN A stated Resident #1 received wound care to the right leg every shift (12 hour shifts) and Resident #1 had previous orders for a Unna Boot (medicated gauze wrap) and a right leg brace that was discontinued last week. Review of Physician Telephone Orders dated 11/24/10 at 6:15 PM documented Bactrim DS (antibiotic) one by mouth twice a day for 7 days per Resident #1's Physician Assistant. Review of Physician Telephone Orders dated 11/26/10 at 5:45 PM documented Discontinue Unna Boots and Discontinue leg brace to right leg on 11/23/10. In an interview on 12/01/10 at 11:45 AM the Director of Nurses (DON) revealed Resident #1's LVN Medication Sheet dated 11/01/10 through 11/30/10, documented the following: Leg brace to right leg at all times (May be removed for showers and treatment) dated 08/04/10. Staff initials were documented for dates 11/01 through 11/25 for two shifts. The shifts were 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. The DON stated the order should have been separated for the leg brace to right leg at all times; then in separate section of the LVN Medication Sheet, write the order to remove right leg brace for showers and treatment. She stated she could not tell if the brace was removed and re-applied on the LVN Medication Sheet. The DON further stated Resident #1 had multiple skin tears to her lower legs and would fidget a lot. Resident #1 was always moving in the wheelchair and had history of fractures to both of her legs. The DON stated it was hard to say if the right leg brace caused the pressure sore. In an interview on 12/01/10 at 12:20 PM the DON stated the floor nurses do weekly summaries, on all the residents, which included weekly head to toe skin assessments. LVN C does weekly skin assessments by exception of problem skin wounds, pressure sores, stasis ulcers, severe skin tears and surgical wounds. LVN C would assist the Wound Physician on Tuesdays and would address the problem skin conditions with the Physician. The DON further stated LVN A checked Resident #1's right leg, without the brace, 3 to 4 days prior to identifying the pressure sore to Resident #1's right leg, and there was no pressure sore. The DON also stated a Stage IV pressure sore could develop in 3 to 4 days. In an interview on 12/01/10 at 1:45 PM LVNs A and B stated when completing the weekly summaries on resident's skin condition they do not do head to toe skin assessments. LVN A and B stated they would obtain information from the Treatment Book to see what skin issues the residents are having. In an interview on 12/01/10 at 1:50 PM LVN A stated on 11/18/10 she observed Resident #1 with increased lethargy (drowsiness) and increased right leg pain. LVN A removed Resident #1's right leg brace and looked and felt her right lower leg. LVN A stated there was no pressure sore at that time. Review of Resident #1's skin condition per Weekly Summary dated 11/16/10 through 11/22/10 had no documentation of Resident #1 having a pressure sore to her right popliteal. In an interview on 12/01/10 at 2:30 PM LVN B stated she did the Weekly Summary dated 11/16/10 through 11/22/10 on Resident #1. She could not give a specific day that the Weekly Summary, skin condition, was completed. LVN B stated she did not do a head to toe skin assessment on Resident #1. LVN B stated she obtained information on Resident #1's skin condition from the Treatment Book. She thought LVN C did the head to toe skin assessments. In an interview on 12/01/10 at 2:50 PM LVN D stated he does not do head to toe skin assessments when completing the skin condition section on the weekly summaries for the residents and completes about 4 weekly summaries a week. LVN D also stated he depended on the Certified Nurse Aides (CNAs) for reporting skin problems to him on residents and he trust the CNAs. Review of Weekly Skin Assessment, for Resident #1, dated 11/20/10 documented the following: Skin tear to left wrist healed 11/14/10, skin tear to right finger, bruise to lower left knee, left anterior shoulder (11/15/10), bruise to right lower arm, skin tear to upper right eye and signed by LVN C. In an interview on 12/01/10 at 2:55 PM LVN C stated she would try to do head to toe skin assessments, on a weekly basis, the best she could, when residents received their showers and upon incontinent care. LVN C stated she would rely on the Nurses and CNAs to identify problem skin areas. When the surveyor asked LVN C when the Stage IV pressure sore was identified to Resident #1's right popliteal area she replied, " We just missed it ". LVN C stated when the smell started that was when the pressure sore started. LVN C stated on 11/23/10 she, the Wound Care Physician, LVN A and LVN B were in Resident #1's room addressing the sacral (buttock area) pressure sore and the multiple skin issues Resident #1 had to her upper, lower and trunk of body. The Wound Physician noted a foul odor and Resident #1's right leg brace was removed and a Stage IV pressure sore behind the knee was identified. The surveyor then asked LVN C if she removed Resident #1's right leg brace on 11/20/10 and complete a head to toe skin assessment on the Weekly Skin Assessment which was signed by LVN C; LVN C stated no she did not complete a head to toe skin assessment. LVN C further stated she assumed the Nurses on the floor do the head to toe skin assessments when doing the weekly summaries. In an interview on 12/01/10 at 3:25 PM the DON stated the Nurses know better to do head to toe skin assessments when doing weekly summaries and she expected the Nurses to do that. The surveyor asked the DON where Resident #1's right leg brace was and the DON replied LVN A threw the brace away. In an interview on 12/01/10 at 3:40 PM LVN D stated he did not know why he answered, " no " during the interview earlier, when the surveyor asked him if he did head to toe skin assessments when doing weekly summaries. LVN D stated yes, he did do head to toe weekly skin assessments on chair and bed bound residents. On the " walkie/talkie " residents he does not do weekly head to toe skin assessments. He asked the residents if they have any skin problems. Review of Resident #1's skin condition per Weekly Summary dated 11/23/10 through 11/29/10 documented a Stage IV pressure sore to Resident #1's right popliteal and treatment signed by LVN E. In an interview on 12/01/10 at 4:31 PM LVN E stated she completed Resident #1's Weekly Summary dated 11/23/10 through 11/29/10. LVN E stated she did not do a head to toe skin assessment on Resident #1 when she documented on her skin condition. LVN E stated she asked the nurse that worked that hall and checked the Treatment Book. LVN E stated she does not always do head to toe skin assessments when completing Weekly Summaries. In an interview on 12/01/10 at 5:20 PM CNA F stated she smelled a foul odor to Resident #1 about a week before the nurses found the pressure sore on Resident #1's right leg. CNA F stated she reported the foul odor to LVN A and LVN A did not remove Resident #1's leg brace and look at Resident #1's right leg. On 12/01/10 at 5:10 PM the Administrator handed the surveyor a sheet of paper titled Inservice dated 12/01/10. In an interview at that time, the Administrator stated the inservice was given by him and would go into affect immediately. The following was documented: Skin Assessments - Weekly Nursing Summaries must have weekly head to toe skin assessments (Floor/Charge Nurse); Infection Control/Treatment Nurse (LVN C) do head to toe weekly assessment on all residents; Coordinator MDS (Care Plan Coordinator) with weekly summaries; CNAs report to charge nurse daily with any skin conditions; Remove any braces or prosthesis for skin assessments (if Doctor orders). The DON reported 3 residents with pressure sores. The Administrator reported a resident census of 93.

Based on observation, interview, and record review the facility failed to provide services by qualified persons in accordance with Resident #1's written plan of care. A pressure sore developed for 1 of 3 sampled residents (Resident #1) reviewed for pressure sores. Two of three Licensed Vocational Nurses (LVNs) (LVN B and C) failed to remove Resident #1's right leg brace and complete the head to toe weekly skin assessment to prevent development of Stage IV pressure sore. An infected Stage IV (four) pressure sore (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures), measuring 4 centimeters (cm) length x 3 cm width x 0.5 cm deep, was initially identified on the right popliteal (behind the knee area) by the Facility's Wound Care Physician on 11/23/10. This deficient practice could affect 2 residents. The facility's failure to provide necessary services to identify and prevent pressure sores resulted in Resident #1 developing an avoidable Stage IV pressure sore to the right popliteal area and suffering actual harm and could place residents with pressure sores, at risk for delay in treatment and deterioration of current pressure sores. The findings include: Review of Resident #1's Care Plan dated 05/20/10 and reviewed on 06/23/10 and 09/22/10 documented the following: At risk for skin breakdown related to limited self mobility due to general body weakness, incontinence, and history of breakdown. Approach was to assess skin for breakdown weekly, initiate protocol if breakdown occurs, notify Doctor and family of breakdown, implement treatment per protocol or Doctor's orders, ensure skin is clean and dry every two hours. Review of Resident #1's Care Plan dated 03/24/10, resolved 05/20/10 and reviewed 06/23/10 documented the following: Skin breakdown, actual - Stage II (two) to both buttocks and coccyx on 03/21/10 and resolved 05/20/10. Initiate protocol if breakdown occurs, monitor and report sign of infection, assess cause of skin breakdown, assess skin daily and document weekly. Observation on 12/01/10 at 9:40 AM revealed Resident #1 in a wheelchair, in her room, trying to propel herself around her room mate, to the room door. In an interview at that time, Resident #1 stated her right leg hurt a little. Resident #1 continued to talk at a low voice that was difficult to understand. Continued observation on 12/01/10 from 9:40 AM to 9:48 AM revealed Licensed Vocational Nurses (LVNs) LVNs A and B provide Resident #1 wound care to the Stage IV pressure sore, on her right popliteal leg. In an interview at that time, LVN B stated Resident #1 acquired the Stage IV pressure sore to her right leg at the facility. LVN B removed the dressing and measured the pressure sore. The pressure sore measured 5.5 cm length x 4.0 cm width. There was no drainage and the wound bed had pink tissue with a small amount of slough (dead tissue separated from living tissue). The pressure sore was cleaned with wound cleanser and an antibiotic cream was applied to the wound. A dressing was applied to the pressure sore by LVN B and she initialed and dated the dressing. During the wound care LVN A stated the Wound Physician was at the facility yesterday and debrided (removal of dead tissue from a wound) the pressure sore to the right leg. LVN B stated she could see a tendon (fibrous connective tissue serving for the attachment of muscles to bones) in the pressure sore last week. During the wound care Resident #1 made facial grimaces and told LVN A her right leg hurt. LVN A stated Resident #1 had a dose of [MEDICATION NAME] at 6:00 AM and would get her another dose for breakthrough pain. Review of Resident #1's Record of Admission sheet dated 08/18/10 documented she was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Sheet (MDS) Admission assessment dated [DATE] documented she had 3 Stage II pressure ulcers (sores) (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). Also documented was Resident #1's cognitive skills for daily decision making was severely impaired. She was verbally abusive and resisted care. Review of Resident #1's MDS Quarterly assessment dated [DATE] documented no pressure ulcers. Review of Resident #1's Quarterly Resident Care Risk assessment dated [DATE] documented Risk for Pressure Ulcers a score of 14 (Total score of 15 or below deems resident at risk). Review of the Wound Care Physician's Wound Care assessment dated [DATE] documented Resident #1 to have associated pain (pressure sore) at a pain score of 4 (pain scale 1 to 10, 10 being the worst). Pain addressed: Give [MEDICATION NAME] 30 minutes prior to wound dressing. Right popliteal area wound: Etiology-Pressure, Stage IV (Four) pressure sore, Description- 4 cm x 3 cm x 0.5 cm, Surface area-12 cm, Surrounding Tissue-purple/Maroon, Thick Adherent Devitalized Tissue- 100%. Additional Information documented: Pressure wound form leg brace. Has exposed tendon. Procedures: Surgical excisional debridement of muscle and expect to repeat debridement in 7 days to excise more necrotic tissue. [MEDICATION NAME] (antibiotic cream) and foam dressing twice a day and off load wound. Discontinue right leg brace. Review of Resident #1's Pressure Ulcer sheet dated 11/23/10 at 3:30 PM documented the following: Resident #1 complained of pain at location of pressure sore. Contributing factors included diabetes, pressure sore history, immobility and dementia. The pressure sore was located on the right popliteal with a width of 3 cm, length of 4 cm and classified as a Stage IV. The exudate (drainage) was purulent (contained pus), large amount, foul odor and the wound bed was red and yellow. Review of Resident #1's Medication Sheet dated November 2010 documented the following: [MEDICATION NAME] (anti-[MEDICAL CONDITION] drug given for mild to moderate pain) 400 milligrams (mg) (give with food) one tablet by mouth every 8 hours with a start date of 03/11/10. [MEDICATION NAME] ER (extended release) (narcotic given to manage moderate to severe pain) 15 mg one tablet by mouth three times a day (6 AM, 2 PM and 10 PM), that was discontinued and changed on 11/04/10 to [MEDICATION NAME] ER 15 mg one cap by mouth now, at 11:15 AM, then [MEDICATION NAME] ER 15 mg (2) caps by mouth every 12 hours (6 AM and 6 PM), that was discontinued and changed on 11/16/10 to [MEDICATION NAME] Solution (narcotic given for relief of moderate to severe pain) 20 mg per ml, give 0.5 ml every 6 hours (12 AM, 6 AM, 12 PM, 6 PM) by mouth sublingual (under the tongue). Also ordered on [DATE] was may have [MEDICATION NAME] Solution 20 mg per ml, 0.5 ml every hour for breakthrough pain as needed. The [MEDICATION NAME] 0.5 ml was given for breakthrough pain on 11/23/10, 11/26/10 and 11/28/10. In an interview on 12/01/10 at 9:50 AM LVN A stated Resident #1 finished her last dose of oral antibiotic, that morning, for the pressure sore infection to her right leg. LVN A stated Resident #1 received wound care to the right leg every shift (12 hour shifts) and Resident #1 had previous orders for a Unna Boot (medicated gauze wrap) and a right leg brace that was discontinued last week. Review of Physician Telephone Orders dated 11/24/10 at 6:15 PM documented Bactrim DS (antibiotic) one by mouth twice a day for 7 days per Resident #1's Physician Assistant. Review of Physician Telephone Orders dated 11/26/10 at 5:45 PM documented Discontinue Unna Boots and Discontinue leg brace to right leg on 11/23/10. In an interview on 12/01/10 at 11:45 AM the Director of Nurses (DON) revealed Resident #1's LVN Medication Sheet dated 11/01/10 through 11/30/10, documented the following: Leg brace to right leg at all times (May be removed for showers and treatment) dated 08/04/10. Staff initials were documented for dates 11/01 through 11/25 for two shifts. The shifts were 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. The DON stated the order should have been separated for the leg brace to right leg at all times; then in separate section of the LVN Medication Sheet, write the order to remove right leg brace for showers and treatment. She stated she could not tell if the brace was removed and re-applied on the LVN Medication Sheet. The DON further stated Resident #1 had multiple skin tears to her lower legs and would fidget a lot. Resident #1 was always moving in the wheelchair and had history of fractures to both of her legs. The DON stated it was hard to say if the right leg brace caused the pressure sore. In an interview on 12/01/10 at 12:20 PM the DON stated the floor nurses do weekly summaries, on all the residents, which included weekly head to toe skin assessments. LVN C does weekly skin assessments by exception of problem skin wounds, pressure sores, stasis ulcers, severe skin tears and surgical wounds. LVN C would assist the Wound Physician on Tuesdays and would address the problem skin conditions with the Physician. The DON further stated LVN A checked Resident #1's right leg, without the brace, 3 to 4 days prior to identifying the pressure sore to Resident #1's right leg, and there was no pressure sore. The DON also stated a Stage IV pressure sore could develop in 3 to 4 days. In an interview on 12/01/10 at 1:45 PM LVNs A and B stated when completing the weekly summaries on resident's skin condition they do not do head to toe skin assessments. LVN A and B stated they would obtain information from the Treatment Book to see what skin issues the residents are having. In an interview on 12/01/10 at 1:50 PM LVN A stated on 11/18/10 she observed Resident #1 with increased lethargy (drowsiness) and increased right leg pain. LVN A removed Resident #1's right leg brace and looked and felt her right lower leg. LVN A stated there was no pressure sore at that time. Review of Resident #1's skin condition per Weekly Summary dated 11/16/10 through 11/22/10 had no documentation of Resident #1 having a pressure sore to her right popliteal. In an interview on 12/01/10 at 2:30 PM LVN B stated she did the Weekly Summary dated 11/16/10 through 11/22/10 on Resident #1. She could not give a specific day that the Weekly Summary, skin condition, was completed. LVN B stated she did not do a head to toe skin assessment on Resident #1. LVN B stated she obtained information on Resident #1's skin condition from the Treatment Book. She thought LVN C did the head to toe skin assessments. In an interview on 12/01/10 at 2:50 PM LVN D stated he does not do head to toe skin assessments when completing the skin condition section on the weekly summaries for the residents and completes about 4 weekly summaries a week. LVN D also stated he depended on the Certified Nurse Aides (CNAs) for reporting skin problems to him on residents and he trust the CNAs. Review of Weekly Skin Assessment, for Resident #1, dated 11/20/10 documented the following: Skin tear to left wrist healed 11/14/10, skin tear to right finger, bruise to lower left knee, left anterior shoulder (11/15/10), bruise to right lower arm, skin tear to upper right eye and signed by LVN C. In an interview on 12/01/10 at 2:55 PM LVN C stated she would try to do head to toe skin assessments, on a weekly basis, the best she could, when residents received their showers and upon incontinent care. LVN C stated she would rely on the Nurses and CNAs to identify problem skin areas. When the surveyor asked LVN C when the Stage IV pressure sore was identified to Resident #1's right popliteal area she replied, " We just missed it ". LVN C stated when the smell started that was when the pressure sore started. LVN C stated on 11/23/10 she, the Wound Care Physician, LVN A and LVN B were in Resident #1's room addressing the sacral (buttock area) pressure sore and the multiple skin issues Resident #1 had to her upper, lower and trunk of body. The Wound Physician noted a foul odor and Resident #1's right leg brace was removed and a Stage IV pressure sore behind the knee was identified. The surveyor then asked LVN C if she removed Resident #1's right leg brace on 11/20/10 and complete a head to toe skin assessment on the Weekly Skin Assessment which was signed by LVN C; LVN C stated no she did not complete a head to toe skin assessment. LVN C further stated she assumed the Nurses on the floor do the head to toe skin assessments when doing the weekly summaries. In an interview on 12/01/10 at 3:25 PM the DON stated the Nurses know better to do head to toe skin assessments when doing weekly summaries and she expected the Nurses to do that. The surveyor asked the DON where Resident #1's right leg brace was and the DON replied LVN A threw the brace away. In an interview on 12/01/10 at 3:40 PM LVN D stated he did not know why he answered, " no " during the interview earlier, when the surveyor asked him if he did head to toe skin assessments when doing weekly summaries. LVN D stated yes, he did do head to toe weekly skin assessments on chair and bed bound residents. On the " walkie/talkie " residents he does not do weekly head to toe skin assessments. He asked the residents if they have any skin problems. Review of Resident #1's skin condition per Weekly Summary dated 11/23/10 through 11/29/10 documented a Stage IV pressure sore to Resident #1's right popliteal and treatment signed by LVN E. In an interview on 12/01/10 at 4:31 PM LVN E stated she completed Resident #1's Weekly Summary dated 11/23/10 through 11/29/10. LVN E stated she did not do a head to toe skin assessment on Resident #1 when she documented on her skin condition. LVN E stated she asked the nurse that worked that hall and checked the Treatment Book. LVN E stated she does not always do head to toe skin assessments when completing Weekly Summaries. In an interview on 12/01/10 at 5:20 PM CNA F stated she smelled a foul odor to Resident #1 about a week before the nurses found the pressure sore on Resident #1's right leg. CNA F stated she reported the foul odor to LVN A and LVN A did not remove Resident #1's leg brace and look at Resident #1's right leg. Review of undated Policy and Procedure titled Weekly Skin Assessment Nurse documented the following: Policy - All residents are minimally required to have a head to toe skin assessment upon admission, re-admission, with significant change of skin condition, transfer/discharge, and weekly. A weekly skin assessment nurse shall be designated to perform and work with other staff to see that all residents skin is assessed on a weekly basis. On 12/01/10 at 5:10 PM the Administrator handed the surveyor a sheet of paper titled Inservice dated 12/01/10. In an interview at that time, the Administrator stated the inservice was given by him and would go into affect immediately. The following was documented: Skin Assessments - Weekly Nursing Summaries must have weekly head to toe skin assessments (Floor/Charge Nurse); Infection Control/Treatment Nurse (LVN C) do head to toe weekly assessment on all residents; Coordinator MDS (Care Plan Coordinator) with weekly summaries; CNAs report to charge nurse daily with any skin conditions; Remove any braces or prosthesis for skin assessments (if Doctor orders). The DON reported 3 residents with pressure sores. The Administrator reported a resident census of 93.

Based on observation, interview, and record review the facility failed to assess, identify, prevent infection and prevent pressure sore development for 1 of 3 sampled residents (Resident #1) reviewed for pressure sores, the facility failed to remove Resident #1's right leg brace and complete the head to toe skin assessment to prevent development of Stage IV pressure sore. An infected stage IV (four) pressure sore (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures), measuring 4 centimeters (cm) length x 3 cm width x 0.5 cm deep, was initially identified on the right popliteal (behind the knee area) by the Facility's Wound Care Physician on 11/23/10. This deficient practice could affect 2 residents. The facility's failure to provide necessary services to identify and prevent pressure sores resulted in Resident #1 developing an avoidable Stage IV pressure sore to the right popliteal area and suffering actual harm and could place residents with pressure sores, at risk for delay in treatment and deterioration of current pressure sores. The findings include: Observation on 12/01/10 at 9:40 AM revealed Resident #1 in a wheelchair, in her room, trying to propel herself around her room mate, to the room door. In an interview at that time, Resident #1 stated her right leg hurt a little. Resident #1 continued to talk at a low voice that was difficult to understand. Continued observation on 12/01/10 from 9:40 AM to 9:48 AM revealed Licensed Vocational Nurses (LVNs) LVNs A and B provide Resident #1 wound care to the Stage IV pressure sore, on her right popliteal leg. In an interview at that time, LVN B stated Resident #1 acquired the Stage IV pressure sore to her right leg at the facility. LVN B removed the dressing and measured the pressure sore. The pressure sore measured 5.5 cm length x 4.0 cm width. There was no drainage and the wound bed had pink tissue with a small amount of slough (dead tissue separated from living tissue). The pressure sore was cleaned with wound cleanser and an antibiotic cream was applied to the wound. A dressing was applied to the pressure sore by LVN B and she initialed and dated the dressing. During the wound care LVN A stated the Wound Physician was at the facility yesterday and debrided (removal of dead tissue from a wound) the pressure sore to the right leg. LVN B stated she could see a tendon (fibrous connective tissue serving for the attachment of muscles to bones) in the pressure sore last week. During the wound care Resident #1 made facial grimaces and told LVN A her right leg hurt. LVN A stated Resident #1 had a dose of [MEDICATION NAME] at 6:00 AM and would get her another dose for breakthrough pain. Review of Resident #1's Record of Admission sheet dated 08/18/10 documented she was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Sheet (MDS) Admission assessment dated [DATE] documented she had 3 Stage II pressure ulcers (sores) (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). Also documented was Resident #1's cognitive skills for daily decisionmaking was severely impaired. She was verbally abusive and resisted care. Review of Resident #1's MDS Quarterly assessment dated [DATE] documented no pressure ulcers. Review of Resident #1's Quarterly Resident Care Risk assessment dated [DATE] documented Risk for Pressure Ulcers a score of 14 (Total score of 15 or below deems resident at risk). Review of Resident #1's Care Plan dated 05/20/10 and reviewed on 06/23/10 and 09/22/10 documented the following: At risk for skin breakdown related to limited self mobility due to general body weakness, incontinence, and history of breakdown. Approach was to assess skin for breakdown weekly, initiate protocol if breakdown occurs, notify Doctor and family of breakdown, implement treatment per protocol or Doctor's orders, ensure skin is clean and dry every two hours. Review of Resident #1's Care Plan dated 03/24/10, resolved 05/20/10 and reviewed 06/23/10 documented the following: Skin breakdown, actual - Stage II (two) to both buttocks and coccyx on 03/21/10 and resolved 05/20/10. Initiate protocol if breakdown occurs, monitor and report sign of infection, assess cause of skin breakdown, assess skin daily and document weekly. Review of the Wound Care Physician's Wound Care assessment dated [DATE] documented Resident #1 to have associated pain (pressure sore) at a pain score of 4 (pain scale 1 to 10, 10 being the worst). Pain addressed: Give [MEDICATION NAME] 30 minutes prior to wound dressing. Right popliteal area wound: Etiology-Pressure, Stage IV (Four) pressure sore, Description- 4 cm x 3 cm x 0.5 cm, Surface area-12 cm, Surrounding Tissue-purple/Maroon, Thick Adherent Devitalized Tissue- 100%. Additional Information documented: Pressure wound form leg brace. Has exposed tendon. Procedures: Surgical excisional debridement of muscle and expect to repeat debridement in 7 days to excise more necrotic tissue. [MEDICATION NAME] (antibiotic cream) and foam dressing twice a day and off load wound. Discontinue right leg brace. Review of Resident #1's Pressure Ulcer sheet dated 11/23/10 at 3:30 PM documented the following: Resident #1 complained of pain at location of pressure sore. Contributing factors included diabetes, pressure sore history, immobility and dementia. The pressure sore was located on the right popliteal with a width of 3 cm, length of 4 cm and classified as a Stage IV. The exudate (drainage) was purulent (contained pus), large amount, foul odor and the wound bed was red and yellow. Review of Resident #1's Medication Sheet dated November 2010 documented the following: [MEDICATION NAME] (anti-[MEDICAL CONDITION] drug given for mild to moderate pain) 400 milligrams (mg) (give with food) one tablet by mouth every 8 hours with a start date of 03/11/10. [MEDICATION NAME] ER (extended release) (narcotic given to manage moderate to severe pain) 15 mg one tablet by mouth three times a day (6 AM, 2 PM and 10 PM), that was discontinued and changed on 11/04/10 to [MEDICATION NAME] ER 15 mg one cap by mouth now, at 11:15 AM, then [MEDICATION NAME] ER 15 mg (2) caps by mouth every 12 hours (6 AM and 6 PM), that was discontinued and changed on 11/16/10 to [MEDICATION NAME] Solution (narcotic given for relief of moderate to severe pain) 20 mg per ml, give 0.5 ml every 6 hours (12 AM, 6 AM, 12 PM, 6 PM) by mouth sublingual (under the tongue). Also ordered on [DATE] was may have [MEDICATION NAME] Solution 20 mg per ml, 0.5 ml every hour for breakthrough pain as needed. The [MEDICATION NAME] 0.5 ml was given for breakthrough pain on 11/23/10, 11/26/10 and 11/28/10. In an interview on 12/01/10 at 9:50 AM LVN A stated Resident #1 finished her last dose of oral antibiotic, that morning, for the pressure sore infection to her right leg. LVN A stated Resident #1 received wound care to the right leg every shift (12 hour shifts) and Resident #1 had previous orders for a Unna Boot (medicated gauze wrap) and a right leg brace that was discontinued last week. Review of Physician Telephone Orders dated 11/24/10 at 6:15 PM documented Bactrim DS (antibiotic) one by mouth twice a day for 7 days per Resident #1's Physician Assistant. Review of Physician Telephone Orders dated 11/26/10 at 5:45 PM documented Discontinue Unna Boots and Discontinue leg brace to right leg on 11/23/10. In an interview on 12/01/10 at 11:45 AM the Director of Nurses (DON) revealed Resident #1's LVN Medication Sheet dated 11/01/10 through 11/30/10, documented the following: Leg brace to right leg at all times (May be removed for showers and treatment) dated 08/04/10. Staff initials were documented for dates 11/01 through 11/25 for two shifts. The shifts were 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. The DON stated the order should have been separated for the leg brace to right leg at all times; then in separate section of the LVN Medication Sheet, write the order to remove right leg brace for showers and treatment. She stated she could not tell if the brace was removed and re-applied on the LVN Medication Sheet. The DON further stated Resident #1 had multiple skin tears to her lower legs and would fidget a lot. Resident #1 was always moving in the wheelchair and had history of fractures to both of her legs. The DON stated it was hard to say if the right leg brace caused the pressure sore. In an interview on 12/01/10 at 12:20 PM the DON stated the floor nurses do weekly summaries, on all the residents, which included weekly head to toe skin assessments. LVN C does weekly skin assessments by exception of problem skin wounds, pressure sores, stasis ulcers, severe skin tears and surgical wounds. LVN C would assist the Wound Physician on Tuesdays and would address the problem skin conditions with the Physician. The DON further stated LVN A checked Resident #1's right leg, without the brace, 3 to 4 days prior to identifying the pressure sore to Resident #1's right leg, and there was no pressure sore. The DON also stated a Stage IV pressure sore could develop in 3 to 4 days. In an interview on 12/01/10 at 1:45 PM LVNs A and B stated when completing the weekly summaries on resident's skin condition they do not do head to toe skin assessments. LVN A and B stated they would obtain information from the Treatment Book to see what skin issues the residents are having. In an interview on 12/01/10 at 1:50 PM LVN A stated on 11/18/10 she observed Resident #1 with increased lethargy (drowsiness) and increased right leg pain. LVN A removed Resident #1's right leg brace and looked and felt her right lower leg. LVN A stated there was no pressure sore at that time. Review of Resident #1's skin condition per Weekly Summary dated 11/16/10 through 11/22/10 had no documentation of Resident #1 having a pressure sore to her right popliteal. In an interview on 12/01/10 at 2:30 PM LVN B stated she did the Weekly Summary dated 11/16/10 through 11/22/10 on Resident #1. She could not give a specific day that the Weekly Summary, skin condition, was completed. LVN B stated she did not do a head to toe skin assessment on Resident #1. LVN B stated she obtained information on Resident #1's skin condition from the Treatment Book. She thought LVN C did the head to toe skin assessments. In an interview on 12/01/10 at 2:50 PM LVN D stated he does not do head to toe skin assessments when completing the skin condition section on the weekly summaries for the residents and completes about 4 weekly summaries a week. LVN D also stated he depended on the Certified Nurse Aides (CNAs) for reporting skin problems to him on residents and he trust the CNAs. Review of Weekly Skin Assessment, for Resident #1, dated 11/20/10 documented the following: Skin tear to left wrist healed 11/14/10, skin tear to right finger, bruise to lower left knee, left anterior shoulder (11/15/10), bruise to right lower arm, skin tear to upper right eye and signed by LVN C. In an interview on 12/01/10 at 2:55 PM LVN C stated she would try to do head to toe skin assessments, on a weekly basis, the best she could, when residents received their showers and upon incontinent care. LVN C stated she would rely on the Nurses and CNAs to identify problem skin areas. When the surveyor asked LVN C when the Stage IV pressure sore was identified to Resident #1's right popliteal area she replied, " We just missed it ". LVN C stated when the smell started that was when the pressure sore started. LVN C stated on 11/23/10 she, the Wound Care Physician, LVN A and LVN B were in Resident #1's room addressing the sacral (buttock area) pressure sore and the multiple skin issues Resident #1 had to her upper, lower and trunk of body. The Wound Physician noted a foul odor and Resident #1's right leg brace was removed and a Stage IV pressure sore behind the knee was identified. The surveyor then asked LVN C if she removed Resident #1's right leg brace on 11/20/10 and complete a head to toe skin assessment on the Weekly Skin Assessment which was signed by LVN C; LVN C stated no she did not complete a head to toe skin assessment. LVN C further stated she assumed the Nurses on the floor do the head to toe skin assessments when doing the weekly summaries. In an interview on 12/01/10 at 3:25 PM the DON stated the Nurses know better to do head to toe skin assessments when doing weekly summaries and she expected the Nurses to do that. The surveyor asked the DON where Resident #1's right leg brace was and the DON replied LVN A threw the brace away. In an interview on 12/01/10 at 3:40 PM LVN D stated he did not know why he answered, " no " during the interview earlier, when the surveyor asked him if he did head to toe skin assessments when doing weekly summaries. LVN D stated yes, he did do head to toe weekly skin assessments on chair and bed bound residents. On the " walkie/talkie " residents he does not do weekly head to toe skin assessments. He asked the residents if they have any skin problems. Review of Resident #1's skin condition per Weekly Summary dated 11/23/10 through 11/29/10 documented a Stage IV pressure sore to Resident #1's right popliteal and treatment signed by LVN E. In an interview on 12/01/10 at 4:31 PM LVN E stated she completed Resident #1's Weekly Summary dated 11/23/10 through 11/29/10. LVN E stated she did not do a head to toe skin assessment on Resident #1 when she documented on her skin condition. LVN E stated she asked the nurse that worked that hall and checked the Treatment Book. LVN E stated she does not always do head to toe skin assessments when completing Weekly Summaries. In an interview on 12/01/10 at 5:20 PM CNA F stated she smelled a foul odor to Resident #1 about a week before the nurses found the pressure sore on Resident #1's right leg. CNA F stated she reported the foul odor to LVN A and LVN A did not remove Resident #1's leg brace and look at Resident #1's right leg. Review of undated Policy and Procedure titled Weekly Skin Assessment Nurse documented the following: Policy - All residents are minimally required to have a head to toe skin assessment upon admission, re-admission, with significant change of skin condition, transfer/discharge, and weekly. A weekly skin assessment nurse shall be designated to perform and work with other staff to see that all residents skin is assessed on a weekly basis. On 12/01/10 at 5:10 PM the Administrator handed the surveyor a sheet of paper titled Inservice dated 12/01/10. In an interview at that time, the Administrator stated the inservice was given by him and would go into affect immediately. The following was documented: Skin Assessments - Weekly Nursing Summaries must have weekly head to toe skin assessments (Floor/Charge Nurse); Infection Control/Treatment Nurse (LVN C) do head to toe weekly assessment on all residents; Coordinator MDS (Care Plan Coordinator) with weekly summaries; CNAs report to charge nurse daily with any skin conditions; Remove any braces or prosthesis for skin assessments (if Doctor orders). The DON reported 3 residents with pressure sores. The Administrator reported a resident census of 93.