Every finding on record at Vivo Healthcare Taylor

Based on observations, record review, staff interviews, and a review of facility policies and procedures, the facility failed to ensure that one (Resident #73) of 15 residents who required respiratory care, received supplemental oxygen at a flow rate of 2 liters per minute (L/min) as prescribed by the physician.The findings include: On 9/29/2025 at 10:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. She was receiving supplemental oxygen via nasal cannula that was connected to an oxygen concentrator located behind her wheelchair. The oxygen flow rate setting on the concentrator was set to 4 L/min, and the oxygen humidifier bottle attached to the concentrator was dated 7/26/2025. (Photographic evidence obtained) On 9/30/2025 at 9:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. She was receiving supplemental oxygen via nasal cannula from an oxygen concentrator located beside her chair. The oxygen flow rate was observed to be set at 4 L/min. (Photographic evidence obtained) On 10/01/2025 at 9:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. Her oxygen concentrator flow rate setting was verified to be set at 4L/min. (Photographic evidence obtained) The oxygen humidifier bottle was still unchanged and remained dated 7/26/2025 (Photographic evidence obtained) On 10/02/2025 at 9:00 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. On 10/2/2025 at 9:05 AM, Nurse A was asked what Resident #73's oxygen flow rate should be. Nurse A replied that the resident was receiving oxygen at 2 L/min. The nurse was accompanied to the resident's room at 9:10 AM, and she checked the oxygen flow rate on Resident #73's oxygen concentrator. She stated it was currently set at a flow rate of 4 L/min. She lowered the setting to 2 L/min. A review of the resident's active physician's orders revealed: 8/5/2025 - Check distilled water level in oxygen humidifier. If less than half full, then refill. Check every shift to ensure oxygen tubing is in Ziplock bag when not in use. 3/25/2025 - Change oxygen humidifier bottle and date monthly. 3/2/2025 - Change O2 (oxygen) tubing and clean O2 concentrator filter once weekly on Sunday. 2/25/2025 - O2 at 2L/min NC (via nasal cannula) every night at bedtime (QHS) for chronic obstructive pulmonary disease (COPD). 2/24/2025 - O2 at 2L/min via nasal cannula as needed to maintain O2 saturation % >92%. Check O2 saturation % every shift to keep O2 saturation levels > 92%. Further review of Resident #73's medical record revealed that she was admitted to the facility on [DATE] with an admitting diagnosis of acute on chronic diastolic (congestive) heart failure. Additional diagnoses included, but were not limited to, atherosclerotic heart disease, atrial fibrillation, anxiety disorder and non-rheumatic aortic (valve) stenosis. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. She was documented as receiving hospice care and had a DNR (Do Not Resuscitate) status. A review of the resident's active care plan, initiated on 8/29/2025, revealed a target completion date of 9/2/2025, and a completed date of 9/26/2025. The resident was noted as at risk for breathing problems related to her diagnosis of COPD and was at risk for respiratory complications. Goals and interventions included but were not limited to: Maintain respiratory baseline as evidenced by no occurrence of dyspnea or SOB (shortness of breath) through the review period. Administer medications as ordered by the physician. Administer oxygen at night as ordered. Encourage to clear secretions. Head of bed with 2-3 pillows while in bed/chair as tolerated per patient. Monitor O2 saturation as ordered. Observe and report signs and symptoms of respiratory infections and report to MD. Observe and report signs of dyspnea and SOB. Observe respiratory status for rate, depth and ease, essence of tachypnea, dyspnea in relation to disease process or decreased energy level. Assess for shortness of breath and cyanosis as needed. Monitor vital signs as ordered. Notify MD (physician) of significant abnormalities. The Medical Director's report dated 9/9/2025 and electronically signed on 9/23/2025 revealed: COPD/SOB - Continue Long-Acting Beta-Antagonist (a type of bronchodilator medication) every 12 hours, as needed O2, and nocturnal O2. Patient has orders for O2 as needed and she does okay with this during the day but reports she needs O2 all throughout the night - order nocturnal O2 via Nasal Cannula @ 2L. Patient assessed and well compensated on Room Air, lungs diminished but clear; 9/9/25 patient seen and assessed, she is alert and doing well - patient wearing O2 today and sats 95%, continue O2 throughout day PRN (as needed) and continuous QHS as well as pulmonary toilet - lungs clear – monitor. On 10/02/2025 at 12:08 PM, Nurse A stated she had worked at the facility for about two years. She further stated she reviewed doctors' orders in the electronic medical record to verify the oxygen flow rate a resident should be receiving. She stated she checked the oxygen concentrator and oxygen delivery tubing about once per shift but would check more often if the resident seemed to be experiencing distress. She checked the oxygen saturation levels per the physicians' orders using the monitor that was kept in the nursing cart. She stated the facility conducted different in-service training throughout the year and had staff sign an attendance log when training was provided. When asked what Resident #73's oxygen flow rate should be, Nurse A stated 2 L/min. Earlier on this date at 9:10 AM, Resident #73's O2 flow rate was adjusted from 4 L/min to 2 L/min by Nurse A after she was asked what the resident's flow rate should be. On 10/02/2025 at 1:00 PM, Nurse B/Unit Manager stated she had worked at the facility for 20 years. She stated she would review the orders in the EMR to verify at what flow rate Resident #73's oxygen should be set. She stated residents' oxygen saturation levels were obtained by using the pulse oximeter kept in the nursing cart. Oxygen delivery tubing was usually ordered to be changed weekly, and oxygen humidifier bottles were changed monthly. She further stated if a resident was receiving oxygen, they should be checked on a regular basis, like, every nurse should check every shift. When she was asked to check the oxygen flow rate order in Resident #73's EMR, she did and replied that the resident should be receiving 2 L/min. A review of the facility's policy titled Oxygen Administration Level III (revised October 2010), revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the preparation section, the policy directed the reader to verify that there was a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. The policy listed a humidifier bottle under equipment and supplies. The policy stated the humidifying jar was to be checked to be sure it was in good working order, securely fastened, and that the water level was high enough that the water bubbled as oxygen flowed through. (Photographic evidence obtained)

Based on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to interact with members of the community and participate in community activities outside of the facility for one (Resident #14) of 22 residents in the total sample. The findings include: On 10/16/23 at 10:46 AM, Resident #14 stated he used to go on outings to buy groceries, as he was not satisfied with the facility's food. He stated he would make his own transportation arrangements using the city bus. However, since the new Administrator returned, he had been denied permission to go out. He stated he had been told that he needed a chaperone and the facility had not been able to find one. He stated he had someone accompany him a few times, but that person was no longer available and it has made him to be depressed. A review of the medical record revealed that Resident #14 was admitted to the facility on [DATE] with a re-entry on 9/13/23. His diagnoses included, but were not limited to hypertensive chronic kidney disease (CKD) - stage 5, chronic or end-stage renal disease, type 2 diabetes mellitus in end-stage renal disease, metabolic encephalopathy, peripheral vascular disease, and dependence on renal dialysis. A review of the resident's profile revealed that he was his own responsible party. A review of the annual minimum data set (MDS) assessment, dated 9/18/23, revealed that Resident #14 had a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. He required extensive assistance for bed mobility, transfers, and toilet use, and supervision for eating. A review of the Physician's Order dated 9/13/23, revealed an active order for psychiatry to re-consult to determine mental capacity for decision making. A review of the Care Plan, last modified on 9/13/22, revealed that the resident had a nutritional problem or potential nutritional problem related to risk of malnutrition, modified diet , disease process and renal diseases. The care plan further noted that the resident preferred to eat meals he purchased outside of the facility rather than meals from facility's kitchen. In an interview with the Activities Director on 10/18/23 at 4:08 PM, she stated she had been employed in the facility since May 2023. When asked how Resident #14 participated in activities outside of the facility, she replied, It is my understanding that ever since COVID, the facility has not been going on outings due to restrictions. I am working on re-starting the outings using the facility bus, but there is no timeline for when this will take effect. She was then asked how the facility was accommodating residents who were alert and oriented and would like to go out. She stated, They would have to work something out with their family. As far as I know, the facility policy is that residents should have a chaperone when going out of the facility. She was asked if the facility provided chaperones for residents who would like to go out. She replied, No, only for medical appointments. If the resident wanted a leisure outing, they had to find their own chaperones regardless of their cognitive status. On 10/19/23 at 11:35 AM, Registered Nurse (RN) D stated she had worked with Resident #14 several times. The resident was alert and oriented and able to make his needs known. She added that the resident refused medication and dialysis at times and seemed to be depressed. When asked if the resident was receiving psychiatric services, she said she was not sure. She reviewed the documents in the resident's medical record and stated she did not see any psychiatric notes. During a 10/19/23 interview at 11:46 AM with the Director of Nursing (DON), she was asked about Resident #14's cognitive status. She stated, He is alert and oriented and able to make his needs known. He is not confused and he understands his choices. When she was asked if the resident had any changes in his condition, she said no. She was then asked if the resident could sign himself out of the facility. She said, Yes, but the facility policy is that the resident has to be escorted. When asked if Resident #14 used to go out by himself, she replied, Yes, however there was a change of Administration and we updated the policy to require someone to accompany the resident just in case they might need assistance while they were out. She was again asked if the facility was providing chaperones and she said only for medical appointments. For personal outings, the residents had to provide their own chaperone. She was again asked about residents who were alert, oriented, able to make their needs known, and were their own responsible party. If they could not find anyone to accompany them, how was that addressed? She replied, I feel like we are going in circles. We go by the policy and that is what we thought was right for the residents. She provided sign-out sheets which revealed that Resident #14 had been signing himself out from June 2023 through September 2023. (Copies obtained) A review of the facility's policy titled Signing Residents Out (revised August 2006) revealed that all residents leaving the premises must be signed out. The policy did not indicate that residents required chaperones. (Copy obtained) A review of the facility's policy titled Safety and Supervision of Residents (revised December 2007), revealed: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy, under System Approach to Safety section, further indicated: Resident supervision is a core component of the facility system approach to safety. The type and frequency of resident supervision as determined by the individual resident's assessed needs and identified hazards in the environment. The time and frequency of resident supervision may vary among residents and over time for the same residents. For example, residents' supervision may need to be increased when there are temporary hazard in the environment or if there is a change in condition. ( Copy obtained)

Based on observations, interviews, and record review, the facility failed to ensure that two (Resident #7 and #68) of three residents who were reviewed for inability to carry out activities of daily living, from a total sample of 22 residents, received necessary assistance to maintain good grooming and personal hygiene. The findings include: 1. On 10/16/23 at 9:44 AM, Resident #7 stated he had not received a shower or bed bath in the last month. He added that the facility was operating with Agency staff who don't care. He further stated he was having diarrhea and it was important for him to get a bath/shower, as it was the only way he would feel clean. A review of the medical record revealed that Resident #7 was admitted to the facility on [DATE] with a re-entry on 5/2/23. His diagnoses included dementia, anxiety, depression, and lactose intolerance. A review of the physician's orders dated 5/3/23, revealed a schedule for weekly bathing on Tuesdays and Fridays during the 7 am to 3 pm shift. Further review of the physician's orders, revealed an order dated 10/18/23, indicating current diarrhea and a history of recurrent C-Diff (Clostridium Difficile - bacteria causing diarrhea and inflammation of the colon). A review of the Care Plan, last revised on 7/26/23, revealed that there was no ADL care plan. (Copy obtained) A review of the Certified Nursing Assistant (CNA) Task List for October 2023, revealed that the resident was to be showered/bathed on the following days: Tuesday, 10/3, Friday, 10/6, Tuesday, 10/10, Friday, 10/13, and Tuesday10/17. Documentation indicated the resident received a bed bath on 10/3/23, refused on 10/6/23, and received another bed bath on 10/10/23. There was no indication of bathing/showering or refusal of care on 10/13 or 10/17. A review of the quarterly Minimum Data Set (MDS) assessment, dated 8/7/23, revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating that he was cognitively intact. He required extensive assistance for bed mobility, transfers, and toilet use, supervision for eating, and he was totally dependent upon staff for bathing. During a 10/19/23 interview with CNA A at 10:01 AM, she stated Resident #7 required total assistance from staff with ADL care. Resident #7 was alert and able to make his needs known. When asked if she worked with this resident on Sunday (10/15), she said she was not the assigned CNA, but the resident had his call light on and she answered it. The resident reported that he asked the assigned CNA to clean him and she had an attitude. CNA A went ahead and cleaned the resident and reported the resident's complaint to the nurse. 2. On 10/16/23 at 10:34 AM, Resident #68 was observed with long fingernails on both hands. She also had a dry, scaly scalp and was scratching her head. When asked if she received her showers/baths as scheduled/desired, she replied, I am lucky if get it at least once a week. She added that she had a prescription shampoo for psoriasis and therefore needed to have a shower. When she was asked about the length of her fingernails she said, As a nurse, I never liked long nails. I also used to have them done, but I have not had that here. I was told that staff were supposed to clip and clean them on shower days and as needed, but as you can see, they don't do it. The last time they were done, the Unit Manager was the one who clipped them. She added that the facility had a lot of Agency staff and they didn't seem to care about the residents. On 10/17/23 at 11:51 AM, Resident #68 was again observed with long fingernails. She was seated in her wheelchair. She stated she had asked the staff to give her a shower and shampoo her hair with the prescription shampoo, and the CNA told her that the nurse should do that. Another observation was made on 10/18/23 at 10:15 AM. The resident was observed in bed. Her fingernails remained long, approximately two inches long, and both thumb nails were observed with debris underneath. A review of the medical record revealed that Resident #68 was admitted to the facility on [DATE] with a re-entry on 2/27/22. Her diagnoses included hemiparesis and hemiplegia following a cerebral infarction (stroke) affecting her left non-dominant side; epilepsy, unspecified dementia, insomnia, anxiety disorder, and major depressive disorder. A review of the quarterly Minimum Data Set (MDS) assessment, dated 8/16/23, revealed that the resident had a brief interview for mental status (BIMS) of 14 out of 15 possible points, indicating that she was cognitively intact. She required extensive assistance with activities of daily living (ADL). No hallucinations or delusional behaviors were documented in the assessment. A physician's order, dated 9/13/23, was noted for Clobetasol propionate shampoo, 0.05%, apply to scalp topically every day shift every Tuesday and Thursday for skin health to be done on shower days. A review of the care plan (last revised on 8/21/23), revealed that the resident had a focus area for ADL/Self-Care Performance Deficit related to impaired mobility. Interventions included that the staff assist the resident with bathing/showering. They were to check her nail length and trim and clean on bath/shower days and as needed. A review of the CNA Task List for October 2023, revealed that the resident was to be showered/bathed on the following days: Tuesday, 10/3, Thursday, 10/5, Tuesday, 10/10, Thursday, 10/12, Tuesday,10/17, and Thursday, 10/19. Documentation indicated that the resident received a shower on 10/6 and a bath on 10/10/23. There was no indication of bathing/showering or refusal of care on 10/3, 10/5, 10/12, or 10/17. In an interview on 10/19/23 at 10:01 AM, CNA A stated Residents #7 and #68 required total assistance from staff for all ADLs. She further stated there was a shower schedule on each unit and the residents received showers two times a week and as needed. Nail care should be provided during showers and as needed. She mentioned that showers were documented in the computerized charting system. When a resident refused care, the nurse should be notified and if the resident still refused, staff documented the task as having been refused. During an interview on 10/19/23 at 10:45 AM with Licensed Practical Nurse (LPN) C/Unit Manager, she stated residents should receive a shower two times a week unless they refused. She said the staff were expected to document in the electronic medical record when a shower was provided, and when a shower was refused, there was an alert that went to the nurses' dashboard for follow up. When she was asked when nail care was provided, she produced a form indicating that nail care should be provided on Wednesdays by the CNAs and as needed. She stated Activities staff also filed and polished residents' nails. When asked what days Residents #7 and #68 received their showers, she replied, Tuesdays and Fridays. She confirmed that Residents #7 and #68 had only three baths/showers documented for the month of October 2023. She also confirmed that Resident #7 did not have an ADL care plan. She was accompanied to Resident #68's room and she confirmed that the resident's nails were long. Resident #68 stated at that time that she would like to have them clipped. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) (implemented on 6/1/23), revealed: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure that a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care services will be provided for the the following activities of daily living: Bathing, dressing, grooming and oral care; transfer and ambulation; toileting and eating. The policy further explained that a resident who was unable to carry out activities of daily living would receive the necessary services to maintain a good nutrition, grooming and personal and oral hygiene. The facility would maintain individual objectives of the care plan and periodic review and evaluation.

Based on observations, interviews, and record review, the facility failed to 1) Provide evidence that alleged violations of abuse were thoroughly investigated, and 2) Prevent further potential abuse while the investigation was in progress for two (Residents #68 and #44 ) of two residents whose grievances were reviewed, from a total sample of 22 residents. The findings include: 1. On 10/16/23 at 10:34 AM, Resident #68 stated she was watching the Grammy's a while back. She stated she pushed the call light button and when the Certified Nursing Assistant (CNA) came to the room, Resident #68 had forgotten what she wanted. She pushed the call light button again after she remembered what she wanted. Per Resident #68, when the CNA returned, she placed a pillow over the resident's face and to tried suffocate her. (Resident #68 could not remember the name of the staff involved.) She stated she was afraid and anxious and she reported the incident to the nurse. She added that the same CNA worked with her the following day in the evening and when she placed the call light on, the CNA asked, What do you want? Resident #68 told the CNA that she wanted her tray table across her bed as she was getting ready for dinner. The CNA responded, It's not even time for dinner yet. Was what I did last night not enough? Resident #68 told the CNA not to return to the room again. The following day, the Director of Nursing (DON) and the Administrator went to her room and stated they would start an investigation. She added that a few days later her sister was told that the facility notified her that she might have been dreaming. Resident #68 denied having hallucinations. She said, I was wide awake watching the Grammy's so there is no way I was dreaming, and I still find it odd that they might think that I was dreaming while the CNA worked with me for two days in a row. A review of the medical record revealed that Resident #68 was admitted to the facility on [DATE] with a re-entry on 2/27/22. Her diagnoses included hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting her left non-dominant side; epilepsy, unspecified dementia, insomnia, anxiety disorder, and major depressive disorder. A review of the quarterly minimum data set (MDS) assessment, dated 8/16/23, indicated that the resident had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating she was cognitively intact. She required extensive assistance with activities of daily living (ADLs). There were no hallucinations or delusional behaviors noted in the assessment. A review of the psychiatric notes dated 2/17 /23, revealed that Resident #68 stated a staff member put a pillow over her face on the 3-11 shift a few weeks ago. A review of the facility's Abuse Report revealed that on 2/7/23 at 4:30 PM, the resident reported that CNA E attempted to suffocate her with a pillow during care. The facility's immediate action included the suspension of CNA E during the investigation of the incident. The resident was assessed for injuries, and adult protective services, the physician and the resident's family were notified of the incident. The facility initiated abuse and neglect training. The findings of the investigation were reported as unsubstantiated. In an interview with the DON on 10/17/23 at 11:45 AM, she confirmed the allegations reported by Resident #68. When asked for the findings of the facility's investigation and the facility's corrective actions, the DON stated the previous Administrator conducted the investigation and she could not find any documentation of it. A review of the personnel file for CNA E revealed that she was hired on 9/19/16. The file included several instances of disciplinary action related to attendance. There was no indication that she was suspended pending investigation when Resident #68 made the aforementioned allegation. There was documented evidence that CNA E was suspended from 5/31/23 through 6/1/23, but that was related to a violation of the facility's attendance policy. 30905 2. During an interview with Resident #44 on 10/16/2023 at 8:48 AM, she stated she wanted a copy of the posters in the front lobby that had the information regarding who to call when she needed help or wanted to file a complaint. She was not familiar with who the Ombudsman was and what role they played. She wanted the Ombudsman's information. She was concerned about saying too much. She stated she was afraid of retaliation by the staff. Things are not always done right around here. Care is not always the best. She did not elaborate and added, That's all I'll say right now. She asked her daughter, who was involved in her health care decisions and care) be contacted for more information. During an interview with the Social Services Director (SSD) on 10/17/23 at 9:47 AM, she was asked for the grievance log and about obtaining copies of the posters in the lobby. She stated she could get them and thought she might know who the resident was that was requesting the posters. The identity of the resident was not provided to her. She mentioned three female residents who she described as manipulative. Resident #44 was one of those residents. A review of the grievance log revealed a grievance was filed on behalf of Resident #44 on 5/15/23 regarding resident care. The grievance form was requested. A review of the grievance form dated 5/15/23 regarding Resident #44, revealed that the grievance was initiated by Resident #44's daughter. It read: [Employee E] used a fork to press into my calf my leg. She had been very rough with me when cleaning me to change my briefs. She shoved me and when I told her it hurt she shoved harder and then pushed me up against the bars, which hurt. I told her to stop. She pressed me harder against the bars of my bed. I was frightened and started yelling for help. No one heard me. When she finished, I told her that hurt. She proceeded to jab me in the leg with my fork. It was as though she was threatening to stab me with it. This all happened because I asked her to clean me with baby wipes instead of a towel on another occasion. I am afraid of [Employee E] because she seems to have a grudge against me. She treats me in a bullying manner. The person investigating the grievance was the SSD. The grievance was given to the Director of Nursing (DON) and the Administrator for follow up and further investigation. On 5/15/23, an Agency for Health Care Administration (AHCA) immediate Abuse and Neglect report was completed. The grievance follow-up section read: 3. 5/22/23 5-day AHCA report completed. 4. Abuse, Neglect, Exploitation and Residents Rights was conducted on 5/16/23, 5/17/23 and 5/25/23. 5. AN&E (abuse, neglect and exploitation) was also addressed during the Town Hall meeting on 5/30/23. Overall, the staff and Administration followed AN&E protocol per facility policy. Both resident and family were notified and satisfied with investigation outcome and resolution. (Photographic evidence obtained) The 5-day report, dated 5/15/23, read: Administrator and Social Services Director interview on 5/15/23: Resident alleges that along with staff member providing care, staff member took resident's fork and pressed it against her leg. (Photographic evidence obtained) During an interview with the DON on 10/17/23 at 10:59 AM regarding Resident #44's investigation of an allegation of abuse, she read the grievance form and the 5-day AHCA report completed by the facility. She stated she could not remember exactly how the investigation was conducted or why they concluded that the allegation was unsubstantiated. She stated she would go look for the documents. The DON returned at 11:13 AM and stated there were no internal investigation documents that she could find. She stated CNA E was either terminated for excessive absences or she quit. She thought she was terminated. She did not have an explanation for the conclusion of the investigation. During a telephone interview with Resident #44's daughter on 10/18/23 at 12:03 PM, she confirmed the information in the grievance form and stated that her mother was pretty shaken up. Her mother told her that CNA E had been very rough with her when cleaning her and changing her brief. She shoved her, and when she told her it hurt, she shoved harder and then pushed her up against the bars. She told her to stop and that she was hurting her. Her mother told her that the CNA pressed her even harder against the bars of her bed. She told her she was frightened and started yelling for help. No one responded. When the CNA finished, she told her that it hurt and then the CNA took her fork and jabbed her in the leg with it. Her mother told her she felt it was as though CNA E was threatening to stab her with it. Resident #44 told her that she was afraid of CNA E because she seemed to have a grudge against her for past incidents. She told her that CNA E bullied her. During a second interview with the DON on 10/19/23 at 2:31 PM, she stated at the time of the alleged incident with CNA E and Resident #44 on 5/13/23, the current Administrator was not the Administrator. The former Administrator investigated the incident and she remembered that there was a red file with the investigation documents in it. When the former Administrator left, the file disappeared and she could not find it. She stated she was sure that a thorough investigation had been done. She could not remember if the police were called, and confirmed it was part of the facility's policy to call them if a crime was suspected. A review of the facility's policy and procedure titled Abuse, Neglect and Exploitation (implemented on 12/31/22 and revised on 12/31/22), revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. V. Investigation of alleged Abuse, Neglect and Exploitation. B. Written procedures for investigations include: 6. Providing complete and through documentation of the investigation.

Based on record reviews and interviews, the facility failed to ensure that one (Resident #26) of 25 sampled residents, remained free of significant medication errors, by failing to administer blood pressure medication as ordered. Failure to administer blood pressure medication as ordered, following parameters set by the physician, could result in a risk of injury from falls and/or extreme [CONDITION(S)]/shock, which could be life-threatening. The findings include: A review of the clinical record revealed that Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician Order Sheets for November and December 2021 revealed current orders for [MEDICATION(S)] 50 mg (milligrams) at bedtime for hypertension ([CONDITION(S)] - high blood pressure), hold if blood pressure (BP) is less than 90/60, and [MEDICATION(S)] 120 mg one time a day for [CONDITION(S)], hold if blood pressure is less than 90/60. Hold BP medication if BP remains low every shift. A review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/12/21, the resident's BP was documented as 100/58 mm Hg (millimeters of mercury) On 12/3/21, the resident's BP was documented as 100/54 mm Hg On 11/11/21, the resident's BP was documented as 116/56 mm Hg On 11/12/21, the resident's BP was documented as 150/56 mm HG, and On 11/28/21, the resident's BP was documented as 135/52 mm Hg. Each diastolic blood pressure was less than 60, however [MEDICATION(S)] 120 mg daily for [CONDITION(S)] was checked off by nursing as having been administered on all of these days, despite the parameters that were in place. The care plan indicated the resident received [CONDITION(S)] medication, which placed resident at risk for drug-related side effects, including [CONDITION(S)]. On 12/16/21 at 11:19 AM during an interview with Registered Nurse (RN) B/Unit Manager, and when asked about the resident's [MEDICATION(S)] parameters, she stated the medication should not be administered outside of the parameters. On 12/16/21 at 12:15 PM, the Director of Nursing (DON) stated she was made aware of Resident #26 having received blood pressure medication outside of the documented parameters ordered by the physician. She added that she conducted random audits of the medication administration records (MARs) but she missed this resident. She stated she would initiate in-service training with the nurses for verification of physicians' orders three times before administering medication. A review of the facility policy and procedure titled, Administering Oral Medication (Revised October 2010), revealed the guideline for safe administration of oral medication included: Review the resident care plan to assess for any special needs of the resident. The procedure steps included to check the medication dosage. Re-check to confirm the proper dose. According to the Mayo Clinic at https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-causes/syc- 465 (Accessed on 1/5/22 at 3:00 p.m.): Low blood pressure might seem desirable, and for some people, it causes no problems. However, for many people, abnormally low blood pressure ([CONDITION(S)]) can cause dizziness and [CONDITION(S)]. In severe cases, low blood pressure can be life-threatening. A blood pressure reading lower than 90 millimeters of mercury (mmHg) for the top number (systolic) or 60 mmHg for the bottom number (diastolic) is generally considered low blood pressure. Shock - Extreme [CONDITION(S)] can result in this life-threatening condition. If you have signs or symptoms of shock, seek emergency medical help. Some heart conditions that can lead to low blood pressure include extremely low heart rate ([CONDITION(S)]), heart valve problems, heart attack and heart failure. Risk factors - Age. Drops in blood pressure on standing or after eating occur primarily in adults older than 65. Neurally mediated [CONDITION(S)] primarily affects children and younger adults. Medications. People who take certain medications, for example, high blood pressure medications such as alpha blockers, have a greater risk of low blood pressure. Certain diseases. [CONDITION(S)] disease, diabetes and some heart conditions put you at a greater risk of developing low blood pressure. Even moderate forms of low blood pressure can cause dizziness, weakness, [CONDITION(S)] and a risk of injury from falls. And severely low blood pressure can deprive your body of enough oxygen to carry out its functions, leading to damage to your heart and brain. .

Based on observations, interviews, and record reviews, the facility failed to ensure that three (Residents #26, #38 and #44) of 11 residents receiving respiratory care, from a total sample of 25 residents, were provided such care, consistent with professional standards of practice and physicians' orders. This failure could place these 11 residents at risk for respiratory complications. The findings include: 1. On 12/13/21 at 02:06 PM, Resident #26 was observed lying in bed. The resident was hard of hearing and could not participate in an interview. She was observed receiving oxygen via nasal cannula at a flow rate of 4 liters per minute (LPM). A review of the clinical record revealed that Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change tubing and clean oxygen filter one time weekly on Sundays 11-7 (night shift). A review of the Annual minimum data set (MDS) assessment, dated 10/25/21, revealed that the resident had a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating she was cognitively intact. She also required extensive assistance for bed mobility, transfers, and toilet use. A review of the resident's care plan revealed she was under the care of hospice for the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was to check with the hospice team related to their scheduled visit and coordinate their plan of care with staff and the certified nursing assistants (CNAs). On 12/14/21 at 10:01 AM, Resident #26 was observed receiving oxygen via nasal cannula at a flow rate of 4 LPM. On 12/15/21 at 12:05 PM, Resident #26 was observed receiving oxygen via nasal cannula at a flow rate of 4 LPM. On 12/16/21 at 11:06 AM, CNA A stated Resident #26 was bed bound and dependent with all activities of daily living (ADLs). She stated the resident was legally blind and was receiving hospice care. When asked about the oxygen setting, she stated, The nurses take care of that. In an interview on 12/16/21 at 11:19 AM, Registered Nurse (RN) B/Unit Manager, confirmed that the oxygen was set at 4 LPM. She adjusted the setting to 2 LPM and stated the resident sometimes manipulated the setting. She confirmed that the concentrator was not within the resident's reach. She added that the resident was rapidly declining, therefore, nurses should check the setting. In an interview on 12/16/21 at 11:30 AM, MDS Coordinator C stated hospice corroborated with the facility and any new orders were added to the resident's care plan. When asked about the oxygen orders for Resident #26, she stated the resident was receiving oxygen for comfort care. She confirmed the resident's oxygen therapy had not been added to her care plan. (Copy obtained) On 12/16/21 at 12:15 PM, the Director of Nursing (DON) stated she was made aware of Resident #26 receiving higher than the prescribed flow rate of oxygen. She mentioned that she would initiate in-service training with the nurses to include verification of physicians' orders three times before administering medication. She added that the oxygen orders should have been added to the care plan. 2. A review of the clinical record revealed that Resident #38 was admitted to the facility on [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Do Not Resuscitate (DNR) order and was receiving hospice care. A review of the December 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medication list included with the 11/30/2021 3008 (hospital to nursing facility transfer form), revealed no indication or order for oxygen. A review of the hospital History and Physical, dated 11/24/2021, revealed no indication or order for oxygen. A review of the hospital referral, dated 11/30/2021, revealed no indication or order for oxygen. On 12/14/2021 at 10:15 AM, Resident #38 was observed in her room receiving oxygen via a nasal cannula. The oxygen flow rate was set at 2.5 LPM. (Photographic evidence obtained) On 12/15/2021 at 1:40 PM, Resident #38 was observed in her room sitting on her bed and receiving oxygen via nasal cannula. The oxygen flow rate was set at 2.5 LPM. A review of the 5-day minimum data set (MDS) assessment, dated 12/7/2021, revealed that Resident #38 had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. Her hearing was highly impaired, she required limited to extensive assitance with activities of daily living (ADLs), and she was receiving oxygen. A review of the resident's current care plan, revealed a focus for Respiratory Complications related to Congestive Heart Failure (CHF). Interventions included oxygen as ordered or needed. A review of the Admission Assessment, dated 4/2/2021, revealed Resident #38 was to receive oxygen at 2 LPM via nasal cannula. A review of the resident's Vital Signs from 11/30/2021 through 12//15/2021, revealed that oxygen was being received on the following dates and times: Date Value Method 12/15/2021 01:16 98.0 % Oxygen via Nasal Cannula 12/14/2021 17:34 98.0 % Oxygen via Nasal Cannula 12/14/2021 00:16 98.0 % Oxygen via Nasal Cannula 12/13/2021 17:26 98.0 % Oxygen via Nasal Cannula 12/11/2021 20:40 100.0 % Oxygen via Nasal Cannula 12/9/2021 18:40 98.0 % Oxygen via Nasal Cannula 12/8/2021 19:07 98.0 % Oxygen via Nasal Cannula 12/7/2021 22:03 98.0 % Oxygen via Nasal Cannula 12/7/2021 18:58 98.0 % Oxygen via Nasal Cannula 12/6/2021 21:13 100.0 % Oxygen via Nasal Cannula 12/6/2021 19:30 97.0 % Oxygen via Nasal Cannula 12/1/2021 01:30 94.0 % Oxygen via Nasal Cannula 11/30/2021 13:04 97.0 % Oxygen via Nasal Cannula On 12/16/2021 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about Resident #38 currently receiving oxygen without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She would have to check the hospital orders. On 12/16/2021 at 12:40 PM, an interview was conducted with RN B/Unit Manager. RN B was asked about verification of oxygen orders/parameters for a resident. The Unit Manager stated she usually verified them with the physician. The Unit Manager was asked to access Resident #38's current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B stated the nurse could not have verified the orders/parameters, because no order was noted on the MAR. 3. A review of Resident #44's clinical record revealed she was admitted to the facility on [DATE]. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 11/3/2021 minimum data set (MDS) assessment revealed that Resident #44 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 8 out of a possible 15 points. She was documented as receiving oxygen therapy while a resident at the facility. On 12/13/2021 at 1:15 p.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM (liters per minute). On 12/14/2021 at 11:05 a.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM. On 12/15/2021 at 9:15 a.m., the resident was observed resting in bed with an oxygen concentrator in use. The flow rate was set at 3 LPM. On 12/15/2021 at 1:10 p.m., the resident was observed sleeping in her bed with an oxygen concentrator in use. The flow rate was set at 3 LPM, but the nasal cannula was lying on the floor beside her bed. A review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/7/2018 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change tubing and clean filter one time weekly on Sunday. A review of the resident's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 3/1/2018 and last revised on 5/28/2021, documented the resident was on oxygen therapy. Interventions included administration of medications as ordered by the physician, and to monitor/document side effects and effectiveness; uses oxygen concentrator when in bed; receives continuous oxygen; and provide extension tubing or portable oxygen apparatus. An interview with Certified Nursing Assistance (CNA) D was conducted on 12/15/2021 at 1:14 p.m. She stated the CNAs were not permitted to touch the residents' oxygen concentrators. If a resident needed more oxygen, or more water in the concentrator, they would tell the nurse. She said oxygen was a medication, so the nurse had to make any changes. She further stated if a resident needed oxygen services, she would take the resident to the nurse. She was not permitted to adjust the flow rate, add oxygen to an empty tank, or monitor oxygen saturations. An interview with Registered Nurse (RN) F was conducted on 12/15/2021 at 1:17 p.m. She observed that Resident #44 was in her bed, and the oxygen tubing and nasal cannula were on the floor. The RN picked up the tubing and said the CNAs needed to let her know if a resident resisted care or their oxygen. She would document all of that in the resident's record. The resident had sometimes taken off her nasal cannula, which the RN would then chart. The RN confirmed that the resident's oxygen concentrator was currently on and set at 3 LPM. She said she would get the resident clean oxygen tubing and put it back on the resident. She stated it was important for the resident to get her oxygen. The nurse was responsible for the oxygen, not the CNAs. She said she checked the oxygen each morning for her residents. An interview was conducted with RN F on 12/15/2021 at 1:25 p.m., after she had assisted Resident #44. She said the record showed that the resident had been on oxygen for a long time, and that her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with RN E/Unit Manager was conducted on 2/15/2021 at 1:30 p.m. She said she was informed that Resident #44 was observed receiving oxygen at 3 LPM, when the order was for a flow rate of 2 LPM. She said sometimes oxygen orders were written with parameters, so the nurses had a little more leeway with the oxygen settings. She said the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses did not document the liters per minute that the oxygen was on when they recorded on the eMAR, they only recorded oxygen saturation levels. She stated regardless of the reason the oxygen flow rate had been adjusted for this resident, they should have treated it like a medication before any adjustments were made to administration. An interview was conducted with the Director of Nursing (DON) on 12/16/2021 at 12:50 p.m. She stated the CNAs could refill oxygen canisters, but they would not adjust the oxygen flow rate. If the CNA had concerns, they were to get the nurse. Only the nurse should adjust the flow rate. If the resident was found to have a change in condition, the nurse should talk with the provider about oxygen needs but should not adjust the oxygen flow rate without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy and procedure titled, Oxygen Administration (Revised October 2010), provided a guideline for safe oxygen administration. The policy further indicated that staff should verify that there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the resident's care plan to assess for any special needs of the resident. Adjust the oxygen delivery device so that it is comfortable for the resident.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment to help prevent the development of infections for two (Residents #25 and #17) of five residents with indwelling catheter bags, from a total of 29 residents in the sample, by allowing catheter bags and tubing to touch the floor. The findings include: A record review was conducted for Resident #25. She was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A physician's orders [REDACTED]. An observation was conducted of Resident #25 in her room lying on her bed on 12/17/19 at 11:13 AM. The indwelling catheter bag was hanging on the side of the low bed with blankets covering the bag and tubing which was lying on the floor at bedside. An observation was conducted on 12/17/19 at 2:20 PM of the resident in her room. She was lying in a low bed with the catheter bag and tubing lying on the floor. An observation was conducted of the resident in her room on 12/18/19 at 8:50 AM. The indwelling catheter and tubing was lying on the floor. An observation was conducted of Resident #25 in her room, lying on her bed at 1:51 PM on 12/18/19. The indwelling catheter and tubing was lying on the floor. An interview was conducted with Employee B, Certified Nursing Assistant (CNA ), on 12/19/19 at 12:34 PM. Employee B reported the resident had a low bed, and she hung the catheter on the side of the bed. Employee B reported she tried to keep the catheter tubing and bag off the floor, but it was difficult with a low bed. When she was shown the photographic evidence, she confirmed the catheter bag and tubing was touching the floor. A review of the Policy and Procedure for Urinary Catheter Care (revised on 9/2014) revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Noted under infection control 2b: Be sure the catheter tubing and drainage bag are kept off of the floor. An interview was conducted with the Director of Nursing (DON) on 12/19/19 at 12:58 PM. She was shown the photographic evidence of the catheter tubing and bag on the floor for Resident #25. The DON confirmed the catheter and tubing was on the floor. There was no denying it. It should not be on the floor. The DON confirmed the indwelling catheter was inserted to promote wound healing. She reported that the resident had a chronic wound. 2. On 12/16/19 at 12:43 PM, an observation of Resident #17 was conducted. She was seated in her Broda chair, and her urinary catheter tubing was resting on the floor. A record review for Resident #17 revealed a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 9/11/19. Section H noted Resident #17 had an indwelling catheter. She also had an active [DIAGNOSES REDACTED].#17's catheter.

Based on observations and interviews, the facility failed to maintain an Infection Control Program for cleaning pulse oximetry equipment and handwashing between direct contact with residents (Residents #129 and #159). The findings include: On 7/26/17 at 9:00 AM, Employee A (Licensed Practical Nurse (LPN) went into Resident #129's room to check the resident's blood oxygen level. She removed the pulse oximeter from her pocket and checked the resident. She then left the room and placed the pulse oximeter back in her pocket without cleansing it. After she left the room, she did not wash her hands or use sanitizer. Employee A went back to the medication cart and started to prepare medications for Resident #159. A review of the facility's handwashing policy revealed all personnel must use an alcohol based hand rub, or soap and water before and after direct contact with residents. A review of the cleaning and disinfection of Resident-Care items and equipment policy revealed reusable items are cleaned and disinfected or sterilized between residents. An interview with Employee A on 7/26/17 at 9:28 AM confirmed she did not wash her hands or use hand sanitizer after checking Resident #129's blood oxygen level prior to administering medications to Resident #159. The employee then pulled the pulse oximeter out of her pocket and cleansed it with Easy Clenz wipes. She stated the pulse oximeter was to be cleansed after every use on a resident. An interview was conducted with Employee B (LPN) on 7/26/17 at 9:36 AM, who stated that the pulse oximeter was to be cleansed with bleach wipes then left for three minutes after every use on a resident.

Based on observations and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for seven (#107, 205, 309, 401, 407, 410, & 411) of twenty rooms observed. The findings include: On 7/26/2017 from 10:47 a.m. through 11:50 a.m., observations revealed stained privacy curtains in the following rooms: Rooms #107, 205, 309, 401, 407, 410, and 411. An interview with Employee D in housekeeping on 7/26/17 at 10:52 a.m., revealed that privacy curtains were washed once a week. Employee D stated that staff would remove curtains right away if stains were found. Employee D also stated that residents could request for curtains to be washed, if needed. An interview was conducted with Employee C in housekeeping on 7/26/17 at 11:07 a.m. Employee C stated that maintenance pulled curtains every Tuesday, and more often if they were dirty. Employee C stated that curtains should be checked daily for stains. Employee C also stated that new curtains were put up every Tuesday and as needed if stains were found or reported. An interview was conducted with Employees E and F (Housekeeping Management) on 7/26/2017 at 1:46 p.m. Employee E toured the 300 and 400 halls with this surveyor and acknowledged the stains present on the privacy curtains in rooms #309, 401, 407, 410, and 411. She stated that the curtains in the rooms mentioned would be removed immediately and replaced.

Based on observations, interviews, and record reviews, the facility failed to maintain, follow, and implement infection control precautions and disinfection procedures to meet the current professional standards for an effective Infection Control Program, affecting three (3) of 40 sampled residents (Residents #36, #48, and #103), as well as 11 unsampled residents during lunch tray distribution on the 400 hall, and potentially affecting all residents who require diabetic blood sugar monitoring in the facility. Cross-contamination with microorganisms in a vulnerable at risk community are serious, and could result in individually contracted infectious disease illnesses and/or infectious disease outbreaks with serious medical health complications. The findings include: On 6/13/2016 at 12:01 PM, a tray pass/dining observation was conducted on the 400 hall. The tray pass was completed by Employee B and Employee C (Certified Nursing Assistants (CNAs)). Employee C was observed starting the tray pass at room [ROOM NUMBER] A/B. The employee did not sanitize prior to entering the resident's room, and she failed to knock or announce her entry. Employee C assisted the resident with set up of the lunch tray and then exited the room. She did not wash her hands before exiting after the resident contact. Employee C then removed the next lunch tray from the tray rack without sanitizing after the resident contact in room [ROOM NUMBER] A/B. Employee C then entered room [ROOM NUMBER] A/B. The employee did not sanitize after the resident contact in room [ROOM NUMBER] A/B, before entering room [ROOM NUMBER] A/B, and she did not announce or knock and wait for response before entering the resident's room. She assisted the resident with set up of the lunch tray and then exited room [ROOM NUMBER] A/B without washing her hands after the resident contact. Employee C then removed another lunch tray from the tray rack without sanitizing after the resident contact in room [ROOM NUMBER] A/B. Employee C entered room [ROOM NUMBER] A/B, she did not knock and wait for response, and she had not sanitized her hands after resident contact in room [ROOM NUMBER] A/B. The employee assisted the resident with tray set up and positioning. Employee C exited room [ROOM NUMBER] A/B without washing her hands after the resident contact. Employee B was observed assisting with set-up of a resident's lunch in room [ROOM NUMBER] A/B. The employee exited the room without washing her hands after the resident contact. Employee B then removed a lunch tray from the tray rack and entered room [ROOM NUMBER] A/B with a tray. Employee B did not knock and announce entry, and did not wait for the resident's response. The employee did not sanitize hands prior to entry after her contact with the resident in room [ROOM NUMBER]. Employee B did not wash hands prior to leaving the resident's room [ROOM NUMBER] A/B, and she exited with a tissue in her left hand. Employee B removed another lunch tray from the tray rack with the dirty tissue in her left hand from the resident contact in room [ROOM NUMBER]. Employee B, still with tissue in her left hand, entered room [ROOM NUMBER] A/B with the lunch tray. She did not sanitize or knock before entering, and did not wash her hands prior to exiting room [ROOM NUMBER] A/B, and the tissue from room [ROOM NUMBER] A/B was no longer in her hand. Employee B exited into the hall and removed another lunch tray from tray rack. She took that tray into room [ROOM NUMBER], and she announced to the resident, I have your lunch. She did not knock or allow for resident response, and she did not sanitize her hands prior to entry after her contact with the resident in room [ROOM NUMBER] A/B. Employee B did not wash her hands prior to leaving room [ROOM NUMBER] after assisting the resident with tray set up. Employee B was observed entering an isolation room (room [ROOM NUMBER]). Employee B did not sanitize after leaving room [ROOM NUMBER] and prior to entering room [ROOM NUMBER]. Employee B failed to knock before entering room [ROOM NUMBER], and she failed to don Personal Protective Equipment (PPE) before entering the isolation room. Employee B exited the isolation room without washing her hands after her contact with the resident on isolation precautions. On 6-13-16 at 12:50 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that when staff were passing lunch trays, they would be expected to wash their hands before starting the tray pass, and that the staff should be washing their hands before leaving resident rooms after assisting residents with trays. The DON stated that all staff were to knock and wait for a resident's response before entering the resident's room. The DON stated that each staff member had received training in infection control procedures, and should be following those procedures. She stated that the CNA and nursing staff recently completed infection control training with the focus on hand hygiene and proper use of personal protective equipment (PPE). The DON stated that all staff were expected to put on PPE before entering into an isolation room. She stated a gown, gloves, and any other protective equipment indicated should be worn before entering a resident's room with isolation precautions in place, and that hand washing and disposal of the PPE should be completed in the resident's room before exiting. On 6-14-16 at 8:48 AM, an observation of Resident #161's room was conducted. It revealed there was an over-the-door multi-pouch PPE supply container with infection control protective equipment stored in the pouches such as gloves, impervious gowns, masks, and eye shields. There was no sign posted or any other indication of infection control precautions, and the resident's door was open. At 8:50 AM, Resident #161's nurse (Employee I) was in the hall just outside the resident's room, and an interview was conducted. Employee I stated that she did not know why there was not an infection control instruction sign posted on the resident's door. Employee I did not know what type of organism the resident was on isolation for, or which specific type of PPE should be worn in order to enter the resident's room properly protected. She was unable to state how a visitor would know which protective equipment would be needed for entry into the resident's room. The employee stated that she would wear a gown and gloves to enter. At 8:55 AM on 6-14-16, the Unit Manager for the 300/400 halls approached Employee I and informed Employee I that the resident was on contact isolation precautions. She told Employee I where to get the signage to post with the instructions for visitors and for staff indicating which type of PPE was needed for proper protection. The employee placed the precautionary sign on the door at the entrance into room [ROOM NUMBER]. An interview with the Unit Manager for the 300/400 hall was conducted at 9:05 AM on 6-14-16. The UM stated that there should have been proper infection control signage posted on Resident #161's door when the isolation order was first implemented to ensure that everyone entering and exiting the resident's room was following precautions to prevent the spread of infection. The UM stated that the sign was used to instruct staff and visitors on proper isolation precautions and procedures. The UM stated that all residents on isolation precautions should have the sign placed and PPE supplies available at the entrance of each isolation room. She stated that nursing staff should be knowledgeable and informed of each resident's current medical diagnosis. On 6-14-16 at 9:20 AM, an interview was conducted with the DON. The DON stated that residents on isolation precautions should have an isolation precaution instruction sign placed on the resident's door at the entrance into the room, in order to provide proper PPE instructions for anyone who may need to enter the resident's room. The DON stated that normally there would have been a sign posted with instructions directing visitors to see the nurse before entering the resident's room. She stated that Resident #161's sign should have been posted when the isolation was initiated on 6-6-16. On 6-15-16 at 5:10 PM, a medication storage observation was conducted with Employee F, who was the assigned nurse for the 100 hall. The employee explained the process for disinfection of the glucometer. He stated that the meter should be disinfected after each resident use. Employee F stated that he would first put down a protective barrier, then he would open a prepackaged disinfecting wipe which was stored on the cart. He stated that he would put on gloves and wipe all sides of the glucometer with the disinfecting cloth, and that he would then place the glucometer on the clean barrier to dry for two minutes. The pre-packaged disinfectant wipe stated that the glucometer or the surface to be disinfected should remain wet with solution for 2 minutes for effective disinfection. Employee F stated that he did not know that the glucometer should be kept wet for two minutes during the disinfection process. Employee F stated he would follow the instructions provided on the disinfecting wipe packaging in the future to be sure to disinfect the glucometers properly. At 11:30 AM on 6-16-16, a medication storage observation was conducted with Employee H, the nurse assigned to the 300 hall. Employee H demonstrated the disinfection procedure for glucometers. The employee placed a clean barrier on the counter top of the medication storage cart. She stated she would put on gloves. She then opened a disinfectant wipe and began wiping the glucometer, she rotated the glucometer to make sure all sides were cleaned for 20 seconds, then placed the meter on the protective surface to dry. She stated it had to dry for at least two minutes. Employee H verified the instructions provided on the disinfecting wipe packaging and stated she should have cleaned the meter with the wipe for 2 full minutes, and then allow the meter to dry. At 12:00 PM, a review of the disinfecting wipe's technical data was conducted. The product information listed efficacy against 30 specific organisms when the recommended 2-minute wet contact time was implemented. The disinfecting wipe product guidelines for use stated, Allow treated surface to remain wet for a full two minutes, and to use additional wipes if needed to assure continuous 2-minute wet contact time. A review of the facility's infection control policy and the policy and procedure for Cleaning and Disinfecting Glucometers was conducted. The facility's Infection Control policy statement read, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage the transmission of diseases and infections. The glucometer cleaning policy stated: #1. After each resident use, the nurse will clean the glucometer with an EPA registered disinfectant product and allow the glucometer to air dry per manufacturer's recommendation. According to the Centers for Disease Control and Prevention (CDC) Guidelines for Disinfection and Sterilization in Healthcare Settings, overall contact time is the time it takes a disinfectant to eliminate all microorganisms on a product's master label. On 6-16-16 at 1:15 PM, during an interview with the DON, the glucometer disinfection policy and procedure, and the glucometer manufacturer's recommendations for disinfection of the device were reviewed. The DON stated that she was unaware of the disinfecting wipe specifications that required the glucometer to remain wet with the solution for a full two minutes during the disinfecting procedure. The disinfecting wipe packaging instructions were reviewed and the DON confirmed that for effective disinfection of the glucometers, staff would need to maintain the wet contact time of two minutes as directed by the manufacturer's guidelines. In an interview with Employee A, the Infection Control nurse, on 6/16/16 at 11:30 am, she stated that when a resident was on contact isolation, staff would need to go in with gown and gloves. There should be a sign on the door, and the staff get reports on who was on isolation. When in doubt, wear PPE (personal protective equipment). A review of the Infection Control Policy for Handwashing/Hand Hygiene revealed that employees must wash their hands for at least fifteen seconds with antimicrobial or non-antimicrobial soap and water under the following conditions: before and after entering isolation precaution settings, and before and after assisting a resident with meals. A review of the Infection Control Policy for Contact Precautions stated that in addition to wearing gloves (clean, non-sterile) when entering the room, staff should remove gloves before leaving the room and perform hand hygiene. Wear a disposable gown upon entering the contact precaution room or cubicle. (Photo copy evidence obtained)

Based on observations, interviews, and record reviews, the facility failed to ensure safe medication storage. It also failed to provide an effective system of accounting, disposition and accuracy in labeling for medications stored in the facility's emergency medication kit and in the medication storage refrigerators. This directly impacted one (1) unsampled resident of 106 total facility residents, and it had the potential to impact all residents requiring emergency medication administration. The findings include: At 2:12 PM on 6-15-16 an observation of the 100/200 hall medication storage room was conducted. The Unit Manager (UM) and Employee D facilitated the observation. The contracted pharmacy's license and the facility pharmacist's license were verified. On 6-15-16 at 2:20 PM during an interview with the UM, she stated that the contracted pharmacy service was responsible for all auditing and disposition records for the emergency drug kit (EDK). She stated that the pharmacy provided services on an as-needed basis. There was an inventory binder on top of the E (electronic) -EDK case listing all medications stored in the E-EDK with quantity and expiration dates of each medication. The E-EDK case was accessed by Employee D (registered nurse (RN). A random audit of labeling, expiration dates and inventory was conducted and cross checked with the inventory list provided in the E-EDK binder. Labeling and expiration date inconsistencies were identified. (Copies obtained) An item by item inventory audit was conducted with the assistance of Employee D and the UM. Additional concerns were discovered. The Director of Nursing (DON) and the UM reviewed the items found during the audit, and stated that there should not be mislabeled, unaccounted for medications and expired inventory in the E-EDK. The DON notified the contracted provider pharmacy of the discrepancies identified during the E-EDK inventory audit and two (2) contracted provider pharmacy representatives arrived to assist with E-EDK observation and interviews. At 2:35 PM on 6-15-16 an interview with the contracted provider pharmacy's pharmacist and technician was conducted. The technician stated that he had been on-site on 6-14-16, and had conducted an inventory audit on the E-EDK with no expired medications found. The technician was unable to explain how there were unaccounted for, mislabeled, and expired medications in the E-EDK. The contracted pharmacist stated that Taylor Care's pharmacist had contacted him last week by phone with concerns related to expired medications identified on the E-EDK inventory. He stated that he had sent the technician out to the facility to run an inventory audit and remove any expired inventory. The contracted pharmacist stated, We thought that we had taken care of the problem. The contracted pharmacy technician stated that he was on-site last week, and had performed the expired medication inventory audit as directed. The contracted pharmacy technician stated that he had removed all expired inventory, and that there should not be any expired inventory in the E-EDK, because he had removed all the expired medications last week. On 6-15-16 at 2:45 PM, a review of the mislabeled, unaccounted for, and expired inventory discovered in the E-EDK during the medication storage observation was conducted with the contracted pharmacist and contracted pharmacy technician. The review revealed the following E-EDK inventory discrepancies: 1. Stock code 1A-202: One (1) Furosemide 40 milligram (mg) vial 10 mg/ml (milliliter), expired in 4/16, packaging mislabeled stated Furosemide 10 mg/ml vial (the medication was not listed on the inventory audit; it was unaccounted for and was expired). 2. Stock code 2C-100: 8 Warfarin 1 mg tabs, expired 3-15-15, initial quantity 16 tabs. (The medication was not listed on the inventory audit; it was unaccounted for.) 3. Stock code 6C-30: Fentanyl 75 micrograms (mcg)/hr (hour) patch. Pharmacy labeled Lot #6e0114 and expiration date of 03-06-15. The manufacturer stamped Lot # and expiration date was 03/17. (Pharmacy labeling was inaccurate) 4. Stock code 6C-27: Fentanyl 100 mcg/hr patch. Pharmacy Labeled Lot # and expiration date of 03/06/15. T he manufacturer stamped lot # , and expiration date was 04/17. (Pharmacy labeling is inaccurate) 5. Stock code 1D-56: Lidocaine 5% (percent) patch. Pharmacy Labeled Lot # 3 and expiration date of 06/30/15, quantity of six (6). The manufacturer labeled Lot # and expiration date of 07/16. (Pharmacy labeling was inaccurate, the medication pain patch was not listed on the inventory audit; medication was unaccounted for, not found on expiring inventory list, quantity 6.) 6. Stock code 6B-212: Dextrose 10%-Water IV (intravenous) Solution, expiration date 5-5-16. Manufacturer stamped expiration date was 05/16. (The IV fluids were expired, the IV fluid was not listed on the EDK inventory audit, and was not listed on the expiring inventory list.) 7. Stock code 6A-17: Dextrose 5%-1/2 NS (normal saline) IV Solution, pharmacy labeled expiration date was 5/15 for Lot #C 2. The manufacturer's stamped expiration date was 12/15. (The pharmacy label has inaccurate expiration date, the IV fluids were expired, the IV fluid was not listed on the EDK inventory audit, and was not listed on the expiring inventory list). 8. Stock code 1C-139: SPS 15 grams (gm)/60 ml Suspension. Pharmacy labeled expiration date was 01/10/17, Lot # 1. The manufacturer's expiration date was 5/16 and Lot # 2. (The pharmacy label was inaccurate, the medication was expired, the medication was found on the inventory audit, the medication was not listed on the expiring inventory list.) The contracted pharmacist stated at approximately 2:55 PM that there was no schedule for routine hands-on, item by item inventory auditing of the E-EDK. He stated that a monthly report should be completed and placed in the inventory binder that was kept on-site. The contracted pharmacist was unable to say when a hands-on, item by item audit had been conducted. The date of the oldest expired medication was 3/15/15. The contracted pharmacist was unable to say whether the facility's pharmacist had conducted any hands-on inventory audits of the E-EDK. During an interview with the contracted pharmacist on 6-15-16 at 3:20 PM, a request for the E-EDK disposition records dating from 3-2015 through 6-15-16 was made. A current E-EDK inventory list and a current expiring inventory list was also requested. At 3:25 PM on 6-15-16 during an interview with the DON, the facility's policy and procedure related to medication storage, medication administration and the facility's pharmacist agreement were requested. On 6-15-16 at 4:30 PM, the medication storage observation for the medication storage area on the 100/200 hall was continued. An observation of the refrigerated stored medications was conducted. The UM assisted with the observation. There was one expired resident medication found in the storage refrigerator. The UM stated that she was responsible for auditing the refrigerated medication storage. The UM stated that she performed weekly checks for expired medications. The expired medication was labeled: Calcitonin 200 U (units) Nasal Spray, inhale one spray in one nostril daily (alternate nostrils daily). The open date was 5-5-16. The contracted pharmacy provided documentation for the Calcitonin Nasal Spray to clarify that the expiration period was 35 days once opened. The Calcitonin Nasal Spray expiration date was 6-9-16. At 4:45 PM on 6-15-15, a medical record review was conducted for the unsampled resident. The resident's Medication Administration Record [REDACTED]. (Copy obtained) An interview with the 100/200 hall UM was conducted on 6-15-16 at 5:00 PM. The UM reviewed the unsampled resident's MAR, and stated that the resident was documented as having received the expired medication for a total of four (4) days on the June 2016 MAR. The UM stated that the medication should have been discarded and that expired medication should not be given to any resident. On 6-16-16 at 10:30 AM, an observation was conducted in the 300/400 hall medication storage room. The UM assisted with the observation. The UM stated that she conducted a weekly audit for expired medications. The UM stated that there were no disposition records kept in the 300/400 medication storage room. She stated that medications taken from the medication storage room were documented electronically on the MAR by the nurses when given, and that provided the disposition of medication used from the EDK stored in the medication refrigerator and any over the counter medications stored in the medication storage room. The facility was unable to provide an accounting of medications stored in the 300/400 hall medication storage area. The observation of the refrigerated medication storage for 300/400 hall revealed that there were expired medications. The medications were labeled: APAP (acetaminophen) 650 milligrams (mg) Suppository (12), fill date on label was 1-2-15. The manufacturer stamped expiration date was 7-15. There were five (5) expired suppositories found mixed in with 3 other current dated (5/17) multi-dose packaged suppositories (6 to a card) contained in a pharmacy labeled package. The UM stated she did not know how the expired suppositories could be there; that she had checked the medications herself. At 2:20 PM on 6-16-16 an interview with the administrator and the DON was conducted. The Administrator stated that she was aware of the expired medications, inaccurately labeled medications, and unaccounted for medications found during the medication storage observations. The administrator stated that this was not an acceptable standard of practice for Taylor Care Center. She stated that she would be developing Quality Assurance (QA) plan to ensure safe and accurate medication storage. She stated that she had initiated education and training for nursing, and that she was working with the facility's pharmacist and the contracted pharmacy to develop more efficient and accurate accounting of medications held in the medication storage rooms and the E-EDK. The DON stated that there would be scheduled auditing of all inventory held in the medication storage rooms, and that there would be an item by item accounting of all medications. She stated that there should have been disposition records for all medications retained in the medication storage rooms, and that expired medications should be removed promptly. A 6-15-16 review of the facility's medication storage policy was conducted. The policy stated under letter M that outdated, contaminated or deteriorated medications, and those in containers that were cracked, soiled or without secure closures were to be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed. Under letter O the policy stated that medication storage conditions were to be monitored on a monthly basis and corrective action should be taken if problems were identified. (Copy obtained) A 6-15-16 review of a policy and procedure entitled Organizational Aspects for Consultant Pharmacist Services (the facility's pharmacist) was conducted, and it revealed on page two (2) under letter F, the specific activities that the consultant pharmacist performed but was not limited to: #4. Checking the medication storage areas (at least monthly), and the medication carts (at least quarterly), for proper storage and labeling of medications, cleanliness, and removal of expired medications. (Copy obtained)

Based on observations, interviews, and record reviews, the facility failed to ensure that the facility's pharmacist and the contracted provider pharmacy maintained accurate record keeping, labeling of stored medications, and effective monitoring of expired medication inventory for one unsampled resident of a total of 106 residents currently in the facility. This potentially affected all residents requiring emergency medication administration. The findings include: On 6-15-16 at 2:20 PM, a medication storage observation was conducted in the 100/200 Hall's medication storage room with labeling and expiration date inconsistencies identified. An item-by-item inventory audit was conducted with the assistance of Employee D and the Unit Manager of the 100/200 hall. There were additional concerns found during the audit. The Director of Nursing (DON) and the Unit Manager reviewed the items discovered during the audit and stated that there should not be mislabeled, unaccounted for medications, and expired inventory in the electronic emergency drug kit (E-EDK). The Unit Manager stated that the contracted pharmacy was responsible for the E-EDK inventory auditing. At 2:35 PM on 6-15-16, an interview with the contracted pharmacist and the contracted pharmacy technician was conducted. The technician stated that he had been on-site on 6-14-2016. He stated that he ran an inventory audit on the E-EDK, and that there were no expired medications found. The technician was unable to explain how there were unaccounted for, mislabeled, and expired medications found in the facility's E-EDK. The contracted pharmacist stated that(NAME)Care's pharmacist had contacted him last week by phone with concerns related to expired medications identified on the E-EDK inventory. He stated that he had sent the technician out to the facility to run an inventory audit and remove any expired inventory. The contracted pharmacist stated, We thought that we had taken care of the problem. The contracted pharmacy technician stated that he was on-site last week, and had performed the expired medication inventory audit as directed. The contracted pharmacy technician stated that he had removed all expired inventory, and that there should not be any expired inventory in the E-EDK, because he had removed all the expired medications last week. On 6-15-16 at 2:45 PM, a review of the mislabeled, unaccounted for, and expired inventory discovered in the E-EDK during the medication storage observation was conducted with the contracted pharmacist and contracted pharmacy technician. The review revealed the following E-EDK inventory discrepancies: 1. Stock code 1A-202: One (1) Furosemide 40 milligram (mg) vial 10 mg/ml (milliliter), expired in 4/16, packaging mislabeled stated Furosemide 10 mg/ml vial (the medication was not listed on the inventory audit; it was unaccounted for and was expired). 2. Stock code 2C-100: 8 Warfarin 1 mg tabs, expired 3-15-15, initial quantity 16 tabs. (The medication was not listed on the inventory audit; it was unaccounted for.) 3. Stock code 6C-30: Fentanyl 75 micrograms (mcg)/hr (hour) patch. Pharmacy labeled Lot #6e0114 and expiration date of 03-06-15. The manufacturer stamped Lot # and expiration date was 03/17. (Pharmacy labeling was inaccurate) 4. Stock code 6C-27: Fentanyl 100 mcg/hr patch. Pharmacy Labeled Lot # and expiration date of 03/06/15. T he manufacturer stamped lot # , and expiration date was 04/17. (Pharmacy labeling is inaccurate) 5. Stock code 1D-56: Lidocaine 5% (percent) patch. Pharmacy Labeled Lot # 3 and expiration date of 06/30/15, quantity of six (6). The manufacturer labeled Lot # and expiration date of 07/16. (Pharmacy labeling was inaccurate, the medication pain patch was not listed on the inventory audit; medication was unaccounted for, not found on expiring inventory list, quantity 6.) 6. Stock code 6B-212: Dextrose 10%-Water IV (intravenous) Solution, expiration date 5-5-16. Manufacturer stamped expiration date was 05/16. (The IV fluids were expired, the IV fluid was not listed on the EDK inventory audit, and was not listed on the expiring inventory list.) 7. Stock code 6A-17: Dextrose 5%-1/2NS (normal saline) IV Solution, pharmacy labeled expiration date was 5/15 for Lot #C 2. The manufacturer's stamped expiration date was 12/15. (The pharmacy label has inaccurate expiration date, the IV fluids were expired, the IV fluid was not listed on the EDK inventory audit, and was not listed on the expiring inventory list). 8. Stock code 1C-139: SPS 15 grams (gm)/60 ml Suspension. Pharmacy labeled expiration date was 01/10/17, Lot # 1. The manufacturer's expiration date was 5/16 and Lot # 2. (The pharmacy label was inaccurate, the medication was expired, the medication was found on the inventory audit, the medication was not listed on the expiring inventory list.) The contracted pharmacist stated at approximately 2:55 PM that there was no schedule for routine hands-on, item by item inventory auditing of the E-EDK. He stated that a monthly report should be completed and placed in the inventory binder that was kept on-site. The contracted pharmacist was unable to say when a hands-on, item by item audit had been conducted. The date of the oldest expired medication was 3/15/15. The contracted pharmacist was unable to say whether the facility's pharmacist had conducted any hands-on inventory audits of the E-EDK. On 6-15-16 at approximately 3:00 PM, the contracted pharmacist placed a call to the facility's pharmacist and informed the facility's pharmacist of the E-EDK discrepancies. On 6-15-16 at 3:05 PM, a phone interview was conducted with the facility's pharmacist. The facility's pharmacist stated that he worked for(NAME)Care Center. He stated that he had been on-site at the facility last week, and that he had concerns with expired medications in the E-EDK. He stated that he had contacted the contracted pharmacy to notify them of his concerns related to expired medications in the E-EDK. The(NAME)Care Center pharmacist stated that he did not open any compartments/drawers in the EDK during his on-site visit, but that he had run an expiring inventory audit. He stated that he thought that the expired medications had been removed by the contracted pharmacy. The(NAME)Care Center pharmacist stated that he did not perform an item by item audit during his on-site visit, and could not say when an item by item audit had last been conducted. The(NAME)Care Center pharmacist stated, There should not be any unaccounted for, mislabeled, or expired medications in the E-EDK. He stated that the contracted pharmacy was responsible for the E-EDK inventory. The facility's pharmacist stated he would provide the facility's policy and procedure for review. During an interview with the contracted pharmacist on 6-15-16 at 3:20 PM, a request for the E-EDK disposition records dating from 3-2015 through 6-15-16 was made. A current E-EDK inventory list and a current expiring inventory list was also requested. A 6-15-16 review of the E-EDK disposition record from 3-16-15 to 4-15-15 revealed: Warfarin 1 mg tab, a quantity of three (3) tabs was removed on 4-8-15 for Resident C. B. (unsampled) at 4:42 PM (remaining count 11). On 4-9-15, Warfarin 1 mg tab, a quantity of two (2) tabs was removed for Resident C. B. at 5:28 PM (remaining count 9). On 4-14-15, Warfarin 1 mg tab, a quantity of one (1) tab was removed for Resident D. N. (unsampled) at 6:49 PM (remaining count 8). The pharmacy labeled expiration date for the Warfarin 1 mg tab was 3-15-15. A review of an unsampled resident's Medication Administration Record [REDACTED]. An interview with the Unit Manager for the 100/200 hall was conducted on 6-15-16 at 5:00 PM. The Unit Manager reviewed the unsampled resident's MAR. She stated that the resident was documented as having received the expired medication for a total of four (4) days on the MAR for the month of June 2016. The Unit Manager stated that the medication should have been discarded, and that expired medications should not be given to any resident. On 6-16-16 at 10:30 AM, an observation was conducted in the 300/400 hall medication storage room. The Unit Manager (UM) of the 300/400 hall assisted with the observation. The UM stated that she conducted a weekly audit for expired medications. The UM stated that there were no disposition records kept in the 300/400 medication storage room. She stated that medications taken from the medication storage room were documented electronically on the MAR by the nurses when given. She stated that that provided the disposition of medication used from the E-EDK stored in the medication refrigerator, and any over-the-counter medications stored in the medication storage room. The facility was unable to provide an accounting of medications stored in the 300/400 hall medication storage area. An observation of the refrigerated medication storage for the 300/400 hall revealed that there were expired medications. The medications were labeled: APAP (acetaminophen) 650 mg Suppository (12), fill date on label was 1-2-15. The manufacturer's stamped expiration date on the packaging was 7-15. There were five (5) expired suppositories found mixed in with three (3) multi-dose packaged suppositories (6 to a card) dated 5/17 and contained in a pharmacy labeled package. The UM stated that she did not know how the expired suppositories could be there; that she had checked the medications herself. A 6-15-16 record review of the facility's medication storage policy was conducted. The policy stated under letter M that outdated, contaminated, or deteriorated medications, and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed. Under the letter O, the policy stated that medication storage conditions were monitored on a monthly basis and corrective action was to be taken if problems were identified. (Copies obtained) A 6-15-16 review of the Pharmaceutical Consulting Agreement was conducted, and it revealed that the consultant pharmacist would provide the following services (There were 15 services included in the agreement; only the services related to deficient practice are noted.): #3. Provide monthly inspections of medication storage areas. (While inspections may have been performed monthly, the inspections were ineffective in eliminating the presence of expired, mislabeled, and unaccounted for medications held in the facility's medication storage areas. Medications dated 3-15-15 were found in the E-EDK.) #11. Attendance during any governmental agency or accrediting body survey process. (While a phone interview was conducted during the survey process; the facility's pharmacist was not in attendance during the survey process.) (Copy obtained) In a 6-15-16 review of the document/letter provided by the(NAME)Care Center pharmacist dated 6-15-16, it stated, We generally do not open the emergency medication kit (EMK), rather we depend on the information posted on the outside of the EMK. It also stated, The expiration date for each item in the EMK is shown on a list attached to the EMK and is supplied by the provider pharmacy. (Copy obtained) A 6-15-16 review of a policy and procedure entitled Organizational Aspects for Consultant Pharmacist Services (the facility's pharmacist) was conducted, and it revealed on page two (2) under letter F, the specific activities that the consultant pharmacist performed but was not limited to: #3. Checking the emergency medication supply (at least monthly) to ascertain that it is properly sealed and stored, and that contents were not outdated. #4. Checking the medication storage areas (at least monthly), and the medication carts (at least quarterly), for proper storage and labeling of medications, cleanliness, and removal of expired medications. A 6-16-16 review of a document/letter dated 6-15-16 and received at 10:13 PM, provided by the contracted pharmacy's pharmacist was conducted and it stated that: 1. We will make sure to provide an updated formulary with expiration dates after each fill of the E-Kit. 2. I will complete hands on inventory of each item in the E-Kit weekly for the first two (2) months, followed by a monthly hands-on inventory moving forward. 3. I will also forward my findings to you, MS. x and Ms. xx. (Copy obtained)

Based on observation and interview, the facility failed to ensure privacy and dignity for residents in eight rooms on one of four hallways in the facility during provision of meal trays at the lunch meal on 6/13/16 by not knocking and waiting for permission to enter prior to entering the residents' rooms. Failure to provide and maintain resident dignity can result in a resident's diminished quality of life. The findings include: On 6/13/2016 at 12:01 PM, a tray pass/dining observation was conducted on the 400 hall. The tray pass was completed by Employee B and Employee C (Certified Nursing Assistants (CNAs)). Employee C was observed starting the tray pass at room [ROOM NUMBER] A/B. She failed to knock, announce herself, or wait for permission to enter before entering the resident's room. Employee C then entered room [ROOM NUMBER] A/B. She failed to knock, announce herself, or wait for permission to enter before entering the resident's room. Employee C then removed another lunch tray from the tray rack. Employee C entered room [ROOM NUMBER] A/B. She failed to knock, announce herself, or wait for permission to enter before entering the resident's room. Employee B removed a lunch tray from the tray rack and entered room [ROOM NUMBER] A/B with a tray. She failed to knock, announce herself, or wait for permission to enter before entering the resident's room. Employee B removed another lunch tray from the tray rack and entered room [ROOM NUMBER] A/B with the lunch tray. She failed to knock, announce herself, or wait for permission to enter before entering the resident's room. Employee B exited into the hall and removed another lunch tray from tray rack. She took that tray into room [ROOM NUMBER], and she announced to the resident, I have your lunch. She did not knock or allow for resident response before entering the resident's room. Employee B was observed entering an isolation room (room [ROOM NUMBER]). Employee B did not knock, announce herself, or wait for permission to enter before entering the resident's room. On 6-13-16 at 12:50 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that when staff were passing lunch trays, they would be expected to knock and wait for a resident's response before entering the resident's room.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program related to fruit flies in the dining room, kitchen, a nursing station, and a resident room. Ineffective pest control may lead to transmission of disease and infection. The findings include: Record review of the Grievance Log revealed a concern related to residents seeing fruit flies in the dining room dated 3/4/2015. Resolution stated pest control treated facility on 3/2/2015 and follow-up treatment by facility staff on 3/5/2015. On 3/25/2015 at 12:30 PM fruit flies were observed on the drink cart in the dining room, on a soiled tray that had food debris, on the walls, by the sink, in the windows, and on the pull cord to the window blinds. Also observed fruit flies in the dishwashing area of the kitchen, all over the back wall. The staff in the dishwashing area of the kitchen confirmed the fruit flies had been in the dishwashing area. On 3/25/2015 at 12:35 PM in an interview with Employee M, kitchen aid, he said he sees fruit flies in the dishwashing area when he works. He said it's because these items are dirty. On 3/25/2015 at 12:36 PM in an interview with Employee N, dietary aid, she said she sees the fruit flies over by the sink. She said we try to clean up wherever they are. She said they are usually around water. On 3/25/2015 at 12:40 PM in an interview with the Dietary Manager, he stated that the facility is addressing this (fruit flies). He said that Friday night the facility's pest control company sprayed the dining room and the kitchen. He said he brings all pest control concerns to maintenance. On 3/25/2015 at 12:49 PM in an interview with the Dietary District Manger, he stated that the fruit flies have been an on-going problem. He stated he identified that they are coming from the drain that has been capped, which was a garbage disposal. He said pest control spray bombed the facility Friday night, and Maintenance poured something down the drain. He stated he planned to make a log of the communication he gives to the facility when he reports the fruit flies. On 3/25/2015 at 12:55 PM in an interview with the Maintenance Director he stated, "We started noticing the fruit flies last week in the dining room and the kitchen. We had pest control come out on Friday and treated the dining room and kitchen." He stated the current problem intensified since last week. On 3/25/2015 at 1:27 PM the Maintenance Director said he called pest control today, since he spoke with this surveyor earlier. He explained he wanted to speak to the pest control manager and stated, "because this is not working and I want it taken care of." He said yesterday he did a drain treatment and an aerosol spot treatment. He said pest control come monthly to treat. He said he was instructed to have UV fly stations put in. He said pest control will install them. At 4:15 PM the Maintenance Director stated that he didn't believe the previous treatments were effective. He said for the month of February, he was lead to believe the problem was the drains. He said that was an incorrect diagnosis. He said there have been occasions where they have treated for [REDACTED]. Review of the pest control report dated 2/9/2015 for routine service revealed they noticed and treated small flies in the kitchen area and work floor. On 3/2/2015, pest control provided routine service and noticed small fruit flies in kitchen area and work floor. On 3/21/2015 pest control returned to specifically treat for small flies with Nyguard and SWAT.The kitchen area was closed during the treatment. 3/25/2015 at 4:00 PM in an interview with the pest control on call technician, he said the SWAT treating was for small flies. He said we scrub out all the pipes, we sanitize and use a chemical that is very good at getting to the organic matter. He said we also use Nyguard, for biologic treatment. He stated they missed the source when they came last week. He said they have just effectively removed the source. He stated, "They were under the stainless steel backsplash." He said he went through the whole kitchen. On 3/25/2015 at 12:50 PM surveyor observed a fruit fly flying around at the 300-400 nurses ' station. On 3/25/2015 at At 2:42 PM surveyor observed a black colored flying insect on the plate and tray table in Room 414 B. An Interview was conducted with Resident # 61 at 2:43 PM on 3/25/2015. Resident #61 stated that she has seen those gnats on and off for a couple of weeks. Record review of the Resident Food Committee minutes dated 2/4/2015 reported fruit flies noticed in the main dining room and on the units, and maintenance was notified. Record review of the Resident Food Committee minutes dated 3/4/2015 reported fruit flies are being noticed in the main dining room and on the units. "This was brought to maintenance's attention last month, but the issues remain."

Based on observations made in the kitchen and in the nourishment rooms during the annual survey days 3/23/2015 through 3/25/2015, and staff interviews, the facility failed to store, prepare and serve foods under sanitary condition. The findings include: During the initial kitchen observation on 3/23/2015 at 9:37 AM, the wall behind the reach in refrigerator was observed covered with a layer of hanging dust. This dust remained there until surveyor intervened on 3/25/2015 at 1:15 PM. The ceiling area above the cooking and serving area in the kitchen was observed with dried food debris splashes. Three of the ceiling light shades were obscured by a dirty film. In an interview with the Certified Dietary Manager(CDM) on 3/25/2015 at 1:15 PM, he agreed that the walls, the ceiling, and 3 of the ceiling light shades needed to be cleaned. He revealed that a work order request will be sent to the Maintenance department immediately. Observation of the 2 nourishment rooms on 3/24/2015 at 1:20 PM revealed 2 boxes of Thickened dairy with expiration dates of 1/4/2015 and 1/26/2015, and a box of Honey Thickened Orange Juice with an expiration date of 2/24/2015 in the resident's nourishment refrigerator on the 100/200 hall unit. .

Based on observation, interview, and record review, the facility failed to ensure an accident prevention safety device was in place for 1 of 3 residents reviewed for accidents (Resident #104), out of 32 sampled residents. This placed the resident at risk for falls and or injury. The findings include: On 3/25/2015 at 8:48 AM an observation of Resident #104 revealed he was sitting in his wheelchair but did not have a wheelchair alarm in place. On 3/25/2015 at 9:15 AM Resident #104 remains in his wheelchair and does not have a wheelchair alarm in place. On 3/25/2015 at 11:30 AM Resident #104 remains in his wheelchair and does not have a wheelchair alarm in place. Review of Resident #104's physician orders [REDACTED]. Record review for Resident #104 revealed he had falls on 3/5/2015, 2/7/2015, 1/22/2015, and 1/5/2015, indicating he was a high risk for falls. Review of Resident #104's Care Plan dated 2/23/2015 revealed he was at risk for falls due to a history of falls. The approach stated, "Use safety device, bed and wheelchair alarms," and ensure he has nonskid footwear when in bed. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #104 had 2 or more falls since admission, 1 with injury. On 3/25/2015 at 9:43 AM in an interview with Employee A, Certified Nursing Assistant (CNA), she stated she works mostly 3-11 shift on a PRN (as needed) status. She said Resident #104 is a fall risk. On 3/25/2015 at 2:00 PM an observation was made of Resident #104 in bed. He had regular socks on his feet, not nonskid socks as care planned. On 3/25/15 at 2:00 PM in an interview with Employee A, CNA, she stated that Resident #104 had been up and dressed when she came in this morning. She stated she didn't notice an alarm on his wheelchair. She observed the resident's feet while he was in bed, and said he did not have on nonskid socks. On 3/25/2015 at 2:10 PM in an interview with Employee B, Licensed Practical Nurse, she stated that Resident #104 was supposed to have a chair alarm when he is up in his wheelchair. She said that part of the fall protocol would be to wear nonskid socks when he was in bed. On 3/26/2015 at 10:00 AM in an interview with Employee E, MDS nurse, she stated that she checks the residents' physician orders [REDACTED]. She said if the facility did not put the alarm on the resident, then they were not following the orders and plan of care. She stated the nonskid shoes or socks are a nursing measure. When asked how the CNAs know about safety devices in place for a resident, she stated the CNAs have activity of daily living (ADL) cards that are located at the nursing station. She stated MDS updates the cards quarterly, and as needed, and the Unit Manager and nurse would update the cards too. Review of the Resident Care Card for Resident #104 revealed concerning safety that he has frequent falls and uses a Bed/Chair alarm. On 3/26/2015 at 10:14 AM in an interview with Employee F, Registered Nurse, she stated that the nurses are supposed to ensure that the CNAs are following the resident care card. .

Based on observation, resident and staff interviews, and medical record review, the facility failed to ensure services to maintain grooming were provided to 1 resident (Resident #64), out of 3 residents reviewed who were unable to independently perform activities of daily living, out of 35 residents reviewed for grooming and cleanliness status. The findings include: On 03/23/2015 at 11:58 a.m., Resident #64 was observed to have thick facial hair on her chin. The resident was further observed to have the presence of thick hair on her chin on 3/25/15 at 10:00 a.m., on 03/25/2015 at 11:51 a.m. and on 3/26/15 at 8:47 a.m. In an interview on 03/25/2015 at 2:22 p.m., Resident #64 stated the Certified Nursing Assistants (CNA) previously attempted to remove the hairs from her chin, but no one has done it recently. She indicated she would like the hairs to be removed. A review of Resident #64's medical record revealed a significant change in status Minimum Data Set (MDS) assessment dated [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's upper and lower extremities were impaired on both sides. The assessment indicated that Resident #64 required extensive staff assistance of at least one person for the completion of her personal hygiene. A review of the resident's care plan dated 2/5/15 revealed a nursing [DIAGNOSES REDACTED]. Her risk was related to tremors, chronic pain and dementia. Her goals included assist with dressing and grooming daily until next review (5/3/15). On 03/25/2015 at 4:38 p.m. Employee K, CNA, stated that Resident #64 required total care for all activities of daily living except feeding. She stated the resident was not capable of performing personal hygiene services on her own. Employee K revealed grooming services such as shaving/removing facial hair is usually offered on showers days. She stated she would remove Resident #64's facial hair during her scheduled shower this evening. During an interview on 3/26/15 at 8:47 a.m., Resident #64 stated no one attempted to remove her facial hair in the past few days. In an interview on 03/26/2015 at 2:03 p.m., Employee L, CNA, revealed Resident #64 requires total assistance of two persons for activities of daily living except eating. Employee L stated resident grooming usually includes hair removal, but she stated she has not addressed this with Resident #64. Employee K further stated the CNA who gives Resident #64 her shower should address the removal of hair from her chin. An interview on 03/26/2015 at 2:09 p.m. with the East Wing Unit Manager revealed that she makes rounds to ensure necessary care is provided to residents. She stated grooming for females includes combing hair, brushing teeth, cleaning glasses, bathing, etc. Females should also receive removal of facial hair. She said she was not aware of the presence of facial hair on Resident #64. On 03/26/2015 at 2:15 p.m., the East Wing Unit Manager verified the observation of thick facial hair on Resident #64's chin. She indicated she would follow-up with the resident's assigned CNA for removal of the hair. .

Based on observation, resident and staff interviews, and medical record review, the facility failed to perform grooming services in accordance with the written plan of care for 1 resident (Resident #64), out of 3 residents reviewed who were unable to independently perform activities of daily living, out of 35 residents reviewed for cleanliness and grooming status. The facility also failed to provide timely pressure ulcer care in accordance with a skin care protocol for 1 of 2 residents reviewed for incidence of pressure ulcer or pressure ulcer worsening (Resident #151). In addition, the facility failed to consistently implement the care plan related to safety devices and splint application for 1 resident (Resident #104), out of 3 residents reviewed for accidents. Failure to implement care plan approaches could potentiate medical or physical complications and/or injury. The findings include: 1) On 03/23/2015 at 11:58 a.m., Resident #64 was observed to have thick facial hair on her chin. The resident was further observed to have the presence of thick hair on her chin on 3/25/15 at 10:00 a.m., on 03/25/2015 at 11:51 a.m. and on 3/26/15 at 8:47 a.m. In an interview on 03/25/2015 at 2:22 p.m., Resident #64 stated the Certified Nursing Assistants (CNA) previously attempted to remove the hairs from her chin, but no one has done it recently. She indicated she would like the hairs to be removed. A review of Resident #64's medical record revealed a significant change in status Minimum Data Set (MDS) assessment dated [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's upper and lower extremities were impaired on both sides. The assessment indicated that Resident #64 required extensive staff assistance of at least one person for the completion of her personal hygiene. A review of the resident's care plan dated 2/5/15 revealed a nursing [DIAGNOSES REDACTED]. Her risk was related to tremors, chronic pain and dementia. Her goals included assist with dressing and grooming daily until next review (5/3/15). On 03/25/2015 at 4:38 p.m. Employee K, CNA, stated that Resident #64 required total care for all activities of daily living except feeding. She stated the resident was not capable of performing personal hygiene services on her own. Employee K revealed grooming services such as shaving/removing facial hair is usually offered on showers days. She stated she would remove Resident #64's facial hair during her scheduled shower this evening. During an interview on 3/26/15 at 8:47 a.m., Resident #64 stated no one attempted to remove her facial hair in the past few days. In an interview on 03/26/2015 at 2:03 p.m., Employee L, CNA, revealed Resident #64 requires total assistance of two persons for activities of daily living except eating. Employee L stated resident grooming usually includes hair removal, but she stated she has not addressed this with Resident #64. Employee K further stated the CNA who gives Resident #64 her shower should address the removal of hair from her chin. An interview on 03/26/2015 at 2:09 p.m. with the East Wing Unit Manager revealed that she makes rounds to ensure necessary care is provided to residents. She stated grooming for females includes combing hair, brushing teeth, cleaning glasses, bathing, etc. Females should also receive removal of facial hair. She said she was not aware of the presence of facial hair on Resident #64. On 03/26/2015 at 2:15 p.m., the East Wing Unit Manager verified the observation of thick facial hair on Resident #64's chin. She indicated she would follow-up with the resident's assigned CNA for removal of the hair. 2) A review of the medical record for Resident #151 revealed he was admitted to the facility on [DATE]. A review of the AHCA-Med Serv 3008 form dated 1/1/15 revealed that the resident had [MEDICAL CONDITION] on his sacrum and posterior thighs. The resident's Admission Data Collection form dated 1/1/15 revealed a skin condition present, but no further information was provided. A review of Resident #151's 5 day MDS assessment dated [DATE] revealed he had two stage 2 pressure ulcers (bed sores) that were present on admission to the facility. A review of the physician's orders [REDACTED]. A review of the resident's interim care plan dated 1/3/15 revealed that it did not address his skin condition. The medical record contained a Skin Care Protocol signed by the facility's Medical Director. The following steps were present for Pressure Ulcers: 1. Assess and document description of wound 2. Cleanse area with normal saline solution 3. Apply wound gel to affected area, cover with a [MEDICATION NAME] pad and secure with paper tape, or roller gauze as indicated. A review of Resident #151's January, 2015 Treatment Administration Record revealed [MEDICATION NAME] cream was applied to the resident's sacrum twice a day from 1/2/15 to 1/11/15. No additional treatment was documented until 1/15/15, when physician orders [REDACTED]. During an interview on 03/26/2015 at 10:59 a.m. with the West Wing Unit Manager, she verified that Resident #151 was documented to have pressure ulcers present on admission. She verified the pressure ulcer Skin Care Protocol noted in Resident #151's record was not followed pending alternate physician orders. 3) On 3/25/2015 at 8:48 AM an observation of Resident #104 revealed he was sitting in his wheelchair, but did not have a splint on or a wheelchair alarm in place. On 3/25/2015 at 9:15 AM Resident #104 remained in his wheelchair and did not have a wheelchair alarm in place and no splint on his upper extremity. On 3/25/2015 at 11:30 AM Resident #104 remained in his wheelchair and did not have a wheelchair alarm in place and no splint on his upper extremity. Review of Resident #104's physician orders [REDACTED]. Record review for Resident #104 revealed he had a fall on 3/5/2015, 2/7/2015, 1/22/2015, and 1/5/2015, indicating he was a high risk for falls. Review of Resident #104's Care Plan dated 2/23/2015 revealed he was at risk for falls due to a history of falls. The approach stated, "Use safety device, bed and wheelchair alarms," and ensure he has nonskid footwear when in bed. A care plan for Resident #104's contracture to his right hand had an approach to wear a right hand splint during the day for 10 hours, when awakened until before bedtime. Record review of Resident #104's MDS assessment dated [DATE] revealed he had 2 or more falls since admission, 1 with injury. The MDS also recorded an upper extremity limitation in range of motion, with splint assistance and application was 7 days/week. On 3/25/2015 at 9:43 AM in an interview with Employee A, CNA, she stated that she works mostly 3-11 shift on a PRN (as needed) status. She said that Resident #104 wears a hand splint that staff applies most of the time. She also said the resident was a fall risk. On 3/25/2015 at 2:00 PM an observation was made of Resident #104 in his bed. He had regular socks on his feet, not nonskid socks. A hand splint was observed on the bedside table. He was not wearing a splint to his upper extremities. On 3/25/15 at 2:00 PM in an interview with Employee A, CNA, she stated that Resident #104 had been up and dressed when she came in this morning. She stated she didn't notice an alarm on his wheelchair. She observed his feet and verified that the resident did not have on nonskid socks. On 3/25/2015 at 2:10 PM in an interview with Employee B, Licensed Practical Nurse, she stated that Resident #104 is supposed to have a chair alarm when he is up in his wheelchair. She said that part of the fall protocol would be to wear nonskid socks when he was in bed. She said she is to apply the splint to his right hand. She stated she did not apply the splint, and she didn't see him wearing the splint. On 3/25/2015 at 2:15 PM in an interview with Employee C, Restorative CNA, she stated that the nurses put the splints on the residents. She said she does not apply Resident #104's splint. On 3/26/2015 at 10:00 AM in an interview with Employee E, MDS nurse, she stated that she checks the residents' physician orders [REDACTED]. She said if the facility did not put the alarm on the resident, then they were not following the plan of care. She stated the nonskid shoes or socks are a nursing measure. When asked how the CNAs know about safety devices for a resident, she stated the CNAs have activity of daily living (ADL) cards that are located at the nursing station. She stated MDS updates the cards quarterly, and as needed, and the Unit Manager and nurse would update the cards too. Review of the Resident Care Card for Resident #104 revealed concerning safety that he has frequent falls and uses a Bed/Chair alarm. On 3/26/2015 at 10:14 AM in an interview with Employee F, Registered Nurse, she stated that the nurses are supposed to ensure that the CNAs are following the resident care card. .

Based on observation, interview, and facility policy review, the facility failed to ensure that the call system was available and working for 2 of 35 residents reviewed (Rooms #401 and #406), which could potentially lead to falls, resident distress or other discomfort if unable to call for staff assistance. The findings include: On 3/25/2015 at 2:48 PM in room [ROOM NUMBER] B (Resident #138), the Surveyor pressed the call system button and it did not work. There was no ring bell or other device which the resident could use to call for help. On 3/25/2015 at 2:51 PM an interview was conducted Employee E, Minimum Data Set coordinator. Employee E confirmed that the call system in room [ROOM NUMBER] B was broken. She picked up the call system and attempted to reconnect it at the wall. Employee E stated that she would have to get maintenance to fix the call system. On 3/25/2015 at 3:27 PM in an interview with Employee F, Unit Manager, she said that she makes rounds on the residents every hour. She said if an individual call system goes out, she will get a ringing bell. She confirmed there were no reports of call systems being out today. On 3/25/2015 at 12:38:53 PM Resident #119 was observed seated in bed with her lunch tray in room [ROOM NUMBER]B. The resident did not have any utensils. The surveyor attempted to use the resident's call system to obtain assistance, but it was not audible in the hall and the call light in the hall was not illuminated. Employee D arrived to the resident's room and verified the call system did not engage. She stated she would inform the resident's nurse and the maintenance department. 03/25/2015 at 2:31 PM, attempted to engage Resident #119's call system in room [ROOM NUMBER]B, but it did not engage. It was not audible in the hall and the call light in the hall did not illuminate. On 3/26/2015 at 9:30 AM, an interview was conducted with the Maintenance Director. He stated there were 2 call systems that were reported yesterday as not working. He said his technician said there was a call system that was broken, and he said he fixed it. He stated he has a weekly log for checking call systems. He stated staff make a work order, or catch him or his staff in the hallway. He stated the call system in room [ROOM NUMBER]B had a severed cord. He said the 400 hall was not checked this week for call systems. He said it was checked last week. He said a work order for room [ROOM NUMBER]B's call system was not completed yesterday, because it was fixed right away. He said room [ROOM NUMBER] had a work order to fix the call system on the panel in the resident's room. Record review revealed a work order dated 3/26/2015 for room [ROOM NUMBER] stating the call system does not light up in resident's room on the panel. Record review of the Call Light policy (no date) revealed, "If call bell is defective, report immediately to maintenance. Provide resident with a manual bell if repair cannot be made in a reasonable time." .

Based on medical record review and staff interview, the facility failed to ensure 1 resident (Resident #151), out of 2 sampled residents with pressure ulcers, received the necessary treatment and services to prevent new sores from developing and to promote healing of existing pressure ulcers. The findings include: A review of the medical record for Resident #151 revealed he was admitted to the facility on [DATE]. A review of the AHCA-Med Serv 3008 form dated 1/1/15 revealed the resident had [MEDICAL CONDITION] on his sacrum and posterior thighs. The resident's Admission Data Collection form dated 1/1/15 noted a skin condition present, but no further information was provided. Resident #151's 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed he had two stage 2 pressure ulcers (bed sores) that were present on admission to the facility. A review of the Wound Assessment Report completed by the facility's previous Director of Nursing (DON) on 1/13/15 revealed the resident had a Stage 2 pressure ulcer on his left inner buttocks at admission. Facility nurses completed Skin Assessments weekly per the resident's January, 2015 Treatment Administration Record, but the facility was unable to provide the results of the skin assessments. A review of the January, 2015 Skin Roster completed by the Certified Nursing Assistants (CNAs) revealed new skin concerns were noted for the resident on 1/6/15 and on 1/13/15. It was documented that the nurse was notified of the change in the resident's skin. A review of Resident #151's interim care plan dated 1/3/15 revealed that it did not address his skin condition. A review of the care plan dated 1/16/15 revealed potential for further skin breakdown related to decline in mobility, and non-compliance with turning and repositioning despite education. Approaches included report changes in skin status to doctor, report new areas of skin breakdown to nurse, provide incontinence care after each incontinence episode and apply barrier cream as needed. The care plan also included a problem for impaired skin integrity due to two stage 2 ulcers to buttocks. In addition to the approaches previously discussed, interventions included wound care as ordered. A review of Resident #151's Physician's orders dated 1/2/15 revealed [MEDICATION NAME] topical ointment was ordered for application twice daily to the resident's sacrum and posterior thighs. The medical record contained a Skin Care Protocol signed by the facility's Medical Director. The following steps were present for Pressure Ulcers: 1. Assess and document description of wound 2. Cleanse area with normal saline solution 3. Apply wound gel to affected area, cover with a [MEDICATION NAME] pad and secure with paper tape or roller gauze as indicated. A review of Resident #151's January, 2015 Treatment Administration Record revealed [MEDICATION NAME] cream was applied to the resident's sacrum twice a day from 1/2/15 to 1/11/15. There was no additional wound treatment documented in the resident's medical record. There was no documentation the Skin Care Protocol for Pressure Ulcers was followed. A further review of the Wound Assessment Report completed on 1/13/15 revealed the attending physician was notified of the presence of a stage 2 pressure ulcer to Resident #151's left buttock on 1/13/15. A review of the Wound Care Specialist Initial Evaluation dated 1/15/15 revealed Resident #151 was followed for right buttock wound by his attending physician. It was noted the resident had stage 2 pressure wounds of the right and left buttock. The wounds were assessed at greater than 6 days duration. Physician orders for wound care and dressing changes daily were incorporated in the documentation. A further review of Resident #151's January, 2015 Treatment Administration Record revealed the Physician orders for wound care and dressing changes recommended by the Wound Care Specialist were enacted as of 1/15/15. An interview with Employee E, an MDS Coordinator, on 03/26/2015 at 12:50 p.m. revealed she personally assessed Resident #151 for the presence of pressure ulcers. She confirmed the ulcers were present prior to the MDS assessment completed on 1/8/15, but she was unsure of the date. During an interview with the West Wing Unit Manager on 03/26/2015 at 10:59 a.m., the procedure for addressing a resident's pressure ulcer was discussed. If a pressure ulcer was noted, the nurse would notify the physician and the resident's family immediately. The nurse may notify the house physician or the wound care physician. The house physician is present in the facility daily. The wound care physician would see the resident on the first Wednesday after notification was received. She verified Resident #151 was documented to have two pressure ulcers present on admission per the previous DON. The Unit Manager was unable to locate any additional documentation related to the resident's skin condition on admission. She also was unable to locate any documentation indicating the house physician was notified of the Resident's pressure ulcers prior to 1/13/15. She verified only [MEDICATION NAME] ointment was used to treat the resident's sacrum between 1/2/15 and 1/11/15. She also confirmed the pressure ulcer Skin Care Protocol noted in Resident #151's record was not followed pending alternate physician orders. .