Every finding on record at Westfield Rehabilitation and Health Center

Based on observations, record review, and resident interview and staff interviews, the facility failed to perform a transfer from the bed to wheelchair in a safe manner for 1 of 3 residents reviewed for accidents (Resident #26). Resident #26 had pain and sustained a skin tear (laceration) to midline shin (the front of the leg below the knee) with significant depth to left lower leg which required a visit to the emergency department and sutures. Findings included: Resident #26 was admitted to the facility on [DATE] with the diagnoses that included hypertension, hyperlipidemia, polyneuropathy and anemia. The admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #26 was coded as cognitively intact, required wheelchair for mobility, required partial/moderate assistance for a chair-to-bed transfer. On the same assessment, she was also coded as requiring supervision or touching assistance with personal hygiene. Documentation on Resident #26's care plan initiated on 8/6/2025 revealed a focus area of Activities of Daily Living (ADL) self-care performance deficit due to impaired, limited mobility, limited Range of Motion (ROM), musculoskeletal impaired and pain. The care plan revealed Resident #26 required the intervention of 2-person assistance with transfers. Review of undated Kardex (a quick- reference tool that provides a concise summary of a patient's essential information and daily care needs for handoff between nursing shifts) report revealed Resident #26 require 2-person assistance with transfers. Review of the transfer status form for Resident #26 dated 08/08/2025 revealed her transfer status was maximum assistance with 2-person assist due to limited shoulder pain. Review of the August 2025 Medication Administration Record (MAR) revealed Resident #26 was not prescribed an anticoagulant medication. Review of the incident report dated 08/08/2025 documented Resident #26 sustained skin tear during transfer from bed to wheelchair. Resident #26 stated she told Nurse Aide (NA) #1 to stop when being transferred because she was hurting her and that she required assist of 2 however NA #1 continued to transfer her. It documented Resident # 26 was transferred to the emergency department for further evaluation. NA #1 was immediately suspended pending investigation. Review of NA #1's statement dated 08/08/2025 revealed she was getting the patient up out of bed, the resident was able to turn and sit on the side of bed, and the resident stated sometimes it took two people to get her up. NA #1 told the resident that she was able to do it alone. During a phone interview on 08/19/2025 at 11:55AM, NA #1 stated another staff told her several times to get Resident #26 up so she could go to therapy. NA #1 stated she proceeded to get the resident up without asking for assistance from another staff member. She stated during the transfer of the resident her lower leg bumped on the wheelchair, and the leg started bleeding. NA #1 stated she did not review the Kardex which indicated the resident needed 2-person assistance for transfer. She added that she realized the resident required 2-person assistance after the skin tear accident. NA #1 stated the resident appeared very fragile and she felt that she could transfer her without assistance from another staff member from bed to her wheelchair. Review of skin tear assessment for Resident #26 dated 08/08/2025 revealed the site of left lower leg (front). It documented skin tear laceration, heavy bleeding and pressure applied. Exact measurements could not be obtained. Resident #26 wound was dressed and cleansed for transport to emergency room (ER) per Medical Doctor's (MD) order for further evaluation. The review of the assessment revealed the resident was given Acetaminophen (pain medication) 325 milligrams (mg) 2 tablets for pain. During an interview on 08/19/2025 at 1:28PM, Nurse #2 stated she was notified about Resident #26's skin tear on 08/08/2025. She stated she observed the resident was bleeding with a deep cut. She added she applied pressure on the deep cut to stop bleeding. She reported the bleeding was heavy, the provider was notified, and he ordered the resident to be sent to the Emergency Department. Review of the Emergency Department (ED) note dated 08/08/2025 documented the chief complaint was the resident was taken to ED after getting small laceration to left shin due to hitting it on a wheelchair. The resident was given (pain medication) enroute to the ED. The note documented a skin tear- about 6 centimeters (cm) to left lower leg which was bleeding, had controlled distal pulses (a pulse felt in an artery located further away from heart) capillary refill and had no neurovascular (the interconnected of nerves and blood vessels) deficits. ED note also documented the medical decision described the resident as coming to the ED with skin tear and laceration to left lower leg, which was repaired using sutures, irrigated and dressed by the provider. Review of the Health Status note dated 08/11/2025 by Nurse #2 documented procedural notes post ED visit for laceration management obtained. Three sutures internal placement will dissolve. (Bandage) placed. Light amount serosanguinous drainage noted. Physician Assistant (PA) ordered dressing changes daily. During an interview on 08/19/2025 at 10:07 AM, Resident #26 stated that she informed NA #1 to transfer her using 2-person assist but NA #1 stated she could transfer her by herself. She reported during the transfer; her leg bumped into the wheelchair, and she felt a sharp pain coming from her left leg. The resident stated that she noticed the blood coming from her leg. She further added a nurse came and dressed the deep skin tear and then she was sent out to the ED. During an interview on 08/19/2025 at 9:48AM the Physical Therapist (PT) stated when the resident was admitted to the facility on [DATE], the resident was assessed as needing 2-person assistance for transfer due to limited shoulder pain. The PT stated the MDS Coordinator was informed about the resident's need for 2-person assistance, and it was added to the resident's care plan. During an interview on 08/19/2025 at 1:48 PM the MDS Coordinator stated the common practice at the facility was that they had weekly meetings to discuss the newly admitted resident's needs. She reported the Physical Therapist notified her about Resident #26 requiring 2-person assistance and the requirement was added in the resident's Kardex and the care plan. During an interview on 08/20/2025 at 10:53PM the Director of Nursing (DON) stated Resident #26 required 2-person assist and NA #1 transferred the resident by herself from the bed to the wheelchair. DON stated the expectation was NA #1 to have reviewed the Kardex before assisting Resident #26. The DON indicated Resident #26's Kardex indicated she required 2-person assistance. The DON further stated NA #1 was an agency staff and was suspended. The DON added agency staff and facility staff were all in serviced in reference to reviewing and following the care guide before transferring the residents. During an interview on 08/20/2025 at 11:45 AM the Administrator stated NA #1 should have reviewed the Kardex before transferring the resident from bed to the wheelchair. She reported the resident should have been transferred using 2-person assist but the NA #1 used one person assist. She stated the agency NAs and the facility NAs were in serviced in reference to reviewing Kardex so they can be aware of how many persons were required to transfer the residents. The facility provided the following corrective action plan with a completion date of 08/12/2025 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 8/8/2025 skin tear assessed by wound nurse and MD and pressure dressing applied. Head to toe assessment, wound assessment completed by the wound nurse.Resident was transferred to the emergency room (ER) for further evaluation.On 8/8/2025 the resident's wheelchair (w/c) was removed from service and inspected by the facility maintenance director.The results included: No concerns noted for wheelchair. 2. Address how the facility will identify other residents having the potential to be affected. On 8/8/2025 the DON identified residents that were potentially impacted by this practice by completing head to toe audits on all residents with a Brief Interview of Mental Status (BIMS) less than 13 (intact) and assessing for any skin integrity concerns to include skin tears/bruising or signs of potential injuries. The results included: No concerns identified.On 8/8/2025 all residents with a BIMS below 13 had a head-to-toe assessment completed by the assigned nurse with no concerns identified.On 8/8/2025 all w/c's were assessed by the facility maintenance director for any concerns to include areas that may be rough/cracked or malfunctioning. The results included: No concerns identified. On 8/08/2025 the DON/ Staff Development Coordinator (SDC) began direct observation of Nurses/NA's/Agency scheduled to work on that day (08/08/2025) and evening/night shift's ability to access the Kardex, to verbalize understanding of process of resident refusal/assuring resident safety and notification of the nurse of any refusal. The results included: 5 of 5 nursing staff/agency directly observed were able to access the Kardex prior to care, verbalize steps to take to assure resident rights/resident refusal were followed and understand the nurse notification process for any refusal of care/transfer etc.On 8/11/2025, residents with BIMS of 13 or above were interviewed by DON/Social Worker (SW) for any concerns related to care concerns/resident refusal concerns or transfer concerns. The results included: No concerns identified.On 8/ 11 /2025 the DON/ MDS nurse began auditing all resident care plans and transfer status to assure the transfer status was current and the care plan/Kardex were in compliance. The results included: All transfers current and in compliance. As of 8/11/2025 any above identified areas of concern were in compliance. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 08/8/2025, the DON/SDC began in-service of all nursing staff (including agency) on: Transfer Safety, Kardex Utilization, and for all staff and agency on Resident Rights/Refusal of Care/Treatment and Abuse/Neglect. To include Full Time(FT)/ Part Time (PT) and as needed (PRN) staff. Accessing the Kardex prior to care How to access the Kardex Using the correct transfer technique and always using 2 staff for all mechanical lift transfers. Assuring resident rights and refusal of care are honored by staff even if the resident is confused. Assuring resident rights are honored when a resident asks staff to stop a task. Assuring resident safety if a resident refuses care or is in the process of care or being transferred, Notification of the nurse of all resident refusals or requests you to stop care/transfer being provided. Reporting any incidents that occur while caring or transferring a resident to the assigned nurse. Abuse/Neglect- types, reporting and assuring resident safety.The Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 8/11 /2025 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation for the above-mentioned staff.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. - Monitoring plan was initiated on 08/08/2025. The DON/designee will monitor Transfer/ Kardex utilization/ Resident Rights Process weekly for 2 weeks and monthly for 3 months for compliance with assuring resident requests are honored and that the Kardex and transfer process are followed to assure resident safety. Reports will be presented to the monthly Quality Assurance (QA) committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the monthly QA Meeting. The monthly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, Health Information Management (HIM), and the Dietary Manager. Date of Compliance: 8/12/2025Validation of the corrective action plan was completed on 08/20/2025 by the following. The Quality Assessment and Performance Improvement Plan was reviewed with corresponding documentation to support the actions taken by the facility. Interviews were conducted with a sample of nurses and nurse aides from all nursing shifts to verify education was provided for licensed nurses and certified nursing assistants regarding assuring the staff were reviewing the Kardex before performing a transfer. The documentation for in-service records was reviewed. Social Worker #1 was interviewed to confirm all alert and oriented residents were interviewed to verify no other inappropriate transfers had occurred. During the investigation, NA#2 was observed transferring Resident #26 according to her plan of care. The MDS nurse was interviewed to confirm the Kardex, and care plans were up to date indicating how many people each resident required for the transfer from bed to wheelchair. The audits were verified as well as the ongoing monitoring audits to ensure residents were being transferred with appropriate person assistance.The corrective action plan completion date of 8/12/2025 was validated.

Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the MD when a stage three pressure ulcer was identified for 1 of 1 resident reviewed for pressure ulcer (Resident #71). Findings Included: Resident #71 was admitted to the facility on [DATE] for fracture of right femur with a plan for discharge home after rehabilitation. Resident #71 was discharged from the hospital after surgery to repair a right femur fracture. Review of the Wound Care Nurse's assessment on admission on 08/02/24 revealed she noted redness to sacral area. On 08/23/24 at 12:31 pm a telephone interview with Nurse #1 revealed on 08/13/24 she was called to the resident's room by the (Nurse Aide) NA providing care to Resident #71. She reported the sacral pressure ulcer appeared to have slough, she measured it and left a message for the Wound Care Nurse to further assess. Wound Care Nurse's note dated 08/14/24 revealed that a sacral pressure ulcer was noted by the 11:00 PM to 7:00 AM shift nurse. This nurse reported that the resident had a stage 3 sacral ulcer. Description of the wound was 70% slough and 30% granulation tissue, unstageable and measured 2.7 cm (cm) in length and 2.5 cm in width. There was no documentation the Medical Director was notified. On 08/23/24 at 09:23 am an interview with Medical Director (MD) revealed that Resident #71 was admitted on [DATE] and he was first informed of the stage three pressure ulcer on 08/16/24. The MD stated the delay in his notification was acceptable if another clinician had been notified.

Based on record review, observations, and staff and Medical Director (MD) interviews, the facility failed to do a weekly skin assessment which resulted in the delay of identification of a stage three pressure ulcer for 1 of 1 resident reviewed for pressure ulcer (Resident #71). The findings included: Resident #71 was admitted to the facility on [DATE] for fracture of right femur with a plan for discharge home after rehabilitation. Resident #71 was discharged from the hospital after surgery to repair a right femur fracture. Review of the Wound Care Nurse's assessment on admission on 08/02/24 revealed she noted redness to sacral area. Further review of records revealed that on 08/02/24 a verbal order for zinc oxide external ointment 20% (topical), apply to sacrum topically two times a day was initiated and to do weekly skin checks. A care plan dated 08/05/24 revealed interventions of assistance with incontinence care and bed mobility to reduce the risk of pressure ulcer development. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #71 was moderately cognitively impaired. Resident #71 was coded to have no pressure ulcer and was incontinent of bladder with substantial /maximal assistance for shower/bathing and for lower body dressing and was dependent on staff for toileting. There was no documentation of a weekly skin assessment in Resident #71's medical record. On 08/22/24 at 10:57 am, an interview with the Wound Care Nurse revealed that she was responsible for the completion of the admission skin assessment for Resident #71. Nurse stated that the sacral skin redness was blanchable and didn't indicate any pressure ulcer on admission. The Wound Care Nurse reported she put the order in place for the zinc oxide twice a day and weekly skin checks. The Wound Care Nurse reported that the nurses were responsible for the weekly skin checks. The interview further revealed that the weekly skin check scheduled on 08/09/24 was not done. On 08/23/24 at 12:31 pm a telephone interview with Nurse #1 revealed on 08/13/24 she was called to the resident's room by the (Nurse Aide) NA providing care to Resident #71. She reported the sacral pressure ulcer appeared to have slough, she measured it and left a message for the Wound Care Nurse to further assess. Wound Care Nurse's note dated 08/14/24 revealed that a sacral pressure ulcer was noted by the 11:00 PM to 7:00 AM shift nurse. This nurse reported that the resident had a stage 3 sacral ulcer. Description of the wound was 70% slough and 30% granulation tissue, unstageable and measured 2.7 cm (centimeters) in length and 2.5 cm in width. Review of records revealed that Resident # 71 was seen by Wound Care Doctor on 08/21/24 for a wound on sacrum, left buttock. The Wound Care Doctor documented the wound was unstageable (due to necrosis), had moderate serous exudate and measured 3.5 cm (length) x 3.5 cm (width) and no measurable depth. Further review of records revealed treatment for the necrosis (the death of most or all the cells in a tissue) required surgical excisional debridement (the removal of damaged tissue from a wound). The Wound Care Doctor's orders for treatment plan was for calcium alginate with silver (absorbs bacteria and fluid from the wound) to be applied once daily for 30 days. Santyl (removes dead tissue from wound) apply once daily for 30 days. May use medical grade honey if unable to use Santyl. Cover with a gauze island with a border. Apply once daily for 30 days. On 08/22/24 at 9:01 am an observation of wound care completed by Wound Care Nurse revealed treatment of sacral wound with Santyl, calcium alginate with silver, and silicone bordered dressing daily. Resident #71 was observed on an air mattress and required assistance with turning. Resident #71 was lying on her left side while wound care was being completed. Resident #71 expressed discomfort prior to treatment but was medicated by the assigned nurse prior to initiation of treatment. The wound bed was clean, and there was no drainage and no odor. Interview with Nurse Aide (NA) #1 on 08/22/24 at 10:22 am revealed that Resident #71 was incontinent and required assistance with turning. The interview further revealed Resident #71 gets a shower twice a week and any skin concerns were addressed with the nurse. NA #1 denied that resident was refusing showers and no abnormal skin issues reported. On 08/22/24 at 11:30 am, an interview with MDS Nurse revealed skin assessments were completed by the unit nurse but if the unit was busy, this was completed by the Wound Care Nurse or the support nurse. During the interview the MDS Nurse reported that she was unsure of any standardized risk assessment tool used on admission. On 08/22/24 at 03:25 pm, an interview with Dietitian (RD) revealed that her initial assessment for Resident #71 was completed on 08/13/2024 and all the resident had was a surgical wound. The interview further revealed that she did not visually see the resident but was told that resident completed 0-75% of meals, and nothing further needed to be done as the resident was already on Pro-stat. Mighty Shake (changed to Ensure due to resident preference) ordered as soon as wound was noticed to assist with nutritional intake. The Dietitian revealed that the process for reporting of wound was via email by the Wound Care Nurse. Interview of the Support Nurse on 08/22/24 at 03:45 pm revealed that she was assigned to the care of Resident #71 on admission. The Support Nurse reported that the expectation was that the nurse assigned to the resident would complete the skin assessment if the Wound Care Nurse was not around. The Support Nurse revealed Resident # 71's skin assessment was completed by the Wound Care Nurse on 08/02/24 and the order for skin checks were flagged automatically in the electronic chart. On 08/23/24 at 09:23 am an interview with Medical Director (MD) revealed that Resident #71 was admitted on [DATE] and he was first informed of the stage three pressure ulcer on 08/16/24. The MD stated the delay in his notification was acceptable if another clinician had been notified. Interview with Nurse Consultant on 08/23/24 at 11:31am revealed that it was possible for the wound to occur given the appropriate circumstances as Resident #71 fell at home prior to admission, and this may have affected her risk for skin breakdown. On 08/23/24 at 11:31 am an interview with the Administrator revealed a plan was set in place after Resident # 71's wound was found. She reported that these steps would be identifying the factors, refer to dietitian, refer to wound care physician, refer to PT for cushions and the need for air mattress. The interview further revealed it was not the expectation for the skin to go from blanchable to stage 3 ulcer. The facility provided the following corrective action plan with a completion date of 08/19/24. 1. Corrective action for resident (s) affected by the alleged deficient practice. -Head to toe assessment was completed on the affected resident, MD (Medical Director), RD (Registered Dietitian) and Family updated. New orders were initiated for wound. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice. -On 08/16/2024 head to toe skin assessments were completed on all current residents by the assigned nurse. This was completed on 08/16/2024. The results included: There were no new skin issues that were identified. 3. Measures/Systemic changes to prevent reoccurrence of deficient practice: Education (change of condition, pressure ulcer and treatment of pressure ulcer). -On 08/16/2024 the Staff Development Coordinator (SDC) initiated in-service of all licensed nurses and Certified Nurse Assistants (CNA), including agency on change of condition, pressure ulcer assessment and treatment of pressure ulcers. -The Director of Nursing (DON) will ensure that any of the above identified staff who do not complete the in-service training by 8/19/24 will not be allowed to work until the training is completed. 4. Monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. -The DON/designee will monitor the skin assessment process weekly for 2 weeks and monthly for 3 months for compliance with the skin/wound process. Reports will be presented to the weekly quality assurance (QA) committee by the wound nurse or DON to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the monthly QA Meeting. The QA Meeting is attended by the Administrator, DON, MDS Coordinator, Wound Nurse, Therapy, Health Information Manager and the Dietary Manager. The corrective action plan was completed on 08/20/2024. Onsite validation was completed on 08/23/24 through staff interviews and record review. Staff were interviewed on training, reporting and timing of reporting. A review of the audits of the residents' notes for skin checks for all residents was noted to be completed on 08/16/24. The review of the audit tools that the facility provided were noted to be completed 08/15/24 to 08/19/2024. The facility's corrective action plan completion date of 08/20/2024 was validated.

Based on record review, observation, and interviews with the Physician, Wound Physician and staff, the facility failed to obtain an order for treatment to the left buttock pressure ulcer (Resident #4) and failed to ensure the alternating air mattress was functioning resulting in a deflated air mattress (Resident #29) for 2 of 3 sampled residents reviewed for pressure ulcers (Residents #4 & #29). Findings included: 1. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus, thoracic, thoracolumbar, lumbosacral, and intervertebral disk disorder, stage 4 chronic kidney disease, and congestive heart failure (CHF). A review of Resident #4's weekly decubitus ulcer assessments dated 1/11/23 revealed that Resident #4 had a stage 3 pressure ulcer on the right buttock measuring 2.7 centimeter (cm) by (x) 2.6 cm x 0.1 cm. with 25 % slough (dead tissue). Resident #4 had a physician order dated 1/11/23 to clean the right buttock pressure ulcer with wound cleanser, pat dry, apply hydrogel gauze (provides a moist wound environment for healing) and cover with dry dressing daily. On 2/2/23, the treatment to the right buttock pressure ulcer was changed to clean with wound cleanser, apply Sulfadiazine (used to prevent/treat wound infections) and cover with dry dressing daily. Resident #4's care plan dated 1/11/23 was reviewed. One of the care plan problems was I currently have a pressure ulcer to my right buttock, and I am at risk for development of additional pressure ulcers due to decreased ability to reposition and incontinence. The approaches included to administer treatments as ordered and monitor for effectiveness. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #4's cognition was intact, and she needed extensive assistance with bed mobility. The assessment further indicated that the resident had a stage 3 pressure ulcer that was not present on admission. The weekly pressure ulcer assessment dated [DATE] revealed that Resident #4 had developed a pressure ulcer on the left buttock. The assessment revealed a stage 3 pressure ulcer measuring 2.5 centimeter (cm) by (x) 1.3 cm x 0.1 cm. and the physician was notified. Review of Resident #4's physician's orders from January through March 2023 revealed no order for treatment to the left buttock pressure ulcer. The January through March 2023 Treatment Administration Records (TARs) were reviewed and there was no evidence that treatment was provided to the left buttock pressure ulcer from January 24, 2023 (pressure ulcer was first identified) through March 7, 2023. On 3/6/23 at 10:05 AM, Resident #4 was observed in bed. She had an air mattress, and she was positioned to her right side. She stated that she had pressure ulcers on her buttocks and the nurses had changed the dressing every day and had turned her from side to side. On 3/7/23 at 4:30 PM, Resident #4 was observed during the dressing change. The resident was observed to have open areas on the right and left buttocks. The Treatment Nurse was observed to clean the pressure ulcers on the right and left buttocks with wound cleanser, Sulfadiazine was applied to both areas and covered with a foam dressing. On 3/8/23 at 1:20 PM, the Treatment Nurse was interviewed. She stated that she started as Treatment Nurse a month ago. She assessed Resident #4's pressure ulcers weekly and provided the treatment on both buttocks daily. She verified that Resident #4 had stage 3 pressure ulcers on her right and left buttocks. She stated that the previous treatment nurse had notified the Physician and the responsible party of the pressure ulcer on the left buttock. The Treatment Nurse reviewed the physician's orders and the TARs and reported that she did not realize that there was no treatment ordered for the left buttock pressure ulcer and there was no evidence on the TARs that the treatment was provided. She reported that she used Sulfadiazine to treat the pressure ulcers on the resident's right and left buttocks. The Treatment Nurse reported that the ulcers on the resident's buttocks were improving. The Treatment Nurse explained that she provided the treatment to the left buttock Monday through Friday and the nurses who were assigned to Resident #4 provided the treatment on Saturday and Sunday. She reported that she could tell that the treatment was provided to the left buttock on the weekends by the date of the dressing. On 3/9/23 at 8:15 AM, the Director of Nursing (DON) was interviewed. She stated that the weekly assessments indicated that the Physician was aware of the pressure ulcers on the right and left buttocks. The DON indicated that it was an oversight on the part of the Treatment Nurse for not ensuring that there was a treatment ordered for the left buttock pressure ulcer and for not ensuring there was a treatment transcribed and documented on the TARs. She reported that the treatment was provided to the left buttock, and the pressure ulcer was improving. The DON indicated that she expected an order for treatment for each pressure ulcer. The Physician was interviewed on 3/9/23 at 9:20 AM. The Physician stated that Resident #4 was a high risk for pressure ulcer due to her comorbidities and her age. He indicated that he expected the Treatment Nurse to obtain a treatment order for each pressure ulcer and she might have obtained the order but forgot to write it down. He also stated that most of the time if the ulcers were on the same area, the order for treatment was the same. 40197 2. Resident #29 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, and Alzheimer's disease. A review of the active physician orders included an order dated 6/30/21 for a low loss air mattress for pressure ulcer protection/preventive and comfort. Maintain proper function every shift. Air mattress settings should be semi firm (dial settings should be at 12 o'clock position). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 had severe cognitive impairment. She was coded as having a pressure ulcer over a bony prominence and one stage 3 pressure ulcer. She had a pressure reducing device to the bed. A review of Resident #29's active care plan, last reviewed 1/18/23, included the following focus areas: - Risk for pressure ulcer development due to decreased ability to assist with repositioning. The interventions included a low loss air mattress to the bed for pressure prophylaxis (pressure injury prevention). - Currently have a pressure ulcer to the right buttock, gluteal fold related to immobility. One of the interventions was an air mattress to the bed. - Activities of Daily Living (ADL) self-care performance deficit related to dementia and overall weakness. The interventions included an air mattress. A review of Resident #29's medical record from 12/13/22 to 3/6/23 revealed wound care was provided to a right buttock pressure ulcer. On 3/6/23 at 10:20 AM, an observation was made of Resident #29 while she was lying in the bed. A hissing sound was coming from the air mattress machine that was hooked to the foot of the bed. Upon observation the bottom connector of the air mattress was dislodged from the machine. Resident #29 was lying on the deflated air mattress. Another observation was made of Resident #29 on 3/6/23 at 12:03 PM while she was lying in bed. The air mattress bottom connector was not connected to the machine and Resident #29 was lying on the deflated air mattress. On 3/7/23 at 8:35 AM, Resident #29 was observed while being assisted with her breakfast meal by Nurse Aide (NA) #1. The bottom connector on the air mattress machine remained dislodged and Resident #29 was lying on the deflated air mattress. NA #1 stated the nurses monitored the air mattress functionality. Another observation was made of Resident #29 while she was lying in bed on 3/7/23 at 2:19 PM. The bottom connector remained unconnected to the machine and Resident #29 was on the deflated air mattress. On 3/7/23 at 3:19 PM, an observation of Resident #29 occurred with Nurse #1, who verified the bottom connector of the air mattress was not connected to the machine and Resident #29 was lying on the deflated air mattress overlay in the bed. Nurse #1 stated when she signed on the Treatment Administration Record (TAR) it was indicating that the air mattress settings were in the correct position. She added she did not visualize the connectors or if the overlay was inflated. The Wound Physician was interviewed on 3/9/23 at 9:00 AM and stated she would expect the air mattress to be connected and functioning properly as Resident #29 currently had a pressure ulcer to her buttock area and remained at high risk for further skin breakdown.

Based on record reviews, observations, Nurse Practitioner, Medical Director, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey on 7/1/21. This was for four deficiencies that were cited in the areas of Accuracy of Assessments, Activities of Daily Living Care Provided to Dependent Residents, Treatment/Services to Prevent/Heal Pressure Ulcers and Drug Regimen is Free From Unnecessary Drugs. The duplicate citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: These citations are cross referenced to: 1. F641- Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Residents # 22, #4 & #1), accidents (Resident #4 & #26), diagnoses (Resident #4) and urinary status (Resident # 54) for 5 of 20 sampled residents whose MDS were reviewed. During the facility's recertification survey of 7/1/21, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of accidents, nutrition, and diagnoses for 3 of 19 sampled residents reviewed. In an interview with the Administrator on 3/9/23 at 9:00 AM, she felt the repeat citation in MDS accuracy was felt to be related to human error. 2. F677- Based on record review, observation and family and staff interviews, the facility failed to provide showers as scheduled for 1 of 5 sampled residents who needed extensive assistance or were dependent on the staff for activities of daily living (Resident #59). During the facility's recertification survey of 7/1/21, the facility failed to provide nail care for a resident dependent on staff for assistance with her activities of daily living (ADLs). This was for 1 of 1 resident reviewed for nail care. In an interview with the Administrator on 3/9/23 at 9:00 AM, she indicated the facility was utilizing agency staff and felt there was a lack of oversight and education to ensure showers were offered, provided, and documented that they were given or refused by the resident. 3. F686- Based on record review, observation, and interviews with the Physician, Wound Physician and staff, the facility failed to obtain an order for treatment to the left buttock pressure ulcer (Resident #4) and failed to ensure the alternating air mattress was functioning resulting in a deflated air mattress (Resident #29) for 2 of 3 sampled residents reviewed for pressure ulcers. During the facility's recertification survey of 7/1/21, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 2 of 4 residents reviewed for pressure ulcer. In an interview with the Administrator on 3/9/23 at 9:00 AM, she stated it was felt to be related to human error not to have documented when a treatment was completed as ordered. 4. F757- Based on record reviews, Nurse Practitioner, Medical Director and staff interviews, the facility failed to hold diabetic medications (Residents #18 and #42) and blood pressure medications (Residents #42 and #22) as ordered by the physician for 3 of 6 residents whose medications were reviewed. During the facility's recertification survey of 7/1/21, the facility failed to hold the blood pressure medications as ordered and failed to check the blood pressure prior to administering the blood pressure medications for 2 of 5 sampled residents reviewed for unnecessary medications. In an interview with the Administrator on 3/9/23 at 9:00 AM, she indicated the facility was utilizing agency staff and felt the repeat citation could be a result of the need for education and oversight.

Based on record reviews, Nurse Practitioner, Medical Director and staff interviews, the facility failed to hold diabetic medications (Residents #18 and #42) and blood pressure medications (Residents #42 and #22) as ordered by the physician for 3 of 6 residents whose medications were reviewed. The findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was cognitively intact. Review of Resident #18's February 2023 and March 2023 physician orders included an order for Levemir Solution (a diabetic medication) 100 unit per milliliter. Inject 5 units subcutaneously in the morning for diabetes. Please hold for blood sugar less than 120. The February 2023 and March 2023 Medication Administration Records (MARs) were reviewed and revealed Resident #18 had received Levemir, despite the blood sugar less than 120 on the following dates: - 2/7/23- blood sugar was 109. - 2/23/23- blood sugar was 116. - 3/1/23- blood sugar was 116. - 3/2/23- blood sugar was 104. - 3/3/23- blood sugar was 98. An interview occurred with Nurse #1 on 3/8/23 at 12:56 PM, who was assigned to Resident #18 on 2/7/23, 2/23/23, 3/1/23 and 3/2/23. Nurse #1 indicated she was aware of the parameters to hold the Levemir. She reported she obtained the blood sugar and recorded on the MAR. Nurse #1 reviewed the February 2023 and March 2023 MARs, verified the Levemir was documented as administered despite the blood sugar being less than 120 when it should have been held and responded it was an oversight. The Nurse Practitioner (NP) was interviewed via the phone on 3/9/23 at 9:15 AM and stated she would expect the nurses to follow the orders for the Levemir parameters as written. Attempts to contact Nurse #3 were made without success. She was assigned to Resident #18 on 3/3/23. 2. Resident #42 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation, heart disease, congestive heart failure, and type 2 diabetes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #42 had moderately impaired cognition. a. Review of Resident #42's active physician orders included an order dated 10/28/22 for Metformin (a diabetic medication) 250 mg one tablet by mouth twice a day for diabetes. Hold for blood sugar less than 110. The March 2023 MAR was reviewed and revealed Resident #42 had received Metformin, despite the blood sugar being less than 110. - 3/5/23 the blood sugar was 108. An interview occurred with Nurse #2 on 3/8/23 at 2:00 PM, who was assigned to Resident #42 on 3/5/23. Nurse #2 reported she took the blood sugar and recorded it on the MAR. She reviewed the March 2023 MAR and verified the Metformin was administered despite the blood sugar being below 110 when it should have been held and felt it was an oversight. The Nurse Practitioner (NP) was interviewed via the phone on 3/9/23 at 9:15 AM and stated if Resident #42 had received a dosage of Metformin outside the parameter it should not have caused any serious harm. The NP added she would have expected the nurses to follow the orders for the Metformin parameters as written. b. Review of Resident #42's active physician orders included an order dated 9/30/22 for Metoprolol (a blood pressure medication) 25 milligrams. Give half a tablet by mouth every 12 hours for high blood pressure. Hold for systolic blood pressure (SBP) less than 100, diastolic blood pressure (DBP) less than 55, heart rate less than 55. The February 2023 Medication Administration Record (MAR) was reviewed and revealed Resident #42 had received Metoprolol, despite the SBP less than 100 and DBP less than 55. - 2/20/23 SBP was 98 and DBP was 52. - 2/25/23 SBP was 88. A phone interview occurred with Nurse #5 on 3/8/23 at 2:17 PM, who was assigned to Resident #42 on 2/25/23. The February 2023 MAR was reviewed with Nurse #5 and stated the medication should have been held per the parameters and felt it was an oversight. The NP was interviewed via the phone on 3/9/23 at 9:15 AM and stated if Resident #42 had received a few dosages of Metoprolol outside the parameters it should not have caused any serious harm. The NP added she would have expected the nurses to follow the orders for the Metoprolol parameters as written. Attempts to contact Nurse #6 were made without success. She was assigned to Resident #42 on 2/20/23. 14652 3. Resident # 22 was admitted to the facility on [DATE] with multiple diagnoses including hypertension. Resident #22 had a physician's order dated 8/26/22 for hydrochlorothiazide (can treat hypertension and fluid retention) 25 milligrams (mgs) - give 1 tablet by mouth in the evening. Hold for systolic blood pressure (SBP) of less than or equal to 130. The Medication Administration Records (MARs) from October through March 2023 were reviewed and revealed that hydrochlorothiazide was administered despite the blood pressure was less than 130 on the following dates: 10/5/22 - blood pressure (BP) 122/57 10/23/22 - BP 114/68 10/14/22 - BP 110/54 10/28/22 - BP 125/85 10/21/22 - BP 117/58 10/29/22 - BP 125/70 11/2/22 - BP 121/66 11/10/22 - BP 104/65 11/4/22 - BP 101/62 11/12/22 - BP 107/59 11/6/22 - BP 114/52 11/14/22 - BP 100/52 11/7/22 - BP 114/62 11/15/22 - BP - 100/52 11/8/22 - BP 101/61 11/17/22 - BP - 120/53 11/19/22 - BP 123/52 11/24/22 - BP 124/72 11/22/22 - BP 111/70 11/26/22 - Bp 129/65 11/23/22 - BP 107/68 12/4/22 - BP 119/73 12/7/22 - BP 126/68 12/8/22 - Bp 120/81 12/9/22 - BP 118/80 12/10/22 - BP 95/50 12/11/22 - BP 95/50 12/16/22 - BP 118/62 12/26/22 - BP 105/66 12/27/22 - BP 114/57 12/30/22 - BP 112/60 1/1/23 - BP 127/75 1/16/23 - BP 107/60 1/18/23 - BP 107/60 1/21/23 - BP 112/66 1/30/23 - BP 118/66 2/1/23 - BP 123/54 2/3/23 - BP 128/66 2/5/23 - BP 130/68 2/6/23 - BP 122/67 2/13/23 - BP 126/74 2/14/23 - BP 127/79 2/22/23 - BP 122/50 3/2/23 - BP 128/64 Nurse #2, assigned to Resident #59 on 3/2/23 was interviewed. She reviewed the physician's order for the hydrochlorothiazide and stated that she was aware of the parameters to hold the medication if the SBP was below 130 but obviously she missed to hold the medication when the resident's blood pressure was 128/64 on 3/2/23. Attempts to interview Nurse #6, who was assigned to Resident #59 on 2/13/23 and 2/22/23 but was unsuccessful. The Pharmacy Consultant was interviewed on 3/8/23 at 3:05 PM. She reported that she identified the irregularity regarding the physician's order to hold the hydrochlorothiazide was not being followed. The Pharmacy Consultant reported that she brought it to the attention of the Director of Nursing (DON) on 6/22/22, 10/5/22 and on 3/6/22. Nurse #8, who was assigned to Resident #59 on 1/23/23, 1/27/23, 1/30/23, 2/5/23, and 2/6/23 was interviewed on 3/9/23 at 8:14 AM. She reviewed the order for the hydrochlorothiazide and indicated that she was aware of the order to hold the medication if the SBP was 130 or below. Nurse #8 reviewed the MARs and stated, I just don't know what to say, I missed it. The Director of Nursing (DON) was interviewed on 3/9/23 at 8:15 AM. She stated that she expected the nurses to follow the physician's orders in holding the medications with parameters. She reported that she provided education to the nurses when she received the report from the Pharmacy Consultant. The Physician was interviewed on 3/9/23 at 9:20 AM. He stated that he expected the nurses to follow the order in holding the BP medications with parameters.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Residents # 22, #4 & #1), accidents (Resident #4 & #26), diagnoses (Resident #4) and urinary status (Resident # 54) for 5 of 20 sampled residents whose MDS were reviewed. Findings included: 1 a. Resident # 4 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF). Resident #4 had a physician's order dated 12/14/22 for Bumetanide (a diuretic drug) 1 milligram (mg.) by mouth twice a day for CHF. Review of the January 2023 Medication Administration Records (MARs) revealed that Resident #4 had received Bumetanide from January 1 through January 31, 2023. The annual MDS assessment dated [DATE] did not indicate that Resident #4 had received a diuretic medication during the assessment period. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the physician's orders and the January 2023 MARs and verified that Resident #4 had received Bumetanide during the assessment period. He reported that he missed to note on the annual MDS assessment dated [DATE] that Resident #4 had received a diuretic medication. b. Resident #4 had a physician's order dated 1/7/23 for Ertapenem (an antibiotic drug) 1 gram (gm) - 500 mgs. intramuscular (IM) in the evening for urinary tract infection (UTI) for 10 days. Review of the January 2023 Medication Administration Records (MARs) revealed that Resident #4 had received Ertapenem from January 7 through January 16, 2023. The annual MDS assessment dated [DATE] indicated that Resident #4 had received an antibiotic medication during the assessment period but did not indicate that the resident had a diagnosis of UTI. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the physician's orders and the January 2023 MARs and verified that Resident #4 had received Ertapenem for UTI during the assessment period. He reported that he missed to note on the annual MDS assessment dated [DATE] that Resident #4 had a diagnosis of UTI. c. Review of the nurse's note and the incident report dated 1/1/23 at 11:15 AM revealed that Resident #4 was found on the floor. The resident complained of head, neck and back pain and noted to have a skin tear to the left shin. The annual MDS assessment dated [DATE] indicated that Resident #4 had no falls since admission/entry, reentry or prior assessment. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the nurse's notes and verified that Resident #4 had a fall on 1/1/23. He reported that he missed to note on the annual MDS assessment dated [DATE] that Resident #4 had a fall. 2. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including hypertension. Resident #22 had a physician's order dated 8/26/22 for hydrochlorothiazide (a diuretic drug) 25 mgs by mouth in the evening for hypertension. The January 2023 Medication Administration Records (MARs) revealed that Resident #22 had received hydrochlorothiazide from January 1 through January 31, 2023. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate that Resident #22 had received a diuretic medication during the assessment period. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the physician's orders and the January 2023 MARs and verified that Resident #22 had received hydrochlorothiazide during the assessment period. He reported that he missed to note on the quarterly MDS assessment dated [DATE] that Resident #22 had received a diuretic medication. 3. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including non-pressure chronic ulcer on the ankle. Resident #1 had a physician's order dated 1/27/23 for Flagyl 500 milligrams (mgs) capsule- apply to ankle wounds topically every Monday, Wednesday, and Friday for wound care. Review of the February 2023 Medication Administration Records (MARs) revealed that Resident #1 had received Flagyl to her wounds every Monday, Wednesday, and Friday from February 1 through February 28, 2023. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate that Resident #1 had received an antibiotic medication during the assessment period. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the physician's orders and the February 2023 MARs and verified that Resident #1 had received Flagyl during the assessment period. He reported that he missed to note on the quarterly MDS assessment dated [DATE] that Resident #1 had received an antibiotic medication. 4. Resident # 26 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia affecting the left dominant side. Review of the nursing note and the incident report dated 12/26/22 at 1:20 PM revealed that Resident #26 was found on the floor in front of his wheelchair. The resident stated that he was trying to go back to bed. There was no injury noted. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #26 had no falls since admission/entry, reentry or prior assessment. The MDS Nurse was interviewed on 3/8/23 at 4:10 PM. The MDS Nurse reviewed the nurse's notes and verified that Resident #26 had a fall on 12/26/22. He reported that he missed to note on the quarterly MDS assessment dated [DATE] that Resident #26 had a fall. The Director of Nursing (DON) was interviewed on 3/9/23 at 8:15 AM. The DON reported that the MDS Nurse was brand new (started last summer), and he had no MDS experience. He is still learning MDS. 40197 5. Resident #54 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A physician's order dated 7/10/22 indicated Resident #54 to have a urinary catheter for obstructive uropathy. Nursing notes dated 12/1/22 through 2/3/23 specified Resident #54 had a urinary catheter in place. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact. She was coded with an indwelling catheter and as frequently incontinent of bladder. Review of Resident #54's active care plan, last reviewed 3/4/23, included a focus area having an indwelling urinary catheter for obstructive uropathy. During an interview with the MDS Nurse on 3/8/23 at 4:00 PM, he confirmed Resident #54 had an indwelling urinary catheter when the 2/3/23 MDS was completed, and it was an error to have coded her with bladder incontinence. This area should have been coded as Not Rated. An interview was conducted with the Director of Nursing on 3/9/23 at 9:30 AM and she indicated it was her expectation for the MDS to be coded accurately.

Based on record review, observations and staff interviews, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 4 sampled residents for respiratory care (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact. She required extensive assistance with 2 people with bed mobility, dressing, and toilet use. She was coded as utilizing oxygen. Resident #33's care plan dated 05/11/22 revealed she required oxygen therapy due to congestive heart failure. The goal included she would have no signs or symptoms of poor oxygen absorptions through the review date. Interventions, in part, included oxygen settings are based on physician orders and observe for signs and symptoms of respiratory distress and report to physician. Review of Resident #33's physician orders dated 12/13/22 revealed supplemental oxygen to be delivered at 2 liters per minute via cannula. On 03/06/23 at 10:21 AM, Resident #33 was observed lying in the bed receiving humidified oxygen at 2.5 liters per minute via nasal cannula when viewed horizontally, eye level. On 03/07/23 at 8:33 AM, Resident #33 was observed lying in the bed receiving humidified oxygen at 2.5 liters per minute via nasal cannula when viewed horizontally, eye level. On 03/08/23 at 8:25 AM Resident #33 was observed lying in the bed receiving humidified oxygen at 2.5 liters per minute via nasal cannula when viewed horizontally, eye level. An observation was made with Nurse #4 of Resident #33's oxygen concentrator on 03/08/23 at 08:30 AM, who stated the oxygen regulator on the concentrator was set at 2 liters when she viewed it while she stood over the machine. She stated she quickly checked the flow rate earlier in the morning at eye level and stated it was 2 liters per minute. Then Nurse #4 viewed the oxygen regulator on the concentrator at eye level and adjusted the flow to administer 2 liters of oxygen as ordered. Nurse #4 stated she did not know why the oxygen regulator was set at 2.5 liters. During an interview with the Director of Nursing on 03/03/23 at 11:15 AM, nurses should view the oxygen regulator on the concentrator at eye level to determine if it was set at the correct flow rate. The Administrator was interviewed on 03/08/23 at 1:05 PM. She stated physician orders should be followed at the correct oxygen flow rate.

Based on record review, observation and family and staff interviews, the facility failed to provide showers as scheduled for 1 of 5 sampled residents who needed extensive assistance or were dependent on the staff for activities of daily living (Resident #59). Findings included: Resident #59 was admitted to the facility on [DATE] with multiple diagnosis including hemiplegia/hemiparesis following cerebral infarction affecting the left dominant side and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #59 had moderate cognitive impairment and she needed extensive assistance with personal hygiene and bathing. The assessment further indicated that the resident had no behaviors including rejection of care. Resident #59's care plan that was reviewed on 1/29/23 revealed that she had an activity of daily living (ADL) self -care performance deficit related to hemiplegia/hemiparesis. The approaches included I required staff extensive assistance with grooming and personal hygiene. Review of the shower schedule revealed that Resident #59 was scheduled to have a shower twice a week on Monday and Thursday on 3-11 shift. Review of the nurse's notes from January 2023 through March 2023 revealed that Resident #59 did not have refusal of care. Resident #59 was observed in bed on 3/6/23 at 11:25 AM. The resident was clean and her hair was a litthe bit greasy. A family member was at bedside visiting. A family member of Resident #59 was interviewed on 3/6/23 at 11:28 AM. The family member voiced a concern that every time she visited, the resident's hair was greasy. The staff did not provide shower to the resident unless she/he asked for it. The family member reported that the resident was supposed to receive a shower twice a week but that was not happening. The shower documentation for the last 3 months was requested but the facility only provided one month of shower documentation (2/9/23 through 3/6/23). Interview with the Administrator on 3/7/23 at 3:20 PM revealed that the computer would only allow the staff to pull 30 days of shower documentation. Review of the shower documentation from 2/9/23 through 3/6/23 revealed that Resident #59 had received a shower on 2/9, 2/20, 2/23, 2/27, 3/2 and 3/6/23. The resident missed her shower on 2/13, and 2/16. There was no documentation on the shower form that the resident had refused shower. Attempts to interview Nurse Aide (NA)#2, who was assigned to Resident #59 on 2/13/23 but was unsuccessful. NA #3, who was assigned to Resident #59 was interviewed on 3/8/23 at 3:50 PM. The NA stated that the resident seldom refused care, especially showers. If she refused shower and you tried to persuade her, most of the time she would allow you to give her a shower. The NA would not comment as to why the resident had missed some showers. The Director of Nursing (DON) was interviewed on 3/9/23 at 8:20 AM. The DON stated that she expected NAs to provide showers to the resident as scheduled and if the resident refused shower to document on the form. The DON also reported that the computer would not allow her to pull the shower documentation for more than 30 days.

Based on record review and staff interview, the facility failed to refer a resident with newly evident diagnosis of mental illness for Preadmission Screening and Resident Review (PASARR) level II screen for 1 of 1 sampled resident reviewed for PASARR (Resident #7). Findings included: Resident # 7 was admitted to the facility on [DATE] with PASARR level I screen which indicated the screen did not go to level II. Resident #7 had no mental health related diagnosis noted on admission to the facility. The psychiatric note dated 3/8/21 indicated that Resident #7 had a diagnosis of major depressive disorder and was on Zoloft and Doxepin for depression and Remeron for appetite stimulant. The note indicated to discontinue Doxepin as part of gradual dose reduction (GDR). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #7 had a diagnosis of depression and had received an antidepressant medication during the assessment period. The psychiatric note dated 5/3/21 revealed that Resident #7 continued to complain of bugs crawling underneath her skin and all over her body and bed. On examination, she appeared anxious and reported that she could feel and see the bugs on her body and placed them in a cup on the table. There was a cup on the table, but the resident would not allow the writer to look inside the cup. Risperdal was initiated to manage distressing psychotic symptoms that were impairing her function and a diagnosis of Schizophrenia spectrum disorder with psychotic disorder type was added to the diagnosis list. Resident #7 had a physician's order dated 5/3/21 for Risperdal (an antipsychotic drug) 0.5 milligrams (mgs) by mouth at bedtime for psychosis. The annual MDS assessments dated 6/17/21 and 5/30/22 revealed that Resident #7 had a diagnosis of psychotic disorder and had received an antipsychotic medication during the assessment period. The assessments further indicated that the resident had not been evaluated by level II PASARR and determined to have a serious illness and or mental retardation. The Social Worker (SW) was interviewed on 3/8/23 at 11:38 AM. The SW stated that when a resident was newly diagnosed with a mental illness, the resident needed to be evaluated for a level II PASARR. The SW reviewed the medical records of Resident #7 and verified that Resident #7 was admitted with a level I PASARR. She stated that the resident was being followed by the psychiatric services and on 5/31/21, a new diagnosis of Schizophrenia spectrum disorder with psychotic disorder type was added. The SW indicated that if she had been made aware by the interdisciplinary team (IDT) of the new diagnosis, she would have made a referral for level II PASARR evaluation, but she was not. She confirmed that no referral for level II PASARR had been made for Resident #7. The Director of Nursing (DON) was interviewed on 3/9/23 at 8:15 AM. She stated that the Social Worker was responsible for making the referral for level II PASARR. She indicated that she expected the SW to make the referral when a resident had a new diagnosis of mental illness.

Based on record review, observation and resident and staff interview, the facility failed to have accurate and complete medical records in the areas of pressure ulcers (Resident #4), wound care (Resident #29) & splint application (Resident #1) for 3 of 20 sampled residents whose medical records were reviewed (Residents # 1, # 4 & #29). Findings included: 1. Resident # 4 was admitted to the facility on [DATE]. A review of the weekly decubitus ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) assessments was conducted. The assessment revealed that Resident #4 had developed a stage 3 pressure ulcer on the left buttock on 1/24/23. Review of the physician's orders from January 2023 through March 2023 revealed there was no treatment ordered for the stage 3 pressure ulcer on the left buttock. Review of the January through March 2023 Treatment Administration Records (TARs) revealed there was no evidence that treatment was provided to the left buttock pressure ulcer. On 3/7/23 at 4:30 PM, Resident #4 was observed during the dressing change. The resident was observed to have open areas on the right and left buttocks. The Treatment Nurse was observed to clean the pressure ulcers on the right and left buttocks with wound cleanser, Sulfadiazine (used to treat and prevent wound infection) was applied to both areas and covered with a foam dressing. On 3/8/23 at 1:20 PM, the Treatment Nurse was interviewed. She verified that Resident #4 had stage 3 pressure ulcers on her right and left buttocks. The Treatment Nurse reviewed the physician's orders and the TARs and reported that she did not realize that there was no treatment ordered for the left buttock pressure ulcer and there was no evidence in the TARs that the treatment was provided. She reported that the treatment to both left and right buttocks was provided 7 days a week as ordered. On 3/9/23 at 8:15 AM, the Director of Nursing (DON) was interviewed. The DON indicated that it was an oversight on the part of the treatment nurse for not writing the treatment order for the left buttock pressure ulcer and therefore there was no treatment transcribed to the TARs. She reported that the treatment was provided to the left buttock, however, it was not documented on the TARs. 2. Resident #1 was admitted to the facility on [DATE]. The quarterly Minimum Data (MDS) assessment dated [DATE] indicated that Resident #1's cognition was intact. Resident #1 had a physician's order dated 11/11/22 to wear bilateral hand splints at night as tolerated and to remove in AM before meal. Resident #1 was observed on 3/6/23 at 1:25 PM with her right and left hands in a fist position. There was no device noted on both hands. The resident was interviewed and stated that the splints were applied at night. Review of the January, February and March 2023 Medication Administration Records (MARs) revealed multiple boxes with no nurse's initials to indicate that the splints were applied as ordered on the following dates: 1/2, 1/9, 1/10, 1/11, 1/13, 1/14, 1/15, 1/16, 1/23, 1/24, 1/25, 1/27, 1/28, 1/30, 2/6, 2/7, 2/8, 2/10, 2/11, 2/12, 2/14, 2/16, 2/21, 2/22,2/24, 2/25, 2/26 and 3/2/23. An attempt was made to interview Nurse #6 who was assigned to Resident #1 on 3/2/23 but was unsuccessful. Nurse #7 was interviewed on 3/7/23 at 10:16 AM. She stated that she worked night shift. Nurse #7 was assigned to Resident #1 on 1/9, 1/10, 1/11, 1/13, 1/14, 1/15, 1/16, 1/23, 1/24, 1/25, 1/27, 1/28, 2/6, 2/7, 2/8, 2/10, 2/11, 2/12, 2/22 and 2/25/23. She stated that she was aware that Resident #1 had an order for splints to be applied at night. Nurse #7 reported that she applied the splints every night and she did not know why the MARS were not signed off. She stated that she might have missed to sign them. The Director of Nursing (DON) was interviewed on 3/9/23 at 8:15 AM. The DON stated that Nurse #6 and Nurse #7 were both agency nurses. She indicated that the nurses were applying the splints as ordered but she expected them to document to ensure complete and accurate medical records. 40197 3. Resident #29's physician orders revealed the following: - An order dated 1/12/23 to cleanse stage 3 pressure ulcer to the right buttock with normal saline. Apply Santyl to the wound bed and cover with a foam dressing every day. This order was discontinued 2/23/23. - An order dated 2/24/23 to cleanse the right buttock with wound cleanser. Apply Collagen sheet to wound bed and cover with dry dressing on Monday, Wednesday, Friday and as needed. This was discontinued 2/28/23. - An order dated 2/25/23 to cleanse the skin tear to the left outer knee, apply Vaseline gauze and cover with dry dressing until healed every day. - An order dated 2/28/23 to cleanse the right buttock pressure ulcer with normal saline. Apply Medihoney gel to the wound bed, top with Calcium Alginate and cover with dry dressing. Change Monday, Wednesday, Friday and as needed. This order was discontinued on 3/3/23. - An order dated 3/3/23 to cleanse the stage 3 pressure ulcer to the right buttock with saline. Apply Santyl to the wound bed, add Calcium Alginate and cover with a dry dressing every day. The February 2023 and March 2023 Treatment Administration Records (TARs) were reviewed and revealed the following: - The stage 3 pressure ulcer to Resident #29's right buttock had not been documented as completed or refused by the resident on 2/8/23, 2/23/23, 3/3/23 and 3/5/23. - The skin tear to the left outer knee was not documented as completed or refused by the resident on 3/5/23. Review of the nursing progress notes from 1/10/23 until 3/8/23 revealed Resident #29 accepted wound care. On 3/8/23 at 1:10 PM, the Treatment Nurse was interviewed and explained she became the Treatment Nurse towards the end of February 2023. She stated Resident #29 she completed wound care to Resident #29 but had forgotten to document the wound care as completed on the TAR for 2/23/23 and 3/3/23. The Treatment Nurse added the former wound care nurse would have been responsible for the wound care on 2/8/23. Nurse #2 was interviewed on 3/8/23 at 2:00 PM and reviewed the March 2023 TAR. She verified caring for Resident #29 on 3/5/23 and completed the wound care. Nurse #2 added she had forgotten to sign the wound care as completed on the TAR. An interview occurred with the Director of Nursing on 3/9/23 at 9:30 AM and indicated she expected the nursing staff to complete wound care as ordered as well as to document it was completed or refused by the resident.

Based on record reviews and interviews with staff, the facility failed to provide the resident and/or Responsible Party (RP) written notification of the reason for a hospital transfer for 2 of 3 residents reviewed for hospitalization (Residents #54 and #17). The findings included: 1. Resident #54 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 was cognitively intact. Resident #54's medical record revealed she was transferred to the hospital on 2/26/23 for altered mental status and was readmitted to the facility on [DATE]. There was no documentation that written notice of transfer was provided to the resident and/or RP for the reason of the transfer. The Social Worker (SW) was interviewed on 3/7/23 at 10:55 AM and stated she was not responsible for notifying the resident or RP when a resident was discharged to the hospital. On 3/7/23 at 10:56 AM, the Admissions staff member was interviewed and stated that she began employment at the facility 2 weeks ago. She was responsible for notifying the resident or RP when a resident was discharged to the hospital. She called the RP, discussed the bed hold policy and requested the RP to come to the facility to sign the bed hold form. She then provided the RP a copy of the form with the reason and date the resident was discharged to the hospital. An interview occurred with the Administrator on 3/9/23 at 9:10 AM. She stated that the Admissions staff member was responsible for notifying the resident or RP when a resident was discharged to the hospital. She added that the Admissions staff member called the RP, explained the bed hold policy and requested the RP come to the facility and to sign the bed hold form. The form included the reason and date of hospital discharge. After the bed hold form was signed, a copy was provided to the RP or resident. The Administrator further explained when Resident #54 was discharged to the hospital, the previous Admissions staff member, who no longer worked at the facility, did not have the bed hold form completed or signed by the resident/RP. 14652 2. Resident # 17 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses including cerebrovascular accident (CVA) with aphasia and dysphasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #17 had severe cognitive impairment. A nursing note dated 1/29/23 at 3:34 AM revealed that Resident #17 had a medium stool with small blood clots present in brief. The note indicated that the resident was stable with no complaints of abdominal pain and his vital signs were within normal limits. The Physician Assistant (PA) was notified and ordered to monitor the resident and to call back if the vital signs or the resident status worsen. A nursing note dated 1/29/23 at 2:12 PM, Resident #17 was seen by the PA and ordered to send the resident to the emergency room for evaluation and treatment. Resident #17 was readmitted back to the facility on [DATE]. The Social Worker (SW) was interviewed on 3/7/23 at 10:55 AM. The SW stated that she was not responsible for notifying the resident or the responsible party (RP) when a resident was discharged to the hospital. The admission staff member was interviewed on 3/7/23 at 10:56 AM. She stated that she started working at the facility 2 weeks ago. She was responsible for notifying the resident or the RP when a resident was discharged to the hospital. She called the RP, discussed the bed hold policy and requested the RP to come to the facility to sign the bed hold form. She then provided the RP a copy of the form with the reason and the date the resident was discharged to the hospital. The Administrator was interviewed on 3/9/23 at 9:10 AM. She stated that the admission staff member was responsible for notifying the resident or the RP when a resident was discharged to the hospital. She added that the admission staff member called the RP, explained the bed hold policy and requested the RP to come to the facility and to sign the bed hold form. The form included the reason and the date the resident was discharged to the hospital. After the bed hold form was signed, a copy was provided to the RP. The Administrator further explained that when Resident #17 was discharged to the hospital, the previous admission staff member, who no longer worked at the facility, did not have the bed hold form completed and signed by the RP.

Based on record review, observation and staff interviews, the facility failed to follow physician's orders to administer a medication on an empty stomach for 3 of 7 residents reviewed for medications (Residents #14, #32 and #257). The findings included: 1) Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #14's cumulative physician orders revealed an order dated 4/9/21 for [MEDICATION(S)] Sulfate 325 milligrams (mg) 1 tablet by mouth two times a day for iron supplementation. Take on an empty stomach with a full glass of water. A review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she had moderately impaired cognition. The April, May, and June 2021 Medication Administration Records (MARs) revealed Resident #14 was scheduled to receive 325mg of [MEDICATION(S)] Sulfate at 9:00 AM and 5:30 PM. A review of the facility's meal delivery times indicated the breakfast trays were delivered to the 200 hall at 7:40 AM and dinner trays were delivered at 5:40 PM. On 6/30/21 at 8:20 AM, Resident #14 was observed with her breakfast tray in front of her and had completed the meal. Nurse #3 was interviewed on 6/30/21 at 10:00 AM and indicated she was assigned to Resident #14. She reported the breakfast cart arrived on the 200 hall around 7:45 AM to 8:00 AM and the dinner cart arrived around 5:30 PM. Nurse #3 indicated Resident #14's [MEDICATION(S)] Sulfate was scheduled to be administered at 9:00 AM and 5:30 PM and normally administered the medication at those times. Nurse #3 reported she was not aware the resident's [MEDICATION(S)] Sulfate was ordered to be given on an empty stomach and would change the time of administration to be given before breakfast and dinner and notify the physician. On 7/1/21 at 9:54 AM an interview occurred with Nurse #5 who reported he was not aware that Resident #14's [MEDICATION(S)] Sulfate was ordered to be given on an empty stomach. He verified the medication was ordered to be administered at 9:00 AM and 5:30 PM and had one hour before and after to administer her medications. Nurse #5 further stated medications ordered to be given on an empty stomach should be given before breakfast and dinner. The Director of Nursing was interviewed on 7/1/21 at 10:25 AM and indicated she expected the nursing staff to follow physician orders and to administer medications ordered on an empty stomach before breakfast and dinner. 2) Resident #257 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #257's cumulative physician orders revealed an order dated 6/15/21 for [MEDICATION(S)] Sulfate 325 milligrams (mg) 1 tablet by mouth once a day. Take on an empty stomach with a full glass of water. A review of Resident #257's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she had severe cognitive impairment. The June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/21 at 8:15 AM, Resident #257 was observed with her breakfast tray in front of her. She had finished her meal. Nurse #2 was interviewed on 6/30/21 at 9:00 AM and indicated she was assigned to Resident #257. She reported the breakfast cart arrived on the 100 hall around 7:30 AM to 7:45 AM . Nurse #2 indicated Resident #257's [MEDICATION(S)] Sulfate was scheduled to be administered at 9:00 AM and normally administered the medication at that time. Nurse #2 reported she was not aware the resident's [MEDICATION(S)] Sulfate was ordered to be given on an empty stomach and would change the time of administration to be given before breakfast and notify the physician. On 7/1/21 at 9:54 AM an interview occurred with Nurse #5 who reported he was not aware that Resident #257's [MEDICATION(S)] Sulfate was ordered to be given on an empty stomach. He verified the medication was ordered to be administered at 9:00 AM and had one hour before and after to administer her medications. Nurse #5 further stated medications ordered to be given on an empty stomach should be given before breakfast. The Director of Nursing was interviewed on 7/1/21 at 10:25 AM and indicated she expected the nursing staff to follow physician orders and to administer medications ordered on an empty stomach before breakfast. 3. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change in status MDS assessment dated [DATE] indicated that Resident #32 had severe cognitive impairment. Resident #32's doctor's orders were reviewed. Resident #32 had doctor's orders dated 4/1/21 for [MEDICATION(S)] (used to treat [CONDITION(S)]) 137 micrograms (mcg) - 1 tablet by mouth daily on empty stomach at least 30-60 minutes before breakfast and on 4/7/21 for [MEDICATION(S)] Sulfate (for iron supplementation) 325 milligrams (mgs) - 1 tablet by mouth daily on an empty stomach. Review of the April, May and June 2021 Medication Administration Records (MARs) revealed Resident #32 was scheduled to receive [MEDICATION(S)] and [MEDICATION(S)] Sulfate at 9 AM. On 6/30/21 at 9:05 AM, Resident #32 was observed with his breakfast tray in front of him. He was finished eating his breakfast. On 6/30/21 at 9:35 AM, Nurse # 4 was interviewed. She indicated that she was assigned to Resident #32. She reported the breakfast cart arrived on the 300 hall at 8 AM. Nurse #4 indicated that resident's medications were scheduled to be administered at 9 AM and she normally administered his medications around 8 AM. Nurse #4 reported that she was not aware that resident's [MEDICATION(S)] and [MEDICATION(S)] Sulfate were ordered to be given on an empty stomach. She indicated that she would change the time of administration on the MAR for the [MEDICATION(S)] and [MEDICATION(S)] Sulfate to be given before breakfast instead of 9 AM and she would notify the physician of the resident. On 7/1/21 at 10:02 AM, Nurse #5 was interviewed. Nurse #5 reported that he was not aware that Resident #32's [MEDICATION(S)] and [MEDICATION(S)] Sulfate were ordered before breakfast. He verified that his medications were ordered to be administrated at 9 AM and he has one hour before and 1 hour after to administer his medications. He commented that medications ordered to be given on empty stomach should be given before breakfast. The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON indicated that she expected the nurses to follow doctor's orders and to administer medications ordered on empty stomach before breakfast.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of accidents (Residents #32 & #11), nutrition (Residents #32 & #11) and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1a. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #32 had no falls since admission/entry, reentry or prior assessment. Review of the facility's incident/accident log revealed that Resident #32 had falls on 4/10/21, 4/12/21, 4/13/21, 4/16/21 and 4/19/21. The Treatment Nurse was interviewed on 6/30/21 at 3:45 PM. She stated that currently, the facility did not have an MDS Nurse. She used to be the MDS Nurse but had changed role to a Treatment Nurse. She indicated that a corporate MDS Nurse was helping the facility in completing the MDS assessments. The Treatment Nurse verified that Resident #32 had falls on 4/10/21, 4/12/21, 4/13/21, 4/16/21 and 4/19/21 and the MDS assessment dated [DATE] should have been coded for falls but it was not. The Corporate MDS Nurse was interviewed on 7/1/21 at 8:58 AM. She stated that she had been helping the facility in completing the MDS assessments remotely starting December 2020 since the facility did not have an MDS Nurse. She verified that Resident #32 had falls during the assessment period and the MDS assessment dated [DATE] should have been coded for falls but it was not. She reported that it was an oversight on her part. The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON indicated that she expected the MDS assessments to be coded accurately. 1b. Review of Resident #32's weights revealed that he had a significant weight loss of 12% in one month. The resident weighed 175 pounds (lbs.) on 4/1/21 and 154 lbs. on 5/11/21. The dietary note dated 4/22/21 revealed that Resident #32's current weight was 154 lbs., a significant weight loss of 11.8 % since admission. The significant change in status MDS assessment dated [DATE] indicated that Resident #32 did have a weight loss during the assessment period. The Corporate MDS Nurse was interviewed on 7/1/21 at 8:58 AM. She stated that she had been helping the facility in completing the MDS assessments remotely starting December 2020 since the facility did not have an MDS Nurse. She reported that the Dietary Manager (DM) was responsible for completing section K (nutrition) of the MDS assessment. The DM was interviewed on 7/1/21 at 9:15 AM. The DM stated that she was responsible for completing section K of the MDS assessments. She verified that Resident #32 had a significant weight loss during the assessment period and the MDS assessment dated [DATE] should have been coded for a significant weight loss but it was not. She reported that it was an oversight and she would correct it. The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON indicated that she expected the MDS assessments to be coded accurately. 2. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #5 did not have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's doctor's orders were reviewed. Resident #5 had orders for [MEDICATION(S)] and [MEDICATION(S)] for depression and [MEDICATION(S)] for [CONDITION(S)]. The Medication Administration Records (MARs) for April 2021 revealed that Resident #5 had received [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] during the assessment period. The Corporate MDS Nurse was interviewed on 7/1/21 at 8:58 AM. She stated that she had been helping the facility in completing the MDS assessments remotely starting December 2020 since the facility did not have an MDS Nurse. She verified that Resident #5 had received [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] during the assessment period and the 4/9/21 MDS assessment should have been coded for depression and [CONDITION(S)] under the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON indicated that she expected the MDS assessments to be coded accurately. 3a) Resident #11 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's weight data revealed the following weights during the Minimum Data Set (MDS) assessment look back period of November 2020 to April 2021, which showed a weight loss: 11/7/20 119.4 pounds (lbs.) 1/7/21 108.2 lbs. 2/7/21 100 lbs. 4/9/21 103.8 lbs. The quarterly MDS assessment dated [DATE] indicated Resident #11 had severe cognitive impairment. She was not coded for weight loss of 5% of more in the last month or a loss of 10% of more in the last 6 months. On 7/1/21 at 8:59 AM, a telephone interview was conducted with the Corporate MDS Nurse who stated the Dietary Manager coded the nutritional section of the MDS assessment. The Dietary Manager was interviewed on 7/1/21 at 9:11 AM who reviewed the MDS assessment dated [DATE] and Resident #11's weight data. She indicated the weight loss section should have been coded and felt it was an oversight. During an interview on 7/1/121 at 10:21 AM, the Director of Nursing indicated it was her expectation for the MDS to be coded accurately. 3b) Resident #11 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #11's medical record revealed she had falls without injury on 3/3/21, 3/10/21, 3/14/21, 3/16/21, 3/19/21, 3/20/21 and 4/1/21. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment. She was not coded with any falls since admission/reentry or prior assessment. On 7/1/21 at 8:59 AM, a telephone interview occurred with the Corporate MDS Nurse. She reviewed the MDS dated [DATE] and confirmed she had coded this section of the MDS. The Corporate MDS Nurse added it was an oversight not to code the MDS with the falls noted in Resident #11's medical record. During an interview on 7/1/121 at 10:21 AM, the Director of Nursing indicated it was her expectation for the MDS to be coded accurately.

Based on observations, staff and resident interviews and record review, the facility failed to provide nail care for a resident dependent on staff for assistance with her activities of daily living (ADLs). This was for 1 (Resident #54) of 1 resident reviewed for nail care. The findings included. Resident #54 was admitted on [DATE] with cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #54's significant change Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact and she exhibited no behaviors. She was coded for extensive assistance with her personal hygiene. Resident #54's ADL care plan last revised on 4/15/21 read she required ADL assistance due to her limited mobility. Interventions included staff assistance with grooming and personal hygiene. Review of Resident #54's undated electronic care guide read as follows: Keep fingernails short. In an observation and interview on 6/28/21 at 8:55 AM, Resident #54 was sitting up in her bed. She stated she finished breakfast and was waiting on the aide to come and get her ready for the day. She confirmed she required staff assistance with her ADLs. Her fingernails appeared unkept. They were clean but long and jagged with partial nail polish to several nails. Resident #54 stated her fingernails had not been done since she attended an activity and they painted her nails. She stated her nails were not cut during the activity but shaped and painted. She stated she really needed her fingernails to be cut and she did not want the polish on my fingernails. In an interview on 6/28/21 at 10:10 AM, Nursing Assistant (NA) #1 confirmed she was assigned Resident #54. She stated the nurses cut fingernails of diabetic residents and the aides or activities department provided routine nail care. NA #1 stated Resident #54 was very cooperative and never refuses care. In another observation on 6/30/21 at 11:18 AM, Resident #54 was sitting up in bed dressed for the day. She stated none of the staff noticed her fingernails and none of the staff had yet provided any nail care. Resident #54's fingernails were clean but their appearance was unchanged. In an interview on 6/30/21 at 11:24 AM, NA #2 stated she was assigned Resident #54 and assisted her with her morning ADLs. She stated the aides provided routine nail care as needed. NA #2 stated Resident #54 was very cooperative and never refuses care. In an observation on 6/30/21 at 1:30 PM, the Director of Nursing (DON) was taken to see Resident #54's fingernails. Resident #54's fingernails were clean but long and jagged with partial nail polish to several nails. The DON stated her fingernails were likely last done a few weeks ago in activities but they only file and paint nails. Resident #54 stated to the DON that she liked her fingernails short and without polish. She further stated it had been a long time since her fingernails were cut and filed. The DON stated she was not aware of Resident #54's preferences for short fingernails. On 6/30/21 at 2:15 PM, the DON stated she completed nail care on Resident #54 and it was the expectation that routine nail care be provided by the aides unless the resident was a diabetic. The DON stated the floor staff should not rely on nail care being completed in activities. In an interview on 6/30/21 at 2:54 PM, the Activity Director (AD) stated she was not allowed to cut fingernails. She could only file and paint. The AD stated Resident #54 seldom attended any out of the room activities. In an interview on 7/1/21 at 9:15 AM, the Administrator stated she expected the aides to complete routine nail care. She stated she audited all the residents on the 200 hall and found other residents in need of nail care which she completed nail care yesterday. In an interview on 7/1/21 at 10:35 AM, the Administrator and DON stated it was their expectation that the aides provide routine nail care and the nurses provide nail care on diabetic residents.

Based on record review, observations, and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 2 of 4 residents reviewed for pressure ulcer (Residents #27 and #45). The findings included: 1) Resident #45 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #45's June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 had severe cognitive impairment and displayed no behaviors or refusal of care during the 7 day look back period. She required limited assistance with personal hygiene and extensive assistance with all other Activities of Daily Living (ADL's), was coded with 1 stage 4 pressure ulcer that was present on admission and had a pressure reducing device to the bed. Resident #45's weight on 6/11/21 was 114.2 pounds (lbs.). Resident #45's active care plan included the following focus areas: - I currently have a pressure ulcer to my sacrum with a wound vac in place and am at risk for development of additional pressure ulcers due to decreased ability to reposition, incontinence and immobility. The interventions included an air mattress. - I am at risk for pressure ulcer development due to incontinence, wheelchair bound, history of pressure ulcers and other comorbidities. The interventions included pressure reducing mattress to the bed. Resident #45's weight on 6/17/21 was 111.8 lbs. Resident #45's alternating pressure reducing mattress machine was observed on 6/28/21 at 9:49 AM and was set at 200 lbs. The machine had settings from 80 to 400 lbs. and indicated to set according to resident's weight per lbs. On 6/30/21 at 10:00 AM, Resident #45 was observed lying in bed on her right side. The alternating pressure reducing mattress machine was set at 200 lbs. On 6/30/21 at 11:00 AM the alternating pressure mattress machine was observed by the Treatment Nurse who confirmed it was set at 200 lbs. She corrected the weight to read 120 lbs. and locked the panel after the mattress was reset to the correct weight. She was unable to state why the weight was set at 200 lbs. and indicated nursing staff are to check each shift for proper functioning. Nurse #4 was interviewed on 6/30/21 at 1:35 PM and verified nursing staff check the air mattresses twice a day for correct functioning then sign as completed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she had not noticed the weight being set at 200 lbs. and agreed it should have been at 120 lbs. The Maintenance Director was interviewed on 6/30/21 at 3:28 PM and stated he set up the alternating air mattresses when ordered by the physician and set the weight according to what he was told by the nursing staff. He added after the initial set-up he was not involved with monitoring the settings. An interview was conducted with the Director of Nursing (DON) on 7/1/21 at 10:21 AM and indicated the nursing staff monitored the functionality of the air alternating pressure mattresses but was unsure if the weight settings were checked as well. She further indicated she expected the alternating air mattresses to be set according to the resident's weight for residents with pressure ulcers to promote healing. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #27's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was cognitively intact and displayed no behaviors or refusal of care during the 7 day look back period. She required extensive assistance with bed mobility and transfers. She also required extensive assistance for dressing, eating, toileting, and personal hygiene. Resident #27 was coded with no existing pressure ulcers and 1 arterial/venous ulcer that was present on admission. The MDS indicated she had a pressure reducing device to the bed and was coded for unplanned weight loss. Resident #27's medical record revealed her most recent documented weight was 80.0 pounds (lbs) on 6/5/2021. The resident's active comprehensive care plan dated 5/27/2021 included a focus area for skin impairment (arterial ulcers) to both feet and heels. Interventions included air mattress on bed. Resident #27's alternating pressure reducing mattress machine was observed on 6/30/2021 at 3:00 PM and was set at 400 lbs. The machine had settings from 80 to 400 lbs. and indicated the mattress should be set according to resident's weight in lbs. On 6/30/21 at 3:25 PM and interview was conducted with nurse assistant (NA) #3 who was assigned to Resident #27, she stated she made sure the mattress was on and functioning. She did not adjust the settings. She further stated she did not know where or how to determine what the resident's mattress setting should be. On 6/30/21 at 1:35 PM Nurse #4, who was assigned to Resident #27 that day, stated nursing staff check the air mattresses twice a day for correct functioning then sign as completed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The Maintenance Director was interviewed on 6/30/21 at 3:28 PM and stated he set up the alternating air mattresses when ordered by the physician and set the weight according to what he was told by the nursing staff. He added after the initial set-up he was not involved with monitoring the settings. An interview was conducted with the Director of Nursing (DON) on 7/1/21 at 10:21 AM and indicated the nursing staff monitored the functionality of the air alternating pressure mattresses but was unsure if the weight settings were checked as well. She further indicated she expected the alternating air mattresses to be set according to the resident's weight for residents with pressure ulcers to promote healing.

Based on record reviews and staff interviews, the facility failed to measure the length of exposed catheter for a peripherally inserted central catheter (PICC) per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident # 256 was admitted to the facility 6/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #256's admission Minimum Data Set (MDS) was not available. The resident's care plan dated 6/11/2021 had a focus for risk of complications such as infection and infiltration of PICC line while receiving intravenous (IV) antibiotics. Resident #256's active orders included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Measure length of exposed catheter to check for migration every night shift, every Wednesday. A review of Resident #256's June 2021 Medication Administration Record (MAR) revealed no measurements documented on Wednesday 6/16/2021 or Wednesday 6/23/2021. A telephone interview was conducted on 6/30/2021 at 3:16 PM with Nurse # 1 who was assigned to Resident #256 Wednesday evening 6/16/2021. She stated she changed the PICC line dressing on Wednesday evening but did not complete any measurements. She further stated she did not measure the line because there was no redness or swelling to the site. Attempts to contact the nurse who was assigned to Resident #256 on Wednesday 6/23/2021 were unsuccessful. However, there were no PICC line measurements documented on the MAR or in the resident's progress notes. The Director of Nursing was interviewed at 7/1/2021 at 10:21 AM and stated she expected nurses to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, and staff interview, the facility failed to hold the blood pressure medications as ordered (Resident #32) and failed to check the blood pressure prior to administering the blood pressure medications (Resident #5) for 2 of 5 sampled residents reviewed for unnecessary medications. Findings included: 1. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #32 had severe cognitive impairment. Resident #32 had doctor's orders dated 5/20/21 for [MEDICATION(S)] (used to treat hypertension) 10 milligrams (mgs) - 1 tablet by mouth daily - hold for systolic blood pressure of less than 120 and on 5/22/21 for [MEDICATION(S)] ( used to treat hypertension) 25 mgs - 1/ 2 tablet by mouth in the morning - hold for systolic blood pressure of less than 120 and hold for heart rate less than 60. Resident #32's May and June 2021 Medication Administration Records (MARs) were reviewed. The MARs revealed that Resident #32 had received the [MEDICATION(S)] and the [MEDICATION(S)] despite the systolic blood pressure (SBP) was below 120 and the heart rate (HR) was below 60 on the following dates: 5/26/21 - HR - 59 5/27/21 - HR - 44 5/28/21 - BP - 108/58 5/30/21 - BP - 119/71 & HR - 54 6/3/21 - BP - 107/62 6/12/21 - HR - 56 6/14/21 - HR - 59 6/15/21 - BP 107/49 6/17/21 - HR -59 6/18/21 - HR -48 6/19/21 - HR 51 6/21/21 - BP - 117/56 & HR -52 6/24/21 - BP 115/62 6/25/21 - HR - 59 6/30/21 - HR - 59 Nurse #4 was interviewed on 6/30/21 at 9:35 AM. She stated that she was assigned to Resident #32 on 6/14/21, 6/18/21, 6/25/21 and 6/30/21. Nurse #4 indicated that she was aware the resident had parameters to hold the [MEDICATION(S)] and the [MEDICATION(S)]. She reported that the vital signs including the BP and the HR were taken by the nursing assistants (NAs) in the morning and were recorded on the MARs. When pointed out that the [MEDICATION(S)] was administered despite the HRs were below 60 on the days she was assigned to the resident, she responded that it was an error on her part. She reviewed the MARs and verified that she should have withheld the [MEDICATION(S)] when the HRs were below 60 but she did not. Nurse #2 was interviewed on 6/30/21 at 12:31 PM. She stated that she was assigned to Resident #32 on 5/27/21, 6/3/21 and 6/15/21. Nurse #2 indicated that she was aware the resident had parameters to hold the [MEDICATION(S)] and the [MEDICATION(S)]. She reported that the vital signs including the BP and the HR were taken by the NAs anytime in the morning prior to the medication administration and were recorded on the MARs. When pointed out that the [MEDICATION(S)] and the [MEDICATION(S)] were administered despite the SBPs were below 120 and the HRs were below 60 on the days she was assigned to the resident, she responded that she might have missed to hold them on the days she was assigned to the resident. She reviewed the MARs and verified that she should have withheld the [MEDICATION(S)] on 6/3/21 and 6/15/21 and the [MEDICATION(S)] on 5/27/21 but she did not. Nurse #5 was interviewed on 7/1/21 at 10:21 AM, He stated that he was assigned to Resident #32 on 6/17/21 & 6/21/21. He was aware that the resident had parameters to hold his blood pressure medications. He verified that on 6/17/21, the resident's HR was 59 and on 6/21/21 his BP was 117/56 and his HR was 52, he should have withheld his [MEDICATION(S)] and [MEDICATION(S)], but he did not. Nurse #5 confirmed that it was an error on his part. The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON stated that she expected the nurses to follow doctor's orders including blood pressure medications with parameters to hold. The DON further stated that she expected the nurses to check the BP and the HR right before medication administration. 2. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #5 had a doctor's order dated 11/11/20 for [MEDICATION(S)] 2.5 milligrams (mgs) - 1 tablet by mouth daily - check manual blood pressure (BP) before administration - hold if systolic BP (SBP) is less than 120. Resident #5 had a doctor's order dated 12/5/21 for [MEDICATION(S)] 25 mgs - 1 tablet by mouth 2 times a day - hold for SBP of less than 110. Review of Resident #5's Medication Administration Records (MARs) from December 2020 through June 2021 revealed that the blood pressure was not checked manually prior to the administration of the [MEDICATION(S)] and the [MEDICATION(S)]. There were no daily BP readings recorded on the MARs from December 2020 through June 2021. Nurse #4 was interviewed on 6/30/21 at 9:37 AM. She stated that she was assigned to Resident #5. She indicated that Resident #5 was a long- term resident, and her vital signs including blood pressure were taken weekly and recorded on the MARs. Nurse #4 reported that the resident did not have ordered medication with a parameter to hold. When she checked the doctor's order and the MARs, she verified that Resident #5 had a doctor's order to check the BP and to hold the [MEDICATION(S)] and the [MEDICATION(S)] if the SBP was below 110 and 120. She also verified that there were no BP readings recorded on the MARs daily. Nurse #4 commented that the nurse who transcribed the order for the [MEDICATION(S)] and the [MEDICATION(S)] to the MARs did not indicate to check the BP prior to the administration. Nurse #2 was interviewed on 6/30/21 at 12:31 PM. She stated that she had known Resident #5. Nurse #2 indicated that she was not aware the resident had parameters to hold the [MEDICATION(S)] and the [MEDICATION(S)] when the SBP was below 110. Nurse #5 was interviewed on 7/1/21 at 10:21 AM, He stated that he had known Resident #5. He was not aware that the resident had parameters to hold his blood pressure medications when the SBP was below 110 The Director of Nursing (DON) was interviewed on 7/1/21 at 10:21 AM. The DON stated that she expected the nurses to check the blood pressure prior to administering the ordered medications with parameters to hold and to document the BP on the MARs daily.

Based on record review, observation, review of facility infection control policy and procedure, and interviews with staff, the facility failed to implement the facility's COVID-19 Preparation and Response policy when the facility failed to ensure 1 of 2 COVID-19 negative residents( #2) did not share a room with a COVID-19 positive resident (#1) which increased the risk of spreading COVID19 to another resident. On 12/22/2020 the facility reported 52 of its 54 residents had tested positive for COVID-19. Immediate Jeopardy began on 12/20/2020 when the facility became aware a COVID-19 positive resident and a COVID-19 negative resident were residing in the same room. These two residents remained in the same room for two days after the positive result was reported to the facility. The Immediate Jeopardy was removed on 12/31/2020 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility's policy titled COVID-19 Preparation and Response issued 3/10/2020 and last updated on 10/5/2020 stated residents with the same condition should be cohorted in an effort to minimize the interactions of infectious individuals with non-infectious individuals as much as possible. Additionally, the policy reads, if positive a resident should be moved into a COVID-19 area in a private room whenever possible. Record review revealed Residents #1 and #2 were tested for COVID-19 via polymerase chain reaction (PCR) on 12/15/2020 and both were negative. On 12/18/2020 Resident #1 and Resident #2 were moved into a room together after both of their roommates tested positive for COVID-19. On that same day, 12/18/2020, Residents #1 and #2 were tested again for COVID-19 via PCR. On 12/20/2020 the results of the PCR test on 12/18/2020 revealed Resident #1 was positive for COVID-19 and Resident #2 was negative for COVID-19. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was coded as cognitively impaired and rarely understood. Resident #1 was also coded as requiring extensive assistance with activities of daily living, personal hygiene, and toileting. The resident used a wheelchair for ambulation. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired, required extensive assistance with all activities of daily living, personal hygiene, and toileting and was bedbound during the assessment period. On 12/22/2020 at 12:00pm Resident #1 and Resident #2 were observed to be residing in the same room which was located outside of the COVID-19 positive designated area. Neither resident was observed wearing a mask and the privacy curtain was not pulled between them. An Enhanced Contact /Droplet precaution sign was observed on the door and staff was observed donning Personal Protective Equipment (PPE) prior to entering the room. An interview was conducted with Nurse Assistant (NA) #1 on 12/22/2020 at 12:00pm. NA#1 stated she was aware one resident was negative for COVID-19 and one resident was positive for COVID-19. She further stated she was not sure why they were still in the same room, typically they would have been separated. She stated most of the administrative staff was out with COVID-19. She stated she was changing personal protective equipment (PPE) and washing hands between residents. On 12/29/2020 at 4:00pm an interview was conducted with the Director of Nursing (DON) in which she stated the Infection Preventionist position was currently being filled by herself and two other individuals. She stated she worked with the local health department, risk management, and corporate on how to best isolate the COVID-19 positive residents. She stated on 12/18/2020 the two residents were moved into a room together after both of their previous roommates tested positive for COVID-19. The decision was made to move the two residents off the 300 hall, that was then designated as a COVID-19 isolation area, and into a room at the top of the hall, outside the isolation area. She stated there was only two rooms at the top of the 300 hall and they had three negative residents at that time. Since both Resident #1 and Resident#2 met the criteria for having been exposed, they were placed in a room together and placed on enhanced contact/droplet precautions. When asked if they typically kept COVID-19 positive and COVID-19 negative residents in rooms together, she stated they would have been separated if there had been administrative staff in the facility who could have moved one of them and if there had been an empty room. When asked about the rooms at the end of the COVID-19 isolation hall (300 hall) with tape across them that indicated they had been deep cleaned on 12/18/2020, she stated those rooms are for residents to go back to once they are cleared of COVID-19. On 12/30/2020 at 8:47am an interview was conducted with the director of housekeeping in which she stated, once rooms were deep cleaned, the doors were taped and the date of the deep clean was written on the tape. She further stated if the tape was still intact, that would indicate the rooms was empty and had been cleaned. 12/30/2020 at 1:15pm an interview was conducted with nurse #1 who took the call form the lab on 12/20/2020 that identified Resident #1 as positive for COVID-19. She stated she sent the information out to the management team which included the DON and then notified the resident's family. She stated she did not recall getting feedback from any of the management team that Residents #1 and #2 needed to be separated. She stated she was aware they should be separated per facility policy. The residents remained together until 12/22/2020 when Resident #1 was moved into the COVID-19 unit into a private room. When asked if a room in the COVID-19 unit was available on 12/20/2020, she stated there were empty rooms on the COVID-19 unit (300 hall) on 12/20/2020. On 12/30/2020 at 1:25pm the DON stated she was made aware Resident #1 was positive for COVID-19 on 12/20/2020. She would have been the next in charge and the one who would have made the decision to separate Residents #1 and #2 once the results came back. She did not make that request and the residents remained in the same room together until 12/22/2020. The COVID-19 positive resident was moved onto the COVID-19 positive isolation hall on 12/22/2020 when she became aware the resident was positive and not on the COVID -19 isolation hall. A phone interview was conducted on 12/31/2020 at 8:14am with the local health department nurse who stated she has been worked with the facility during the recent outbreak. The health department provided the facility with the most recent CDC guidelines regarding cohorting positive residents away from negative residents in a designated area. She further stated no one from the health department had physically been in the facility to observe how the guidelines were implemented. She stated she had not been asked about this specific situation or any similar scenario. On 12/30/2020 at 2:15pm a phone interview was conducted with the facility's medical director. He stated he can give the facility his opinion but ultimately it is up to the facility how they cohort residents. He stated he would have suggested the resident not be roomed together on 12/18/2020 since it is likely they both had been exposed. However, once the facility was notified of one resident's positive status on 12/20/2020, he would have left them together for 14 days regardless. The facility administrator was notified of the immediate jeopardy by phone on 12/31/2020 at 9:15am. Allegation of immediate jeopardy removal F880 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 12.18.2020 residents #1 and #2 were cohorted as negative residents. Resident # 1 received a positive COVID test result on 12/20/2020. Resident # 1 was moved to a room on the COVID unit on 12/22/2020 per policy that positive patients are on isolation. As of 12/31/2020, resident # 2 is the only resident who has had a recent negative COVID-19 test and is the only resident that is impacted by this practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/31/2020, the Director of Nursing and Administrator were educated by the Chief Clinical Officer of the policy regarding not allowing a newly tested patients who have tested negative for COVID-19 to remain in the same room as a resident who has tested positive for COVID-19. Additionally, they were educated on the fact that on 12/20/2020 the results were called the nursing management team but the room change was not communicated to the nursing staff at the facility. It is important that as soon as positive COVID-19 results are received that the Director of Nursing and nurse management make the necessary arrangements for the room change to occur immediately. Nurses and Medication aides will be trained that if this does not occur to notify the Administrator as a backup. If the Administrator is notified, then it is the administrator's responsibility to ensure that the room changes occur. The Director of Nursing will be responsible for educating the other nurse managers on 12/31/2020. On 12/31/2020, the Director of Nursing and Nurse Management Team began educating all licensed nurses and medication aides on the need to move roommates when one is positive for COVID-19 and the other is negative for COVID-19. They were also educated that anytime they receive a positive result for COVID-19 they should notify the nurse on call and the Director of Nursing using phone numbers posted at the nurse's station. Plans should be made to separate the residents immediately. If plans have not been identified, then they should call the Administrator immediately. If the Administrator is not available, then call Director of Nursing. All numbers are posted at the nurse's station. As of 12/31/2020 3 PM, any employee who has not received this training will not be allowed to work until the training has been completed. This includes full time, part time, and agency staff. On 12/31/2020, the Director of Nursing and Nurse Management Team began educating all nursing assistants and housekeepers. They were educated that anytime there is a newly tested positive COVID-19 resident in the room with a negative COVID-19 resident that they should be separated. This is to ensure that there is not a positive COVID-19 resident in the same room as a negative COVID-19 resident. If they become aware that there are residents in the same room with one being positive for COVID-19 and one being negative for COVID-19 they should ask about plans to move one of the residents. If plans have not been identified, then they should call the administrator immediately. If the administrator is not available, then call Director of Nursing. All numbers are posted at the nurse's station. As of 12/31/2020 3 PM, any employee who has not received this training will not be allowed to work until the training has been completed. This includes full time, part time, and agency staff. Date immediate jeopardy removed 12/31/2020 On 1/5/2021 the facility's credible allegation for Immediate Jeopardy removal was validated by the following: Review of in-service training records of administrative, nursing, agency, and housekeeping staff. The training received included identifying and reporting any COVID19 positive resident that was found to be residing with a COVID19 negative resident, what action was to be taken and who would take that action. The facility ensured 100% participation by all administrative, nursing, agency, and housekeeping staff. Interviews with facility staff revealed they received training and were able to describe the facility's policy on the cohort of residents with like conditions. Additionally, staff gave verbal understanding on identifying and reporting residents that were housed in a way that was not consistent with the facility policy and CDC guidelines. Observations on the quarantine unit revealed two residents under enhanced precautions and both were housed separate from the general population and both were in private rooms. Immediate jeopardy was removed on 12/31/2020.

Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of discharge status (Resident #66), active diagnoses (Residents #116 and #20) and rejection of care (Resident #15) for 4 of 17 sampled residents reviewed. Findings included: 1. Resident 66 was admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #66 was discharged to the hospital on [DATE]. Review of Resident #66's nurse's notes revealed that the resident was discharged to home on 2/17/19. On 4/16/19 at 3:10 PM, MDS Nurse #1 was interviewed. The MDS Nurse reviewed the nurse's notes and verified that Resident #66 was discharged to the community instead of the hospital. The MDS Nurse indicated that the discharge MDS assessment dated [DATE] was coded incorrectly under the discharge status. On 4/18/19 at 8:34 AM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the MDS assessments to be coded accurately. 2. Resident # 116 was admitted to the facility on [DATE] with multiple diagnosed including: [DIAGNOSES REDACTED]. Resident #116's admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The assessment did not indicate that Resident #116 had a diagnoses of [MEDICAL CONDITION]. Resident #116's care plan was reviewed. The care plan problems dated 1/29/19 included I am at risk for acute pain related to [MEDICAL CONDITION] and I have [MEDICAL CONDITION]. On 4/17/19 at 2:35 PM, MDS Nurse #2 was interviewed. The MDS Nurse reviewed the resident's medical records and verified that Resident #116 had a diagnoses of [MEDICAL CONDITION]. The MDS Nurse indicated that the admission MDS assessment dated [DATE] was coded incorrectly under the active diagnoses. On 4/18/19 at 8:34 AM, the Director of Nursing (DON) was interviewed. The DON stated that she expected the MDS assessments to be coded accurately. 3. Resident #15 was admitted to the facility on [DATE] with diagnoses that included visual loss in right eye and dry eye syndrome. A review of nursing notes dated 1/27/19 indicated Resident #15 frequently refused medications and eye drops. A review of Resident #15' s Medication Administration Records (MARs) from 1/26/19 through 2/1/19 indicated she refused medications and/or eye drops on 7 of 7 days. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 ' s cognition was intact, and she had no rejection of care. The Behavior Section of the 2/1/19 MDS for Resident #15 was completed by the Social Worker (SW). A review of Resident #15 ' s active care plan was conducted on 4/16/19. This care plan had not addressed Resident #15 ' s rejections of medications and/or eye drops. An interview was conducted with the SW on 4/17/19 at 2:30 PM. She stated that she completed the Behavior Section of the MDS by reviewing nursing notes. She reported there also was a section on the electronic medical record that showed her any Nursing Assistant (NA) documentation related to behaviors and/or rejection of care. She reported that she had not reviewed the MARs to when she completed the Behavior Section of the MDS assessments. The nursing notes dated 1/27/19 and the MARs from 1/26/19 through 2/1/19 (the 7-day look back period for the 2/1/19 MDS) for Resident #15 were reviewed with the SW. The 2/1/19 MDS that indicated Resident #15 had no rejection of care was reviewed with the SW. She revealed that she must have missed the 1/27/19 nursing notes and that she had not reviewed Resident #15 ' s MARs. She further revealed she was unaware Resident #15 had frequent refusals of medications and/or eye drops. The SW indicated the 2/1/19 MDS for Resident #15 was coded inaccurately for rejection of care. An interview was conducted with the Director of Nursing (DON) on 4/17/19 at 11:40 AM. She verified Resident #15 had no care plan that addressed rejection of care. A follow up interview was conducted with the DON on 4/18/19 at 8:27 AM. She indicated she expected the MDS to be coded accurately. 4. Resident #20 was admitted to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION] and adult failure to thrive. A review of the medical record indicated Resident #20 was admitted to hospice services on 1/24/19 with a primary hospice [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 ' s cognition was moderately impaired, and she was receiving hospice services. Resident #20 ' s active diagnoses had not included malnutrition. The Active Diagnoses Section of the 2/6/19 MDS for Resident #20 was completed by MDS Nurse #1. An interview was conducted with MDS Nurse #1 on 4/17/19 at 2:25 PM. She stated that she coded the 2/6/19 MDS for Resident #20 in the area of Active Diagnoses. The 2/6/19 MDS for Resident #20 that included no [DIAGNOSES REDACTED].#1. The hospice documentation that indicated Resident #20 was admitted to hospice services on 1/24/19 with a primary hospice [DIAGNOSES REDACTED].#1. MDS Nurse #1 confirmed malnutrition was an active [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DON) on 4/18/19 at 8:27 AM. She indicated she expected the MDS to be coded accurately.