Every finding on record at Westward Heights Care Center

Based on medical record review, resident representative, hospital staff, and staff interview, the facility failed to ensure residents were allowed to return following acute hospitalization for 1 of 4 sample residents (#1) reviewed for transfer and discharge. The findings were: 1. Review of a discharge MDS assessment dated [DATE] showed resident #1 admitted to the facility on [DATE] and had an unplanned hospital discharge return not anticipated on 4/10/26. Review of progress notes dated 4/10/26 and timed 7:50 AM, 8/24 AM, and 1:01 PM showed at approximately 6 am the resident had increased agitation with behaviors. Further review showed the resident had an elevated blood glucose, was administered insulin per a sliding scale, and was transferred via EMS for evaluation and treatment. The following concerns were identified:a. Review of a progress note dated 4/10/26 and timed 1:28 showed LATE ENTRY Note Text: IDT team met with Westward Height's management company. That meeting included Director of Facility Operations, Director of Clinical Services, Social Worker, and Director of Revenue Services. Given the background of situation and current status of theresident [sic], the team discission was to issue an involuntary discharge notice d/t: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; and it is necessary for resident's welfare, and [his/her] needs cannot be met in the facility. Call was then placed to ER to notify of immediate discharge of facility at 11:17 AM. ER supervisor [Name] stated that resident did not qualify for admission or psych stay stating denying suicidal or homicidal ideation. Call then placed to [name] state ombudsmen to notify of situation. Ombudsmen recommended placement at a psychiatric skilled nursing facility in Utah that has had good results in the past for a similar situation. IDT placed call to Utah facility called [Name of facility] in SLC. They stated they have open beds at this time and information given to provide referral via fax. Call then placed by IDT team back to ER director, the information was passed to ER director for [Name of facility] information. ER director stated that no case management was in ER, it was not her responsibility to send the referral, and the ER is not able to send referrals. Then IDT placed phone call to [name], the resident's [spouse] notifying [him/her] of [Name of facility] aspotential [sic] option for safe placement. [Spouse] was also notified of involuntary discharge d/t [due to] level of care and safety and health of the individual in facility due from the Administrator and IDT team. [Spouse] was in agreement with no return to Westward Heights d/t concerns listed above that [Name of facility] would be a better fit for [him/her] right now. [Spouse] was going to make [his/her] way to the hospital and discuss this with ER staff. [Spouse] then called IDT team back and stated ER was ready to discharge [him/her] and [s/he]was [sic] ready for pickup and please coordinate with hospital in regard to plan moving forward. [Spouse] did state at this time that [s/he] was willing to help with anything that needed to be coordinated but would be unable to provide facility with any 1:1 resident support needed for [his/her] return. IDT then called to discuss with management company and give update on current situation. Management company re-irritated to IDT that it was unsafe to take resident back d/t suicidal ideation and safety and health of individuals in the facility. Nurse manager then called IDT team back again and stated resident discharged from ER and WHCC staff needed to work on transport. IDT team then again re-iterated involuntary discharge was issued and was no longer a resident effectiveimmediately [sic] on 4/10/26 d/t health and well being [sic] of others and suicidal ideation. IDT then placed a phone call to Westward Height's Medical Director to notify of situation at hand. Medical Director in agreement with discharge of resident. She placedcall [sic] to ER and discussed the situation with the ER. ER provider refused to speak with Westward Height's Medical Director. Medical Director spoke with the nurse manager explaining the discharge and asked questions regarding the psych evaluation. Medical Director returned call to DON and notified DON that she was waiting on call from psychiatrist to discuss the severity of resident's mental health. After Medical Director spoke with psychiatrist at hospital, he was in agreement to make an addendumto [sic] his recommendation that [s/he] was unsafe to return to WHCC and required placement in memory care. [Name], the ER nurse manager then called facility and asked IDT if they have received records in attempt again to make arrangements for transport, IDT team re-iterated again that involuntary notice has been issued and [s/he] is no longer a resident of this facility. The nurse manager then asked if family had been notified. IDT was able to confirm that family was also notified of discharge. [Name] then informed IDT that [s/he] would be discharged from ER and would need to return home with family. [Name] [spouse] then placed phone call to IDT team stating the hospital was discharging [him/her] with an unsafe plan and he was unable to care for [him/her] at home. IDT team then againexplained [sic] that we could not accept back due to safety of individual and the safety of all residents in facility. Following this phone call Social Services called [Name of facility] in SLC and asked if we could send a referral on behalf of hospital. [Name] at [Name of facility] reviewed referral however, did recommend WHCC excuse themselves from referral process as it needs to come from the hospital. Call then placed to [spouse] to notify [him/her] of referral was placed to [name of facility]. [Name]was appreciative of this call and had since calmed down from previous conversation and stated the hospital admitted her since he is unable to care for her at his home. DON then placed a phone call to primary care provider to be aware of situation. Primary care stated he has talked with ER and agreed that [Name of facility] would be in [his/her] best option for a transition. Provider was thankful for phone called placed with no further questions or concerns.b. Review of a Social Services Transfer/Discharge Plan and Notice to Resident dated 4/13/26 and timed 9:30 AM showed the resident was transferred on 4/10/26 to the hospital, and the reason for transfer was Suicidal ideation/ combative. Further review showed the notice was provided to the resident/representative by mail on 4/13/26.c. Review of a hospital Psychiatry [NAME] Note dated 4/10/26 and timed 10:21 AM showed .Discussed treatment options with the patient. The patient does not need inpatient psychiatric treatment at this time. [S/he] can be discharged if [s/he] is medically stable.d. Review of an addendum to hospital Psychiatry [NAME] Note dated 4/10/26 and timed 3:21 PM showed [His/her] current facility does not want to accept [him/her] because of [his/her] recent behavioral changes. They do not feel safe to keep [him/her]. The patient is unable to take care of [him/herself]. [S/he] will not be safe to be discharged without any placement. At this time I recommend to transfer [him/her] to a memory care unit .e. Review of a hospital note dated 4/11/26 showed .Patient with dementia that has been somewhat increased since [s/he] had changed blood pressure medications about a week ago and [s/he] has had some increased confusion. [S/he] had been sent up here from the nursing home and they would NOT take [him/her] back and discharged [him/her] from their facility declining to allow [him/her] back into their facility today. The ER had done a workup and planned to send [him/her] back however they would not take [him/her]. Administration here was notified and request to me to place patient in hospital. Patient will be placed in the hospital with supportive care. Ordered a one-to-one staff. Working on getting the patient to facility that will be most supportive for [him/her] with memory Care ideally. Will work on controlling [his/her] anxiety as well here. [S/he] was seen by tele psychiatry has [sic] it was reported from the facility that [s/he] was suicidal however [s/he] has not been suicidal at all and the psychiatrist did not feel like [s/he] was suicidal .f. Review of the hospital notes showed the resident received 1-to-1 from hospital staff on 4/10/26 and 4/11/26, and had been removed from 1-to-1 on 4/12/26 at 7:15 AM.g. Review of a hospital note dated 4/15/26 and timed 5:24 AM showed .No new issues reported overnight. Patient overall does not have any specific new complaints or problems. [S/he] is calm and pleasant this morning.h. Review of a hospital note dated 4/16/26 and timed 5:58 AM showed .Patient slept well overnight. There are no new issues reported. [S/he] is calm and pleasant.i. Review of a hospital note dated 4/17/26 and timed 10:14 AM showed .pt very chatty today, a little stream of conscious. pleasant .waiting on placement.m. Review of a hospital Discharge summary dated [DATE] and timed 12:52 PM showed .1. Dementia, w overlying acute metabolic encephalopathy likely due to acute respiratory infection, possible clonidine use. Reportedly worsening dementia. Possibly in part due to recent initiation of clonidine contributing, though appears may have been longer in history. UA and other workup for other causes of worsened dementia were negative. [S/he] had been sent up here from the nursing home and they would NOT take [him/her] back and discharged [him/her] from their facility - declining to allow [him/her] back into their facility.[His/her] mental status after being taken off Clonidine has seemed to have improved some.Has been appropriate and cooperative here. Per family did have improvement in the acute confusion and seemed back to [his/her] baseline.j. Interview with the resident's representative on 5/19/26 at 2:42 PM revealed the resident had been on a 1-to-1 at the hospital for 24 hours, and had stabilized within a day after medication changes had been made. Further interview revealed the resident had been moved to a long term care facility 2 and a half hours away, and did not require memory care.k. Interview hospital staff #1 on 5/19/26 at 3:14 PM revealed facility staff did not reassess the resident at the hospital.l. Interview with the NHA and DON on 5/20/26 at 10 AM revealed the facility could not provide mental health services or 1-to-1 supervision for the resident, and an emergent discharge had been issued for the resident's safety and the safety of other residents in the facility based on his/her behaviors at the time of discharge. Further interview confirmed the resident had not been assessed because s/he had already been discharged as a resident from the facility.m. Interview with the DON on 5/20/26 at 1:14 PM revealed the resident had been provided with a 1-to-1 on for approximately 1 1/2 hours prior to being discharged to the hospital. Further interview revealed the resident had never been involved in any resident-to-resident altercations.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery and assistance during 2 of 3 meal observations in the main dining room. The census was 56. The findings were: 1. Observation on 3/24/25 beginning at 5:43 PM showed CNA #1 was assisting a resident to eat dinner. The CNA was observed touching the resident's shoulder, arm, and wheelchair wheel while assisting the resident. Without performing hand hygiene, the CNA moved around the table and was observed placing her ungloved hand on top of another resident's hamburger and using her other hand to cut the hamburger in half. After it was cut, the CNA picked up half the hamburger, using both hands, and handed it to the resident, which the resident ate. The CNA then used her ungloved hand to pick up a French fry, dip it in ketchup, and hand it to the resident, which s/he ate. The CNA again picked up the resident's hamburger and handed it to the resident before standing from the table at washing her hands at the sink in the dining room. 2. Observation on 3/26/25 beginning at 12:04 PM showed CNA #1 assisted a resident by cutting his/her food and then touched the resident's shirt. The CNA left the table and obtained another plate at the kitchen window and took it to a 2nd resident, where she cut up the food using his/her silverware. The CNA placed her hand into her hair then obtained another plate from the kitchen window and delivered it to a 3rd resident. While delivering the meal tray, the CNA touched the resident's wheelchair before returning to the kitchen window to obtain another tray and delivering it to a 4th resident. No hand hygiene was performed during the observation. 3. Interview with the DON, infection preventionist, and dietary director on 3/27/25 at 9:48 AM revealed hand hygiene should occur during meal service between residents if resident contact occurred. They confirmed the CNA should perform hand hygiene before assisting a second resident and they would like staff to wear gloves if they are touching the resident's food items. Further interview revealed they expected hand hygiene to be performed after touching potentially contaminated items. 4. Review of a facility procedure titled . Hand Hygiene Competency dated 12.2019 showed .When to wash hands .Before each resident contact .After touching a resident or handling their belongings .After handling contaminated items (linens/garbage/briefs, etc.) .When can hand sanitizer be used .Before/after direct contact with resident .After contact with resident's intact skin .After contact with inanimate objects, such as medical equipment in resident's room or vicinity .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a gradual dose reduction was performed for 1 of 5 sample residents (#28) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #28 had a brief interview for mental status score of 14 out 15, which indicated s/he was cognitively intact, and diagnoses which included end-stage renal disease and insomnia. Further review showed the resident used antidepressant medications during the look-back period. Review of the resident's physician orders showed s/he received trazodone (antidepressant) 50 mg by mouth at bedtime related to insomnia which was ordered on 7/21/23. The following concerns were identified: a. Review of the treatment administration records for January, February, and March 2025 showed the facility was monitoring the resident for restlessness at night and there were no documented episodes of restlessness indicated. b. Review of a Consultation Report dated January 1, 2025 through January 18, 2025 showed the pharmacist recommended to .Please attempt a gradual dose reduction (GDR) to 25 mg qhs (every day at hours of sleep). If you do not wish to decrease, please document risk vs. benefit of continuing Trazadone . The review showed the physician declined the recommendation because a GDR was Clinically Contraindicated for the resident and checked the box for the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. Further review showed there was no additional or resident specific information documented below. c. Review of a Consultation Report dated May 20, 2024 through May 22, 2024 showed the pharmacist recommended If clinically appropriate, please consider a gradual dose reduction (GDR) to trazadone 25 mg daily, while concurrently monitoring for reemergence of target and withdrawal symptoms. The review showed the physician declined and checked the box that stated Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating and underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . Further review showed the physician wrote [S/he] is able to sleep with trazadone. d. Review of a Consultation Report dated January 29, 2024 through January 30, 2024 showed the pharmacist recommended If clinically appropriate, please consider a gradual dose reduction (GDR) to trazadone 25 mg daily, while concurrently monitoring for reemergence of target and withdrawal symptoms. The review showed the physician declined and checked the box that stated Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating and underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . Further review showed there was no additional or resident specific information documented below. 2. Interview with the DON on 3/27/25 at 10:22 AM revealed the resident #28 previously had a successful gradual dose reduction attempted and she was unable to find any unsuccessful attempts. In addition, she was unable to locate where the physician provided additional resident specific information for the need of the medication. 3. Review of the facility policy titled Psychoactive Medication and Medication Regimen Review Management Standard dated 9.2024 showed .5. Gradual Dose Reduction/Tapering of Medications: The requirements underlying this guidance emphasize the importance of seeking an appropriate dose and duration for each medication and minimizing the risk of adverse consequences, The purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. Tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying cases of the original symptoms have resolved, and/or non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms .

Based on medical record review, staff interview, facility incident review, and policy and procedure review, the facility failed protect the resident's right to be free from physical abuse by another resident for 1 of 3 sample residents (#2). Corrective measures were implemented prior to the survey and compliance was determined to be met on 8/9/24. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 5 out of 15, indicating severe cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. Review of the admission MDS assessment dated [DATE] showed resident #3 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. The following concerns were identified: a. Review of an incident report dated 7/20/24 and timed 5 PM showed both resident #2 and #3 were in the dining room when resident #3 was seen rubbing resident #2's shoulder. Resident #3 then put his/her hand in resident #2's groin area. Resident #2 and #3 were separated at the time of the incident. b. Interview with CNA #1 on 12/27/24 at 12:05 PM revealed s/he witnessed resident #3 massaging resident #2' s groin area outside his/her pants. The CNA revealed resident #3 was immediately redirected and separated from resident #2. The CNA stated the residents didn't know what happened, they both have dementia. The CNA stated resident #2 showed no changes in demeanor following the incident. c. Interview with RN #2 on 12/27/24 at 2 PM with revealed s/he did not witness the incident but was made aware of it by CNA #1 immediately after it happened. The RN revealed s/he followed the facility policy and procedure for reporting abuse which included notifying the social services director. RN #1 confirmed resident #2 and #3 were separated and resident #3 was placed on increased supervision. RN #1 revealed no effects were noted after the incident but it's hard to tell with dementia. 2.Review of the Resident Rights provided on admission and last revised 05/19 showed .Restraint and Abuse, your right to be free from abuse and neglect . 3.Review of the facility's policy titled Abuse and Neglect Prevention Standard, last revised 1/23 showed .the resident has the right to be free from abuse . The definition of sexual abuse was .non-consensual sexual contact of any type with a resident . The definition of sexual abuse included .capacity and consent-residents have the right to engage in consensual sexual activity, however anytime the facility has a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse . 4.The following corrective action was implemented on 8/9/24 and verified during the survey: a. Resident #3 was monitored with increased supervision. b. Daily behavioral/intervention flow record was implemented for resident #3 until discharge from the facility on 8/9/24. c. New focus area with interventions was initiated in care plan on 7/25/24 for resident #3 to include out of character responses (sexual desires) due to dementia. Interventions included redirecting behaviors and providing male caregiver. d. Facility initiated assistance on 7/22/24 to family with helping find a memory care center for transfer. e. Abuse and neglect drill was performed 8/1/2024 and included summary of drill, improvement needed/actions taken and trends noted. f. Abuse and neglect education was provided at all staff meeting on 8/15/24. g. Safety fair on 11/14/24 for all staff included abuse and neglect training. h. Quality Assurance and Performance Improvement (QAPI) report included monthly abuse and neglect monitoring with trends and actions taken.

Based on medical record review, staff interview, and review of incident and facility documentation the facility failed to provide care in accordance with physician's orders and professional standards of practice for 1 of 3 residents (#1) with change in condition including resident #1. The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 11/19/24. The following concerns were identified: 1. Review of complaint/grievance report dated 11/13/24 showed resident #1 did not get transported to an appointment after it was ordered by the physician. 2. Medical record review showed resident #1 had a physician's order for an x-ray of his/her hip dated 10/26/24. On 11/8/24 the nurse attempted to have facility scheduler transport the resident for the x-ray; however, the scheduler was unable to take the resident until 11/11/24. Further review showed the resident received hip x-ray on 11/13/24, 5 days after it was ordered. 2. Interview with the social services staff member #4 on 12/30/24 at 11 AM revealed the delay in time of order and when x-ray done was due to facility miscommunication with scheduler and transportation. 3. Interview with the administrator on 12/27/24 at 12:40 PM confirmed the delay in completion of the treatment was due to facility miscommunication and transportation issues. 4.The facility implemented the following corrective action by 11/19/24 a. Inservice documentation on 11/18/24 revealed meeting with scheduling manager and DON regarding communication and transportation. b. Inservice documentation on 11/19/2024 revealed meeting with nursing staff regarding resident care management in regards to appointments and transportation process. c. QAPI report indicated issues with the timely appointment in trends and current actions taken as well as future intervention.

Based on observation, medical record review and staff and resident interviews, the facility failed to monitor the resident's access site upon return from dialysis treatment for 1 of 1 sample resident (#33) who received dialysis at an off-site dialysis center. The findings were: 1. Observation of resident #33 on 1/8/24 at 4:09 PM showed a bandage visible on his/her upper right chest. Interview with the resident at that time revealed s/he received dialysis three times a week at an off-site dialysis center. The following concerns were identified: a. Review of physician's orders showed the only order related to dialysis was for staff to record the resident's weight following dialysis. There lacked any orders related to the monitoring of the resident's dialysis access site. b. Review of the resident's care plan for hemodialysis initiated 8/23/23 showed Monitor/document/report PRN [as needed] signs/symptoms of infection to access site: redness, swelling, warmth or drainage and Monitor/document/report PRN for signs/symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock. The care plan did not instruct staff to immediately monitor the status of the access port upon return from the dialysis center to observe for bleeding or other complications. c. Review of the December 2023 and January 2024 medication and treatment administration records and progress notes since December 1, 2023 showed no documentation that the resident's access site was monitored upon return from the dialysis center. d. During an interview on 1/10/24 at 3:23 PM the resident stated staff did not observe his/her access site when s/he returned from dialysis. e. On 1/10/24 at 3:24 PM RN #1 was asked what monitoring the resident received following a dialysis treatment. The RN stated they only needed to record the resident's weight, which the dialysis center usually recorded for them. f. On 1/11/24 at 8:23 AM the DON stated the facility did not have policies related to the monitoring of the access site. She confirmed the care plan only instructed for PRN monitoring and further confirmed there was no documentation to show staff were monitoring the access site.

Based on observation, staff interviews, review of manufacturer's instructions, and policy review, the facility failed to ensure infection prevention practices were followed by staff during 1 of 6 medication pass observations which affected residents (#5, #20). The findings were: 1. Continuous observation on 1/9/24 starting at 11:38 AM showed LPN #1 obtained a blood glucose level on resident #20. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. At 12:23 PM LPN #1 obtained a blood glucose level on resident #5 using the same glucometer. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. 2. Interview on 1/9/24 at 12:37 PM with LPN #1 confirmed she had not disinfected the glucometer between residents. 3. During an interview on 1/9/23 at 3:12 PM the infection control nurse and the MDS coordinator both confirmed the facility did not have any residents with known blood borne pathogens. 4. Interview on 1/10/24 at 2 PM with the DON and ADON revealed it was the facility's expectation to clean the glucometers between resident use. 5. Review of the manufacturer's instructions provided by the DON on 1/11/24 at 8:35 AM showed Cleaning & Disinfecting Guidelines .Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use using a commercially available EPA-registered disinfectant detergent or germicide wipe. 6. Review of the facility policy titled Blood Glucose Monitoring Equipment and Supplies provided by the DON on 1/11/23 at 9:54 AM showed .Clean and disinfect blood glucose meters between uses when equipment is shared .

Based on medical record review and staff interview, the facility failed to ensure PRN orders for anti-psychotic medications were limited to 14 days for 1 of 3 sample residents (#95). The findings were: 1. Review of physician's orders for resident #95 showed an order dated 10/18/22 for Zyprexa (anti-psychotic) 5 mg every 24 hours as needed for agitation. Review of the MAR for October and November 2022 verified the medication was a PRN order, with a start date of 10/18/22. The resident received one dose on 10/27/22. 2. During an interview on 11/2/22 at 5:39 PM the DON confirmed the PRN order for Zyprexa was not limited to 14 days. She stated the medication order should have had a 14 day end date, but did not. She further stated the facility was aware that regulations required PRN orders for anti-psychotics be limited to 14 days and required the physician to evaluate the resident before renewing the order.

Based on review of policy and procedures, staff interview, and review of the facility's staff vaccination and COVID-19 testing records, the facility failed to ensure 100% of staff were vaccinated against SARS-CoV-2, held an exemption, or had a temporary delay. The facility's staff vaccination rate was 98.9%. In addition, the facility failed to ensure the policy was followed related to extra precautions for staff who were not fully vaccinated. The findings were: 1. Review of the facility's vaccination records showed CNA #1 was hired on 9/6/22 and was administered the first dose of a two dose COVID-19 vaccination series on 9/7/22. The vaccination log sheet showed a note dated 10/7/22 which stated the vaccine was unavailable at a local pharmacy and the pharmacy would contact the CNA when it was available. There was no evidence the CNA had received the second dose of the vaccine at the time of the survey. 2. Review of the facility's COVID-19 staff testing records showed CNA #1 had not been tested during the month of October 2022. Interview with the infection preventionist (IP) on 11/2/22 at 11:37 AM confirmed the unvaccinated CNA had not been tested for COVID-19 in October 2022. 3. Review of the Mandatory COVID-19 Vaccination Policy, last updated 10/4/22, and required the signature of the employee, showed New team members will be required to have their first vaccination prior to their first day on the job. The second dose would need to be administered within 30 days of the first dose. This policy failed to include what action would be taken if the deadline was not met. 4. Review of the COVID-19 Vaccine Mandate Policy and Procedure, last updated 10/5/22, showed All team members are required to receive vaccinations as determined by CMS, unless an exemption is approved, and the team member accepts a reasonable accommodation. Team members not in compliance with this policy will be placed on unpaid leave until their employment status is determined by the administrator. In addition the policy stated The facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19 including but not limited to: COVID-19 testing once per week. This policy failed to include a deadline for newly hired staff to have obtained the second dose of the primary vaccination series. 5. Interview with the NHA and the IP on 11/2/22 at 4:28 PM revealed there was a communication breakdown which resulted in the CNA working past the 30 day deadline without receiving the second dose of the COVID-19 vaccination series and not being tested weekly as specified in the policy.

Based on observation, medical record review, and staff interview, the facility failed to ensure resident assessments accurately reflected their health status for 1 of 22 sample residents (#25). The findings were: 1. Review of the 5/20/21 admission MDS assessment showed resident #25 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident did not have a feeding tube. The following concerns were identified: a. Observation on 10/11/21 at 5:24 PM showed the resident in the dining room eating dinner. Review of the care plan, with a revision date of 8/25/21, showed the resident was on a regular diet with meal fortification. b. Review of the 8/23/21 quarterly MDS assessment showed the resident had a feeding tube. c. Interview on 10/12/21 at 4:52 PM with the DON revealed the resident did not have a feeding tube. d. Interview on 10/12/21 at 4:56 PM with the MDS coordinator revealed the resident did not have a feeding tube, and the entry was placed by mistake. She further stated the dietician filled the nutrition section on the MDS assessment, and there wasn't a process to double check entries for accuracy.

Based on observation, review of the nursing staff postings, and staff interview the facility failed to ensure the information on the posted 24 hour nursing staff information was maintained and updated to reflect the actual hours work for 17 of 17 days. The census was 53. The findings were: 1. Observation on 10/11/21 through 10/14/21 of the posted 24 hour nursing staff information showed only the number of hours each care level was scheduled to work. 2. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Interview on 10/13/21 at 9:14 AM with the DON confirmed the posted 24 hour nursing staff information failed to include the actual hours worked of the resident care staff.

Based on medical record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) level II as required for 1 of 22 residents (#45) reviewed for PASARR needs. The findings were: 1. Review of the 9/30/19 annual MDS assessment showed resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following concerns were identified: a. Review of progress notes dated 7/6/21 at 10:10 AM showed the resident was seeing dead squirrels hanging outside the window. b. Review of the 9/22/21 annual MDS assessment showed additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the assessment showed a PASRR level II was not recorded. c. Interview with the Director of Social Services and the DON on 10/12/21 at 5:07 PM revealed the staff did not recognize the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interviews, and review of orientation documentation, the facility failed to ensure the environment remained free of accident hazards for 2 of 24 sample residents (#26, #41) reviewed. The findings were: Observation on 7/22/19 at 3:13 PM showed the cord for the call light in resident #41's room was strung across the width of the room, causing a potential trip hazard. Observation of resident #26's room during the same time period revealed oxygen tubing was placed where the room could not be entered without walking on or impinging on the tubing. Observation on 7/23/19 at 10:48 AM showed these hazards remained unaddressed. Interview with certified nurse aide (CNA) #1 on 7/24/19 at 10:26 AM revealed the CNA had worked in facility for over 4 years. She stated the initial orientation covered safety, and that clutter in the room was identified as a tripping hazard. She further stated that when it was seen, it was the responsibility of the one discovering it to rectify and report the condition. Interview with the DON on 7/24/19 at 11:24 AM confirmed that the general orientation training included safety. She stated clutter in rooms and tripping hazards were to be removed immediately. If the staff was uncomfortable with moving the cords/tubing, the charge nurse had that responsibility. The DON further stated it was the expectation that trip hazards were removed as soon as possible. Review of General Orientation Handbook under the General Safety section revealed Tripping Hazards - Keep your area clean and clear of tripping hazards including rooms.

Based on observation, medical record review, and staff interview, the facility failed to provide timely assistance for 1 of 2 sample residents (#3) who required incontinence care assistance from staff. The findings were: Review of the 2/11/19 quarterly MDS showed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review showed the resident required extensive assistance of one staff member for toileting, was on a toileting program, and was frequently incontinent of urine. The following concerns were identified: a. Continuous observation on 5/1/19 from 3:45 PM until 8:35 PM (4 hours and 50 minutes) showed the resident was not toileted, asked if s/he needed to toilet, or checked for incontinence by staff. The resident was toileted and provided urinary incontinence care at 8:35 PM by CNAs #1 and #2. b. Interview with CNAs #1 and #2 on 5/1/19 at 8:35 PM revealed their usual routine was to check the resident every 2 hours for incontinence, and provide toileting assistance as required. They both confirmed the resident had not been checked or offered toileting assistance from 3:45 PM until 8:35 PM, and s/he was incontinent of urine at that time, though not saturated. c. Review of the resident's incontinence care plan, last revised on 2/21/19, confirmed the resident had bladder incontinence with impaired mobility and physical limitations. For the goal, the plan showed, Will be continent during waking hours through the review date. However, the interventions failed to specify individualized staff guidance to accomplish the goal, and showed, Monitor/document signs and symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, dark urine, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns PRN (as needed) .Perineal care PRN. d. Interview with the DON on 5/1/19 at 8:40 PM confirmed it was her expectation for staff to toilet resident #3 every two hours or provide incontinence care at that time.

Based on observation, medical record review, and staff interview, the facility failed to develop an individualized care plan for 1 of 2 sample residents (#3) who had urinary incontinence. The findings were: Review of the 2/11/19 quarterly MDS showed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review showed the resident required extensive assistance of one staff member for toileting, was on a toileting program, and was frequently incontinent of urine. The following concerns were identified: a. Continuous observation on 5/1/19 from 3:45 PM until 8:35 PM (4 hours and 50 minutes) showed the resident was not toileted, asked if s/he needed to toilet, or checked for incontinence by staff. The resident was toileted and provided urinary incontinence care at 8:35 PM. b. Review of the resident's incontinence care plan, last revised on 2/21/19, confirmed the resident had bladder incontinence with impaired mobility and physical limitations. For the goal, the plan showed, Will be continent during waking hours through the review date. However, the interventions failed to specify individualized staff guidance to accomplish the goal, and showed, Monitor/document signs and symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, dark urine, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns PRN (as needed) .Perineal care PRN. c. Interview with the DON on 5/2/19 at 9 AM confirmed the care plan for resident #3 was not individualized with specific interventions to address the goal of remaining continent while awake.

Based on observation, medical record review, product label and direction information review, and staff interview, the facility failed to implement a system to ensure thickened liquids were provided at the ordered consistency for 2 of 3 residents who received thickened liquids (#22, #155). Observations during the survey showed staff were not knowledgeable about the preparation of nectar-thickened liquids and provided these residents drinks that were too thin, increasing their risk for swallowing and potential aspiration problems. The record reviews for these residents showed they both had recent [DIAGNOSES REDACTED]. This resulted in an immediate jeopardy situation for these residents. The findings were: 1. Review of speech therapy notes showed resident #22 was evaluated on 6/5/17, 11/9/17, and 6/29/18. The notes from these evaluations showed the resident presents with a high risk of aspiration. Review of the 6/29/18 evaluation showed the reason for referral was choking during meal time, and according to the plan the resident would be seen twice weekly for a certification period from 6/29/18 to 9/20/18. Review of the care plan showed the resident had a problem dated 5/18/18 for Potential risk for infection related to dependence for cares, swallowing/aspiration risk . In addition, the care plan identified a problem on 6/19/17 related to Resident is at risk for dehydration r/t (related to) contractures in his hands, dementia, inability to retrieve fluids on his own along with current thickened liquids status. The 9/9/17 intervention for this problem included Thicken all liquids to nectar thick consistency .Ensure proper consistency of fluids at activities, etc .Offer fluids in wavy straw cups .Needs to sit upright for 30 mins (minutes) after meals. The following concerns were identified: a. Observation on 7/23/18 at 5:20 PM showed CNA #1 prepared thickened coffee for the resident by shaking thickening powder from a sugar shaker located on the beverage counter in the dining room. The CNA shook some powder into a wavy straw cup, swirled it and gave it to the resident. At no time did she stir the liquid to check for proper consistency. At 5:27 PM the resident was noted to be coughing. b. Review of the nurse's note dated 7/24/18 and timed at 8:28 AM showed the resident had vomited during the night, had an elevated temperature of 100.5 degrees Fahrenheit (F), and had Fine crackles noted to bilateral bases upon assessment with diminished sounds noted to all other lobes. The physician was contacted for treatment instructions. c. Review of a nurse's note dated 7/24/18 timed at 1:06 PM showed the resident was sent to the urgent care clinic at approximately 9:30 AM and was then sent to the hospital for further evaluation. d. Review of the 7/24/18 hospital discharge instructions showed the resident was diagnosed with [REDACTED]. e. Observation on 7/25/18 at 12:29 PM showed the resident was seated at the dining table, the resident had a cup with thickened water, and also had a cup of coffee. As the resident drank the coffee from the wavy straw cup it was noted to be thin. Interview with dietary aide #1 on 7/25/18 at 12:30 PM revealed the coffee did not look to be nectar-thick, she was not sure who prepared it, and she would prepare a new one. At that time, CNA #2 who was sitting next to the resident to assist with eating got up and retrieved a small portion cup of thickening powder. She added it to the remaining coffee which the resident had been drinking. During interview with CNA #2 at that time she stated the coffee was difficult to thicken. CNA #2 revealed she didn't follow specific directions to add thickening powder, but just added it until it was ready. The CNA had to retrieve more thickening powder to add to the coffee before returning the cup to the resident. f. Interview with the DON and administrator on 7/24/18 at 10 AM verified a contract was in place to provide speech therapy. However, the contracted therapist was on vacation that week. The administrator stated if speech therapy was required while the contracted therapist was on vacation, a therapist could be used from another agency or the hospital. 2. Review of the 6/1/18 quarterly MDS assessment showed resident #155 had a BIMS score of 10/15 (moderate cognitive impairment), required the limited assistance of 1 staff member for eating, and had [DIAGNOSES REDACTED]. Review of the care plan dated 3/6/18 showed the resident had a potential risk for infection related to swallowing issues and was dependent for personal care. The following concerns were identified: a. Review of the medical record showed the resident was admitted to the hospital on [DATE]. Re-admission orders [REDACTED]. b. Review of a nurse's note dated 7/19/18 and timed 12:49 PM showed the resident has been observed to have difficulty swallowing and it was reported to this RN by occupational therapist that resident has been coughing when (s/he) drinks water . The physician was notified and an order was requested for the resident to have nectar-thick liquids. c. Review of a physician communication form dated 7/19/18 showed Resident has been observed to have difficulty swallowing and has been coughing when (s/he) drinks water. We do not have in-house speech therapy until the end of next week. Could we have an order for [REDACTED]. The physician agreed with the request and the order was noted by the DON. d. Review of a Diet order and Communication form dated 7/19/18 showed the resident's diet had been changed to nectar-like thickened liquids. e. Observation on 7/25/18 at 8:40 AM showed the resident was served un-thickened water in a wavy straw cup. Interview with the dietary manager at this time confirmed the water was not thickened and the dietary manager was observed to replace the un-thickened water with prepackaged thickened water. 3. Interview with the consultant RD on 7/24/18 at 2:52 PM revealed she was not aware of the specific thickening/thickened products used by the facility at that time. She stated the speech therapist had provided education in the past related to thickened liquids. The RD further stated the product directions would be expected to be followed to meet the desired consistency. 4. Interview with the CDM on 7/24/18 at 12:33 PM revealed liquids were thickened using a powder contained in a sugar shaker on the counter. The dietary manager demonstrated the procedure by shaking the powder into the liquid and then stirred the beverage until it was the correct consistency; adding more thickener as needed. Further, she stated the facility did not use measuring devices because the amount needed varied depending on the temperature of the liquid being thickened. There was no instructional chart located on the beverage counter. 5. Review of the manufacturer's instructions, provided by the facility, for the thickening powder showed a chart for how much thickener was needed for different amounts and types of liquids to achieve nectar, honey, or pudding consistency. The directions showed for 4 ounces of coffee/tea 3-1/2 to 4 teaspoons should be added. For 8 ounces the amount of thickener was shown to be 7 to 9 teaspoons. The instructions also informed the user to 1. Scoop and level off recommended amount of Thick-It Instant Food and Beverage Thickener using enclosed measuring spoon. 2. Slowly add Thick-It Instant Food and Beverage Thickener to the liquid while stirring briskly with a spoon, fork or whisk until thickener has dissolved. Let thickened liquid stand 30 seconds to 1 minute to achieve desired consistency and serve . 6. On 7/25/18 at 3:03 PM, the administrator was notified of the immediate jeopardy. The facility's removal plan included the following corrective actions: a. Education to all nursing and dietary staff working on 7/25/18 on directions and process for thickening liquids. Additional staff will be educated on the process prior to returning to work. b. Family members of residents who receive thickened liquids were provided education and asked to allow staff to prepare the thickened liquids. c. A monitoring system was put into practice to ensure the physician's orders [REDACTED]. A list of residents with these orders and the thickening directions was placed in a drawer for staff to access in the drink area. The dietary manager or designee was assigned to complete spot checks of the thickened consistency of drinks. The removal plan was accepted on 7/25/18 at 5:33 PM, and the immediate jeopardy was removed on 7/26/18 at 10:08 AM. However, deficient practice remained at a scope and severity of D (isolated noncompliance with potential for more than minimal harm that is not Immediate Jeopardy).

Based on observation, staff interview, review of monitoring logs, review of maintenance records, and review of product labels, the facility failed to implement a system that ensured dietary staff were knowledgeable regarding the importance of taking action to correct inadequate final rinse temperatures of the dish-machine, and implementing alternatives to ensure resident dinnerware and utensils were effectively sanitized to minimize the potential for food-borne illness in 1 of 1 food preparation areas (kitchen). The census was 54. Further, the facility failed to ensure appropriate hand-hygiene techniques in 1 of 1 food preparation areas (kitchen), and failed to ensure proper dating and labeling of pre-thickened beverage products in 2 of 2 storage areas (resident room, beverage refrigerator in the dining room). The findings were: Regarding inadequate final rinse temperatures of the dish machine: 1. Review of the (MONTH) 1-23, (YEAR) dish-machine temperature log showed the hot water rinse temperature was recorded twice per day for the month with the exception of 7/3/18 and 7/22/18 when there were no temperatures recorded. Of the times when hot rinse temperatures were recorded, there were 27 temperatures that were shown to be less than 180 degrees Fahrenheit (F). There were no notes on the log to show corrective actions taken. Interview with the CDM on 7/23/18 at 3:09 PM revealed she was aware the rinse temperatures had been problematic since after the installation of the new booster heater. The CDM revealed the recorded temperatures were taken by looking at the temperature gauge located on the outside of the machine. The manager verified an internal temperature was not taken by using a temperature strip indicator or a holding thermometer. The manager also stated there were times when the maintenance director was contacted to fix the problem, and it would be okay for a few days. She further acknowledged the dish-machine continued to be used although the temperatures were not sufficient. 2. Review of the invoice for the dish-machine booster heater showed it was dated 4/16/18. Review of the (MONTH) (YEAR) hot rinse temperatures for the dish-machine showed the temperatures were recorded 3 times daily with the exception of 5/1, 5/2, 5/3, and 5/4, when there were no temperatures recorded for the breakfast temperatures. Of these temperatures recorded, there were 2 times (5/3/18 at dinner and 5/21/18 at breakfast) when the temperatures were less than 180 degrees F. There was nothing documented in the area for corrective action. 3. Review of the (MONTH) (YEAR) hot water rinse temperatures for the dish-machine showed temperatures were recorded 3 times daily. There were 38 times when the temperature was recorded as less than 180 degrees F. There were two days when a corrective action note was made: on 6/6/18 and on 6/29/18 notes showed advised maintenance. 4. Observation on 7/23/18 at 2:10 PM as the dish machine was in use, showed the final rinse temperature on the display was 171 degrees F. Interview with dietary aide #1 at that time revealed she was not aware what temperature was required. Review of the log showed the PM temperature had not yet been recorded for the day. Interview with dietary aide #2 at that time stated the rinse temperature had been a problem, and she reported it to maintenance last Thursday. She also verified the plan was to continue using the machine. 5. A test of the dish-machine hot water temperature was done on 7/23/18 at 4:56 PM by the surveyor and witnessed by the CDM. The machine was a 2 temperature machine which displayed the wash temperature and also the rinse temperature. The test was done using indicator stickers (thermolables) designed to turn black when the dish surface reaches 160 degrees F when run through the dish machine cycle (160 degrees F at the dish/rack surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish-machine is measured). During the test the facility's label and the surveyor's label both failed to turn black. 6. Interview with the maintenance director on 7/24/18 at 10:15 AM revealed he had called to have the dish-machine booster heater serviced and was having difficulty in getting service scheduled. He stated he did not have documentation of when these calls were made. Further, he recalled times when the dietary staff requested him to come check the machine related to low temperatures, and stated these are documented on the maintenance log. When notified, he would adjusted the temperature and they continued to use it. 7. Review of the maintenance log from 5/27/18 to 7/9/18 showed 3 entries related to low temperature readings of the dish-machine. These dates were 6/7, 6/29 and 7/1. The dates when the work was documented as completed on the log were 6/8/18 and 7/2/18. 8. According to Food Code (YEAR), U.S. Public Health Service: 4-501.112 (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF). Regarding proper dating and labeling of pre-thickened beverage products: 1. Observation on 7/24/18 at 8:55 AM showed a clear mug with a lid on the dresser in the room of resident #22. The liquid in the mug was opaque and appeared to be thin when the cup was picked up. There was no date or label on the cup/lid. Interview with CNA #3 at that time revealed it was the resident's thickened water. Interview with domestic aide #1 on 7/24/18 at 10:43 AM revealed there were 2 residents in that hallway that received thickened water in their rooms. The aide stated she had training in the past from the SLP on how to thicken beverages. She stated there was a powder thickener and also a prepared pre-thickened product which was water or juice. The aide said the schedule was to provide these thickened beverages to the resident rooms twice daily, at approximately 9:45 AM and 2 PM. Observation on 7/25/18 at 12:41 PM showed thickened water in the sippy mug on the dresser in the resident's room. There was no label of any kind on the cup or lid. 2. Observation on 7/25/18 at 11:28 AM showed 4 open multi-serving cartons of thickened beverages located in the beverage refrigerator located in the dining room. The cartons failed to include a date when the product had been opened or was to be discarded. The package information showed the product it was good for 8 hours in ambient air temperature, or up to 7 days if refrigerated. Interview with the CDM on 7/25/18 at 11:28 AM revealed once a carton was opened they used the product within 7 days, so she was not aware they required a date. 3. Interview with the CDM on 7/26/18 at 8:50 AM revealed the system for leaving thickened beverages in the resident rooms needed to be revised to ensure the appropriate time frame was followed. 4. According to Food Code (YEAR), U.S. Public Health Service: 3-501.17 (A) .refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. Regarding hand hygiene: Observation in the kitchen on 7/25/18 at 11:38 AM showed the CDM used hand gel upon entering the kitchen and, without washing her hands, donned gloves to prepare resident beverages. At 11:39 AM dietary aide #1 handled the refrigerator door and, without hand washing, donned gloves to prepare a grilled sandwich. At 11:53 AM cook #1 used hand gel between tasks and prior to donning gloves to serve the noon meal. At no time during this observation did the cook wash his hands. During the observation it was noted there was a hand gel dispenser in the kitchen near the service window. The staff who were observed using the hand gel used this dispenser or the one on the wall just outside the entrance of the kitchen. Interview with the CDM on 7/26/18 at 8:50 AM revealed she was not aware there was a hand gel dispenser located in the kitchen, she further verified the expectation was to wash hands when they became contaminated and prior to glove use. According to Food Code (YEAR), U.S. Public Health Service 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms .(H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. According to Food Code (YEAR), U.S. Public Health Service 2-301.12 (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK .(B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water . (D) If APPROVED and capable of removing the types of soils encountered in the FOOD operations involved, an automatic handwashing facility may be used by FOOD EMPLOYEES to clean their hands or surrogate prosthetic devices.

Based on medical record review and staff interview the facility failed to ensure a transfer notice was issued to 5 of 5 sample residents with hospital transfers (#4, #34, #36, #43, #47). The findings were: 1. Review of the medical records showed resident #4 was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 2. Review of the medical record showed resident #34 was transferred to the hospital on [DATE] and 7/3/18 for acute changes of condition. In addition the resident was transferred to the hospital on [DATE] for a scheduled surgery. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 3. Review of the medical record showed resident #36 went to the hospital due to a change in condition on 3/16/18 and returned on 3/19/18. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 4. Review of the medical record showed resident #43 was transferred to the hospital on [DATE] for an acute change of condition. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative 5. Review of the medical record showed resident #47 was transferred to the hospital via the facility van on 1/18/18 and 7/17/18 for an acute change of condition. On 5/31/18 the resident was transferred to urgent care for an acute change of condition and was then transferred to the hospital and admitted to the intensive care unit. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 6. Interview on 7/25/18 at 10:03 AM with the DON and the administrator confirmed the facility did not issue a written notice of transfer with all required information to the resident or the resident's representative.

Based on review of resident council meeting minutes and resident and staff interview, the facility failed to ensure grievances from the resident council were acted upon and followed through to resolution for 3 of 3 months reviewed (May (YEAR), (MONTH) (YEAR), (MONTH) (YEAR)). The findings were: 1. Review of the resident council meeting minutes for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) showed concerns were discussed related to call light response times. The following concerns were identified: a. Interview with 9 residents on 7/24/18 at 11 AM revealed there had been no response from the facility in regard to the grievance made about call lights in both (MONTH) (YEAR) and (MONTH) (YEAR). b. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) resident council minutes section Old Business showed no reference to the concern about call lights. c. Interview with the life enrichment coordinator on 7/24/18 at 2:26 PM revealed concerns brought up at council meetings were converted to individual resident grievances and then assigned to the appropriate department head. Further, she verified she did not discuss the resolution of the concerns with the resident council because she thought they were handled individually.

Based on medical record review, and staff interview, the facility failed to ensure the care plan was revised as needed for 1 of 13 sample residents (#155). The findings were: 1. Review of a nurse's note dated 7/11/18 and timed 6:02 PM showed resident #155 was being transferred from urgent care to the hospital for septic shock to Right Upper Lobe. The resident was readmitted to the facility on [DATE]. The following concerns were identified: a. Review of a nurse's note dated 7/19/18 and timed 12:49 PM showed the resident has been observed to have difficulty swallowing and it was reported to this RN by occupational therapist that resident has been coughing when (s/he) drinks water . The physician was notified and an order was requested for the resident to have nectar thick liquids. b. Review of a physician communication form dated 7/19/18 showed Resident has been observed to have difficulty swallowing and has been coughing when (s/he) drinks water. We do not have in-house speech therapy until the end of next week. Could we have an order for [REDACTED]. The physician agreed with the request and the order was noted by the DON. c. Review of a Diet order and Communication form dated 7/19/18 showed the resident's diet had been changed to nectar-like thickened liquids. d. Review of the nutrition care plan revised on 7/25/18 (6 days after liquids had been downgraded) showed the resident was to have a regular diet, regular texture, and nectar thick liquid consistency. 2. Interview on 7/26/18 at 9:34 AM with the DON confirmed the care plan had not been revised until 7/25/18.

Based on medical record review, staff interview, and review of medication error reports, the facility failed to provide necessary services for 1 of 8 sample residents (#1) who were on anticoagulants. This failure resulted in a missed laboratory test for resident #1, who subsequently experienced signs of internal bleeding. The findings were: Review of the 11/17/17 admission Minimum Data Set assessment showed resident #1 had [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of telephone orders showed on 11/25/17 the physician ordered [MEDICATION NAME] (antibiotic) 100 mg twice per day for 7 days for a urinary tract infection [MEDICAL CONDITION]. At the same time (11/25/17) the physician ordered INR one time only for [MEDICATION NAME] for 1 Day. The order had a start date of 11/28/17. The following concerns were identified: a. Review of the medical record showed no evidence the INR was done. During an interview on 3/13/18 at 8:46 AM the administrator stated the INR was not done on this resident on 11/28/18 as scheduled because the nurse performed the lab draw on the wrong resident. Review of a medication error report dated 11/29/17 showed the INR lab draw was not done for this resident because it was done on the wrong resident. b. Review of nursing notes showed on 11/27/17 the physician was sent culture results and wrote a new order [MEDICATION NAME] mg twice per day for 7 days because the bacteria causing the UTI was not susceptible to [MEDICATION NAME]. Review of progress notes showed on 11/27/17 an alert/warning was entered for possible drug to drug interactions related to the Cipro. There was a possible interaction with [MEDICATION NAME] sodium. The alert read [MEDICATION NAME] effects of [MEDICATION NAME] Sodium Tablet 2 mg may be increased [MEDICATION NAME] 250 mg. Dosage reduction of [MEDICATION NAME] Sodium tablet 2 mg may be required. Review of a fax showed the pharmacist alerted the physician on 11/27/17 of the possible interaction. c. Review of nursing notes dated 11/29/17 and timed 3:09 AM showed the resident had black tarry stools x 2 this shift with small amount of bright red blood. d. Review of a nursing note dated 11/29/17 and timed 3:52 PM showed observed resident this morning .noted to have increased, new bruises to bilateral hands and arms .was reported for dark tarry stools .Dr (name of physician) faxed requesting INR as next one not scheduled until 12/6 .printed out fax with ok to obtain INR and also get Guiac on next stool .lab assistant from (medical clinic) came to draw labs and CNA went to retrieve resident from dining room .immediately returned and reported that he would not open (his/her) eyes .resident removed from dining room .listened for heart beat, checked for radial pulse and breath sounds. Absence of vital signs at 8:17 AM. e. During an interview on 3/13/18 at 11:35 AM, physician #1 (the resident's physician) stated she was told by the facility that the INR lab draw scheduled for 11/28/17 had not been done. She confirmed that there was a potential interaction [MEDICATION NAME], and stated she usually would check the INR after a day or two on the Cipro. She stated she was not sure what the cause of death was and stated it did not appear that an INR was done after the resident's death.

Based on medical record review, staff interview, review of the facility incident log, and policy and procedure review, the facility failed to investigate and report allegations of abuse for 1 of 9 allegations (resident #54) reviewed. The failure resulted in an immediate jeopardy situation related to a possible perpetrator having further access to at-risk adults. The census was 53. The findings were: 1. Review of a social services note for resident #54 dated 6/20/17 and timed 2:22 PM showed Given behaviors exhibited by (resident's name) during the day, including threatening staff, telling therapy that people were trying to rape (him/her) within the facility, and stating that people were stealing (his/her) money . Further, the note indicated the facility contacted the regional ombudsman for information about how to handle the situation and Project Out to discuss potential discharge plans. 2. Review of a social services note for resident #54 dated 6/20/17 and timed 5:14 PM showed the resident had a BIMS score of 12/15 (moderately impaired) and a depression score of 3/27 (minimal). Further, the note showed (s/he) spoke about the people in the hallways peaking in (his/her) room and gossiping about (him/her) .(s/he) said people out there keep trying to come in (his/her) room and touch (him/her) and do inappropriate things with (him/her) . 3. Interview with the DON on 7/11/17 at 2:05 PM revealed all allegations of abuse or neglect should be reported to the charge nurse, and then the DON and administrator to ensure the resident is safe and to keep the alleged perpetrator away from the resident and the facility. The nurse would then investigate by assessing the resident for signs of injury and the facility cameras would be reviewed to attempt to identify the perpetrator. Further, it was revealed even if a resident had a cognitive deficit, the incident is still investigated and all theft, resident-to-resident altercations, and physical abuse should be reported to local law enforcement. The DON was not aware of any allegations during the previous 3 months. 4. Review of the facility's incident log between 7/10/16 and 7/10/17 showed no evidence the facility had identified, investigated, or reported an allegation of abuse for resident #54. 5. Interview with the DON and administrator on 7/11/17 at 3:53 PM revealed social services was part of the facility's abuse investigation protocol, and none of the allegations recorded in the 6/20/17 social service notes were investigated. Further, it was revealed the administrator became aware of the allegations on July 5th or 6th and the DON became aware on July 10th; however, no investigation was initiated at that time. The resident discharged from the facility on 7/8/17. 6. Review of the policy and procedure titled Abuse and Neglect Prevention Standard last revised on 3/2017 showed .IV. Identification: A, All team members will be observant for any resident or team members' conditions that might be indicative or predictive of potential abuse and/or neglect, such as suspicious bruising, withdrawn behaviors, stress, change in behaviors, etc. All observations of suspected abuse should be immediately reported to your supervisor or the facility administrator. If a crime is suspected, the Elder Justice Act requires all individuals to report .V. Investigation A. All allegations of abuse and/or neglect will be investigated and reported in accordance with the state and federal laws. B. In the situation of an allegation of abuse, the following people will be notified immediately: Administrator, DON, and Social Services .VII. Reporting/Response Reporting must be made to the Administrator or Designee and other officials (including State Survey Agency and/or APS where state law provides for jurisdiction in LTC facilities) in accordance with state law through established procedures. Follow the state's specific reporting guidelines and requirements. Any alleged physical, mental, verbal or sexual abuse; mistreatment, neglect, misappropriation of resident's property, (Property includes medications), exploitation, or involuntary seclusion of a resident by a team member is to be reported to the proper authorities . 7. On 7/11/17 at 5:05 PM the administrator and DON were notified of the immediate jeopardy situation that had the potential to affect all residents because the facility had failed to investigate and report an allegation of abuse. The facility's action plan included the following corrective actions: a. An investigation of the allegations of abuse was initiated on 7/11/17. b. All interviewable residents, and family members of residents who were not interviewable were contacted to identify any other allegations of abuse. c. All allegations will be investigated and reported per the facility policy. d. All team members will be educated on the Abuse and Neglect Prevention Standard prior to returning work. e. All newly hired team members are trained on hire and prior to contact with residents. 8. The facility action plan was accepted on 7/12/17 at 4:35 PM, and the immediate jeopardy was removed on 7/12/17 at 7:32 PM. However, deficient practice remained at a scope and severity of F (widespread potential for harm that is not immediate jeopardy).

Based on medical record review, and family and staff interview, the facility failed to identify and implement nutritional interventions to prevent weight loss for 1 of 3 sample residents (#22) with significant weight loss. This failure resulted in a 24% weight loss in 29 days for resident #22. The findings were: 1. Review of the 5/20/17 admission MDS assessment showed resident #22 had [DIAGNOSES REDACTED]. The resident's BIMS score was 3 (severely impaired), and s/he required limited assistance of 1 person for eating. The resident had a weight of 137 pounds. Review of Weights and Vitals Summary showed a 5/14/17 weight of 135.2 pounds. The following concerns were identified: a. Review of the care plan showed no evidence a nutritional care plan was developed or implemented. b. Review of a nursing note dated 5/15/17 and timed 1:56 AM showed .Remained in room this evening for dinner by request due to being tired from the move. Able to take medications whole without difficulty . c. Review of a Nutrition/Dietary note dated 5/16/17 and timed 9:29 AM showed the resident's diet was regular and the registered dietician (RD) recommended a change to limited concentrated sweets (LCS) related to the diabetes [DIAGNOSES REDACTED]. Further, the documented weight at that time was 135 pounds. d. Review of Weights and Vitals Summary showed a 5/17/17 weight of 137 pounds and a 5/21/17 weight of 124.5 pounds (12.5 pounds or 9.1% weight loss in 4 days). e. Interview with the registered dietician on 7/14/17 at 11:26 AM revealed she did not believe she was notified of a significant weight loss in the week after the resident was admitted . Further, she stated she would have been concerned about a 12.5 pound weight loss in 4 days. f. Review of Weights and Vitals Summary showed a 5/24/17 weight of 121 pounds, a 5/28/17 weight of 117.5 pounds, and a 5/31/17 weight of 116 pounds (21 pounds or 15.3% weight loss in 14 days). There was no evidence the facility implemented interventions to prevent further weight loss. g. Review of the nursing note dated 6/2/17 and timed 6:23 PM showed .Family also wanted to know how much resident had been eating; this RN reported that intake had been between 25-75 percent for most meals, though (s/he) occasionally refuse (sic) a meal. h. Review of a Nutrition/Dietary note dated 6/7/17 and timed 1:33 PM showed IDT (interdisciplinary team) review of weight. Resident continues to have poor po (by mouth) intake. Resident may have acute illness. New order for UA obtained. taking supplements. Will continue to observe weekly. i. Review of the June 2017 MAR indicated [REDACTED] j. Review of Weights and Vitals Summary showed a 6/7/17 weight of 117.5 pounds, a 6/11/17 weight of 106 pounds (11.5 pound or 9.7% weight loss from previous weight 4 days prior), and 6/14/17 weight of 104 pounds (33 pound or 24% weight loss in 29 days). k. Review of a nursing note dated 6/16/17 and timed 10:53 AM showed .Spoke with ST (speech therapist) r/t (related to) resident having possible stricture, will fax MD again for response/orders. l. Interview with the DON and dietary manager on 7/13/17 at 5:05 PM confirmed the resident's nutrition care plan was not developed. It was revealed a care plan should have been developed related to the resident's identified weight loss and need for interventions. The DON further revealed the resident had nausea, vomiting, and other acute illness they believed to contribute to the weight loss. m. Review of the Medication Administration Record [REDACTED]. n. Review of the Medication Administration Record [REDACTED]. o. Interview with the resident's family members on 7/13/17 at 8:20 PM revealed the family felt the resident's stay wasn't going well because the resident continued to decline. The family stated the resident did not have issues with eating prior to admitting to the facility. The family revealed the resident never ate healthy, has always eaten small portions, and ate better when s/he was offered sweets. Further, the family felt pressured to have the esophagram performed; however, they felt the resident would not want the procedure completed and they declined to have it performed.

Based on observation, medical record review, staff and resident interview, and policy and procedure review, the facility failed to implement interventions to promote healing and prevent avoidable worsening of pressure ulcers for 1 of 5 sample residents (#28) with pressure ulcers. This failure resulted in actual harm for resident #28 whose pressure ulcer worsened. The findings were: 1. Review of the 6/22/15 quarterly MDS assessment showed the resident required extensive assistance of two or more persons for ADL's (activities of daily living) including transfers, dressing, and toilet use, and was totally dependent on assistance from two or more persons for bed mobility. Further, the assessment showed the resident had a stage 4 pressure ulcer that measured 2 cm by 1.8 cm by 2.7 cm. Review of weekly pressure ulcer records showed a stage 4 pressure ulcer, located on the right gluteal fold, was identified on 1/28/15. On 6/26/15 the ulcer measured 1.5 cm by 0.6 cm by 1.5 cm and had tunneling at the one o'clock positioning that measured 2.8 cm. Further review showed there was also undermining noted at the eleven to twelve o'clock position that measured 1.3 cm. Review of the resident's care plan for pressure ulcer, initiated on 3/2/15, showed the resident had a [DEVICE] applied on 5/6/15 and was to be repositioned every 2 hours. Review of the indwelling catheter care plan, reviewed on 6/24/15, indicated the reason for use was a stage 4 pressure ulcer to the right ischial tuberosity. a. Observation of the resident on 7/7/15 at 9 AM showed the resident was sitting in his/her wheelchair eating breakfast. Continued observation on that date showed the resident remained sitting in the wheelchair reading a book at 11:04 AM. Further observation showed the resident sat in the wheelchair eating lunch at 12:30 PM. b. Observation of wound care on 7/8/15 at 3:30 PM revealed the resident had a stage IV pressure sore with tunneling on the right gluteal fold. c. Interview with the resident on 7/7/15 at 11:04 AM revealed the resident required staff to reposition him/her in the wheelchair and reading helps to distract him/her from being uncomfortable. Further interview at that time revealed staff had not repositioned or offloaded the resident. d. Review of 7/3/15 weekly pressure ulcer record showed the stage 4 to the right gluteal fold measured 1.4 cm by 1.0 cm by 2.0 cm with tunneling at the twelve o'clock position that measured 2.3 cm. Further review showed specialty interventions included specialty bed, wheelchair cushion, positioning devices, and to reposition often. e. Review of the policy Pressure Ulcer Risk Assessment revised 6/2015 showed .c) Repositioning.Note: Repositioning should occur during rounds which are expected approximately every two hours. Note: Residents in a wheelchair should be repositioned or weight shifted approximately every hour. f. Interview with the SCD on 7/9/15 at 11 AM confirmed that residents should be repositioned every two hours while in bed, every 45 minutes while in a wheelchair, and resident #28 should be assisted by staff to reposition.

Based on observation, resident and staff interviews, and medical record review, the facility failed to ensure 1 of 5 sample residents (#24) with urinary incontinence received the necessary care and treatment to restore bladder function. This failure resulted in avoidable psychosocial harm for the resident. In addition, the facility failed to ensure 1 of 2 sample residents (#28) with a urinary catheter received appropriate catheter care. The findings were: 1. On 5/10/11 an unidentified housekeeper was observed donning personal protective equipment at 8:40 AM prior to entering the room of resident #24. When questioned, the housekeeper stated she was going to wash the resident's bed as the resident had been incontinent of urine. Observation at 8:50 AM that morning showed the resident's bed had been stripped and was still damp; the resident was sitting in a wheelchair and stated the bed needed to be washed and changed as s/he had been incontinent of urine and it "went through again." The resident further stated, the urge to urinate "...sneaks up real fast. I'm like a big baby. You wouldn't think a (man/woman) my age would wet the bed." Review of the medical record showed a comprehensive assessment for bladder incontinence had not been completed. Refer to F272 for details. Review of the care plan showed no individualized care plan for toileting that would promote continence and enhance the resident's self esteem. With additional observation, interviews, and medical record review, indicators of psychosocial outcome related to incontinence were identified. According to the medical record, the resident was admitted on [DATE] for rehabilitation and wound care after falling at home. Further review showed the resident's indwelling urinary catheter was discontinued on 4/6/11 so therapy could work on increasing the resident's mobility. However, the resident's wound became infected, surgical debridement was required, and s/he returned to the facility on [DATE] with a [DEVICE]. Although the incontinence assessments were incomplete, review showed the facility developed an incontinence care plan. Per that plan, staff were to assist with toileting by "pivot c (with) assist" and "assist me with toileting by providing pericare and incontinence product as needed." Even though the resident was not on a weight reduction plan, review of the resident's weight showed a loss of 7.5 pounds since admission. Review of the life enhancement (activity) care plan showed staff were to do one-to-one visits, the resident would work on word search and read books/newspaper, and pet therapy would be encouraged during pet visits. These were all individual activities that did not assist the resident in becoming more "socially active," a desire expressed by the resident and documented by social services in the 3/8/11 discharge plan. Observation throughout the survey showed the resident's room was dark with the dividing and entrance curtains partially pulled, but no individual activities occurred. Interview with the resident on 5/10/11 at 9:30 AM, revealed it frequently took twenty minutes for staff to answer lights, especially at night and during meals. The resident stated that because of the wait, "I pee the bed." S/he reiterated that it made him/her feel "...like a baby" as "can't hold it (urine)." Additionally, the resident stated, that due to a fear of falling, s/he wanted staff present before trying to get out of bed and that the lack of independence was frustrating. Review of the fall care plan showed staff were to remind the resident to ask for assistance with all ambulation and provide stand-by assistance with ambulation. At 9:45 AM OT #1 entered the room and tried to get the resident to attend therapy. The resident refused at first because s/he was "...afraid to walk..." as "...will pee my clothes." During this interaction, the resident told the therapist s/he wanted "to be six feet under." The following concerns were identified: a. Although indicators of psychosocial outcome were present (weight loss, decreased social interaction and inability to leave the room without assistance, loss of interest in previous activities, indicators of depression and frustration), the facility failed to identify and address them. b. The facility failed to develop and implement an individualized toileting care plan that would enhance the resident's self esteem. c. Refer to F272 for details related to incomplete bowel and bladder assessments for this resident. d. Refer to F248 for detailed information related to lack of a life enhancement plan for this resident. e. Refer to F250 for information related to failure to address medically related social service issues for this resident. 2. Observation of staff providing care for resident #28 on 5/9/11 at 5:05 PM showed the resident had an indwelling urinary catheter. During the observation, CNAs #5 and #6 attached the catheter drainage bag to the mechanical lift while transferring the resident from the bed to the wheelchair. Continuous observation revealed the attached catheter bag was positioned at the level of the resident's head during the transfer, and urine drained back toward his/her bladder. Interview on 5/11/11 at 1:45 PM with the DON confirmed this was not an acceptable standard of practice for catheter care.

Based on observation, family and staff interview, medical record review and review of policies and procedures, the facility failed to ensure 3 of 7 sample residents (#24, #28, #48) assessed as being at risk for developing pressure ulcers received the necessary treatment and services to prevent the development of pressure ulcers. This failure resulted in avoidable harm to resident #28. The findings were: According to the policy and procedure entitled "Skin and Wound Management", revised October 2010, once risk has been identified, staff should initiate appropriate preventative measures to ensure minimizing the risk of pressure ulcer development. The preventive measures included the following: (1) Residents should be placed on a pressure reduction sleep surface. If the level of risk is higher, a more specialized mattress may be necessary. (2) Residents should be repositioned every hour while up in a chair. Consider limiting high risk resident's time in one position, such as in wheelchair. (3) Registered dietitians and rehab should be involved as indicated. (4) Residents with moisture issues should have an appropriate plan to keep moisture minimized. 1. Review of the medical record for resident #28 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. At the time of admission, hospice care was initiated due to decline in functional ability; oxygen via nasal cannula was needed to maintain oxygen saturation rates greater than ninety percent; extensive assistance with a walker was needed for toileting; and daily doses of [MEDICATION NAME] and multivitamins were included in the medication regime. Further review revealed the only open skin area that the resident had, at that time, was an "ulcerated" toe on the left foot. Review of the 12/28/10 admission MDS assessment and CAT showed the resident was assessed as being at risk for developing pressure ulcers due to the following risk factors: occasional bladder incontinence related to the need for extensive assist with transfers and pain; the resident required assistance when turning around and walking with an assistive device, existing pressure ulcer, immobility, cognitive loss, anxiety medications, diabetes, pain, chronic/[MEDICAL CONDITION], liver disease, [MEDICAL CONDITION], depression, and devices that can cause pressure such as oxygen. The CAA analysis of findings revealed, "resident was admitted with a pressure ulcer and has the potential for further breakdown related to [DIAGNOSES REDACTED]. ... will care plan skin care, pressure ulcer treatment and prevention of further breakdown." Review of the 3/22/11 quarterly MDS assessment showed the resident did not have diabetic ulcers, open [MEDICAL CONDITION] or rashes, but continued to be at risk for developing pressure ulcers due to the following: The resident had a urinary catheter, but wore disposal briefs due to episodes of bowel incontinence. The functional status for balance during transition and walking declined to "walking with an assistive device did not occur." The active [DIAGNOSES REDACTED]. Review of the 12/29/10 and 1/12/11 Braden Scale for predicting pressure sore risk showed limited or impaired sensory perception, occasionally moist skin, severely limited ability to walk, very limited ability to make changes in position, adequate nutrition and moving required moderate to maximum assistance. With the exception of skin being rarely moist, review of the 3/22/11 Braden Scale showed the same risks that were identified on 12/29/10 and 1/12/11. Review of the plan of care revealed a bowel program, the interval for position changes while up in the wheelchair, possible moisture in abdominal folds and other areas of the body, issues regarding the resident's refusals, and protecting the resident from pressure related to oxygen and catheter tubings were not addressed. Concerns identified by family were revealed during an interview on 5/10/11 at 12:15 PM. At that time the family member stated the resident was able to use a walker with assistance when s/he was admitted ; however, in the past month family members had noted the increased amount of time the resident remained in bed. The family member also stated s/he and other family members had observed the resident refusing to get up, eat or do anything; and staff responded by not doing it instead of providing the additional encouragement that was needed. The family concerns were verified during the following staff interviews: Interviews with CNAs #2 and #5 on 5/9/11 at 6:59 PM revealed the resident used a walker with staff assistance when admitted , but had not been able to do that in the past three months. The CNAs also stated the resident spent more time in bed than s/he did in past months, but they were unable to identify changes in interventions that occurred as a result of the resident's declining mobility. Interview with CNAs #1 and #3 on 5/12/11 at 10 AM revealed the resident frequently refused to eat and/or get out of bed. Both stated sometimes they were able to encourage the resident and sometimes they had to just leave him/her alone. They also stated they were aware of the decline in the resident's condition. Concerns regarding the facility's failure to address treatment orders, and the need for an appropriate pressure relieving mattress and nutrition assessment in a timely manner were identified as follows: Review of the 4/29/11 interdisciplinary progress notes showed, "decubitus ulcer discovered to resident's gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum) 2 centimeters (cm) x 1 cm appears to be stage II." According to the April 2011 treatment administration record, treatment for [REDACTED]. At that time the treatment was clean with SEA-CLENS, apply [MEDICATION NAME] ointment and cover with gauze, [MEDICATION NAME] or coversite every four days and prn. Review of the 5/3/11 physician's orders [REDACTED]. Review of the interdisciplinary progress note showed the resident was placed on an air mattress on 5/2/11, three days after s/he developed the pressure ulcer. On 5/11/11, the surveyor asked whether a nutritional assessment had been completed by a registered dietitian that addressed nutritional needs related to the newly developed pressure ulcers, but the facility was unable to provide evidence of this. Continuous observation on 5/9/11 from 5:05 PM to 7:05 PM, and again on 5/10/11 from 8 AM until 10:30 AM revealed the resident sat in the wheelchair without repositioning. Observation on 5/9/11 at 7:05 PM revealed CNA #2 and #5 removed the resident's disposal brief and provided peri-rectal cleansing due to fecal incontinence. Observation of RN #1 and the DON providing pressure ulcer care for the resident on 5/10/11 at 12:18 PM revealed the resident had a larger pressure ulcer on the gluteal cleft that had a necrotic center and a smaller reddened stage II pressure ulcer on the right buttocks. A dime size stage I area of redness was located directly above the stage II pressure ulcer. Review of Skin and Wound Management policy and procedure showed the following documentation should be recorded in the resident's medical record: date and time the dressing was changed, the type of dressing used and care given, pressure ulcer appearance, and all assessment data obtained when inspecting the pressure ulcer (i.e. wound bed color, size, drainage, etc.). Concerns identified regarding the failure to follow the aforementioned policy and procedures were as follows: Review of the 5/3/11 documentation in the pressure ulcer record showed the resident had one stage II pressure ulcer on the "coccyx" that measured 8 cm x 6 cm with a red wound bed and serosanguineous drainage. However, according to the documentation on the 5/4/11 wound measurement chart, there were three pressure ulcers on the coccyx area: one 2.2 cm by 2.8 cm on the gluteal cleft with 80% slough, one 1.8 cm by 1.5 cm, and one 1 cm by .5 cm. Review of the PT note, dated 5/4/11, showed the therapist changed the dressing; however, additional documentation regarding the appearance of the pressure ulcers was lacking. The 5/6/11 PT documentation showed "removal of devitalized tissue from sacral wound through [MEDICATION NAME] debridement to promote wound healing. Wound measurements not taken with 90% slough in main wound and granulation in other two close sights." The documentation in the 5/11/11 wound measurement chart showed two pressure ulcers were on the coccyx area: one 9.3 cm x 6.3 cm x 0.3 cm on the gluteal cleft and a second area close by that wasn't measured or described. The documenting did not mention the third area that was identified on 5/4/11. Review of the physician's progress note dated 5/10/11 showed the following documentation: "stage III decub gluteal cleft - discussed with hospice, nursing and PT - will change dressing to santyl [MEDICATION NAME], 4 x 4 and coversite. Needs close attention." Review of the physician's orders [REDACTED]." Interview with the DON on 5/12/11 at 8:30 AM revealed she was unable to provide evidence that the facility had a system for ensuring comprehensive preventive measures were consistently implemented as early as possible for residents who were identified at risk for developing pressure ulcers. 2. According to the medical record, resident #24 was admitted to the facility on [DATE] with pressure ulcers on the left lower buttock and left medial ankle. The orders instructed that physical therapy (PT) was to provide wound care for both ulcers with Santyl ointment as necessary per PT recommendation. Further review showed the resident was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the readmission orders [REDACTED]. This was the only instruction included for ulcer care. Observation on 5/9/11 at 4:45 PM showed neither PT #1 nor LPN #1 provided wound care for the ulcer on the resident's ankle. Review of PT's wound information showed no documentation the dressing on the ankle had been changed since 5/4/11. However, in interview on 5/10/11 at 9:30 AM, the resident stated the dressing on his/her ankle was last changed on 5/6/11. The following deficient practice was identified: a. The resident's readmission orders [REDACTED]. Refer to F325 for information regarding nutrition. Interview with the DON on 5/11/11 at 3:10 PM revealed new orders were required any time a resident was out of the facility longer than 24 hours. At that time, the DON reviewed the readmission orders [REDACTED]. b. According to available PT documentation, therapy last changed the dressing and treated the resident's ankle ulcer on 5/4/11; there was no documentation indicating who changed the dressing on 5/6/11. On 5/4/11 therapy performed [MEDICATION NAME] debridement and documented "wound measures not taken today with good granulation of wound bed." The treatment after debridement was "...santyl, alginate and 3X3 [MEDICATION NAME] border light dressing." Prior to this date, the last documented measurements were recorded by nursing on 4/20/11. At that time the facility's description was of a "stage 3" pressure ulcer measuring 1.1 cm long by 1.2 cm wide by 0.5 cm deep with a small amount of serosanguinous drainage, and a normal wound bed. There was no indication of eschar (brown, black, or grey dead tissue on a wound) in this description, or in previous descriptions. Measurements and descriptions were not documented on the records dated 4/29/11 or 5/4/11. c. On 5/11/11 at 5 PM PT #1 stated he had forgotten about the ankle ulcer on 5/9/11. He removed the old dressing on the resident's left medial ankle, and observation showed it was dated as placed on 5/6/11. The ulcer had not been evaluated or treated during the past five days. Per the therapist, the ulcer measured 1.5 centimeters (cm) in diameter. Continued observation showed black eschar approximately 1 cm wide around the edges with red, puffy looking tissue in the middle. Without using any cleansing agent, the therapist scrubbed the wound with dry gauze, placed a new dry gauze 2 X 2 pad over it, and wrapped the resident's foot with Kerlix (stretchy gauze). Refer to F441 for details regarding lack of aseptic (clean) technique during this procedure. d. Review of all available information completed by therapy revealed no documentation related to this ulcer after 5/4/11. Further, there was no evidence the physician was notified of the worsened appearance of the ulcer or approved the treatment provided by therapy. 3. According to the 4/25/11 admission MDS assessment and CAA for resident #48, the resident did not have pressure ulcers, but s/he was assessed as being at risk for developing pressure ulcers due to decline in mobility and use of oxygen. Review of the care plan showed interventions for preventive skin care included pressure relieving device in wheelchair and bed. Periodic observations on 5/9/11 - 5/12/11 revealed the resident sat in the wheelchair without a pressure relieving device. Interview with the DON on 5/12/11 at 8:30 AM revealed the resident should have a pressure relieving device and she did not know why staff had not placed one in the resident's wheelchair.