Every finding on record at Wood Village

Based on review of medical record, and interviews, the facility failed to notify the Long-Term Care (LTC) District State Ombudsman of resident discharges and transfers from the facility for 5 residents (Resident #76, Resident #38, Resident #83, Resident #86, and Resident #75) of 5 residents reviewed for discharges and transfers which had occurred during the past 6 out of 6 months reviewed.The findings include:1. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Peripheral Vascular Disease. Further review revealed the resident discharged from the facility on 3/12/2026. Review of a Discharge Summary progress note for Resident #76 dated 3/12/2026, revealed .Resident discharged completed .Discharge instructions given .Transferred by family via personal vehicle .Review of a discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed the discharge for Resident #76 was planned. 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease Stage 3, Myocardial Injury, and Muscle Weakness. Review of a Nurses Note for Resident #38 dated 4/20/2026, revealed .Resident not eating well .has had nausea/vomiting .Resident asked to go to the hospital .Family at bedside and in agreement .Report called to ER [Emergency Room] and .County dispatch contacted for transport .left with resident at 12:00 pm [PM] .Review of a discharge return anticipated MDS assessment dated [DATE], revealed the discharge for Resident #38 was unplanned. 3. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Heart Failure, Myocardial Injury, and Muscle Weakness. Further review revealed the resident discharged from the facility on 4/16/2026. Review of a Health Status Note for Resident #83 dated 2/19/2026, revealed .EMS [Emergency Medical Services] here to transport resident to hospital .Review of a discharge return anticipated MDS assessment dated [DATE], revealed the discharge for Resident #83 was unplanned.Review of a Health Status Note for Resident #83 dated 4/16/2026, revealed .discharged home with family .Review of a discharge return not anticipated MDS assessment dated [DATE], revealed the discharge for Resident #83 was planned.4. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, and Muscle Weakness. Further review revealed the resident discharged from the facility on 4/13/2026.Review of a Transfer to Hospital Summary progress note for Resident #86 dated 3/8/2026, revealed .Upon family request .resident was sent to .hospital to eval [evaluate] and treat .Review of a discharge return anticipated MDS assessment dated [DATE], revealed the discharge for Resident #86 was unplanned.Review of a Nurses Note for Resident #86 dated 4/13/2026, revealed .discharged home .Left with family .Review of a discharge return not anticipated MDS assessment dated [DATE], revealed the discharge for Resident #86 was planned.Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Cerebral Infarction and Chronic Congestive Heart Failure.5. Review of a Health Status Note for Resident #75 dated 2/8/2026, revealed .EMS .Transferring to .Medical Center for evaluation and treatment .Review of a discharge return anticipated MDS assessment dated [DATE], revealed the discharge for Resident #75 was unplanned.Review of a Nurses Note for Resident #75 dated 4/18/2026, revealed .[Resident #75] stating that his chest was hurting .[Resident #75] requesting to be sent to [Named Medical Center] .EMS called .Review of a discharge return anticipated MDS assessment dated [DATE], revealed the discharge for Resident #75 was unplanned.During an interview on 6/2/2026 at 3:06 PM, the Social Services Director (SSD) stated he was not responsible for notifying the LTC District State Ombudsman of resident discharges and transfers and he was not aware of which staff member was responsible for notifying the LTC District Sate Ombudsman of resident discharges and transfers.During a telephone interview on 6/2/2026 at 4:11 PM, the LTC District State Ombudsman confirmed the facility had not provided notification of resident discharges and transfers to the LTC District State Ombudsman office. The LTC District State Ombudsman further stated he was in the process of sending an email to the facility administrator which contained information regarding education and his expectation of the regulation regarding the facility notifying the LTC District State Ombudsman of resident discharges and transfers. During an interview on 6/2/2026 at 4:20 PM, the Administrator confirmed the facility had not routinely notified the LTC District State Ombudsman of resident discharges and transfers.

Based on facility policy review, observations, and interviews, the facility failed to provide podiatry services for 1 resident (Resident #18) of 3 residents reviewed for podiatry services. The findings include:Review of the facility's policy titled, Nail and Foot Care, dated 3/2018, revealed .Residents will receive appropriate care and treatment in order to maintain mobility .and foot health .in accordance with professional standards of practice .Residents will be assisted in making transportation appointments to and from .any .foot specialists .trained staff may provide routine .foot care .for residents without complicating disease processes .Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals .Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Fracture of Right Femur, and Myocardial Infarction.Review of the comprehensive care plan for Resident #18 dated 11/21/2025, revealed a self-care deficit care plan to include .Provide nail care PRN [as needed], keep nails clean and trimmed, podiatry consult PRN .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #18 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident required substantial assistance with personal hygiene.Review of weekly skin assessments dated 3/4/2026-4/18/2026, revealed the resident had foot evaluations completed. Further review revealed Resident #18's skin and foot assessments had not been completed after 4/18/2026 (6 weeks since last skin and foot assessment).Review of the Podiatry schedule for 4/26/2026 and 5/12/2026, revealed Resident #18 had not received podiatry services. Further review revealed the podiatry schedule was not available for 3/2026.During an observation and interview on 6/2/2026 at 8:10 AM, Licensed Practical Nurse (LPN) A observed the length of Resident #18's toenails and stated the resident's toenails were long, thick, yellow, and jagged. LPN A confirmed the resident had not had his toenails clipped or trimmed and stated the Certified Nursing Assistants (CNA) provide all nail care on shower days and as needed. LPN A confirmed nail and foot care had not been provided for Resident #18. During an observation and interview on 6/2/2026 at 8:24 AM, in Resident #18's room, with the resident's permission, CNA A lifted the bedsheets uncovering the resident's feet revealing thick, yellow, jagged, and overgrown toenails. CNA A and CNA D observed the resident's toenails and stated the toenails were long and thick and the resident needed foot care. CNA A and CNA D stated nail care was provided on shower days and as needed. The CNA's stated the nurse provides nail care and/or clipped or trimmed the nails and refers to podiatry services if the service cannot be provided by the nurse. During an interview on 6/2/2026 at 2:00 PM, the Social Service Director (SSD) stated podiatry services were provided approximately every 2 months. The SSD stated he received requests from the nursing staff and families for podiatry services then arranged facility visits with an outside vendor. During an observation and interview on 6/3/2026 at 9:12 AM, Licensed Practical Nurse (LPN) Unit Manager (UM) observed Resident #18's toenails. The UM confirmed the resident's toenails were thick, jagged, and overgrown. The UM confirmed the resident was not referred to podiatry. The UM stated she was notified by nursing staff if a resident required podiatry services and if the resident was not a diabetic the CNAs clipped the nails. Further interview revealed the UM was unable to remember if she had been notified of the resident's need for podiatry services. During an interview on 6/3/2026 at 2:20 PM, the SSD stated he had not been made aware Resident #18 needed podiatry services and confirmed Resident #18 was not added to the 4/2026 or 5/2026 podiatry list. During an interview on 6/3/2026 at 2:56 PM, the Director of Nursing (DON) stated her expectation was for the resident's toenails to be clipped, trimmed, and cleaned by nursing staff or for podiatry services to be provided to residents.

Based on facility policy review, observation, and interview, the facility failed to ensure expired medications were discarded in 2 of 2 medication storage rooms observed. The findings include: Review of the facility's policy titled, Storage of Medications, revised 4/2019, revealed, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . During an observation and interview with Licensed Practical Nurse (LPN) A, on 5/21/2025 at 8:15 AM, of the South Hall (300 Hall) medication room located behind the 300 Hall nurses' station, revealed an opened bottle of Cranberry tablets sitting on the shelf with an open date of 6/28/2024 and available for use. Continued observation revealed an expiration date of 4/2025. LPN A confirmed the opened bottle of Cranberry tablets was expired and available for resident use and stated the bottle should have been discarded after 4/2025. During an interview on 5/21/2025 at 8:20 AM, the Director of Nursing (DON) confirmed the opened bottle of Cranberry tablets was expired and stated that the bottle of Cranberry tablets should have been discarded after 4/2025. During an observation and interview with LPN A, on 5/21/2025 at 8:25 AM, of the refrigerator located in the Main medication room located across from the central nurses' station, revealed an opened bottle of Magic Mouthwash labeled, .Do Not Use after 4/16/2025 at 6:05 PM . LPN A stated, .I'm pretty sure this has been dc'd (discontinued) . and confirmed the opened bottle of Magic Mouthwash medication should have been discarded after 4/16/2025 at 6:05 PM. During an interview on 5/21/2025 at 8:30 AM, the DON confirmed the opened bottle of Magic Mouthwash had expired on 4/16/2025 and should have been discarded per the facility policy.

Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan for 1 resident (Resident #9) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed .The Interdisciplinary Team [IDT] .develops .a comprehensive, person-centered care plan for each resident .person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practical physical wellbeing .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect currently recognized standards of practice for problem areas . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Urinary Tract Infection. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #9 revised 4/7/2025, revealed Enhanced Barrier Precautions (EBP) was not revised on the care plan. During an observation on 5/20/2025 at 8:00 AM, Resident #9 had a Peripherally Inserted Central Catheter (PICC) (long flexible tube inserted in a vein to provide medication or fluids) in her right upper arm. Review of an Order Summary Report for Resident #9 dated 5/21/2025, revealed .Enhanced Barrier Precautions [EBP] . During an interview 5/21/2025 at 8:00 AM, the Director of Nursing (DON) stated it was the facility's expectation for the care plans to be revised when there was an order for EBP. The DON confirmed EBP was not revised on the care plan for Resident #9 after insertion of the PICC line on 4/4/2025.

Based on medical record review, observation, and interview the facility failed to monitor the use of a restraint for 1 resident (#23) of 24 residents reviewed for restraints. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive two person physical assist for transfers and bed mobility. Medical record review of the Physician Telephone orders dated 5/5/18 revealed .Move left side of bed next to wall to reduce falls from bed .Observe every 15 minutes. Reposition every 2 hours and prn . Medical record review of the Treatment orders dated 5/1/18- 5/31/18 revealed no restraint observations performed by staff as ordered from 5/5/18 to 5/22/18. Medical record review of the Informed Consent For Use of Restraint undated revealed .Recommended restraint: Left side of bed to wall .Release and reposition schedule: Observe q (every) 15 min (minute) .Elder requires assist to exit bed safely . Observation on 5/22/18 at 8:50 AM, in the resident's room, revealed the resident lying in bed with head of the bed elevated eating her breakfast. Continued observation revealed the resident's left side of bed was against the wall. Interview with Licensed Practical Nurse #2 on 5/22/18 at 9:04 AM, at the north nurses station, confirmed . Her bed to the wall is a restraint had a incident were slide out bed.We don't document restraints .we do an initial restraint assessment . Interview with Certified Nursing Assistant (CNA) #1 on 5/22/18 at 9:05 AM, at the north nurses station, confirmed CNAs were not required to observe residents restraints or document observations of restraint usage. Interview with the Director of Nursing on 5/22/18 at 1:26 PM, in the classroom, confirmed . Should have been on treatment sheet (observation of restraint every 15 minutes) .It has not been documented since 5/5/18. It is a restraint . Continued interview confirmed the facility failed to monitor Resident #23's restraint.

Based on facility policy review, observation and interview, the facility failed to perform proper hand hygiene during 1 of 3 medication administration observations. The findings included: Review of the facility policy, General Infection Control Guidelines, not dated revealed .Employees must wash their hands using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents . Observation of medication administration on 5/21/18 at 12:05 PM on the 200 Hallway with Licensed Practical Nurse (LPN) #1 revealed LPN #1 prepared medications for administration at the medication cart parked in the 200 Wing Hallway. Continued observation revealed LPN #1 entered a resident's room, gave the oral medication to the resident, prepared the nebulizer treatment, placed the mask over the resident's face and exited the resident's room without performing hand hygiene. Further observation revealed upon exiting the resident's room LPN #1 returned to the medication cart, opened the Medication Administration Record [REDACTED]. Interview with the LPN #1 on 5/21/18 at 12:15 PM, outside the resident's day room, confirmed she had not performed proper hand hygiene during medication administration.

Based on facility policy review, medical record review and interview, the facility failed to document wound measurements and the application of barrier cream to a pressure ulcer for 1 resident (#225) of 3 residents reviewed with pressure ulcers. The findings included: Review of the Facility Guideline, Wound Care Guidelines undated revealed .Measure the wound .Document measurements on appropriate wound sheet during your shift .Document the wound care given on the TAR (Treatment Record) . Review of the Facility's Wound Care Guidelines dated 9/18/14 revealed .Stage 1 .Apply Barrier Cream . Medical record review revealed Resident #225 was admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Medical record review of Resident #255's Care Plan with a problem start date of 6/20/17 and a goal target date of 6/28/18 revealed .Potential for impaired skin integrity r/t (related to) immobility and incontinence .admitted with .pink coccyx . Continued review revealed intervention .Wound care per facility guidelines and/or per MD orders .See TAR . Medical record review of Wound Measurement and Assessment Record dated 5/10/18 revealed Resident #225 was readmitted to the facility with a Stage 1 pressure ulcer on the coccyx area. Continued review revealed no measurements for Resident #255 stage 1 pressure ulcer from 5/10/18-5/21/18. Medical record review of a Physician Telephone Order dated 5/10/18 revealed an order to observe stage 1 to coccyx every day until resolved. Medical record review of the Physician Summary Orders dated 5/10/18-5/31/18 revealed .Wound Care per Protocol . Medical record review of the Treatment Record dated 5/10/18-5/31/18 revealed Observe Stage 1 to coccyx QD (everyday) until resolved . Continued review revealed no documentation of Barrier cream being applied to Resident #225's coccyx area from 5/10/18-5/21/18. Medical record review of the significant change Minimum (MDS) data set [DATE] revealed Resident #255 had a Brief Interview for Mental Status score (BIMS) of 15 indicating the resident was cognitively intact. Continued review revealed the resident had one stage 1 pressure ulcer. Observation and Interview with Registered Nurse (RN) #1 and Certified Nurse Assistant (CNA) #2 on 5/22/18 at 10:17 AM, in the resident's room, of wound care, revealed Resident #255's stage 1 pressure ulcer on the coccyx area was resolved (5/22/18). Interview with RN #1 confirmed the pressure ulcer was classified as healed and resolved on 5/22/18. Interview with the Director of Nursing on 5/22/18 at 9:17 AM, in the conference room, confirmed the facility failed to document the application of barrier cream to Resident #255's coccyx area from 5/10/18-5/21/18. Continued interview confirmed the facility failed to measure Resident #255's pressure ulcer from 5/10/18-5/21/18. Further interview confirmed the facility failed to follow their Wound Care Guidelines. Interview with the Registered Nurse (RN) #1 on 5/22/18 at 9:36 AM, in the conference room, confirmed the RN had been assigned to Resident #255 during the time period of 5/10/18-5/22/18. Continued interview confirmed the RN had not documented application of barrier cream or performed measurements of Resident #255 stage 1 pressure ulcer on the coccyx area. Further interview confirmed the facility failed to follow their Wound Care Guidelines.

Based on medical record review, facility documentation review, incident report review, and interview the facility failed to ensure all allegations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the Administrator of the facility and other officials in accordance with State Law through established procedures for 1 resident (#4) of 4 residents reviewed for abuse, of 33 sampled residents. The findings included: Medical record review revealed Resident #4 was admitted to the facilityon 2/12/16 with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating the resident was unable to complete the interview for cognition. Continued review revealed the resident had [MEDICAL CONDITION] and exhibited hallucinations and delusions. Medical record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Annual MDS dated [DATE] revealed the resident had a BIMS of 8 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 indicating the resident was moderately cognitively impaired. Review of the Complete Facility Investigation dated 7/15/17 revealed Certified Nursing Assistant (CNA) #3 noted a resident's door was closed. Continued review revealed CNA #3 and CNA #4's entered the room and observed Resident #53 in female Resident's #4 and #18's room. Continued review revealed Resident #53 backed away from Resident #4's bed when the CNAs entered the room. Further review revealed when CNA #3 asked Resident #4 if Resident #53 had touched her she stated yes and patted her private area. Continued review revealed CNA #3 asked Resident #18 what Resident #53 was doing in the room and Resident #18 informed the CNA he had tried to kiss her (Resident #4). Review of the Incident Report dated 7/17/17 revealed the alleged allegation of abuse occurred on 7/15/17 and was not received and reported to the state agency until 7/17/17. Further review revealed the state agency was not notified of the allegation of abuse until 2 days after the alleged incident.

Based on facility policy review, medical record review, and interview the facility failed to revise a care plan to include wandering behavior, for 1 resident (#53) of 33 residents reviewed. The finding Included: Review of the facility policy, Care Plan Guidelines undated revealed .The facility must develop a comprehensive Care Plan for each resident that includes measureable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified .Physician orders and the Care Plan are reviewed and updated quarterly or more frequently as orders change or as indicated . Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Care Plan dated 10/22/15 with a target goal date of 10/12/17 revealed the resident was care planned for a Cognitive deficit related to varied memory recall, comprehension and decision making due to Dementia. Continued review revealed the care plan was not updated to include the resident's wandering behavior. Medical record review of Resident #53's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS of 12 indicating the resident was moderately impaired. Medical record review of the Nurse Progress note dated 5/6/17 revealed .Around 5:30 pm this resident (Resident #53) took his supper tray into another resident's room and would not leave the room .(Resident #53) said that was his room and his wife was coming . Review of the Complete Facility Investigation dated 7/15/17 revealed Certified Nursing Assistant (CNA) #3 noted a resident's door was closed. Continued review revealed CNA #3 and CNA #4's entered the room and observed Resident #53 in female Resident's #4 and #18's room. Continued review revealed Resident #53 backed away from Resident #4's bed when the CNAs entered the room. Further review revealed . (Resident #53) acted like he had no clue what he was doing in there. He said This ain't my room .Acted surprised and started to leave the room on his own and left the room . Interview with the Director of Nursing on 5/22/18 at 4:39 PM, in the conference room, confirmed Resident #53 had a history of [REDACTED]. Continued interview confirmed the facility failed to update and revise Resident #53's care plan to include the resident's wandering behavior.

Based on facility policy review, medical record review, observation, and interview the facility failed to follow their policy and failed to provide appropriate personal protective equipment to visitors and staff at the facility to prevent the transmission of an infectious disease for 1 resident (#134) of 1 of 1 resident on contact isolation of 29 residents reviewed. The finding included: Review of the facility policy, Clostridium Difficile undated revealed .Objective .To provide all personnel with a guide in the care for residents with the [DIAGNOSES REDACTED].Residents with [DIAGNOSES REDACTED].All personnel, physician, technicians, students, and others must practice contact precautions .Visitors must be instructed in contact precautions prior to visitation with residents .Procedure . Initiate Contact precautions for symptomatic patients .personnel should wear gloves when entering resident's rooms .personnel should wear gowns if soiling of clothing is likely .equipment whenever possible will be assigned to resident . Medical record review revealed Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Lab report dated 3/21/16 revealed the resident had a positive stool culture (stool specimens tested for toxins) for Clostridium Difficile (infectious bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). Medical record review of a Physician Order dated 3/25/16, revealed an order for [REDACTED].Standard Contact Isolation Precaution (wearing a gown and gloves to prevent the spread of infection by contact with bacteria or virus) D/T (due to) + (positive)[DIAGNOSES REDACTED] (Clostridium Difficile) . Medical record review of the resident's Care Plan dated 3/25/16, revealed Resident #134 was care planned for a self-care deficit related to effects of the disease process. Continued review revealed the resident was admitted with a [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #134 had a Brief Mental Status score of 5 indicating the resident was severely cognitively impaired. Continued review revealed the resident was incontinent of urine and bowel. Observation of Resident #134's room on 4/18/16 at 5:30 AM, on the Skilled Hall, revealed an orange sign on the resident's door with the instructions to report to the nurse's station before entering the room. Continued observation revealed no personal protective equipment (gowns, mask and gloves) available for use outside of the resident's room. Observation of Resident #134's room on 4/18/16 at 10:31 AM, on the Skilled Hall, revealed a box of gloves located in the resident's room on the wall behind the resident's door. Continued observation revealed no personal protective equipment readily available for use outside of the resident room for staff and visitors. Interview with License Practical Nurse #1 on 4/18/16 at 10:36 AM, on the Skilled Hall, outside of the resident's room, confirmed the staff did not don gowns when entering resident #134's room. Continued interview confirmed the staff did not don gloves prior to entrance into the resident's room. Further interview confirmed staff donned gloves once inside of the resident's room from the box of gloves located behind the resident's door. Continued interview confirmed there was no personal protection equipment outside of resident #134's room which would include disposable gowns and gloves for staff and visitors use upon entering the resident's room. Interview with the Director of Nursing on 4/18/16 at 11:28 AM, on the Skilled Hall, outside of Resident #134's room, confirmed the facility failed to have staff and visitors don gloves and gowns prior to entering the resident's room as was their policy. Continued interview confirmed the facility failed to provide and have readily available the appropriate personal protective equipment for staff and visitors use outside of the resident's room to prevent the transmission of infections to others.

Based on medical record review, observation, and interview, the facility failed to assess for the use of a restraint prior to starting a potential restraint for 1 resident (#85) of 3 residents reviewed. The findings included: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 4/21/15 at 12:22 PM, revealed the Resident sitting across from the nurse's station in a reclined Broda chair (type of reclining wheelchair). Continued observation revealed the resident attempting to get up from the chair. Interview with the Director of Nursing (DON) on 4/21/15 at 12:45 PM, in the Administrators office confirmed the resident had been placed in the chair on 4/15/15 and the facility failed to assess the reclined chair prior to starting for a potential restraint. C/O

Based on review of facility admission agreement, medical record review, and interview, the facility failed to notify a resident of a new roommate without advance notice for 1 residnet (#89) of 30 residents reviewed. The findings included: Review of facility policy, Room Assignment, undated revealed "...assign rooms to the agreement of the residents who dwell therein..." Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to the skilled area of the facility. Medical record review revealed no documentation of advance notice of the new roommate by the facility. Interview with Resident #89 on 4/20/15 at 3:20 PM, in the resident's room revealed the resident received a new roommate on 4/17/15. Further interview confirmed Resident #89 was not informed of the new roommate by the facility. Continued interview confirmed the roommate "...would make noises at night and have to be removed from the room by the nurses..." Interview with the Social Service Director on 4/22/15 at 10:25 AM, at the skilled nursing station confirmed Resident #89 was not notified of a new roommate. Interview with the Administrator on 4/22/15 at 10:45 AM, in the classroom confirmed Resident #89 did not receive notice of the new roommate prior to the roommates arrival.

Based on medical record review, observation, manufacturer's instructions, and interview, the facility failed to instruct a resident prior to use and failed to follow manufacturer's recommendations after use for one resident (#67) of three residents reviewed for medication administration. The findings included: Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident is cognitively intact. Medical record review of the Physician's Recapitulation Orders for March 2015 revealed, " [MEDICATION NAME] (type of inhaler)..." Observation of the Licensed Practical Nurse (LPN #1) in the resident's room on 4/21/15 at 7:37 AM, revealed LPN #1 administered the [MEDICATION NAME] and failed to give instruction on medication use prior to administration. Continued observation revealed the resident took two quick puffs and handed the inhaler back to the LPN. Review of the manufacturer's recommendations revealed, "...Taking your full daily dose (two inhalations from the same [MEDICATION NAME] capsule)...Breathe out completely in one breath, emptying your lungs of any air...Important do not breathe into your ...device...breathe in deeply until your lungs are full. You should here or feel the...capsule vibrate. Hold your breath for a few seconds...The rattle tells you that you breathed in correctly...To get your full daily dose, you must breathe out completely and for a second time, breathe in from the same...capsule..." Interview on 4/21/15 at 9:30 AM, with LPN #1 at the 100/200 hall nurse's desk confirmed the manufacturer's recommendations were not followed.

Based on review of facility policies, medical record review, observation, and interview, the facility failed to monitor weight loss and nutritional status for 1 resident (#15) of 5 residents of 30 residents reviewed. The findings included: Review of facility policy, Weight Monitoring, reviewed 9/16/08 revealed "...weights will be obtained...deemed necessary to monitor an elder's nutritional status and/or medical condition, of the resident guidelines...reweighed if there is a change of 3# (pounds) up or down and report to CDM (Certified Dietary Manager) for review..." Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 9 (moderately impaired), and independent for eating with set-up help. Medical record review of Resident #15's Annual Weight Record revealed an readmission weight dated 1/21/10 of 122 lbs. Continued review revealed revealed on 2/24/15 116 lb., 3/25/15 116 lb., and on 4/21/15 117 lbs. Medical record review of Resident #15's physician's orders [REDACTED]. Dash." Continued review revealed no appetite stimulants or dietary supplements were ordered. Medical record review of Resident #15's Nutritional Progress Notes revealed the last documented note dated 1/10/15. Further review revealed "...weight is stable..." Observation of Resident #15 on 4/21/15 at 12:30 PM, in the resident's room revealed the resident eating lunch in bed. Continued observation revealed the resident was able to feed self without difficulty. Interview with Resident #15 on 4/21/15 at 12:30 PM, in the resident's room confirmed her appetite "...not too good...I have to make myself eat..." Interview with the Restorative Certified Nursing Assistant (CNA), on 4/22/15 at 8:30 AM, at the skilled nursing station confirmed she did not notify the Case Manager, Dietician, or Acting Dietary Manager (DM) of Resident #15's weight loss. Interview with the Case Manager/ MDS Coordinator on 4/22/15 at 2:00 PM, in the Case Manager's office confirmed Resident #15 "...doesn't eat as much as she used to...we go by weights...then alert the MD (Physician), start with med pass (dietary supplement)...fortified meals..." Further interview confirmed the resident was not on dietary supplements for weight loss. Interview with the DM on 4/22/15, at 2:15 PM, in the Case Manager's office confirmed no nutritional progress note documented since 1/10/15 and no dietary supplement ordered for Resident #15. Continued interview revealed the Resident at Risk (RAR) meeting was held at the facility earlier today and Resident #15 was not on the risk list. Further interview confirmed no dietician attended the RAR meeting. Telephone interview with the Dietician on 4/22/15 at 2:20 PM, in the Case Manager's office confirmed not aware of weight loss for Resident #15, or on the weight loss or RAR trigger list. Further interview confirmed "...doesn't sound like we did anything for her...should have been put on weekly weights and started on a supplement, but we failed to do that..."

Based on review of facility policy, observation, and interview, the facility failed to maintain a sanitary kitchen by not properly cleaning, storage of kitchen equipment, and maintenance of safe milk temperatures for three of three milks of one of one kitchen reviewed. The findings included: Review of facility policy, Food Storage, dated 2009 revealed "...scoops are not to be stored in food..." Review of facility policy, General Food Preparation and Handling, dated 2009 revealed "...all food service equipment should be cleaned, sanitized...after each use..." Review of facility policy, Sample Cleaning Schedule, dated 2009 revealed "...monthly...refrigerator condenser coils..." Review of facility policy, Food Temperatures, dated 2009 revealed "...all cold food items must be maintained and served at a temperature of 41 degrees or below..." Observation with the Dietary Manager on 4/20/15 at 9:10 AM, in the kitchen revealed a scoop in the sugar container. Continued observation revealed a three-tier drawer. Continued observation revealed in the middle drawer contained four ladles and the bottom drawer contained five spatulas with the bottoms of the drawers coated with a dried sticky brown substance. Observation with the Dietary Manager on 4/20/15 at 9:25 AM, of the walk-in cooler revealed a cooling fan covered with dust debris. Observation with the Dietary Manager on 4/20/15 at 11:45 AM, in the kitchen of a resident's tray revealed a carton of two-percent milk with a temperature of 47 degrees. Further observation revealed a carton of two-percent milk with a temperature of 42 degrees sitting on a container filled with ice. Observation with the Dietary Manager on 4/21/15 at 8:05 AM, in the kitchen revealed a carton of two-percent milk with a temperature of 43 degrees on a bed of ice. Interview with the Dietary Manager on 4/20/15 at 9:30 AM, in the kitchen confirmed the facility failed to keep the sugar scoop in a separate area out of the sugar container, to clean the two utensil bins, and to clean the dust debris from the walk-in cooling fan. Further interview at 11:45 AM confirmed the facility failed to maintain a safe temperature of the milk. Interview with the Dietary Manager on 4/21/15 at 8:30 AM, in the kitchen confirmed the facility failed to maintain a safe temperature of the milk. Further interview confirmed ''...I didn't have time to call maintenance yesterday..."

Based on medical record review, observation, and interview the facility failed to provide care and treatment to prevent the decline of one pressure ulcer for one (#145) of three residents reviewed with pressure ulcers. This failure resulted in harm to resident #145. The findings included: Resident #145 was admitted to the facility on [DATE], from the hospital with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set (MDS) with a reference date of February 13, 2014, revealed the resident was completely dependent for bed mobility, (required assistance of two or more staff members), was incontinent of bowel and bladder, wore an external catheter, (to drain urine) and had a Brief Index of Mental Status (BIMS) score of 15, indicating no problems with mental acuity. Medical record review revealed the resident was status [REDACTED].#7, #8, & #12. Further record review revealed the spinal injury resulted in bilateral lower extremity paralysis. Review of the Resident Assessment, dated February 6, 2014, completed by the admitting Registered Nurse (RN) #4, revealed the area provided for "Skin Condition" recorded a Stage II pressure ulcer, midline at the coccyx, measuring 3.5 cm (centimeters) by 2.5 cm. Further review of the admission Resident Assessment revealed the depth of the pressure ulcer was not documented. Record review of the Interim Care Plan initiated February 6, 2014, by RN #4, revealed, "... Problem...8. Stage II ulcer coccyx...Goal: Will have improved skin condition...by 2/19/2014..." Further review revealed the Approaches to meet the goal did not include assisting the resident with bed mobility. Review of the Treatment Record for February 2014 revealed an entry dated and initated on February 18, 2014, "Turn and Reposition q (every) 2 hours." Review of the weekly Wound Measurement and Assessment Record revealed the entry from February 6, 2014, did not include a depth or description of the Stage II coccyx ulcer. Review revealed the next entry from February 11, 2014, revealed, "Now Stage III - slough..." Review revealed no depth measurement was included. Record review of a Nurse's Note dated February 11, 2014, at 2:30 p.m., revealed, "On assessment, coccyx/sacral wound not improving. Yellow dry slough observed in wound bed..." Medical record review of the physician's orders [REDACTED]. Cleanse with NS (normal saline). Apply alginate (a dressing used to wick moisture) and [MEDICATION NAME] (a [MEDICATION NAME] agent) to wound bed. Cover with dry protective dressing. Change every day until healed." Review of the Registered Dietician's (RD) Nutritional assessment dated [DATE], revealed The RD's initial assessment was completed four days after the resident was referred to dietary on February 6, 2014, by the admitting nurse. Further review revealed, "Increased protein needs for healing with wound...low [MEDICATION NAME] 2.3 (a nutritional marker with the normal range 3.2-4.5) - goal: repletion...Recommend Med Pass 2.0 (a high calorie/high protein liquid) 90 ml (milliliters) TID (three times a day) for maintenance of nutritional parameters, healing, and repletion. This will provide 540 calories/22 grams protein..." Medical record review of the physician's telephone order dated February 11, 2014, revealed, "Fortified cereal at breakfast and 90 cc (cubic centimeters) Ready Care 2.0 (another name for Med Pass) TID to maintain nutritional parameters." Medical record review revealed the Ready Care was not being administered to the resident by the nursing staff during the Medication Administration. Further review revealed the nutritional supplementation had not been initiated by nursing or dietary. Further review revealed the resident had not received the Ready Care 2.0 from February 10, 2014, through February 25, 2014, a period of fifteen days. Review of a faxed notification to the physician dated February 18, 2014, revealed, "...Stage III on 2/11/14 measured...3.5 x 2.5. Today 2/18/14 Stage III measured 6 cm L (length) x 2.5 cm W (width) x 0.8 cm D (depth). 95% of wound is covered with slough." Further review revealed no new orders were received. Observation of the resident on February 23, 2014, at 10:40 a.m., revealed the resident was lying on their back. Observation of the resident at 2:00 p.m., and 4:25 p.m., on February 23, 2014, revealed the resident was lying on their back. Observation of the resident at 8:30 a.m., on February 24, 2014, revealed the resident was tilted to the left side with one pillow, lying in a flat bed, eating breakfast. Interview with the RN in charge (#5) on February 24, 2014, at 10:00 a.m., in the skilled unit's nursing station, revealed the RN stated the resident frequently ate with a flat bed because of the resident not wanting to donn the back brace ordered for when the resident was up in the bed greater than thirty degrees or out of the bed. Further interview revealed the resident "doesn't eat well." Interview continued and the RN stated the resident did not "like to turn" in response to a question about the treatment entered twelve days after admission to be turned every two hours. Observation of the resident in resident's room on February 25, 2014, at 10:20 a.m., as the resident was positioned on the left side for a dressing change and treatment of [REDACTED]. Continued observation revealed the pressure ulcer measured 5.5 cm by 2.5 cm with 1.5 cm depth. Interview with registered nurse (RN) #3 at the time of the observation, confirmed the wound bed had increased in depth, had a large amount of sloughing tissue, two small areas of black, necrotic tissue at the ulcer's edges, and a foul odor when the old dressing was removed. Interview with the Director of Nurses (DON) on February 25, 2014, at 3:00 p.m., in the conference room, verified the facility did not employ a designated wound care nurse and the resident had received care of the pressure ulcer by different staff nurses. Interview confirmed the depth of the coccyx pressure ulcer was not measured at admission or when the ulcer had deteriorated to a Stage III on February 11, 2014. Interview confirmed the first measurement of depth was done on February 18, 2013, twelve days after admission. Interview continued and confirmed the resident had a low [MEDICATION NAME], a need for increased protein intake to replace nutritional needs not met, and to promote healing of the pressure ulcer from admission. Interview confirmed the resident did not receive the protein supplement recommended by the RD from February 10-25, 2014. Continued interview confirmed the coccyx pressure ulcer enlarged in length, depth, and developed sloughing dead tissue from admission to the present time, resulting in harm to resident #145. .

Based on review of kitchen logs, meal menus, the kitchen Operations Manual, observation, and interview, the facility failed to obtain temperatures of the foods on the serving line prior to the food being plated 23 out of 54 days in 2014, failed to clean the fryers (cleaning included changing the oil) each week, and failed to perform weekly cleaning behind the food preparation area. The findings included: Observation and interview in the kitchen on February 23, 2014, at 8:50 a.m., with the dietary staff, revealed the serving line for the breakfast meal was completed. Interview revealed the staff had not obtained food temperatures prior to serving the breakfast meal. Observation continued and the metal wall, behind the two fryers, revealed debris and a build-up of grease on the wall with debris of dirt hanging from flexible tubing between the wall and the fryers. Interview at 9:00 a.m., on February 23, 2014, with the staff, in the kitchen, confirmed the wall and tubing were not clean. Interview revealed the kitchen procedure for the fryers included changing the frying oil "when the fryers were cleaned on Tuesday and Wednesday each week." Further interview revealed the left fryer was scheduled for each Tuesday and the right fryer scheduled for each Wednesday. Review of the Cleaning Assignment Logs revealed the left fryer had not been cleaned on January 21, 28, 2014, & February 4, 11, or 18, 2014. Continued review revealed the right fryer was not cleaned on January 22, & February 5 & 12, 2014. Review of the Cleaning Assignment Logs revealed a cleaning area listed as " ...area behind stove, oven, and steamer had not been cleaned for the previous five weeks of 2014. Review of the kitchen's Temperature Log revealed twenty-three of the first fifty-four days of the year 2014 had meals with food temperatures not obtained. Review revealed temperatures were not obtained for the following dates and meals: 1) January 4 - none for breakfast or supper; 2) January 5 - none for breakfast or lunch; 3) January 10, 24, 25, 26, 27, 28, 31, & February 1, 2, 7, 10 - none for supper on these eleven days; 4) February 11 - none for lunch or supper; 5) February 12 & 13 - none for supper; 6) February 14 - none for lunch; 7) February 16 & 17 - none for supper; 8) February 20 - none for lunch or supper; 9) February 21 & 22 - none for supper; and 10) February 23 - none for breakfast. Review of the kitchen Operations Manual revealed on page 79, "...Food must be held >135 degrees or <41 degrees F (Fahrenheit)." Further review revealed on page 80, "7. Food Temperatures for Meal Service...Check to be sure the staff actually takes food temperatures..." Review of the meal menus for the previous four weeks revealed meals were served containing fried foods at least once each week. Interview with the kitchen's Certified Dietary Manager (CDM) at 10:55 a.m., on February 23, 2014, revealed the Operations Manual served as both the training criteria and the kitchen's policies and procedures. Interview revealed the CDM was aware the staff had not been adhering to obtaining food temperatures on the serving line for each meal and confirmed the temperatures had not been taken on the twenty-three days not recorded. Continued interview revealed, "I have written some employees up for this." Interview continued and confirmed the area not cleaned for the previous five weeks included the observed wall behind the fryers. Interview continued and verified fried foods were served weekly and confirmed there were five consecutive weeks the fryers had not been cleaned and the cooking oil had not been changed.

Based on medical record review, facility policy review, and interview, the facility failed to ensure a residents' drug regimen was free from unnecessary drugs by not completing the Behavior/Intervention Monthly Flow Record for one resident (#128), of twenty-nine residents reviewed. The findings included: Medical record review revealed resident #128 was admitted to the facility January 13, 2014, with [DIAGNOSES REDACTED]. Continued medical record review revealed the physician ordered [MEDICATION NAME] (antipsychotic) 50 mg. (milligrams) at hs (bedtime) on February 19, 2014. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at hs from February 19, 2014, through February 24, 2014. Review of the facility policy on Antipsychotic Monitoring Guidelines revealed, "[MEDICAL CONDITION] monitoring record will be complete on resident's receiving antipsychotic medications..." Medical record review revealed the resident's Behavior/Intervention Monthly Flow Record ([MEDICAL CONDITION] monitoring record) had not been completed from February 19, 2014 through February 23, 2014. Interview with the Director of Nursing (DON) on February 25, 2014, at 10:40 a.m., at the North Nurse's Station, confirmed the resident's Behavior/Intervention Monthly Flow Record was not completed while the resident received [MEDICAL CONDITION] medication from February 19, 2014 through February 23, 2014.

Based on medical record review and interview, the facility failed to report an allegation of possible abuse to the proper authorities for one resident (#2) out of two residents reviewed for abuse or neglect. The findings included: Resident #2 was admitted to the facility in January 2007, with [DIAGNOSES REDACTED]. Medical record review of the comprehensive assessment from the Minimum Data Set (MDS) dated [DATE], revealed the resident was born October 18, 1965, and had previously been readmitted to the nursing home on June 18, 2012. Review of the MDS revealed the resident did not have any speech or hearing problems, understood others and was easily understood, had no short or long term memory problems and a brief index of mental status (BIMS) of 15, the highest score possible, indicating normal mental abilities. Medical record review of the Social Worker's note dated February 28, 2013, revealed the social worker and the social worker assistant spoke with the resident three days after the resident returned from an out-patient procedure at the hospital. Further review revealed the resident stated, "did feel safe at this facility and had no concern/worries about staying here." Interview with the Social Worker and the facility Administrator on February 24, 2014, at 4:45 p.m., in the Social Worker's office, revealed the Social Worker and Administrator worked together as the facility's abuse officers to investigate allegations of abuse. Interview continued and revealed the allegation of "possible sexual abuse" was received by a telephone call made to the facility from the hospital's Medical Social Worker the day after resident #2 returned from a procedure at the hospital's out-patient surgery on February 25, 2013. Further interview revealed the Administrator and the Social Worker interviewed the alert and oriented resident separately and the resident denied being sexually abused. Continued Interview and confirmed the facility did not report the allegation of possible sexual abuse and the investigation findings to the State Agency. Complaint #

Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on September 4, 2012, from 9:45 a.m. until 11:10 a.m., revealed: 1. One twenty-eight ounce can of unpeeled/diced Tomato's was dented and was available for use; 2. One hundred eight ounce can of Applesauce was dented and was available for use; 3. A stand up electric slicer had food debris on the lip, the blade, and the top of the machine, and was available for use; 4. The stand up mixer had food debris in the bottom of the bowl, and was available for use; 5. A large container of Peanut Butter was open on the prep table with no open date on it, and was available for use; 6. One of two skillets was dirty with food debris stuck to the inside bottom of the pan, and was available for use; 7. Two of four knives checked were dirty, and were available for use; 8. One five pound container of Pure Cocoa was open on the shelf with no open date and the lid was not secured, and was available for use; 9. The following items were open and not dated in the walk in refrigerator, and were available for use; a. A turkey breast was partially covered with foil; b. Sliced ham was wrapped in foil; c. Cottage Cheese, five pound container; d. Sliced American Cheese, several slices in a container; e. Salad Dressing, one gallon container; f. Two-Cranberry Sauce, six pound and five ounce container; g. Five-Assorted Flavored Icing's, sixteen ounce containers; h. Pickles, one gallon container; i. Mustard, one gallon container; j. Vanilla Cream Cake Icing, eleven pound container; k. Pimento Cheese, five pound container; 10. The following items open and not dated in the dry storage area, and were available for use; a. Baking Soda, two pound container; b. Freeze Dried chives, five and one-half ounce container; c. Seasoning Sloppy Joe Mix, fifteen ounce container; d. Browning and Seasoning Sauce, thirty-two ounce container; e. Golden Molasses, one gallon; f. Worcestershire Sauce, one gallon container; g. Parsley Flakes, eleven ounce container; h. Black Pepper, four and one-half ounce container; i. Honey, five pound container; 11. The following items were open and not dated in the spice storage area, and were available for use; a. Two-Ground Cumin Seed, fifteen ounce container; b. Ground Nutmeg, sixteen ounce container; c. Salt, twenty-six ounce container; d. Whole Tarragon Leaves, four ounce container; e. Paprika, sixteen ounce container; f. Allspice, sixteen ounce container; g. Italian Seasoning, six and one quarter ounce container; h. Two-Ground Clove, sixteen ounce container; i. Curry Powder, sixteen ounce container; j. Ground Thyme, eleven ounce container; k. Three-Ground Cinnamon, fifteen ounce container; l. Pan Coating Spray, seventeen ounce container; m. Ground Marjoram, eleven ounce container; n. Imitation Vanilla, thirty-two ounce container; o. Lemon Pepper, twenty-eight ounce container; p. Ground Ginger, sixteen ounce container; q. Cream of Tarter, twenty-five ounce container; r. Chicken Flavor Soup Base, sixteen ounce container; s. Beef Flavor Soup Base, sixteen ounce container. Interview with the dietary manager on September 4, 2012, at 11:15 a.m., in the dietary department, confirmed dented cans were to be removed from stock, the stand up slicer and mixer were to be cleaned prior to storage, the skillet and knives were to be cleaned prior to being stored for use, the turkey breast and sliced ham was to be labeled, dated, and secured completely prior to storage in the walk in refrigerator, and all items stored in the walk in refrigerator, dry storage area, and spice storage area were to be labeled with the date once they were opened.