HERITAGE AT LONGVIEW HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported by staff immediately or not later than 24 hours for 2 of 2 residents reviewed for abuse and neglect. The facility failed to report verbal altercation between Resident #45 and Resident #53 during week of 6/23/2025. This failure could place residents at risk for abuse and neglect. Findings included:1. Record review of a face sheet dated 6/30/2025 revealed Resident #45 was [AGE] year-old female who was admitted on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage (a type of stroke that causes bleeding in the brain), protein-calorie malnutrition (a form of undernutrition is characterized by insufficient intake of protein and calories leading to various health issues), Type II Diabetes (occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin), cerebral infarction (a type of stroke that results from the interruption of blood supply to the brain), and hypertension (a common condition where the force of blood against the artery walls is consistently too high). Record review of a quarterly MDS dated [DATE] indicated Resident #45 was usually able to make self-understood and usually understood others. The MDS indicated a BIMS 10 indicating moderate cognitive impairment. The MDS indicated Resident #45 did not exhibit any physical or verbal behavioral symptoms during the look back period. Further review of MDS revealed Resident #45 was taking an antidepressant for depression. Record review of a care plan last revised on 1/29/2025 indicated Resident #45 required an antidepressant with goal to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions included to administer antidepressant medication as ordered, monitor and document side effects and effectiveness. Additional interventions included monitoring, documenting and reporting to Physician as needed any ongoing signs and symptoms of depression, unaltered by antidepressant medications such as sadness, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety and constant reassurance. During an interview on 6/30/2025 at 11:19 AM, Resident #45 said a white staff member called her a N word and a B word. Resident stated the incident happened sometime last week. Resident said there were witnesses but could not provide names or description. Resident #45 said she was in the TV room with the incident occurred. Resident #45 had difficultly conveying details and information. During an interview on 6/30/2025 at 1:30 PM, discussed with survey team of Resident #45's report of a white staff member who she reported called her the N word and a B word and the story being difficult to follow. This surveyor notified the DON of Resident #45's report. The ADM was out of the building at the time of report and returned at approximately 1:35 PM. He said Resident #45's story was difficult to follow but would make a self-report and begin investigation. During an interview on 6/30/2025 at 2:44 PM, Resident #45's RP said she had been talking with Resident #45. RP said her Resident #45 had not reported any staff being disrespectful to her. RP said the staff call her with any changes with her mother and did not indicate any verbal altercation with staff or residents.2.Record review of Resident #53's face sheet dated 7/2/2025 revealed Resident #53 was a [AGE] year-old female who was admitted on [DATE] with diagnoses which included heart failure (occurs when the heart muscle does not pump blood as well), chronic venous hypertension with ulcer of bilateral lower extremities (when blood refluxes and starts to accumulate in the lower leg), lymphedema (tissue swelling caused by fluid buildup in the lymphatic system), Type II diabetes (occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin), hypertension (a common condition where the force of blood against the artery walls is consistently too high), chronic atrial fibrillation (am irregular and often rapid heart rhythm that can lead to stroke), and chronic obstructive pulmonary disease (a lung condition caused by damage to the airways that limit airway). Record review of a quarterly MDS dated [DATE] indicated Resident #53 was understood and usually understood others. The MDS indicated a BIMS 12 indicating moderate cognitive impairment. The MDS indicated Resident #53 did not exhibit any physical or verbal behavioral symptoms during the look back period. Further review of MDS revealed Resident #53 was taking antianxiety medication. Record review of a care plan last revised on 3/10/2025 indicated Resident #53 used antianxiety medication with goal to decrease episodes of signs and symptoms of anxiety. Interventions included to administer antianxiety medications as ordered by physician, monitor, document side effects and effectiveness, monitor and record occurrence for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards others and document per facility protocol. During an interview on 7/2/2025 at 9:50 AM, MA G said she had not observed or overheard any staff members being ugly to Resident #45. She said she had overheard other residents being ugly to each other. MA G said she did hear the aftermath of a confrontation between Resident #45 and Resident #53. She said Resident #45 had been upset last Thursday or Friday. MA G said she was not sure what the staff did but she said she had provided Resident #45 with reassurance. MA G said she had asked Resident #45 what was wrong, and Resident #45 told her she had words with a friend. MA G said she did not report this to anyone. MA G said Resident #45 told her Resident #53 called her a B word. MA G said she did not hear or observe the occurrence and did not report it to staff. MA G said the two residents were loud with each other and other staff could hear what was going on. MA G could not recall the date or time of the incident. During an interview on 7/2/2025 at 10:31 AM, RN B said he heard the arguing between Resident #45 and Resident #53. He said Resident #53 said she did not use the N word. He said they were yelling back and forth. RN B said Resident #45 and Resident #53 were good friends. He said the residents separated themselves. RN B said he reported the incident to the DON and said he was not sure what she did. He said he thought something was written up about it yesterday. RN B said there had not been any changes in Resident #45 and Resident #53's mood. RN B said he reported the incident to the DON, family and NP but did not document in the computer about his report. RN B said resident to resident interactions could affect the residents depending on what was said. He said staff monitor behaviors every shift. He said the staff put the information in a 24-hour report and the staff usually send a request for psychiatric referral. RN B said if a resident's feelings were hurt, it could cause depression. During an interview on 7/2/2025 at 12:17 PM, LVN L said she heard it get loud in the dining/TV room next to the nurse's station. She said Resident #45 and Resident #53 were arguing with each other. LVN L said she did not recall all what was said. LVN L said Resident #53 was upset and down after the incident. LVN L said she thought RN B reported the incident to the DON and ADM. LVN L said she was in-serviced on Abuse, Neglect and Exploitation. During an interview on 7/2/2025 at 1:52 PM, Resident #53 said Resident #45 had a bad attitude toward her one-day last week. She said they were both calling each other the B word. She said Resident #45 had told someone that Resident #53 had called her the N word. Resident #53 said she would never do that, and her family would be upset with her if she did something like that. Resident #53 said the staff separated them. Resident #53 said she had been friends with Resident #45 for a long time. Resident #53 said it bothered her that her friend was upset with her. Resident #53 said she was not experiencing any adverse depression symptoms from the incident and she and Resident #45 were friends again. During an interview on 7/2/2025 at 3:00 PM, ADON said she was not aware of the incident between Resident #45 and Resident #53. She said she expected staff to report any resident-to-resident abuse allegations. She said not reporting could result in the resident becoming depressed or perpetrator could continue to abuse the other person. The ADON said the staff had been in-serviced on abuse, neglect, and exploitation. The ADON said the staff jump in and separate residents to keep them safe. She said the facility would complete a trauma informed care assessment at 24 hours, 48 hours, and 72 hours to identify if a resident needed additional services. She said the facility would report to the NP/family and it would be documented on an incident report.During an interview on 7/2/2025 at 3:30 PM, the DON said she did not know what had happened with Resident #45 and Resident #53. She said she was out of town last week and was not made aware of verbal altercation. DON said she expected the staff to report resident to resident altercations and should have been reported to the ADM. She said it was investigated after reported by this surveyor. The DON said the residents should have been separated and staff in-serviced on resident-to-resident altercations. The DON said the staff should make sure there were no injuries of physical or mental distress to the residents. During an interview on 7/2/2025 at 4:27 PM, the ADM said he was not aware of verbal altercation until reported by surveyor. Resident #45 had not told anyone about the incident. The ADM said he expected his staff to report to him immediately any allegations of abuse. He said the facility put both residents on Q 15-minute checks, referred to psychiatric services and kept the residents apart. The ADM said Resident #45 cussed at Resident #53 first. He said it was confirmed that Resident #45 was the perpetrator and not Resident #53. The ADM said Resident #45 had been more sensitive lately due to the loss of a friend. Review of a policy titled Abuse/Neglect revised on 3/29/2018 indicated, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Definition .1. Abuse: Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 3. Verbal abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or within or within their hearing distance, regardless of their age, ability to comprehend, or disability.6. Mental Abuse: Includes but not limited to, humiliation, harassment, threats of punishment or deprivation. B. Training.The facility will train through orientation and on-going in-services in issues related to abuse/neglect prohibition practices regularly. C. Prevention.1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 2. The facility will post the Customer service hotline and the Abuse Preventionist of the facility.3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect.5. All employees will sign a statement acknowledging the receipt of information notifying the employee of 1.) possible criminal liability for failure to report abuses.E. Reporting.A. If the allegation involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of three residents reviewed for a change of condition.<BR/>The facility failed to notify the responsible party or family of a change in condition for Resident #1 after finding a new wound on her buttocks on 7/22/2024.<BR/>This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition. <BR/>Findings included:<BR/>Record review of the face sheet dated 2/13/2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), paranoid schizophrenia (hallucinations, delusions, and disorganized speech), contractures of left and right knee (permanent shortening or tightening of muscles, tendons, ligaments, or skin), dementia (decline in memory, thinking, reasoning, and problem solving).<BR/>Record review of the face sheet dated 2/13/2025 indicated Resident #1's daughter was her responsible party with a phone number and a directive to please text the daughter. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #1 required was completely dependent on staff for all activities of daily living. The MDS indicated Resident #1 was dependent with transfers. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #1 did not have any unhealed pressure ulcers/injuries. <BR/>Record review of the discharge MDS dated [DATE] indicated Resident #1 did not have any unhealed pressure ulcers/injuries. <BR/>Record review of the care plan last revised on 8/05/2024 indicated Resident #1 had the potential for pressure ulcer development due to decreased mobility, incontinence and decreased cognition with interventions that included: 1. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 2. Follow facility policies/protocols for the prevention/treatment of skin breakdown. 3. Incontinent care after each episode and apply moisture barrier. 4. Inform the resident/family/caregivers of any new skin breakdown . 6. Notify the nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care .<BR/>Record review of the physician orders dated 7/25/2024 indicated Resident #1 had an order to: 1. Non-pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed with an order date of 7/23/2024 and an order start date of 7/23/2024. 2. Non-pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement one time a day with an order date of 7/23/24 and an order start date of 7/24/2024. <BR/>Record review of Braden Scale for Predicting Pressure Sore Risk dated 8/4/2023 revealed Resident #1's score of 9 which indicated Resident #1 was at high risk for developing a pressure sore.<BR/>Record review of Weekly Skin Assessment-V 5 dated 7/19/2024 indicated Resident #1 did not have any moisture associated skin damage or pressure, venous, arterial, or diabetic ulcers. <BR/>Record review of eTransfer Form-V6 dated 7/25/2024 indicated Resident #1 was sent to the hospital for the following: Resident partially opening her eyes to verbal and tactile stimulus. Non verbal. No facial dropping noted. Generalized weakness. Will not squeeze my hands. Rapid shallow breathing noted. Sending out for possible AMS [altered mental status]. The form indicated Resident #1 had special treatments and precautions of: contact infection control precautions for an infection of the buttocks. The form indicated Resident #1 was on EBP (enhanced barrier precautions). The form indicated Resident #1 was receiving wound treatment with a current wound to the buttocks. The form indicated Resident #1's responsible party (daughter) was notified on 7/25/2024 at 9:30 AM of the transfer. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 as a Late Entry for 7/22/2024 indicated the CNA C informed LVN A that she was doing care on Resident #1 and wanted LVN A to look at Resident #1's bottom. CNA C helped LVN A to assess Resident #1's bottom by rolling her on her side. Resident #1 was noted to have MASD (moisture associated skin damage) to bilateral buttocks. LVN A documented to wound bed was pink in color with no drainage noted. LVN A documented there were no signs or symptoms of infection noted. LVN A documented the edges were attached. LVN A documented he consulted the NP (nurse practitioner) about Resident #1's buttocks with recommendation noted till treatment nurse could assess. LVN A documented cleanse area with soap and water, pat dry and apply clean dry dressing. LVN A documented treatment was initiated at that time. LVN A documented he would advise treatment nurse of findings to follow up on NP (nurse practitioner) recommendation. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:32 PM the ADON documented on 7/23/2024 at 1:31 PM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Treatment Administered Daily. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:33 PM the ADON documented on 7/23/2024 at 2:32 PM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. PRN Administration was: Effective. Dressing was changed after bath. <BR/>Record review of Resident #1's nursing progress note completed on 7/23/2024 at 10:57 PM, LVN D documented she called residents daughter to give update on resident with no answer. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:34 PM the ADON documented on 7/24/2024 at 10:33 AM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Wound care provided by charge nurse and ADON. <BR/>Record review of Resident #1's nursing progress note completed on 7/25/2024 at 9:49 AM LVN A documented on 7/25/2024 at 9:35 AM Resident this morning presenting with possible AMS [altered mental status]. Resident partially opening her eyes to verbal and tactile stimulus. Resident nonverbal this morning. Residents' tardive dyskinesia [chronic involuntary movement disorder] is generally very active and this morning it is very mild. Resident will not squeeze my fingers on command. No facial Dropping noted. Generalized weakness noted with her extremities and trunk. Rapid shallow breathing noted . Talked to NP [nurse practitioner] and informed of resident's current status with order to send to [hospital emergency room] for eval and tx [treatment] due to AMS [altered mental status]. Daughter .notified and ok with transfer to [hospital emergency room]. 911 initiated and resident was transported per stretcher via ambulance to [hospital emergency room] at this time. All paperwork sent with EMS [emergency medical services] for them and ER [Emergency Room]. <BR/>During a phone interview on 2/12/2025 at 12:25pm with Resident #1's RP (responsible party), she said neither she nor her sister had been notified that Resident #1 had developed any kind of skin problem. She said it was not until she got to the hospital emergency room that she was notified that Resident #1 had an unstageable wound to her sacral (upper buttocks) area. <BR/>During an interview on 2/12/2025 at 3:22 PM the ADON said she was not aware of Resident #1 had a wound until the day on 7/22/2024 when LVN A was notified by CNA C. She said she never notified Resident #1's responsible party or any family.<BR/>During an interview on 2/13/2025 at 10:30 AM the DON said if a new skin area was identified and the treatment nurse was not available, the residents charge nurse was to notify the MD and Responsible. <BR/>During a phone interview on 2/13/2025 at 11:58 AM LVN A said he thought he remembered notifying the daughter that night but didn't know who it was that he talked to. He said he notified the wound care nurse to look at it by putting a paper note in her box for the next day for her to address.<BR/>During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for the nurses to notify the resident's responsible party. <BR/>Record review of the facility policy Notify the Physician of Change in Status revised on March 11, 2013, indicated: .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. <BR/>Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 3 residents (Residents #2) reviewed for care plans.<BR/>The facility failed to implement Resident #2's care plan by not changing the dressing to her diabetic ulcer on the left second toe daily. On 2/12/2025 Resident #2's dressing was dated for 2/9/2025.<BR/>This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.<BR/>Findings include: <BR/>Record review of a face sheet for Resident #2 dated 2/18/2025 indicated that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: diastolic congestive heart failure (left ventricle of the heart cannot relax normally), protein calorie malnutrition (reduced availability of nutrients), type 2 diabetes mellitus (high blood sugar levels). <BR/>Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated she had a BIMS score of 13, indicating intact cognition. Section M of same MDS assessment indicated that she was at risk of developing pressure ulcers/injuries and Resident #2 did not have any diabetic foot ulcers. <BR/>Record review of a care plan for Resident #2 dated 2/13/2025 indicated Resident #2 had a diabetic ulcer to left second toe with interventions that included: Administer treatments as ordered and monitor for effectiveness. <BR/>Record review of physician orders for Resident #2 dated 1/17/2025 indicated: Left foot 2nd toe-cleanse area with N/S [normal saline] pat dry apply silvasorb gel to wound with [NAME] peri-wound cover with dry foam and secure with tape PRN [as needed] soiled/dislodgement one time a day. <BR/>Record review of the treatment administration record dated 2/18/2025 indicated Resident #2 had not received treatment to the left foot 2nd toe on 2/9/2025, 2/10/2025, and 2/11/2025. <BR/>Record review of physician's progress note dated 2/6/2025 indicated: Patient here with her [family member] very concerned that her mother is not getting good care for her left second toe. She states the bandage is not changed initially .<BR/>During an observation and interview on 2/12/2025 at 10:10 AM with Resident #2's family member said she was concerned that Resident #2 was not getting wound per the physician's orders. She said on 2/12/2025 Resident #2's dressing to the left foot 2nd toe had not been changed since 2/9/2025. She said Resident #2's dressing changes had not been getting changed daily as ordered. She said she had addressed the issue with the ADON previously. Observation of Resident #2's left foot 2nd toe revealed a dressing dated 2/9/25. <BR/>During an interview on 2/19/2025 at 1:23 PM the DON said she did not know why Resident #2's treatment to her left 2nd toe had not been done. She said by not having her treatment done per the physician's orders could cause the residents wound to become worse. <BR/>During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for all wound care to be done as per the physician's orders. He said it just was not done on Resident #2. He said he was told the treatment nurse was out sick but the charge nurse should have completed the wound care. He said by not receiving the wound care per physician orders and the care plan it could cause the wound to become worse.<BR/>During an interview on 2/19/2025 at 3:15 PM the ADON said she did not know why the wound care had not been completed on Resident #2. <BR/>Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 Residents (Resident #1) reviewed for pressure injuries. <BR/>The facility failed to implement interventions to prevent Resident #1 from developing a facility acquired unstageable pressure ulcer.<BR/>The facility failed to identify and treat an unstageable pressure ulcer to Resident #1's sacral area.<BR/>The facility failed to identify residents who are at risk for pressure ulcer development. <BR/>An IJ was identified on 2/18/2025 at 3:49 PM. The IJ template was provided to the facility on 2/18/2025 at 3:49 PM. While the IJ was removed on 2/19/2025 at 3:30 PM, the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, decreased quality of life, and hospitalization.<BR/>Findings included:<BR/>Record review of the face sheet dated 2/13/2025 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), paranoid schizophrenia (hallucinations, delusions, and disorganized speech), contractures of left and right knee (permanent shortening or tightening of muscles, tendons, ligaments, or skin), dementia (decline in memory, thinking, reasoning, and problem solving).<BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #1 required was completely dependent on staff for all activities of daily living. The MDS indicated Resident #1 was dependent with transfers. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #1 did not have any unhealed pressure ulcers/injuries. <BR/>Record review of the discharge MDS dated [DATE] indicated Resident #1 did not have any unhealed pressure ulcers/injuries. <BR/>Record review of the care plan last revised on 4/25/2023 indicated Resident #1 had the potential for pressure ulcer development due to decreased mobility, incontinence and decreased cognition with interventions that included: <BR/>1. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 2. Follow facility policies/protocols for the prevention/treatment of skin breakdown. <BR/>3. Incontinent care after each episode and apply moisture barrier.<BR/>4. Inform the resident/family/caregivers of any new skin breakdown . <BR/>6. Notify the nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care .<BR/>Record review of Braden Scale for Predicting Pressure Sore Risk dated 8/4/2023 revealed Resident #1's score of 9 which indicated Resident #1 was at high risk for developing a pressure sore.<BR/>Record review of Weekly Skin Assessment-V 5 dated 7/19/2024 indicated Resident #1 did not have any moisture associated skin damage or pressure, venous, arterial or diabetic ulcers. <BR/>Record review of Resident #1's clinical record from 7/19/2024 to 7/25/2024 revealed Resident #1 did not have a documented skin assessment with wound measurements or description of sacral wound.<BR/>Record review of the physician orders dated 7/25/2024 indicated Resident #1 had the following orders: <BR/>1. Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed with an order date of 7/23/2024 and an order start date of 7/23/2024. <BR/>2. Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement one time a day with an order date of 7/23/2024 and an order start date of 7/24/2024. <BR/>Record review of the treatment administration record for July 2024 indicated Resident #1 had the following treatment: Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement completed on the following dates: <BR/>1. 7/23/24 completed by the ADON<BR/>2. 7/24/24 completed by the ADON and RN B<BR/>3. 7/25/24 completed by LVN A. <BR/>During an interview on 2/19/2025 at 3:15 PM the ADON said she provided wound care to Resident #1 prior to her being discharged to the hospital. She said Resident #1 had moisture associated skin damage to her buttocks, but she did not see an unstageable to her sacral area. She said she must have forgotten to sign off on the treatment administration record and that was why on 7/26/2024 she signed the treatment administration record for the dates of 7/23/2024 and 7/24/2024. She said yes it had been discussed in the morning meeting that Resident #1's Responsible party called and said Resident #1 would not be returning to the facility due to Resident #1 receiving the wound while at the facility. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 as a Late Entry for 7/22/2024 indicated the CNA C informed LVN A that she was doing care on Resident #1 and wanted LVN A to look at Resident #1's bottom. CNA C helped LVN A to assess Resident #1's bottom by rolling her on her side. Resident #1 was noted to have MASD (moisture associated skin damage) to bilateral buttocks. LVN A documented to wound bed was pink in color with no drainage noted. LVN A documented there were no signs or symptoms of infection noted. LVN A documented the edges were attached. LVN A documented he consulted the NP (nurse practitioner) about Resident #1's buttocks with recommendation noted till treatment nurse could assess. LVN A documented cleanse area with soap and water, pat dry and apply clean dry dressing. LVN A documented treatment was initiated at that time. LVN A documented he would advise treatment nurse of findings to follow up on NP (nurse practitioner) recommendation. LVN A did not document that he notified any family or family representative of the new skin breakdown or new order received from the NP (nurse practitioner). <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:32 PM the ADON documented on 7/23/2024 at 1:31 PM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Treatment Administered Daily.<BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:33 PM the ADON documented on 7/23/2024 at 2:32 PM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. PRN Administration was: Effective. Dressing was changed after bath.<BR/>Record review of Resident #1's nursing progress note completed on 7/23/2024 at 10:57 PM, LVN D documented she called residents family member to give update on resident with no answer. <BR/>Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:34 PM the ADON documented on 7/24/2024 at 10:33 AM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Wound care provided by charge nurse and ADON.<BR/>Record review of CTNR Shower Sheets dated 7/24/2024 signed by CNA E indicated Resident #1 had an open area to her buttocks area. <BR/>Record review of Resident #1's nursing progress note completed on 7/25/2024 at 9:49 AM LVN A documented on 7/25/2024 at 9:35 AM Resident this morning presenting with possible AMS [altered mental status]. Resident partially opening her eyes to verbal and tactile stimulus. Resident nonverbal this morning. Residents tardive dyskinesia [chronic involuntary movement disorder] is generally very active and this morning it is very mild. Resident will not squeeze my fingers on command. No facial Dropping noted. Generalized weakness noted with her extremities and trunk. Rapid shallow breathing noted . Talked to NP [nurse practitioner] and informed of residents current status with order to send to [hospital emergency room] for eval and tx [treatment] due to AMS [altered mental status]. [family member] .notified and ok with transfer to [hospital emergency room]. 911 initiated and resident was transported per stretcher via ambulance to [hospital emergency room] at this time. All paperwork sent with EMS [emergency medical services] for them and ER [Emergency Room]. <BR/>Record review of eTransfer Form-V6 dated 7/25/2024 indicated Resident #1 was sent to the hospital for the following: Resident partially opening her eyes to verbal and tactile stimulus. Non verbal. No facial dropping noted. Generalized weakness. Will not squeeze my hands. Rapid shallow breathing noted. Sending out for possible AMS [altered mental status]. The form indicated Resident #1 had special treatments and precautions of: contact infection control precautions for an infection of the buttocks. The form indicated Resident #1 was on EBP (enhanced barrier precautions). The form indicated Resident #1 was receiving wound treatment with a current wound to the buttocks. <BR/>Record review of hospital Disclosure and Consent Medical Care and Surgical Procedure dated 8/4/2024 at 12:16 PM for wound debridement indicated Resident #1's condition was infected wound of the sacral area measuring 3cm x 3.5cm x2cm that was classified as unstageable.<BR/>Record review of a picture taken at the hospital dated 7/25/2024 at 7:48 PM indicated Resident #1 had an unstageable wound to the sacral area measuring 3cm x 3.5cm x 2cm. <BR/>Record review of the hospital paperwork dated 7/25/2024 indicated admitting diagnosess of metabolic encephalopathy and pressure injury of sacral region, unstageable. <BR/>During a phone interview on 2/12/2025 at 12:25pm with Resident #1's RP (responsible party), she said neither she nor her family members had been notified that Resident #1 had developed any kind of skin problem. She said it was not until she got to the hospital emergency room that she was notified that Resident #1 had an unstageable wound to her sacral (upper buttocks) area. She said when she saw the area she took pictures and the wound was horrible. She said she made the decision in the hospital emergency room that Resident #1 would not be returning to the facility due to the unstageable wound she had received while at the facility. <BR/>During an interview on 2/12/2025 at 3:22 PM the ADON said she was not aware of Resident #1 had a wound until the day on 7/22/2024 when LVN A was notified by CNA C. She said when she saw Resident #1's bottom there was old scar tissue in the sacral area but what she treated was on the actual buttocks area and that was red with spots of blood like a scrape. She said she never saw a wound on the sacrum. She said it was possible that the necrotic tissue could have been mistaken for moisture associated skin damage tissue. She said the treatment nurse was responsible for doing weekly skin assessments.<BR/>During an interview on 2/13/2025 at 10:30 AM the DON said she went and looked at Resident #1 buttocks when a CNA asked her to look at the resident because she needed her to put a new dressing on the resident. She said the wound was on the right buttock and seemed like someone had pulled her across the bed and caused the top layer of skin to come off. She said she cleaned the wound and applied calcium alginate to the wound. She said she did not remember anything being on Resident #1's left buttock. She said she only remembered applying a dressing to one buttock on the right side. She said she did not remember seeing anything to Resident #1's sacral area. She said Resident #1 had scarring due to old pressure areas that had healed. The DON said she thought the area to the sacrum could have been missed due to Resident #1's skin coloration. She said she had a conversation with one of Resident #1's family member about the resident being in the bed by 5pm and the family member wanted her up all day and she explained that it was not good for Resident #1. She said she never staged or classified Resident #1's wound. She said she would have classified the wound as MASD (moisture associated skin damage). The DON said a skin notification worksheet was not completed and did not know why. She said the treatment nurse goes to the nurse's station and looked at the 24-hour report to check for any new skin issues every day when she came to work. The DON said if a new skin area was identified and the treatment nurse was not available, the residents charge nurse was to notify the MD and put a treatment in place, if the treatment nurse was at the facility, then it was her responsibility. She said the nurse that initially identified a new wound was supposed to do measurements, but it was not done on Resident #1. She said once the treatment nurse assessed the wound then she was supposed to measure the wound, then the resident should have been seen by the Wound Care Doctor weekly and the Wound Care Doctor would then do the measurements weekly. The DON said she made rounds with the Wound Care Doctor if the treatment nurse was not at the facility and if she was there then she looked at the worst wounds. She said the Wound Care Doctor came every Wednesday to the facility. The DON said the Wound Care Doctor never saw Resident #1 and did not know why. <BR/>During a phone interview on 2/13/2025 at 11:58 AM LVN A said the CNA C asked him to look at Resident #1's buttocks. He said the wound he saw was in her gluteal fold, low sacral area to the right. He said when he assessed the wound it was not bleeding and looked like moisture associated skin damage red area to him. He said to best of his knowledge he did not see anything that he could remember in the sacral area. He said he wiped and applied barrier cream to the area. He said he did not measure the wound. LVN A said he thought he remembered notifying the family member that night but did not know who it was. He said he notified the wound care nurse to look at it by putting a paper note in her box for the next day for her to address.<BR/>During a telephone interview on 2/13/2025 at 12:34 PM CNA C said she had been a CNA for 24 years and had taken care of a lot of residents with wounds. She said she remembered reporting an open wound on the top of Resident #1's sacrum and reported it to LVN A. CNA C said on the next day when she came back to work, she did not see a dressing on Resident #1's wound. She said she took a picture of Resident #1's wound and took her phone to the nurse's station and showed it to LVN A and told him it was bad. CNA C said the wound on Resident #1 was on the upper middle crease of the residents' buttocks and it was a bad bed sore that was open with dead tissue. She said she never reported the wound to anyone else other than LVN A.<BR/>During an interview on 2/13/2025 at 1:19 PM CNA E said she worked with Resident #1 prior to her discharging from the facility but was not working the day Resident #1 left the facility. She said Resident #1 had a place on her buttocks that looked like carpet burn like a little scrape on it. She said they were putting barrier cream on it. CNA E said she saw a pink area on her buttocks but never saw an area on her sacrum.<BR/>During an interview on 2/13/2025 at 1:40 PM CNA F said when Resident #1 discharged from the facility she had a skin tear on her bottom. She said the wound on Resident #1's bottom looked like a burn with pus and redness. She said she had reported it to the Treatment Nurse and the Treatment Nurse was treating the wound. CNA F said it looked like the picture of the residents wound that was showed to the CNA. Said she always reports any skin issues to the nurse or treatment nurse.<BR/>During a telephone interview on 2/13/2025 at 4:30 PM the Wound Care Doctor said she had never seen Resident #1. <BR/>During an interview on 2/19/2025 at 9:30 AM MDS LVN said there was a morning clinical meeting every morning and the staff nurses report to the administrative nurses on any resident issues. She said she remembered LVN A said in the morning clinical meeting that he had assessed Resident #1 and she did not have any open areas. The MDS LVN said she was never notified Resident #1 had a skin issue. She said she remembered the BOM said in the morning meeting 7/26/2024 that Resident #1's family member had called said Resident #1 would not be returning to the facility due to her having an unknown wound that she had gotten while at the facility. <BR/>During an interview on 2/19/2025 at 1:23 PM the DON said her expectation for pressure ulcers was for the nurse to measure, stage, notify the physician, responsible party and dietician. She said the nurse should also make sure treatment orders were in place. Said most of the nurses have gone through the wound care training course. She said LVN's cannot stage or classify a wound so either she or the Wound Care Doctor would stage it or classify the wound by the next day. She said she was not sure how the wound on Resident #1 got missed, she said all she saw was Resident #1's right buttock and did not see the unstageable wound. She said Resident #1's family called the BOM and said they were not bringing Resident #1 back due to the wound that she had received while at the facility. The DON said there was no notification to Resident #1's Responsible Party because they were not aware that Resident #1 had a wound. She said her expectation was if there was an order for a treatment, she expected it to be done and that nurses are responsible for total patient care.<BR/>During an interview on 2/19/2025 at 2:02 PM the Administrator said skin assessments should be completed on admission/readmission and weekly. He said his expectation was for the nurses to identify and treat wounds per the physicians' orders and plan of care. <BR/>Record review of Licensed Nurse Proficiency Audit dated 11/09/2024 indicated LVN A had shown satisfactory performance with dressing changes. <BR/>Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV). 11. Director of Nursing or designee to inservice nurses and CNAs on above prevention . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed. 7. Nursing Care Plan. 1. Identify the problem of pressure injuries on the Nursing Care Plan. 2. Under Nursing Intervention, list physician ordered treatments. 3. Staffing definitions recognize the following limitations: .When necrosis is present accurate staging of the pressure injury is not possible until the necrosis has sloughed or the wound has been debrided . Assessment of the pressure injury should also include the site, size, and W x Lx D, of the injury. Surrounding tissue, color, exudate, wound edges, sinus tracts, odor, tunneling and undermining should also be documented at least weekly and upon decline. <BR/>An Immediate Jeopardy (IJ) was identified on 2/18/2025 at 3:49 PM due to the above failures. The facility Administrator was notified. The Administrator was provided with the IJ template on 2/18/2025 at 3:49 PM. <BR/>The following plan of removal submitted by the facility was accepted on 2/18/2025 at 5:30 PM:<BR/>Plan of Removal <BR/>Problem: F686- Failure to Provide Treatment/Services to Prevent/Heal Pressure Ulcer<BR/>Interventions:<BR/>Resident #1 no longer resides in the facility as of 2/18/25.<BR/>A head-to-toe assessment was completed on all residents as of 2/18/25 by the DON/ADON/MDS/Compliance Nurse. The MD was notified as of 2/18/25 on all residents with pressure wounds by the DON. Orders were received for treatment and implemented as of 2/18/25 by the Treatment and Charge Nurses. <BR/>Weekly ulcer assessments and non-ulcer assessments were completed as of 2/18/25 to include measurements by DON/ADON/MDS/Compliance Nurse. <BR/>The Dietician was notified as of 2/18/25 of all residents with pressure wounds by the DON. <BR/>All residents with pressure wounds have appropriate supplements in place to promote wound healing. Reviewed and completed by the DON and Compliance Nurse as of 2/18/25.<BR/>The Dietician and Physician will be notified for recommendations/orders when new or worsening pressure wounds are identified by the DON and Treatment Nurse. This will start 2/18/25. <BR/>All wound care orders were reviewed as of 2/18/25 by DON, ADON, and Compliance Nurse to ensure pressure wound care recommendations are being followed appropriately for all residents.<BR/>Braden Scale assessments were completed on all residents as of 2/18/25 by the Regional Compliance Nurse and DON. <BR/>Resident care plans for pressure wounds and skin issues were reviewed and updated to include interventions promoting wound healing. This was completed by the Regional Compliance Nurse and DON as of 2/18/25. <BR/>The Medical Director was notified of immediate jeopardy on 2/18/25 by the Administrator. <BR/>An ADHOC QAPI meeting was held with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal as of 2/18/25.<BR/>Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse as of 2/18/25 on the following topics. <BR/>o Pressure Injury Prevention, Assessment, staging, and Treatment Policy to include early prevention/treatment whenever a change in skin status occurs. Documentation to include measurements and staging/classifying pressure wounds appropriately with documentation of an accurate description in the weekly ulcer assessment. Completing Braden Scale assessments upon admission, readmission, and as needed to help identify when a resident might be at risk for skin breakdown. <BR/>o Skin Integrity management Policy to include identifying/documenting skin issues to include staging/classifying pressure wounds appropriately and initiating an appropriate treatment plan. Also to include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing.<BR/>o Notification of a Change in Condition Policy-to include notifying the physician and family/RP when a new skin issue or pressure wound has been identified with documentation in the weekly skin assessment, weekly non-pressure assessment, weekly ulcer assessment, and care plan. Also including notifying the nurse when a new skin issue has been identified.<BR/>o Skin Assessment policy to include completing head-to-toe assessments upon admission/readmission and weekly to help identify/document skin issues with physician and family/RP notification and treatment orders.<BR/>o Abuse and Neglect - failure to identify properly stage pressure wounds, classify skin issues, or provide treatments as ordered can be considered neglect.<BR/>In-services:<BR/>The following in-services were initiated by Regional Compliance Nurse, DON for all charge nurses. Any charge nurses not present or in-serviced as of 2/18/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completion date 2/18/25. <BR/>o Pressure Injury Prevention, Assessment, staging, and Treatment Policy to include early prevention/treatment whenever a change in skin status occurs. Documentation to include measurements and staging/classifying pressure wounds appropriately with documentation of an accurate description in the weekly ulcer assessment. Completing Braden Scale assessments upon admission, readmission, and as needed to help identify when a resident might be at risk for skin breakdown. <BR/>o Skin Integrity management Policy to include identifying/documenting skin issues to include staging/classifying pressure wounds appropriately and initiating an appropriate treatment plan. Also to include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing.<BR/>o Notification of a Change in Condition Policy-to include notifying the physician and family/RP when a new skin issue or pressure wound has been identified with documentation in the weekly skin assessment, weekly non-pressure assessment, weekly ulcer assessment, and care plan. Also including notifying the nurse when a new skin issue has been identified.<BR/>o Skin Assessment policy to include completing head-to-toe assessments upon admission/readmission and weekly to help identify/document skin issues with physician and family/RP notification and treatment orders.<BR/>o Abuse and Neglect - failure to identify properly stage pressure wounds, classify skin issues, or provide treatments as ordered can be considered neglect.<BR/>o <BR/>The following in-services were initiated by Regional Compliance Nurse, DON for all other nursing staff and therapy. Any staff not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completed as of 2/18/25. <BR/>o Notification of a Change in Condition Policy- to include notifying the nurse when a new skin issue has been identified.<BR/>o Skin integrity management and pressure injury prevention, assessment, and treatment. To include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing.<BR/>The following in-services were initiated by Regional Compliance Nurse, DON for all staff. Any staff who are not present will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completed as of 2/18/25.<BR/>o Abuse and Neglect - failure to identify skin issues or provide treatments can be considered neglect.<BR/>On 2/19/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Record review of Resident #1's electronic medical record confirmed Resident #1 discharged to the hospital on 7/25/2024 and did not return to the facility. <BR/>Record review of electronic head to toe assessments date 2/13/2025 through 2/18/2025 with no concerns noted.<BR/>Record review of weekly ulcer and non-ulcer assessments completed 2/12/2025 through 2/18/2025 with no concerns noted.<BR/>Record review of attestation dated 2/18/2025 at 3:58 PM confirmed the Dietician was notified of all residents with pressure wounds. <BR/>Record review of attestation dated 2/18/2025 confirmed all residents with pressure wounds have appropriate supplements in place to promote wound healing. <BR/>Record review of attestation stating the Dietician and Physician will be notified for recommendations/orders when new or worsening pressure wounds were identified. <BR/>Record review of all wound care orders were reviewed by the DON, ADON, and Compliance Nurse on 2/18/2025 to ensure pressure wound care recommendations were being followed. <BR/>Record review of the electronic medical record confirmed all Braden scores had been updated on 2/13/2025.<BR/>Record review of the electronic medical record confirmed all resident care plans had been reviewed and updated as of 2/18/2025. <BR/>Record review of AdHoc QAPI meeting minutes confirmed to discuss plan of removal as of 2/18/2025 with the following in attendance: Administrator, ADON, DON, Medical Director, HR, MDS, Dietary Manager, DOR, Activity Director, Housekeeping Supervisor, BOM, and Medical Records. <BR/>Record review of inservices provided to the Administrator, DON, and ADON dated 2/12/2025 consisted of: Pressure Injury Prevention, Skin Integrity Management Policy, Skin Assessment Policy, and Abuse and Neglect. <BR/>Record review of inservices provided to Charge Nurses dated 2/12/2025 and consisted of: Pressure Injury Prevention, Skin Integrity Management Policy, Notification of a Change in Condition Policy, Skin Assessment Policy, and Abuse and Neglect. <BR/>Record review of inservices provided to all staff dated 2/12/2025 and consisted of: Notification of a Change in Condition Policy, Skin Integrity Management, and Abuse and Neglect. <BR/>During an interview on 2/19/2025 at 12:10 PM CNA E said some wound prevention interventions consisted of: turning and repositioning every 2 hours, elevating legs, changing positions, wedges, pillows to offset pressure points, wheelchair cushions, and movement. She said she would immediately notify the charge nurse and DON of any new wounds or wounds without dressings. She said it could be considered abuse or neglect for not preventing and treating wounds. <BR/>During an interview on 2/19/2025 at 12:18 PM CNA G said some wound prevention interventions consisted of: turning and repositioning every 2 hours, elevating legs, changing positions, wedges, pillows to offset pressure points, wheelchair cushions, and movement. She said she would immediately notify the charge nurse and DON of any new wounds or wounds without dressings. She said it could be considered abuse or neglect for not preventing and treating wounds. <BR/>During an interview on 2/19/2025 at 12:21 PM LVN H said some wound care interventions consisted of: Assessment, Notify DON and ADON, Notify family and Physician, initiate treatment, wound care sheet, documentation, measurements, and Braden scale. She said skin integrity management consisted of: identifying, classifying, and[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 5 residents (Resident #3, Resident #4 and Resident #5) and reviewed for pharmacy services. <BR/>The facility failed to remove discontinued controlled medications from the medication cart for Resident #3, Resident #4 and Resident #5 who had expired. <BR/>The facility failed to ensure proper destruction of 71 Hydrocodone 10/325mg, 103 Lorazepam 1mg, 17 Lorazepam 0.5mg, and 94.75ml Morphine Sulfate 100mg/5ml that were controlled medications for Resident #3, Resident #4 and Resident #5 who had expired. <BR/>These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion.<BR/>Findings included: <BR/>1.Record review of facility electronic face sheet indicated Resident # 3 was an [AGE] year-old female admitted to facility on [DATE]. Resident #3's diagnoses included: malignant neoplasm of liver (liver cancer), and secondary malignant neoplasm of bone (bone cancer).<BR/>Record review of Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 14 indicating no cognitive impairment.<BR/>Record review of discharge MDS dated [DATE] indicated Resident #3 had expired in the facility on [DATE].<BR/>Record Review of comprehensive care plan dated [DATE] indicated Resident # 3 had a terminal prognosis of malignant neoplasm of liver and had received hospice services with interventions that included: .Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately is there is breakthrough pain .<BR/>Record review of physician orders for [DATE] indicated Resident #3 had an order for Hydrocodone 10/325mg give 1 tablet every 6 hours as needed, Lorazepam 1mg give 1 tablet every 6 hours as needed, and Morphine Sulfate 100mg/5ml give 0.25ml-0.5ml every 2 hours as needed. <BR/>Record review of narcotic count sheets indicated Resident #3 had 31 Hydrocodone 10/325mg, 56 Lorazepam 1mg, and 26.75ml of Morphine Sulfate remaining at the time of Resident #3's expiration. <BR/>2.Record review of facility electronic face sheet indicated Resident #4 was an [AGE] year-old male admitted to facility on [DATE]. Resident #4's diagnoses included: metabolic encephalopathy (brain does not function properly), malignant neoplasm of lower lobe, right bronchus or lung (lung cancer), and hypertension (high blood pressure).<BR/>Record review of admission MDS dated [DATE] indicated Resident #4 had a BIMS of 10 indicating moderate cognitive impairment.<BR/>Record review of discharge MDS dated [DATE] indicated Resident #4 had expired in the facility on [DATE].<BR/>Record Review of comprehensive care plan dated [DATE] indicated Resident #4 had a terminal prognosis of squamous cell carcinoma and had received hospice services with interventions that included: .work with nursing staff to provide maximum comfort for the resident .<BR/>Record review of physician orders for [DATE] indicated Resident #4 had an order for Hydrocodone 10/325mg give 1 tablet every 4 hours as needed, Lorazepam 1mg give 1 tablet every 2 hours as needed, and Morphine Sulfate 100mg/5ml give 1ml every hour as needed. <BR/>Record review of narcotic count sheets indicated Resident #4 had 40 Hydrocodone 10/325mg, 30 Lorazepam 1mg, 17 Lorazepam 0.5mg, and 44ml of Morphine Sulfate remaining at the time of Resident #4's expiration. <BR/>3.Record review of facility electronic face sheet indicated Resident #5 was an [AGE] year-old male admitted to facility on [DATE]. Resident #5's diagnoses included: atrial fibrillation (irregular heartbeat), malignant neoplasm of prostate (prostate cancer), and dementia (decline in mental ability).<BR/>Record review of admission MDS dated [DATE] indicated Resident #5 had a BIMS of 04 indicating severe cognitive impairment.<BR/>Record review of discharge MDS dated [DATE] indicated Resident #5 had expired in the facility on [DATE].<BR/>Record Review of comprehensive care plan dated [DATE] indicated Resident #4 had a terminal prognosis and had received hospice services with interventions that included: .if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met .<BR/>Record review of physician orders for [DATE] indicated Resident #3 had an order for Lorazepam 1mg give 1 tablet every 6 hours as needed, Morphine Sulfate 20mg/ml give 0.25ml every 2 hours as needed, and Morphine Sulfate 20mg/ml give 0.5ml every 2 hours as needed. <BR/>Record review of narcotic count sheets indicated Resident #5 had 17 Lorazepam 1mg, and 24ml of Morphine Sulfate remaining at the time of Resident #5's expiration.<BR/>During an interview on [DATE] at 12:21 PM LVN H said when a resident had expired, they count the residents remaining narcotics with the hospice nurse. She said she counted the remaining narcotics the night Resident #3 and Resident #4 expired with the hospice nurse and then locked the medications in the cart to give to the DON. She said the next evening on [DATE] when she came in to work and counted the cart with LVN A he told her he had thinned out the cart and turned the medication in with the count sheets to the DON. She said the hospice sheets were still on the cart in the back of the book, but the narcotic count sheets were missing from the book. She said the following day [DATE] the DON called her and woke her up asking where the narcotics where and she told her that LVN A had said he had thinned the cart out and turned them in to the DON. <BR/>During a phone interview on [DATE] at 11:58 AM LVN A said he had been passing pills and was tired and frustrated that day, so he decided to lighten his load by destroying the expired residents' medications. He said he wasted the medication in the 100-hall guest room bathroom. LVN A said he poured the medications in a cup and then flushed them in the toilet. LVN A said he had been a nurse for 29 years and knew he was supposed to give the medication to the DON and the Pharmacist was supposed to destroy them. He said in hindsight he knew it was not his best idea. Said he was suspended and terminated. He said he had worked for the facility on and off for 11-12 years and had never destroyed medications before. He said the facility had in the past educated him on the proper way to destroy medications. <BR/>During an interview on [DATE] at 1:23 PM the DON said on Tuesday [DATE], she went to get the expired residents narcotics out the medication cart. She said LVN H told her they were not on the cart and LVN A had said he gave them to the DON to destroy. She said she did not remember LVN A giving her the medications but went and checked her locked medication cabinets for medications in case she had forgotten but did not find the medications. She said she called LVN A he told her that he had destroyed the medications by flushing them down the toilet in the family room bathroom because he needed space on the cart. The DON said LVN A told her he had the count sheets in his personal bag and needed to find someone to sign with him that he had destroyed the medications. She said she told LVN A he was not going to find anyone to sign with him if they had not witnessed the destruction. She said LVN A did return the count sheets to the facility. She said LVN A told her he just was not thinking straight. The DON said she called and reported the incident to the Administrator immediately and LVN A was suspended and ultimately terminated. She said her expectation was for the nurses to turn in medications to her to be destroyed with the pharmacy consultant.<BR/>During an interview on [DATE] at 2:02 PM the Administrator said his expectation was for nurses to turn in all discontinued narcotic medications to the DON for destruction with the pharmacy consultant.<BR/>During an interview on [DATE] at 2:02 PM the Administrator said when he spoke with LVN A he asked him to take a drug test. He said when the results of the drug test where positive LVN A told him he had prescriptions for the positives on the drug test. He said he asked LVN A to provide the prescriptions to the facility, but LVN A never provided any prescriptions. He said LVN A was suspended and ultimately terminated. The Administrator said the expectation for drug destruction would be for the nurses to hand over discontinued narcotics to the DON. He said the DON and the pharmacy consultant should reconcile the drugs and then destroy them according to facility policy.<BR/>Record review of a urine drug screen dated [DATE] for LVN A indicated positive for cocaine, opiates, codeine, and hydrocodone.<BR/>Record review of facility policy Discontinued Medications undated indicated: 1. The nurse that received the order to discontinue a medication is responsible for: .Removing the medication from the medication storage, filling out the form to be attached to the medication that discontinued, if applicable, personally giving the form and medication to the DON or ADON .<BR/>Record review of facility policy Drug Destruction Policy dated [DATE], indicated: It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law . 2. Drugs to be destroyed will be destroyed under the supervision of a consultant pharmacist and at least one of the following: Director of Nursing, Assistant Director of Nursing, or Administrator. 3. Nursing staff will submit to Director of Nursing any medication and any applicable log that has expired, been discontinued by physician or that had been prescribed to a resident who no longer resides at the facility. 4. The nurse submitting the discontinued medication, will verify along with the Director of Nursing that the amount of medication remaining matches the log. After verification, both the nurse and the Director of Nursing will sign the log. 5. The nurse will make a copy of the signed log and provide to the administrator. The Director of Nursing will maintain the original log and medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 16 residents reviewed for assessments. (Resident #26).<BR/>The facility failed to complete an accurate resident assessment for Resident #26 indicating the resident had an inaccurate diagnosis of bipolar. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of the face sheet dated 04/16/24 indicated Resident #26 was [AGE] year-old female and was admitted [DATE] with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), mood disorder (a mental health condition that primarily affects emotional state) , and cognitive communication disorder (difficulty communicating due to injury of the brain that control ability to think). <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #26 was understood and understood others. Resident #26 did not have a BIMS score which indicated severely cognitively impairment. The MDS indicated Resident #26 was bipolar.<BR/>Record review of PASRR Level 1 screening dated 4/3/2020, indicated Resident #26 did not have a mental illness.<BR/>Record review of care plan revised on 2/1/2024 indicated Resident #26 had potential for mood, behaviors and impaired social interaction, severe anxiety, and disorganized thinking and was referred to psychiatry services within the facility and Resident #26 refused. <BR/>Record review of Visit note dated 4/27/2024 indicated Resident #26 had Huntington's, mood disorder, depressive episodes, cognitive communication deficit, agitation, aggressive behaviors, verbal behaviors and resistance to ADL's and medications. <BR/>During an interview on 6/5/2024 at 2:11 p.m., the MDS nurse said she was responsible for ensuring the MDS was accurate. The MDS nurse said it would be important to have an accurate assessment for Resident #26 to have proper treatment and care. The MDS nurse said she was responsible for the diagnoseis on the MDS. The MDS nurse said she did not see a diagnosis on Resident #26's chart for bipolar and she would get with the Rregional Nurse to modify the assessment and the Regional Nurse would ensure corrections. The MDS nurse said she was expected to make corrections and modifications when a data error was identified. <BR/>During an interview on 6/5/2024 at 2:21 p.m., the ADON said the MDS should be corrected when an error is identified. The ADON said it was important to have an accurate assessment on the residents, so the staff know how to care for the residents. The ADON said the staff could have the wrong interventions and goals in place. She said if the wrong diagnosis was added, a resident would have incorrect orders in place and the plan of care would not be addressed properly. <BR/>During an interview on 6/5/2024 at 2:36 p.m., the ADM said the MDS nurse, and the DON was responsible for ensuring the MDS and assessments were completed with accuracy. The ADM said the MDS should be corrected when an error was identified. The ADM said an inaccurate assessment may or may not affect the resident's care depending on what was inaccurate. The ADM said the facility would want to make sure the staff provide the residents with the correct diagnosis. <BR/>Review of the facility's policy titled Minimum Data Set (MDS) Policy for MDS assessment data accuracy, dated 2/2021, indicated, .the purpose of the MDS policy was to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who were familiar with his/her physical, mental, and psychological well-being . according to CMS's RAI Version 3.0 Manual . the MDS was a core set of screening, clinical and functional status elements, including common definitions and coding categories, which form a foundation of a comprehensive assessment for all residents of nursing home .Federal regulations at 42 CFR 483.20 (b) (1) (xviii), (g) and (h) require that .the assessment accurately reflects the resident's status .the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shift . Procedure .8. Each individual participating in the completions of the MDS . In addition, each individual responsible for a portion of the MDS must sign and certify that their portion of the assessment if accurate and complete .9. Once the assessment is completed, the RN signs certifying the assessment is completed .By signing the assessment, the RN is certifying each section was completed by the appropriate person and the individual is qualified to determine the accuracy of the portion of the resident's assessment he/she completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 3 residents (Residents #2) reviewed for care plans.<BR/>The facility failed to implement Resident #2's care plan by not changing the dressing to her diabetic ulcer on the left second toe daily. On 2/12/2025 Resident #2's dressing was dated for 2/9/2025.<BR/>This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.<BR/>Findings include: <BR/>Record review of a face sheet for Resident #2 dated 2/18/2025 indicated that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: diastolic congestive heart failure (left ventricle of the heart cannot relax normally), protein calorie malnutrition (reduced availability of nutrients), type 2 diabetes mellitus (high blood sugar levels). <BR/>Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated she had a BIMS score of 13, indicating intact cognition. Section M of same MDS assessment indicated that she was at risk of developing pressure ulcers/injuries and Resident #2 did not have any diabetic foot ulcers. <BR/>Record review of a care plan for Resident #2 dated 2/13/2025 indicated Resident #2 had a diabetic ulcer to left second toe with interventions that included: Administer treatments as ordered and monitor for effectiveness. <BR/>Record review of physician orders for Resident #2 dated 1/17/2025 indicated: Left foot 2nd toe-cleanse area with N/S [normal saline] pat dry apply silvasorb gel to wound with [NAME] peri-wound cover with dry foam and secure with tape PRN [as needed] soiled/dislodgement one time a day. <BR/>Record review of the treatment administration record dated 2/18/2025 indicated Resident #2 had not received treatment to the left foot 2nd toe on 2/9/2025, 2/10/2025, and 2/11/2025. <BR/>Record review of physician's progress note dated 2/6/2025 indicated: Patient here with her [family member] very concerned that her mother is not getting good care for her left second toe. She states the bandage is not changed initially .<BR/>During an observation and interview on 2/12/2025 at 10:10 AM with Resident #2's family member said she was concerned that Resident #2 was not getting wound per the physician's orders. She said on 2/12/2025 Resident #2's dressing to the left foot 2nd toe had not been changed since 2/9/2025. She said Resident #2's dressing changes had not been getting changed daily as ordered. She said she had addressed the issue with the ADON previously. Observation of Resident #2's left foot 2nd toe revealed a dressing dated 2/9/25. <BR/>During an interview on 2/19/2025 at 1:23 PM the DON said she did not know why Resident #2's treatment to her left 2nd toe had not been done. She said by not having her treatment done per the physician's orders could cause the residents wound to become worse. <BR/>During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for all wound care to be done as per the physician's orders. He said it just was not done on Resident #2. He said he was told the treatment nurse was out sick but the charge nurse should have completed the wound care. He said by not receiving the wound care per physician orders and the care plan it could cause the wound to become worse.<BR/>During an interview on 2/19/2025 at 3:15 PM the ADON said she did not know why the wound care had not been completed on Resident #2. <BR/>Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living the necessary services to maintain personal hygiene for 2 of 16 residents reviewed for ADLs. (Resident #25 and Resident #43)<BR/>The facility failed to provide scheduled baths/showers to Resident #25 and Resident #43.<BR/>This failure could place residents who required assistance from staff for ADL's at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 06/05/24 revealed Resident #25 was [AGE] years old and was admitted on [DATE] with diagnoses including brain damage, reduced mobility, and depression. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #25 was understood and understood others. The MDS indicated a BIMS score of 12 which indicated moderate impaired cognition. The MDS indicated Resident #25 required substantial/maximal assistance with bathing/showering. <BR/>Record review of a care plan last revised on 03/26/24 indicated Resident #25 had a history of depression and was at risk for impairment to skin integrity. There was an intervention to keep skin clean and dry. The care plan indicated the resident had an ADL self-care performance deficit and required 1 staff member assistance with bathing. There was an intervention to provide the resident with a sponge bath when a full bath or shower could not be tolerated. The care plan did not indicate the resident refused or resisted care. <BR/>Record review of the nurse's notes from 05/01/24 to 06/05/24 did not indicate Resident #25 had refused baths/showers.<BR/>Record review of a Bath Schedule indicated Resident #25 was to receive baths on Tuesdays, Thursdays, and Saturdays. There was a note at the bottom of the schedule that indicated, Please adjust bath schedule to the needs of the resident. If resident desires bath/shower on another shift accommodate that resident. NO EXCEPTIONS!!!.<BR/>Record review of bathing documentation dated 05/2024 for Resident #25 indicated no documented evidence the resident received a bath/shower on Tuesday - 05/02/24, Thursday - 05/09/24, Saturday - 05/11/24, Tuesday - 05/14/24, Thursday 05/16/24, Saturday - 05/18/24, Tuesday - 05/21/24, Thursday - 04/23/24, and Thursday - 05/30/24. There were only 3 baths/showers documented for 05/2024. <BR/>Record review of bathing documentation for Resident #25 from 06/01/24 - 06/05/24 indicated no documented evidence the resident received a scheduled bath/shower on Saturday - 06/01/24 or Tuesday - 06/04/24. <BR/>During an interview on 06/03/24 at 9:25 a.m., Resident #25 said she was only showered every once in a while. She said she only had one bath in May 2024. She said CNA D gave it to her. She said CNA D was the only aide that would give her a shower. <BR/>During an interview and observation on 06/05/24 at 12:10 p.m., Resident #25 said bed baths were okay, but she preferred to go to the shower. She said she had never refused a bath or shower. She said sometimes her hair itched from not being bathed. She said she did not feel clean. She said she had not had a shower in June 2024. She said she marked a S on her calendar on the days she was showered. There was a June 2024 calendar hanging on the wall beside her bed. There were no days marked with an S. <BR/>2. Record review of a face sheet dated 06/05/24 revealed Resident #43 was [AGE] years old and was admitted on [DATE] with diagnoses including heart failure, depression, reduced mobility and need for assistance with personal care. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #43 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #43 required partial/moderate assistance with bathing. <BR/>Record review of a care plan last revised on 04/19/24 indicated Resident #43 had an ADL self-care performance deficit due to decrease mobility, morbid obesity, and limited range of motion. The care plan indicated the resident was bedfast most of the time. There was an intervention to provide the resident with a sponge bath when a full bath or shower could not be tolerated. The care plan indicated Resident #43 required extensive staff participation with bathing. The care plan did not indicate the resident refused or resisted care.<BR/>Record review of the nurse's notes from 05/01/24 to 06/05/24 did not indicate Resident #43 had refused baths/showers.<BR/>Record review of a Bath Schedule indicated Resident #43 was to receive baths on Monday, Wednesday, and Friday. There was a note at the bottom of the schedule that indicated, Please adjust bath schedule to the needs of the resident. If resident desires bath/shower on another shift accommodate that resident. NO EXCEPTIONS!!!.<BR/>Record review of bathing documentation dated 05/2024 for Resident #43 indicated no documented evidence the resident received a bath/shower on Wednesday - 05/01/24, Friday - 05/03/24, Monday - 05/06/24, Wednesday - 05/08/24, Monday - 05/13/24, Friday - 05/17/24, Monday - 05/20/24, Wednesday - 05/22/24, Friday - 05/24/25, Monday - 05/27/24, Wednesday - 05/29/24, and Friday - 05/31/24. There were only 2 baths/showers documented for 05/2024. <BR/>Record review of bathing documentation for Resident #43 from 06/01/24 - 06/05/24 indicated no documented evidence the resident received a scheduled bath/shower on Monday - 06/03/24. <BR/>During an interview on 06/03/24 at 9:42 a.m., Resident #43 said she did not receive her scheduled baths. She said she was only being bathed once a week.<BR/>During an interview on 06/05/24 at 1:36 p.m., Resident #43 said she did not like to be showered because it hurt her to sit on the shower chair. She said she preferred bed baths. She said she was scheduled for baths on Mondays, Wednesdays, and Fridays. She said it bothered her to not get her baths. She said she felt dirty. She said it upset her .<BR/>During an interview on 06/05/24 at 1:40 p.m., CNA D said she had never provided care to Resident #43. She said she had provided care to Resident #25. She said the 2:00 p.m. to 10:00 p.m. shift was responsible for bathing Resident #25. She said she would bathe Resident #25 any time she asked to be bathed. She said Resident #25 had told her that she was the only aide that would give her a bath. She said residents should be bathed three times a week and whenever they asked to be bathed. She said Resident #25 never refused to be showered and would always go when asked. CNA D said, She loves her showers.<BR/>During an interview on 06/05/24 at 2:04 p.m., CNA H said Resident #43 had never asked her to give her a bath. She said the 2:00 p.m. to 10:00 p.m. shift was responsible was responsible for giving her baths. She said if she had asked she did not mind bathing her. She said she never told her she had missed her baths. She said she did not know if she had refused her baths. CNA H said if a resident refused a bath the CNAs were supposed to tell the charge nurse and they were supposed to chart it. She said she had known Resident #43 to have refused baths. <BR/>During an interview on 06/05/24 at 2:10 p.m., CNA E said residents were bathed three times a week. She said she had worked with Resident #25, and she did get her baths. She said she did not know where it was documented. She said Resident #43 had told her she was not getting her baths. She said she did not know why Resident #43 had missed her baths . She said she documented any refusals from any resident and told the charge nurse. She said the charge nurse was supposed to document the refusal.<BR/>During an interview on 06/05/24 at 2:16 p.m., LVN A said Resident #43 received bed baths if she got anything . He said she did not like getting out of bed. She said Resident #25 had not complained of not getting her baths. He said Resident #25 did not like getting out of bed. He said he did not know why the residents had missed their scheduled baths. He said if a resident refused it was supposed to be reported to the charge nurses and they were supposed to chart the refusal in the progress notes. He said not being bathed could cause skin issues and dignity issues.<BR/>During an interview on 06/05/24 at 2:35 p.m., the ADON said the DON was out of the facility on vacation. She said all residents were scheduled to be bathed or showered three times a week. She said any time a resident wanted a bath staff should give them a bath. She said she would have expected for the residents to have at least received their scheduled bath. She said she did not know why the residents had not been bathed. She said she felt they had been bathed. She said she felt it was a documentation issue. She said Resident #43 had refused baths at times. She said charge nurses were supposed to document any refusals in the progress notes.<BR/>During an interview on 06/05/24 at 2:58 p.m., the Administrator said he had encouraged Resident #43 to get out of bed. He said she cried and had refused baths. He said he did visit with all the residents and Resident #25 had never told him she was not getting her baths. He said he understood how the documentation looked. He said both residents were offered baths, and both refused baths. He said he would have expected any refusals to have been documented. He said there had been a problem with their electronic charting system. He said neither resident had any skin issues and he felt if they went that long without a bath, they would. He said a resident not getting their scheduled baths could cause a dignity issue, skin breakdown, and/or cause an odor. <BR/>Record review of a Refusal of Showers by Resident, In-Service Training Attendance Roster for CNA's and Nurses Only dated 02/13/24 indicated, .All showers must be given on the days and shifts that they are assigned. If the Resident refuses, please report to the Charge Nurse, the Charge Nurse is to follow-up and chart accordingly .<BR/>Record review on a Giving Showers, In Service Training Attendance Roster dated 04/05/24 indicated, Please remember to give showers to residents as they are scheduled .we must offer them a shower on scheduled days, if they refuse, please report refusal to the charge nurse. Sometimes it takes someone else to speak to them and they will accept, this isn't always the case, but it can then be charted concerning showers . <BR/>Review of a Bedbath, Complete facility policy dated 2003 indicated, .The complete bedbath is performed for those residents on bedrest who need total or partial assistive care. It is done to cleanse the skin to remove soil, dead epithelial cell, microorganisms, and promote comfort, exercise, and relaxation. The aging skin becomes thinner, drier, and more fragile and requires special consideration in regards to soaps, oils, and frequency of bathing .Goals .The resident will maintain skin integrity .The resident will be clean and free of dryness, irritation, or pruritus (itching) .The resident will verbalize a feeling of comfort and well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 3 of 12 residents reviewed for respiratory care. (Resident #20, Resident #35 and Resident #247).<BR/>The facility failed to date the oxygen tubing for Resident #35 and Resident # 247. <BR/>The facility failed to properly store the oxygen tubing for Resident 35.<BR/>The facility did not ensure Resident #20 nebulizer (a device used to deliver liquid medication in an aerosol form to a resident's lungs) was dated and stored properly when not in use.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/> Findings included: <BR/>1. Record review of the face sheet dated 07/1/20 indicated Resident #35 was [AGE] years old, readmitted on [DATE] with diagnoses of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Heart Failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and Parkinson (disease of the nervous system). <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #35 made himself understood and understood others. Resident #45 had a BIMS (brief interview for mental status) score of 15 which indicated he was cognitively intact. The MDS indicated Resident #35 required extensive assist with bed mobility, dressing, toileting, personal hygiene and bathing; set up help for eating. The MDS indicated that Resident #35 required oxygen. <BR/>Record review of the care plan dated 01/20/22 for Resident #35 indicated he was at risk for SOB (shortness of breath), chest pain and increased edema. Intervention: Apply oxygen as ordered.<BR/>Record review of the Physician order dated 11/15/21 indicated Resident #35 was to have oxygen at 3 liter per nasal cannula while in bed and as needed when out of bed.<BR/>During an observation on 03/07/22 at 10:19 a.m., water canister dated 03/4/22 but no date on tubing and tubing was on the floor. <BR/>During an observation on 03/8/22 at 09:06 a.m., Resident #35 in his bed with HOB (head of bed) up, alert and watching TV. Noted oxygen tubing with no date and tubing on floor, not properly stored. <BR/>During and observation on 03/09/22 at 10:08 a.m., resident #35 in his bed, oxygen tubing on concentrator but not properly stored.<BR/>2. Record review of the face sheet dated 04/7/20 indicated Resident #20 was [AGE] years old, readmitted on [DATE] with diagnoses of COVID (a highly contagious respiratory disease), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Diabetes Mellitus. <BR/>Record review of the care plan for Resident #20 had no indication for nebulizer treatments.<BR/>Record review of the Physician order dated 03/2/22 indicated Resident #20 was to have Albuterol Sul 2.5MG/3ML Solution, give 1 inhalation every six hours as needed for SOB (shortness of breath) or wheezing. <BR/>During an observation on 03/07/22 at 09:35 a.m., HHN (handheld nebulizer) machine on nightstand with no date on tubing and not stored properly. <BR/>During and observation on 03/08/22 at 11:25 a.m., Resident # 20 in her bed with HHN machine on nightstand with no date on tubing and not stored properly. <BR/>During an observation on 03/09/22 at 01:32 p.m., Resident #20 in her bed alert, HHN machine on nightstand with no date on tubing and not stored properly. <BR/>3. Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident is a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). <BR/>Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems.<BR/>Observation on 03/07/22 09:35 AM revealed that Resident #247 had oxygen on at 3L/min no dates on oxygen tubing. <BR/>Observation on 03/09/22 01:50 PM revealed that Resident #247 had returned to his room after therapy and did not have date on oxygen tubing. <BR/>During an interview on 03/09/22 at 02:05 p.m., LVN A said that HHN tubing should be dated and, in a bag, when not in use. She said that her order was for PRN and she was not using at this time. DON removed HHN machine. LVN A said failure to properly store tubing could lead to infection.<BR/>During an interview on 03/09/22 at 02:11 p.m., the DON said that her expectations was for tubing on oxygen and HHN should be changed every Sunday night and should have nurse initial and date on tubing and water canister. She said if tubing was not being used, tubing should be properly stored and failure to properly change or store tubing could cause infection.<BR/>During an interview on 03/09/22 at 02:42 p.m., the ADM said she was not sure when oxygen and HHN tubing should be changed but felt like the DON was responsible to make sure this is happening. Failure to make sure that oxygen and HHN tubing are changed could lead to residents becoming sick and can lead to an infection control issue.<BR/>During an interview on 03/09/22 at 03:35 p.m., LVN H said water canisters and tubing for oxygen and HHN should be changed out every Sunday nights; nurse should initial and date when changed. If tubing was not in use it should be properly stored. Failure could cause the resident an infection. <BR/>Record review of policy revised October 2010; steps 29-30 indicate: When equipment is completely dry, store in plastic bag with residents' name and date on it and change equipment and tubing every seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 16 residents reviewed for pain. (Resident #203)<BR/>1.The facility failed to effectively manage Resident #203's pain. <BR/>2.The facility failed to ensure Resident #203's low air loss mattress was plugged in, functioning, and fully inflated to prevent pain. <BR/>3.The facility failed to ensure LVN B notified Resident #203's physician after a family member requested a medication change to manage his pain related to muscle spasms. <BR/>These failures could result in residents experiencing unnecessary pain and a decreased quality of life. <BR/>Findings included: <BR/>Record review of Resident #203's face sheet dated 6/04/24 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #203 had diagnoses which included stage 4 pressure ulcer to sacrum (most severe pressure ulcer to bottom of spine, full thickness skin loss, may be muscle, bone tendon, or joint involvement), incomplete C5-C7 quadriplegia (paralysis or weakness in all four limbs, but with some ability to move, feel sensations, or control automatic body processes), reflex neuropathic bladder (nerves and muscles that control the bladder do not work properly and causes difficulty urinating), benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlarges and results in difficulty urinating), resistance to multiple antimicrobial drugs, depression (persistent sadness), insomnia (hard to fall asleep, stay asleep, or get quality sleep), cystostomy (opening into gallbladder to drain fluid), and pain.<BR/>Record review of Resident #203's hospital history and physical dated 4/30/24 revealed he had incomplete Quadriplegia with a history of muscle spasms and pain, and he should continue as needed medications for spasms and pain control.<BR/>Record review of Resident #203's admission MDS revealed it had not been completed prior to survey exit.<BR/>Record review of Resident #203's care plan initiated on 5/28/24 indicated: <BR/>Resident #203 had a potential for uncontrolled pain with interventions which included anticipate the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions with alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; and notify physician if interventions were unsuccessful or if the current complaint was a significant change from resident's past experience of pain.<BR/>Resident #203 had peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs causing leg pain) with interventions which included to monitor/document/report to physician as needed for any signs or symptoms of complications of extremities such as pain. <BR/>Resident #203 had a pressure ulcer or potential for pressure ulcer development with interventions which included to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. <BR/>Resident #203 required antidepressant medication with interventions which included to monitor/document/report to physician as needed of depression unaltered by antidepressant meds with behaviors of sad, irritable, anger, never satisfied, crying, negative mood/comments, and agitation.<BR/>Record review of Resident #203's Order Summary Report dated 6/04/24 revealed orders for Gabapentin 300 mg one capsule by mouth two times daily for neuropathy (nerve pain) with a start date of 5/28/24, Methocarbamol 500 mg one tablet by mouth four times a day for muscle relaxer related to Quadriplegia with a start date of 5/28/24, Tylenol 325 mg two tablets by mouth every four hours as needed for pain or fever with a start date of 5/28/24, May have pressure relieving mattress every shift for wound with a start date of 5/28/24, and Norco 10/325 mg one by mouth every six hours for pain routinely with a start date of 5/29/24. <BR/>Record review of Resident #203's MAR dated 5/01/24-5/31/24 and MAR dated 6/01/24-6/30/24 revealed the above medications were administered as ordered.<BR/>Record review of Resident #203's Pain-MDS dated [DATE] revealed he experienced pain almost constantly and the pain frequently affected his sleep and almost constantly interfered with his activities of daily living.<BR/>Record review of Resident #203's pain level summary dated 5/28/24-6/05/24 revealed he had pain values from 0 to 7 on a 1-10 scale (1 being the least pain to 10 being the worst pain). Resident #203's pain level on 6/03/24 was a 4 at 11:59 AM, a 7 at 2:05 PM, a 7 at 5:04 PM, and a 5 at 8:56 PM. <BR/>Record review of Resident #203's NP visit note dated 5/29/24 revealed the resident stated he could move both lower extremities but chose not to because with movement muscle spasms would follow. There was a new order to change Resident #203's Norco to 10/325 mg by mouth every six hours scheduled.<BR/>Record review of Resident #203's progress notes dated 5/28/24-6/03/24 revealed on 5/29/24, LVN M received new orders to change his Norco 10/325 mg every six hours to routinely. On 5/30/24, LVN B documented he continued to complain of pain upon turning and repositioning and getting weight. On 5/31/24, LVN B documented Resident #203 was known to holler for a while when treatments were done. On 6/02/24, RN N documented Resident #203 had a low air loss mattress in place and the resident was receiving routine pain medication and reported it was effective. There was no documentation of Resident #203's continued complaints of pain being reported to the physician. There was no documentation related to Resident #203's family member requesting a different medication for his pain related to leg spasms from LVN B.<BR/>During an observation on 6/03/24 beginning at 11:16 AM, the surveyor entered Resident #203's room while LVN G and CNA E were still in the resident's room after performing wound care. CNA E repositioned Resident #203's pillow. Resident #203 was hollering out that he was having severe pain and he felt like he was lying on a board. LVN G told Resident #203 it was just the wound vac (wound dressing and tubing attached to a machine that pulls a vacuum to assist in the closure and drainage of wounds), but the resident continued to holler out saying it had never felt like that before and to please look back there (his bottom). LVN G asked CNA E to roll the resident over so she could look under Resident #203. CNA E rolled the resident toward her while LVN G looked under the resident and again told him it was just the wound vac. Resident #203 was then propped up his on right side with pillows under his left back. LVN G said she would tell Resident #203's nurse and see if he could have a pain pill.<BR/>During an observation and interview on 6/03/24 beginning at 11:21 AM, Resident #203 said he was having severe pain on his bottom, and he felt like he was lying on a board. Resident #203 said he had never had it feel like that before. Resident #203 said with tears in his eyes, he was not crazy, and something was wrong. Resident #203 continued to holler out in pain and asked the surveyor to please do something, because it had never felt like that before. Resident #203 said he had been in the facility for about a week. Resident #203 had a low air loss mattress (prevents and treats pressure wounds) and it was not operating and there were no lights on the control box to indicate it was on. The power the cord of the low air loss mattress was unplugged from the wall and was lying across the top of the bed frame at the head of the bed . <BR/>During an observation and interview on 6/03/24 beginning at 11:52 AM, with surveyor intervention, RN F accompanied the surveyor to Resident #203's room and she said LVN G had told her Resident #203 was having pain and she was going to get him a pain pill. While entering Resident #203's room, he continued to holler out that it was killing him, and he felt like he was lying on a board on his back. RN F put on gloves and rolled Resident #203 over to his right side and ran her gloved hand under him and looked under him. RN F told Resident #203 there was nothing under him except the wound vac to his bottom. RN F then repositioned Resident #203 with pillows and told him she would get him a pain pill. With surveyor intervention, RN F was asked if the low air loss mattress was functioning. RN F looked at the low air loss mattress control box and she said it was not on and she found the cord/plug that was lying at the head of the bed on the bed frame. RN F had to unwrap the cord from under the bed and plugged it in to the electrical plug and turned it on at the control box. RN F said it would take a few minutes for the low air loss mattress to re-inflate. RN F told Resident #203 she was going to get his pain medication.<BR/>During an observation and interview on 6/04/24 at 5:01 PM, Resident #203 said after the air mattress re-inflated yesterday, it helped his pain level tremendously. Resident #203 said he felt like he was lying on a board, and he said the therapist told him the mattress was not inflated and he was lying on the steel frame. Resident #203 thanked the surveyor for bringing it to the facility's attention and getting it turned back on. Resident #203 said he had only had that feeling of lying on a board after the nurse did his wound care yesterday (6/03/24). Resident #203 continued to have right leg spasms and would holler out and would speak to his leg when it would start to spasm and said please, please, don't do it, don't do it as he rubbed his right leg. Resident #203 said he has had leg spasms and chronic pain for a long time. Resident #203 said he wished they could find something to help the pain with his muscle spasms or if they could just cut his right leg off, but they would not do it.<BR/>During an interview on 6/03/24 at 12:02 PM, RN F brought Resident #203 a pain pill and said if the treatment nurse had let her know she was going to change his wound vac, she could have gotten him pain meds before the wound care to help prevent pain. RN F said the purpose of the low air loss mattress was to relieve pressure and if it was not plugged in, it could cause increased pressure to Resident #203's wounds. RN F said Resident #203 usually hollered out and complained of pain, but she felt his pain had gotten better. RN F said she thought they probably accidently unplugged his low air loss mattress when they were doing his wound care earlier and did not realize it.<BR/>During an interview 6/05/24 at 1:50 PM, CNA H said she had worked at the facility for fourteen years. CNA H said it was just her second day to take care of Resident #203. CNA H said Resident #203 was in pain all the time and he had muscle spasms and hollered while she provided care. CNA H said she had not told the nurse anything about Resident #203's pain because she felt the nurse should already know. CNA H said Resident #203 mainly hurts when they moved him. CNA H said she would let Resident #203 do most of the positioning himself as much as he could, and it seemed easier on him.<BR/>During an interview on 6/05/24 at 2:04 PM, LVN G said she had worked at the facility for eleven years and had been the treatment nurse for two years. LVN G said Resident #203 came into the facility hollering and complaining of pain and legs spams. LVN G said Resident #203 took routine pain medications. LVN G said she was positioning Resident #203 when the surveyor came into Resident #203's room on 6/03/24 and Resident #203 was complaining about being on a board. LVN G said she had already checked under him for anything that could cause him pain and she did not find anything other than the wound vac dressing on the wound to his sacrum she had just changed. LVN G said they did not do anything to unplug the low air loss mattress while performing Resident #203's wound care. LVN G said she did not know how the low air loss mattress became unplugged. LVN G said she knew there was air in the mattress because she put her hand on it when she checked under Resident #203. LVN G said the low air loss mattress had air in it and she did not hear a hiss like it was losing air. LVN G said if the air deflation level was very low, it could have made Resident #203 feel like he was lying on a rail, but she did not think it was that deflated. LVN G said everything they did for Resident #203 hurt him. LVN G said when she could not determine why Resident #203 was hurting, she reported to RN F and told her Resident #203 needed something for pain. LVN G said not addressing pain could make the resident feel hopeless, lose trust, have anger, depression, and a multitude of negative thought processes. <BR/>During an interview on 6/05/24 at 2:26 PM, RN F said she had worked at the facility for approximately a year as needed. RN F said Resident #203 had a pressure wound on his sacrum with a wound vac dressing. RN F said Resident #203 was awake, alert, and oriented. RN F said Resident #203 could follow a verbal pain scale and he had a low pain tolerance. RN F said if residents complained of pain, she would look for the cause of pain, check to see what medications they had for pain, and use alterative pain management methods such as redirection. RN F said if the resident was awake, alert, and oriented, the resident would know what they wanted. RN F said she would notify the physician for new or changed orders if what they were doing was not working or managing the resident's pain. RN F said Resident #203's low air loss mattress not being plugged in on 6/03/24 could have contributed to his pain level, but she did not feel it was completely deflated and it still had air in it when she checked under him. RN F said pain management was important to keep the resident as comfortable as possible. RN F said if pain was not controlled, the resident could start losing functions. RN F said if the resident's pain was not managed effectively, the resident could have extreme pain and irritably and it could cause psychological issues such as not eating, decline in functions, and they could become depressed.<BR/>During an interview on 6/05/24 at 2:43 PM, LVN B said she had worked at the facility since September 2023 and normally worked the day shift. LVN B said Resident #203 was receiving round the clock pain medications. LVN B said Resident #203 complained of pain all the time and hollered out even when just touching the bed and he seemed to do it worse when his family was in the room. LVN B said they tried to reposition him, got him a longer bed, and gave pain medications routinely to manage Resident #203's pain and thought he had not complained as much since. LVN B said Resident #203 usually just complained when they provided care. LVN B said Resident #203 said he had spasms to his legs. LVN B said Resident #203's family member wanted him to have a different medication for his leg spasms. LVN B said the family member told her the name of the medication they wanted to change to, but LVN B did not remember the name of the medication. LVN B said she told the family member she (LVN B) would have to talk to the physician about it to obtain an order for the medication. LVN B said the family member asked her about wanting the medication for his pain from the muscle spasms changed about 3-4 days ago. LVN B said she had not talked to the physician and had forgotten all about it . LVN B said if the low air mattress was not plugged in, it could make a difference in the how the resident felt. LVN B said pain management was important to manage. LVN B said if pain was not managed effectively, then it could affect the resident's behavior, they could become more irritable and complain.<BR/>During an interview on 6/05/24 at 3:01 PM, CNA E said she had worked at the facility full-time for approximately three months, but she had worked at the facility for about ten years as needed. CNA E said Resident #203 hollers out in pain a lot. CNA E said if she did anything to Resident #203, he would holler out in pain. <BR/>During an interview on 6/05/24 at 3:19 PM, the ADON said when a resident reported pain, they could give medications, provide alternative measures, and then go back in 45 minutes to evaluate if the resident had relief from pain. The ADON said if there was no relief, then they should notify the physician for new or changed orders. The ADON said pain management could cause a lot of problems in the resident such as they could stop eating, change in behaviors, and unable to sleep. The ADON said she did not know why the physician had not been notified related to Resident #203's continued pain and muscle spasms, but the ADON said the physician would be notified as soon as she was done with the surveyor. <BR/>During an interview on 6/05/24 at 3:41 PM, the ADM said he would expect residents' pain to be managed. The ADM said Resident #203 was a new resident and he felt Resident #203's pain was being managed. The ADM said he had visited with Resident #203 a lot and the ADM said he would not say his pain was out of control. The ADM said he had talked to RN F, and she had told him Resident #203 was not on the bed frame and the low air loss mattress was not deflated when it was not plugged in. The ADM said he did not feel Resident #203 had a negative effect because they were managing his pain with routine pain medications.<BR/>Record review of the facility's In-service Attendance Record dated 6/01/24 with the subject of Monitoring for pain/pain management revealed . pain assessments should be ongoing . individualized and documented so that all involved in the patient's care understand the pain problem . asking patient's to describe their pain using words would guide staff to the appropriate interventions for specific pain types . patients may have more than one type of pain . and it said to see attached sheets and the Pain Management, Assessment Scale policy was attached to the in-service. The Inservice Attendance Record was signed by LVN G, RN F, and CNA E.<BR/>Record review of the facility's policy titled Pain Management, Assessment Scale with a revised date of May 25, 2016 revealed . pain was a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli . complaints of pain would be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . talk with the resident about pain and assess for pain relief after interventions . monitor for effectiveness of pain interventions .

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that,<BR/>- Two stand up freezers that held frozen meat and vegetables had a large accumulation of food particles and crumbs on the bottom of both freezers.<BR/>-Four bottles of buttermilk with use by dates of 2/21/22 were in the milk refrigerator. <BR/>These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness.<BR/>Findings Included:<BR/>During an initial kitchen observation on 3/7/22 at 10:01 a.m., 2 of 2 stand up freezers that held frozen meat and vegetables had large accumulations of food particles, crumbs, and a yellow sticky substance on the bottom of both freezers. The refrigerator that held the milk had 4 bottles of buttermilk with use by dates of 2/21/22. <BR/>During an interview on 3/7/22 at 10:10 a.m., the DM said that the freezers had scheduled cleaning days and that she thought that they were due to be cleaned. The DM said that she expected all kitchen equipment to be kept clean and that failure to do so could cause contamination of the food. She said that dietary aides were responsible for cleaning the freezer but ultimately it is her responsibility to ensure they were being cleaned. The DM said that the expired milk should have been removed or separated from the good milk so that it could have been sent back to the milk company. The DM said that she thought that the milk company checked dates on the milk when they delivered but that it was her responsibility to ensure expired milk was removed from the refrigerator. The DM said failure to remove expired foods could result in illness to the residents. <BR/>A dietary services cleaning schedule indicated freezers were to be deep cleaned every 2 weeks on the morning shift. The freezers were due to be cleaned on 3/5/22 but were not signed out as cleaned. <BR/>During an interview on 3/10/22 at 1:15 p.m., the DM said she did not have a policy related to expired food. <BR/>During an interview on 3/10/22 at 3:00 p.m., the administrator said she expected kitchen equipment to be kept clean and expired foods to be disposed. She said it was the DMs responsibility to ensure these things were being completed but that it was also her responsibility to follow up. The administrator said failure to keep kitchen equipment clean and not removing expired food could have a negative outcome for the residents. <BR/>Review of the facility policy Refrigerators, Coolers and Freezers, dated 2018, indicated . The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed. <BR/>The U.S. Food and Drug Administration Food Code dated 2017 reflected: .3-305.11 Food Storage. (B) .refrigerated, ready- to -eat/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: In a clean, dry location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #17) reviewed for infection control practices.<BR/>CNA B during incontinent care failed to perform hand hygiene prior to exiting Resident #17's room to obtain more gloves and exiting Resident #17's room after incontinent care for a pillowcase.<BR/>These failures could place residents and staff at risk for cross contamination and the spread of infection.<BR/>Findings included:<BR/>Record review of Resident #17's face sheet dated 04/26/2023, indicated a [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses of Alzheimer's dementia (a progressive disease that destroys memory) and difficulty swallowing.<BR/>Record review of Resident #17's quarterly MDS dated [DATE], indicated she was rarely understood and rarely understood others. The MDS indicated Resident #17 required total assistance with bed mobility, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #17 was always incontinent of bowel and bladder.<BR/>Record review of Resident #17's comprehensive care plan, dated 12/06/2022, indicated she was dependent on staff for ADLs.<BR/>During an observation and interview on 04/26/2023 at 9:05 a.m., CNA B donned (applied) clean gloves, removed the trash bag from the trashcan next to Resident #17's bed and placed it on the bed linen. CNA B removed numerous incontinent wipes and placed them inside the trashcan liner on Resident #17's bed. Resident #17's was soiled with urine. CNA B cleansed Resident #17's front perineal area, then touched the incontinent wipe package to remove more wipes with the same pair of gloves. CNA B moved Resident #17's bed and repositioned Resident #17 with the same unclean gloves she used to provide incontinent care. CNA B removed the unclean gloves, and without performing hand hygiene, exited Resident #17's room to retrieve more gloves from the linen cart. CNA B reentered Resident #17's room, washed her hands, and donned clean gloves. CNA B provided Resident #17's incontinent care to her buttock area. CNA B then applied Resident #17's clean brief. CNA B removed her gloves, and adjusted Resident #17's bed linen. CNA B then picked up Resident #17's pillow off the floor, she removed the pillowcase and then exited the room without performing hand hygiene. CNA B returned to Resident #17's room and applied the pillowcase. CNA B then washed her hands. CNA B said she should have been more prepared when she performed incontinent care. CNA B said she should have had her gloves and the cleansing wipes in a clean bag. CNA B said she should have washed her hands prior to exiting the room to retrieve the gloves and pillowcase. CNA B said not performing hand hygiene could spread infection.<BR/>Record review of CNA B's Proficiency Audit dated 11/16/2022, indicated she was proficient in handwashing and perineal care. <BR/>During an interview on 04/26/2023 at 2:46 p.m., the DON said she expected CNA B to perform hand hygiene before the initiation of care, during care as needed, and after care. The DON said not performing hand hygiene could cause a break in infection control. The DON said she completed skill check offs with the nursing staff to ensure compliance with infection control and technique. <BR/>During an interview on 04/26/2023 at 2:56 p.m., the Administrator said exiting a resident's room without performing proper hand hygiene could cause cross contamination. The Administrator said the DON or designee monitored hand hygiene monthly with a random audit. The Administrator said the DON was responsible for ensuring compliance with the infection control program.<BR/>Record review of a Personal Care policy with an effective date of 05/11/2022 revealed an incontinent resident of urine and or bowel should be identified, assess, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing, infections and skin irritation, and observing the resident's skin condition. Start .10. Perform hand hygiene 11. DON gloves 24. Doff gloves .25. Perform hand hygiene Important Points Always perform hand hygiene before and after glove use.<BR/>Record review of an Infection Control Policy dated 03/2023 revealed the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 3 of 12 residents reviewed for respiratory care. (Resident #20, Resident #35 and Resident #247).<BR/>The facility failed to date the oxygen tubing for Resident #35 and Resident # 247. <BR/>The facility failed to properly store the oxygen tubing for Resident 35.<BR/>The facility did not ensure Resident #20 nebulizer (a device used to deliver liquid medication in an aerosol form to a resident's lungs) was dated and stored properly when not in use.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/> Findings included: <BR/>1. Record review of the face sheet dated 07/1/20 indicated Resident #35 was [AGE] years old, readmitted on [DATE] with diagnoses of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Heart Failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and Parkinson (disease of the nervous system). <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #35 made himself understood and understood others. Resident #45 had a BIMS (brief interview for mental status) score of 15 which indicated he was cognitively intact. The MDS indicated Resident #35 required extensive assist with bed mobility, dressing, toileting, personal hygiene and bathing; set up help for eating. The MDS indicated that Resident #35 required oxygen. <BR/>Record review of the care plan dated 01/20/22 for Resident #35 indicated he was at risk for SOB (shortness of breath), chest pain and increased edema. Intervention: Apply oxygen as ordered.<BR/>Record review of the Physician order dated 11/15/21 indicated Resident #35 was to have oxygen at 3 liter per nasal cannula while in bed and as needed when out of bed.<BR/>During an observation on 03/07/22 at 10:19 a.m., water canister dated 03/4/22 but no date on tubing and tubing was on the floor. <BR/>During an observation on 03/8/22 at 09:06 a.m., Resident #35 in his bed with HOB (head of bed) up, alert and watching TV. Noted oxygen tubing with no date and tubing on floor, not properly stored. <BR/>During and observation on 03/09/22 at 10:08 a.m., resident #35 in his bed, oxygen tubing on concentrator but not properly stored.<BR/>2. Record review of the face sheet dated 04/7/20 indicated Resident #20 was [AGE] years old, readmitted on [DATE] with diagnoses of COVID (a highly contagious respiratory disease), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Diabetes Mellitus. <BR/>Record review of the care plan for Resident #20 had no indication for nebulizer treatments.<BR/>Record review of the Physician order dated 03/2/22 indicated Resident #20 was to have Albuterol Sul 2.5MG/3ML Solution, give 1 inhalation every six hours as needed for SOB (shortness of breath) or wheezing. <BR/>During an observation on 03/07/22 at 09:35 a.m., HHN (handheld nebulizer) machine on nightstand with no date on tubing and not stored properly. <BR/>During and observation on 03/08/22 at 11:25 a.m., Resident # 20 in her bed with HHN machine on nightstand with no date on tubing and not stored properly. <BR/>During an observation on 03/09/22 at 01:32 p.m., Resident #20 in her bed alert, HHN machine on nightstand with no date on tubing and not stored properly. <BR/>3. Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident is a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). <BR/>Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems.<BR/>Observation on 03/07/22 09:35 AM revealed that Resident #247 had oxygen on at 3L/min no dates on oxygen tubing. <BR/>Observation on 03/09/22 01:50 PM revealed that Resident #247 had returned to his room after therapy and did not have date on oxygen tubing. <BR/>During an interview on 03/09/22 at 02:05 p.m., LVN A said that HHN tubing should be dated and, in a bag, when not in use. She said that her order was for PRN and she was not using at this time. DON removed HHN machine. LVN A said failure to properly store tubing could lead to infection.<BR/>During an interview on 03/09/22 at 02:11 p.m., the DON said that her expectations was for tubing on oxygen and HHN should be changed every Sunday night and should have nurse initial and date on tubing and water canister. She said if tubing was not being used, tubing should be properly stored and failure to properly change or store tubing could cause infection.<BR/>During an interview on 03/09/22 at 02:42 p.m., the ADM said she was not sure when oxygen and HHN tubing should be changed but felt like the DON was responsible to make sure this is happening. Failure to make sure that oxygen and HHN tubing are changed could lead to residents becoming sick and can lead to an infection control issue.<BR/>During an interview on 03/09/22 at 03:35 p.m., LVN H said water canisters and tubing for oxygen and HHN should be changed out every Sunday nights; nurse should initial and date when changed. If tubing was not in use it should be properly stored. Failure could cause the resident an infection. <BR/>Record review of policy revised October 2010; steps 29-30 indicate: When equipment is completely dry, store in plastic bag with residents' name and date on it and change equipment and tubing every seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #17) reviewed for infection control practices.<BR/>CNA B during incontinent care failed to perform hand hygiene prior to exiting Resident #17's room to obtain more gloves and exiting Resident #17's room after incontinent care for a pillowcase.<BR/>These failures could place residents and staff at risk for cross contamination and the spread of infection.<BR/>Findings included:<BR/>Record review of Resident #17's face sheet dated 04/26/2023, indicated a [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses of Alzheimer's dementia (a progressive disease that destroys memory) and difficulty swallowing.<BR/>Record review of Resident #17's quarterly MDS dated [DATE], indicated she was rarely understood and rarely understood others. The MDS indicated Resident #17 required total assistance with bed mobility, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #17 was always incontinent of bowel and bladder.<BR/>Record review of Resident #17's comprehensive care plan, dated 12/06/2022, indicated she was dependent on staff for ADLs.<BR/>During an observation and interview on 04/26/2023 at 9:05 a.m., CNA B donned (applied) clean gloves, removed the trash bag from the trashcan next to Resident #17's bed and placed it on the bed linen. CNA B removed numerous incontinent wipes and placed them inside the trashcan liner on Resident #17's bed. Resident #17's was soiled with urine. CNA B cleansed Resident #17's front perineal area, then touched the incontinent wipe package to remove more wipes with the same pair of gloves. CNA B moved Resident #17's bed and repositioned Resident #17 with the same unclean gloves she used to provide incontinent care. CNA B removed the unclean gloves, and without performing hand hygiene, exited Resident #17's room to retrieve more gloves from the linen cart. CNA B reentered Resident #17's room, washed her hands, and donned clean gloves. CNA B provided Resident #17's incontinent care to her buttock area. CNA B then applied Resident #17's clean brief. CNA B removed her gloves, and adjusted Resident #17's bed linen. CNA B then picked up Resident #17's pillow off the floor, she removed the pillowcase and then exited the room without performing hand hygiene. CNA B returned to Resident #17's room and applied the pillowcase. CNA B then washed her hands. CNA B said she should have been more prepared when she performed incontinent care. CNA B said she should have had her gloves and the cleansing wipes in a clean bag. CNA B said she should have washed her hands prior to exiting the room to retrieve the gloves and pillowcase. CNA B said not performing hand hygiene could spread infection.<BR/>Record review of CNA B's Proficiency Audit dated 11/16/2022, indicated she was proficient in handwashing and perineal care. <BR/>During an interview on 04/26/2023 at 2:46 p.m., the DON said she expected CNA B to perform hand hygiene before the initiation of care, during care as needed, and after care. The DON said not performing hand hygiene could cause a break in infection control. The DON said she completed skill check offs with the nursing staff to ensure compliance with infection control and technique. <BR/>During an interview on 04/26/2023 at 2:56 p.m., the Administrator said exiting a resident's room without performing proper hand hygiene could cause cross contamination. The Administrator said the DON or designee monitored hand hygiene monthly with a random audit. The Administrator said the DON was responsible for ensuring compliance with the infection control program.<BR/>Record review of a Personal Care policy with an effective date of 05/11/2022 revealed an incontinent resident of urine and or bowel should be identified, assess, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing, infections and skin irritation, and observing the resident's skin condition. Start .10. Perform hand hygiene 11. DON gloves 24. Doff gloves .25. Perform hand hygiene Important Points Always perform hand hygiene before and after glove use.<BR/>Record review of an Infection Control Policy dated 03/2023 revealed the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 12 residents reviewed for advanced directives. (Resident #37)<BR/>The facility failed to ensure Resident #37's code status was accurate and consistent with all records at the facility.<BR/>This failure placed the residents at risk of not having their end of life wishes honored.<BR/>Findings included:<BR/>Record review of Resident #37's face sheet dated [DATE] revealed Resident #37 was [AGE] years old male, admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of gastrointestinal hemorrhage (stomach, intestinal bleeding), Dysphagia (difficulty swallowing), cerebral infarction (stroke) and dementia.<BR/>Record review of a MDS dated [DATE] indicated Resident #37 was able to understand and was understood by others. The MDS indicated Resident #37 had memory problems and his BIMS score was 0 indicating severe cognitive impairment. The assessment indicated Resident #37 required limited assistance with bed mobility, extensive assistance with dressing, toilet use and personal hygiene and was independent with transfers, walking, and eating.<BR/>Record review of a care plan dated [DATE] with an update of the care plan on [DATE] indicated Resident #37 had requested a code status of full code. The goal was his wishes regarding his code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to his code status at his request.<BR/>Record review of consolidated physician orders dated [DATE] revealed an order for Full Code status on [DATE].<BR/>Record review of a handwritten physician order dated [DATE] revealed a DNR (Do Not Resuscitate) status.<BR/>Record review of Resident #37's OOH-DNR (out of hospital do not resuscitate) form dated [DATE] revealed Resident #37's daughter, two witnesses, and his physician signed indicating there would be no resuscitation measures initiated or continued for Resident #37.<BR/>Record review of Resident #37's electronic medical record on [DATE] revealed heart-shaped symbol and CPR (cardiopulmonary resuscitation) in red letters. These symbols indicated to provide CPR.<BR/>During an interview on [DATE] at 1:06 p.m., LVN A indicated Resident #37's electronic record indicated he was designated a full code status. LVN A indicated Resident #37's paper chart had a signed OOH-DNR (out of hospital do not resuscitate), a physician's order for DNR, and a red colored paper indicating a DNR status. LVN A indicated the discrepancy could cause Resident #37 to receive resuscitation efforts against his and his family's wishes.<BR/>During an interview on [DATE] at 1:18 p.m., the DON indicated Resident #37 could receive resuscitation efforts due to the full code status indicator on the electronic record. <BR/>During an interview on [DATE] at 3:24 p.m., the Administrator indicated Resident #37 could have received CPR (cardiopulmonary resuscitation) against his wishes. The administrator indicated the social worker was responsible for updating the resident's code status on admission or with changes. The administrator indicated the care planning process should as well be a time the code status was reviewed for accuracy. The administrator said ultimately, she was responsible for ensuring the code status of the residents were honored. <BR/>During an interview on [DATE] at 3:30 p.m., the DON indicated the social worker was responsible for ensuring audits were conducted on the code status of each resident. The DON indicated the SW was out ill at this time.<BR/>Record Review of a policy dated [DATE] named, Do Not Resuscitate Order revealed the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 6. The Interdisciplinary Care Planning Team will review advance directives with the residents during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 12 residents reviewed for quality of care. (Resident #45)<BR/>The facility did not thoroughly conduct a comprehensive weekly skin assessment for Resident #45.<BR/>This failure could place residents at risk for decreased quality of care and injury. <BR/>Findings included:<BR/> Record review of a face sheet dated 05/8/20 indicated Resident #45 was [AGE] years old, re-admitted on [DATE] with diagnosis including Quadriplegia (paralysis of all four limbs), anxiety (Intense, excessive, and persistent worry and fear about everyday situations), Peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and Heart failure (condition in which the force of the blood against the artery walls is too high). <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #45 made himself understood and understands others. Resident #45 had a BIMS (brief interview for mental status) score of 7 which indicated Resident #45 was moderately cognitively impaired. The assessment indicated Resident #45 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #45 required total dependence with bed mobility, dressing, toileting, eating, personal hygiene and bathing. The MDS indicated that Resident #45 at risk of developing pressure ulcers and injury.<BR/>Record review of the care plan revised on 08/12/21 indicated Resident #45 had the potential for self-care deficit in ADLs related to Quadriplegia (paralysis of all four limbs). Interventions: provide total assistance for mobility, dressing, eating, toileting, personal hygiene, oral care, and bathing. The care plan indicated that Resident #45 had diagnosis of Diabetes Mellitus and was at risk for frequent infections, pressure, venous and statis ulcers, and physical limitations. Interventions: Monitor and document skin weekly and report to physician for changes, redness, circulatory problems and breakdown.<BR/>During an observation on 03/09/22 at 08:41 a.m., CNA D provided incontinence care for Resident #45. A dressing was on his upper left buttock dated 02/16/22. LVN A, entered room and verified a dressing was intact to resident #45 's upper left buttock which had BHP initials and dated 02/16/22. LVN A, removed dressing that had dark brown drainage to inside of dressing and observed three open area to upper left buttock.<BR/>During an observation and interview on 03/09/22 at 09:18 a.m., the DON and the treatment nurse (TX) entered the room and they both confirmed that Resident #45 had three open areas to upper left buttock. <BR/>During an interview on 03/9/22 at 9:30 a.m., The wound care physician said she assessed areas to Resident #45's upper left buttock. She said the wounds were trauma/adhesive dressing superficial wounds and she was going to recommend moisture barrier with no more tape. The wound care physician said that Resident # 45 had a history of skin issues and that he had a recent healed area to upper left buttock. The wound care physician said she had given a verbal order to apply a dry dressing to upper left buttock area until dressing dislodgement a few weeks ago. The wound care physician said she expected the dressing to stay intact to skin for about one to two weeks depending on the resident.<BR/>During an interview on 03/09/22 at 09:48 a.m., LVN A said she was not aware of anything on resident #45's buttock. She said the nurses were responsible for the skin assessments and that they had an assignment list at the nurses' station. LVN A looked at the assignment sheet and said Resident #45 skin assessment was due on the night shift of 03/8/22. <BR/>During an interview on 03/09/22 at 09:58 a.m., CNA E said she was unaware of any skin issue on Resident #45 until 03/9/22. <BR/>During an interview on 03/09/22 at 10:01 a.m., Resident #45, said staff told him the area was healed to his buttock area, but that they were putting dressings on for prevention. Resident #45 said that the dressing has been on there a while, but when he asked, staff said the area looked good. Resident #45 said he had his bed bath on Monday, but he did not ask about his skin.<BR/>During an interview on 03/09/22 at 10:38 a.m., CNA D said she did not see any dressing on Resident #45 when she provided care on 03/7/22. She saw dressing on 03/9/22, when providing bowel incontinence care. CNA D also verified that dressing on Resident #45 upper left buttock was dated 02/16/22 with initial BHP on dressing.<BR/>During an interview on 03/09/22 at 01:48 p.m., the treatment nurse (TX) said she was not aware of resident #45 having had any skin issues to his buttock area. She said the last time she remembered; he had an area to lower back that had resolved. TX nurse said she did not remember that the wound care doctor had given a verbal order to apply a dry dressing until dislodgement. She said that staff had received an order today from Resident #45 primary physician to apply barrier cream to left side of lower back. TX nurse said it is the charge nurse's responsibility to make sure assessments are done; they have an assigned schedule that they are to follow. If any resident had a wound stage two or greater, then she was responsible for weekly assessments. TX nurse said failure to assess skin could harm skin integrity, wound healing and could cause infection to the wound.<BR/>During an interview on 03/09/22 at 03:02 p.m., CNA F, said she gave resident #45 a bed bath on 03/7/22. She said he had a dressing on his back but unsure of date on dressing.<BR/>During an interview on 03/09/22 at 03:05 p.m., LVN G, said she was not aware of any open areas to resident #45. She saw resident #45's torso (central part, or the core, of the body) area on 03/7/22, but did not see any open area or dressing to that area. <BR/>During an interview on 03/09/22 at 03:21 p.m., LVN B, said she did a complete skin assessment on resident #45 on her shift of 03/8/22 but did not see any open areas on his skin nor any kind of dressing on his skin.<BR/>During an interview on 03/09/22 at 02:09 p.m., the DON said nurses were responsible for the assessments, but TX nurse should follow up. TX nurse was responsible to do treatments daily and nurses in her absent. DON said that if treatments and assessment were not done as assigned; it could cause wounds to worsen or one to developed and staff not aware.<BR/>During an interview on 03/09/22 at 02:42 p.m., ADM said wounds are to be done by the TX nurse and doctor. ADM expected dressing to be in place as needed to any wounds and for the residents to receive the right amount of nutrition to help with wound healing. She said management nurses should follow up. <BR/>Record review did not identify any prior order written for staff to apply dressing to upper left buttock area.<BR/>Record review of shower sheet reviewed for 03/7/22 did not indicate any skin issues on resident #45.<BR/>Record review of skin assessment completed on 03/9/22 revealed no skin issues on resident #45.<BR/>Record review of Braden risk assessment (Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores) dated 03/9/22 for resident #45 had a risk score of 13. Which indicated a moderate risk for skin breakdown.<BR/>Record review of policy revised July 2017, The purpose of this procedure is to provide information regarding identification of pressure ulcers/injury risk factors and interventions for specific risk factors. Risk Assessment shall be performed on admission and weekly and upon any changes in condition.<BR/>implemented interventions<BR/>o Implemented care plan and monitored<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide appropriate treatment and service of care for 1 of 3 residents reviewed with a clinically justified indwelling catheter.(Resident #10)<BR/>The facility failed to ensure resident # 10's indwelling catheter securement device was in place.<BR/>This failure could place residents at risk for urethral tears, discomfort, infection and hospitalization. <BR/> Findings included:<BR/>Record review of a face sheet dated 11/10/15 indicated Resident #10 was [AGE] years old, re-admitted on [DATE] with diagnosis including Bacteremia (bacteria in the circulating blood), Alzheimer's and Hemiplegia (paralysis of muscles on one side of the body). <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #10 usually made himself understood and understood others. Resident #10 had a BIMS (brief interview for mental status) score of 9 which indicated Resident #10 was moderately cognitively impaired. The assessment indicated Resident #10 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated Resident #10 required total dependence with transfers, dressing, toileting; extensive assist with bed mobility, personal hygiene and bathing; supervision with eating. The MDS for Resident #10 indicated that he has an indwelling catheter.<BR/>Record review of the care plan revised on 02/24/22 indicated Resident #10 had the potential for self-care deficit in ADLs related to Alzheimer's and left BKA (below the knee amputation). Interventions: assist with mobility, dressing, eating, toileting, personal hygiene, oral care, and bathing. Also, resident #10 has a foley catheter with diagnosis of neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Interventions: apply leg strap to thigh.<BR/>During an observation on 03/07/22 at 09:41a.m., resident # 10 was lying in his bed with without an indwelling catheter securement device in place.<BR/>During an observation on 03/08/22 at 09:57 a.m., CNA C, providing care resident #10 without an indwelling catheter securement device (leg strap) in place. <BR/>During an observation on 03/09/22 at 08:32 a.m., CNA D in room providing care, resident noted without an indwelling catheter securement device in place.<BR/>During an observation on 03/09/22 at 01:13 p.m., the DON applied an indwelling catheter securement device to resident #10.<BR/>During an interview on 03/09/22 at 10:42 a.m., CNA D said that resident #10 should have an indwelling catheter securement device on to keep it from pulling out. <BR/>During an interview on 03/09/22 at 10:48 a.m., resident #10, said he wanted a cloth strap on his leg because the tape irritated his leg. <BR/>During an interview on 03/09/22 at 01:36 p.m., CNA E said a foley catheter leg strap is needed to keep the foley catheter from pulling out and for safety.<BR/>During an interview on 03/09/22 at 01:44 p.m., LVN A said resident # 10 did not have a foley catheter leg strap on until DON went to apply it earlier. LVN A said the importance of having on a leg strap was to help the flow of urine and prevent pulling of catheter. <BR/>During an interview on 03/09/22 at 01:44 p.m., the DON said the importance of having a catheter foley strap in place was to prevent dislodging of foley and prevent infection. <BR/>During an interview on 03/09/22 at 02:42 p.m., the ADM said she expected for the residents to have on a catheter foley leg strap to prevent the foley from pulling out when turning the resident.<BR/>Record Review of policy revised September 2014 stated, Ensure that catheter remain secure with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Catheter stabilization shall be used to preserve the integrity and position of the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 3 of 12 residents reviewed for respiratory care. (Resident #20, Resident #35 and Resident #247).<BR/>The facility failed to date the oxygen tubing for Resident #35 and Resident # 247. <BR/>The facility failed to properly store the oxygen tubing for Resident 35.<BR/>The facility did not ensure Resident #20 nebulizer (a device used to deliver liquid medication in an aerosol form to a resident's lungs) was dated and stored properly when not in use.<BR/>These failures could place residents who required respiratory care at risk for respiratory infections. <BR/> Findings included: <BR/>1. Record review of the face sheet dated 07/1/20 indicated Resident #35 was [AGE] years old, readmitted on [DATE] with diagnoses of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Heart Failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and Parkinson (disease of the nervous system). <BR/>Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #35 made himself understood and understood others. Resident #45 had a BIMS (brief interview for mental status) score of 15 which indicated he was cognitively intact. The MDS indicated Resident #35 required extensive assist with bed mobility, dressing, toileting, personal hygiene and bathing; set up help for eating. The MDS indicated that Resident #35 required oxygen. <BR/>Record review of the care plan dated 01/20/22 for Resident #35 indicated he was at risk for SOB (shortness of breath), chest pain and increased edema. Intervention: Apply oxygen as ordered.<BR/>Record review of the Physician order dated 11/15/21 indicated Resident #35 was to have oxygen at 3 liter per nasal cannula while in bed and as needed when out of bed.<BR/>During an observation on 03/07/22 at 10:19 a.m., water canister dated 03/4/22 but no date on tubing and tubing was on the floor. <BR/>During an observation on 03/8/22 at 09:06 a.m., Resident #35 in his bed with HOB (head of bed) up, alert and watching TV. Noted oxygen tubing with no date and tubing on floor, not properly stored. <BR/>During and observation on 03/09/22 at 10:08 a.m., resident #35 in his bed, oxygen tubing on concentrator but not properly stored.<BR/>2. Record review of the face sheet dated 04/7/20 indicated Resident #20 was [AGE] years old, readmitted on [DATE] with diagnoses of COVID (a highly contagious respiratory disease), COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Diabetes Mellitus. <BR/>Record review of the care plan for Resident #20 had no indication for nebulizer treatments.<BR/>Record review of the Physician order dated 03/2/22 indicated Resident #20 was to have Albuterol Sul 2.5MG/3ML Solution, give 1 inhalation every six hours as needed for SOB (shortness of breath) or wheezing. <BR/>During an observation on 03/07/22 at 09:35 a.m., HHN (handheld nebulizer) machine on nightstand with no date on tubing and not stored properly. <BR/>During and observation on 03/08/22 at 11:25 a.m., Resident # 20 in her bed with HHN machine on nightstand with no date on tubing and not stored properly. <BR/>During an observation on 03/09/22 at 01:32 p.m., Resident #20 in her bed alert, HHN machine on nightstand with no date on tubing and not stored properly. <BR/>3. Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident is a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). <BR/>Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems.<BR/>Observation on 03/07/22 09:35 AM revealed that Resident #247 had oxygen on at 3L/min no dates on oxygen tubing. <BR/>Observation on 03/09/22 01:50 PM revealed that Resident #247 had returned to his room after therapy and did not have date on oxygen tubing. <BR/>During an interview on 03/09/22 at 02:05 p.m., LVN A said that HHN tubing should be dated and, in a bag, when not in use. She said that her order was for PRN and she was not using at this time. DON removed HHN machine. LVN A said failure to properly store tubing could lead to infection.<BR/>During an interview on 03/09/22 at 02:11 p.m., the DON said that her expectations was for tubing on oxygen and HHN should be changed every Sunday night and should have nurse initial and date on tubing and water canister. She said if tubing was not being used, tubing should be properly stored and failure to properly change or store tubing could cause infection.<BR/>During an interview on 03/09/22 at 02:42 p.m., the ADM said she was not sure when oxygen and HHN tubing should be changed but felt like the DON was responsible to make sure this is happening. Failure to make sure that oxygen and HHN tubing are changed could lead to residents becoming sick and can lead to an infection control issue.<BR/>During an interview on 03/09/22 at 03:35 p.m., LVN H said water canisters and tubing for oxygen and HHN should be changed out every Sunday nights; nurse should initial and date when changed. If tubing was not in use it should be properly stored. Failure could cause the resident an infection. <BR/>Record review of policy revised October 2010; steps 29-30 indicate: When equipment is completely dry, store in plastic bag with residents' name and date on it and change equipment and tubing every seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 12 residents reviewed in sample (Resident # 247).<BR/>The facility failed to have resident medications stored and locked in an area not accessible to other staff, residents, or visitors. <BR/>This failure could place residents at risk of injury by eating or drinking medications. <BR/>Findings included: <BR/>Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident was a 73year old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). <BR/>Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems. <BR/>Record review of Resident #247 Physician Orders dated March 2022 revealed that Resident #247 had an order dated 03/09/2022 for medication Diclofenac 1% gel to apply to joints and back QID (four times a day) PRN (as needed) for pain. <BR/>Observation on 03/07/22 at 09:35 AM revealed that Resident #247 was in his room and had medication Diclofenac 1% cream was on his bedside dresser. <BR/>Observation on 03/08/22 at 09:54 AM revealed that Resident was in bed resting. Said he did not sleep well night before. diclofenac 1% gel was on his bedside dresser. <BR/>Observation on 03/09/22 at 08:34 AM revealed that Resident was in bed finishing up breakfast. Diclofenac 1% gel and pain cream was on his bedside dresser.<BR/>Interview on 03/09/2022 at 01:50 PM with Resident #247 revealed that resident said he had medications brought to him, by his nephew, three days after he admitted (03/28/2022). He said he used it three times a day on his knees and back. Resident #247 said he did not know he could not keep medication in his room.<BR/>Interview on 03/09/2022 at 02:11 PM with LVN H revealed that LVN H was unaware that Resident #247 had medications in his room. LVN H removed medications. LVN H said she would call doctor and get order for medication found in room and call the family to notify. LVN H said she knew that residents could not keep any medication in the room, and it must be locked in cart for nurse to administer. LVN H was not aware of a policy that residents can administer their own medications on a nursing facility. <BR/>Interview on 03/09/2022 at 02:16 PM with DON revealed that DON said residents should not have medications in their rooms. All medications should be in the med room or carts locked. DON said families bring things into the facility that we are not aware of. What about that? She then walked off. <BR/>Interview on 03/09/2022 at 02:20 PM with Administrator revealed that administrator said she was not aware of any resident self-medicating, so medications should not be in resident rooms. Medications should be in carts. She said she expected all nurses to check medications they bring in when residents admit and ensure orders are in place. Administrator said all medications should be given by the nurse. This could be a hazard to all residents. <BR/>Policy for Storage of Medications dated April 2007, stated .The facility shall store all drugs and biologicals in a safe, secure, orderly manner.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that,<BR/>- Two stand up freezers that held frozen meat and vegetables had a large accumulation of food particles and crumbs on the bottom of both freezers.<BR/>-Four bottles of buttermilk with use by dates of 2/21/22 were in the milk refrigerator. <BR/>These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness.<BR/>Findings Included:<BR/>During an initial kitchen observation on 3/7/22 at 10:01 a.m., 2 of 2 stand up freezers that held frozen meat and vegetables had large accumulations of food particles, crumbs, and a yellow sticky substance on the bottom of both freezers. The refrigerator that held the milk had 4 bottles of buttermilk with use by dates of 2/21/22. <BR/>During an interview on 3/7/22 at 10:10 a.m., the DM said that the freezers had scheduled cleaning days and that she thought that they were due to be cleaned. The DM said that she expected all kitchen equipment to be kept clean and that failure to do so could cause contamination of the food. She said that dietary aides were responsible for cleaning the freezer but ultimately it is her responsibility to ensure they were being cleaned. The DM said that the expired milk should have been removed or separated from the good milk so that it could have been sent back to the milk company. The DM said that she thought that the milk company checked dates on the milk when they delivered but that it was her responsibility to ensure expired milk was removed from the refrigerator. The DM said failure to remove expired foods could result in illness to the residents. <BR/>A dietary services cleaning schedule indicated freezers were to be deep cleaned every 2 weeks on the morning shift. The freezers were due to be cleaned on 3/5/22 but were not signed out as cleaned. <BR/>During an interview on 3/10/22 at 1:15 p.m., the DM said she did not have a policy related to expired food. <BR/>During an interview on 3/10/22 at 3:00 p.m., the administrator said she expected kitchen equipment to be kept clean and expired foods to be disposed. She said it was the DMs responsibility to ensure these things were being completed but that it was also her responsibility to follow up. The administrator said failure to keep kitchen equipment clean and not removing expired food could have a negative outcome for the residents. <BR/>Review of the facility policy Refrigerators, Coolers and Freezers, dated 2018, indicated . The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed. <BR/>The U.S. Food and Drug Administration Food Code dated 2017 reflected: .3-305.11 Food Storage. (B) .refrigerated, ready- to -eat/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: In a clean, dry location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen days for 1 of 12 residents selected for unnecessary medications review. (Resident #18)<BR/>Resident #18 had a PRN order for Zolpidem (Ambien), a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication.<BR/>This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary medications. <BR/>Findings include:<BR/>Record Review of face sheet indicated Resident #18 admitted [DATE], was [AGE] years old with diagnoses that included: acute respiratory failure with hypoxia, endocarditis, (inflammation of the heart), Chronic obstructive pulmonary disease (respiratory symptoms with airflow limitation), congestive heart failure (weakened heart muscle causing fatigue and edema), anxiety disorder (nervousness, trembling, increased heart rate), and chronic pain. <BR/>Record review of Resident #18's physician's orders dated March 2022 indicated: <BR/>1/27/22 Zolpidem Tartrate 5 mg tablet, one tablet at bedtime as needed. <BR/>Record review of the MDS dated [DATE] indicated Resident #18 had clear speech, understood others, and was understood by others. The MDS indicated she was cognitively intact. The MDS indicated she had not had any hypnotic (medications used to induce, extend, or improve sleep) medications in the last 7 days. <BR/>Record review of the care plan dated 1/3/22 indicated Resident #18 was at risk for side effects related to psychotropic medication therapy. The care plan indicated she had difficulty getting to or staying asleep related to insomnia. <BR/>Record review of the Narcotic Administration Record dated 2/7/22 (indicated receipt of Zolpidem Tartrate, 5 mg tablet, one tablet at bedtime as needed.), through 3/8/22 indicated Resident #18 received the medication every day in February 2022 except 2/26/22. The Narcotic Administration Record indicated Resident #18 had received the medication 3/1/22 through 3/8/22. <BR/>During an interview on 3/09/22 at 10:51 AM, the DON said the medication Zolpidem for Resident #18 was ordered 1/27/22 and was not received by the facility until 2/7/22. <BR/>During an interview on 3/09/22 at 12:40 PM, the DON said the order for Zolpidem for Resident #18 did not have an end date. She said it should have had an end date of 14 days. She said the order for Zolpidem was written by the physician on 1/27/22, but the medication was not delivered to the facility until 2/7/22. <BR/>During an interview on 3/09/22 at 1:06 PM, the DON said they do not have an unnecessary medication policy. She said she talked with corporate and confirmed there was no unnecessary medication policy. She said the risk of continuing an antipsychotic past 14 days could be addiction. <BR/>During an interview on 3/09/22 at 1:20 PM, the ADON said Resident #18's Zolpidem should have had an end date of 14 days. She said the risk of not having an end date could be oversedation (sleepiness, fatigue) of the resident. <BR/>During a record review on 3/09/22 at 3:06 PM, Resident #18 had no documented side effects of Zolpidem medication. (This information was accessible by the facility computer only and could not be printed.) <BR/>During a record review 3/9/33 at 3:11 PM of the Behaviors Roster, Resident #18 had no documented behaviors 1/1/22 through 3/9/22. <BR/>During an interview on 3/09/22 at 3:24 PM, the administrator said she expected any antipsychotics ordered for residents to have a stop date within 14 days. She said they did not have a policy regarding unnecessary medications. <BR/>An Antipsychotic Medication Use policy dated December 2016, provided by the DON 3/9/33 at 3:52 PM indicated: <BR/> .14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. <BR/>15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 3 residents (Residents #2) reviewed for care plans.<BR/>The facility failed to implement Resident #2's care plan by not changing the dressing to her diabetic ulcer on the left second toe daily. On 2/12/2025 Resident #2's dressing was dated for 2/9/2025.<BR/>This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.<BR/>Findings include: <BR/>Record review of a face sheet for Resident #2 dated 2/18/2025 indicated that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: diastolic congestive heart failure (left ventricle of the heart cannot relax normally), protein calorie malnutrition (reduced availability of nutrients), type 2 diabetes mellitus (high blood sugar levels). <BR/>Record review of an admission MDS assessment dated [DATE] for Resident #2 indicated she had a BIMS score of 13, indicating intact cognition. Section M of same MDS assessment indicated that she was at risk of developing pressure ulcers/injuries and Resident #2 did not have any diabetic foot ulcers. <BR/>Record review of a care plan for Resident #2 dated 2/13/2025 indicated Resident #2 had a diabetic ulcer to left second toe with interventions that included: Administer treatments as ordered and monitor for effectiveness. <BR/>Record review of physician orders for Resident #2 dated 1/17/2025 indicated: Left foot 2nd toe-cleanse area with N/S [normal saline] pat dry apply silvasorb gel to wound with [NAME] peri-wound cover with dry foam and secure with tape PRN [as needed] soiled/dislodgement one time a day. <BR/>Record review of the treatment administration record dated 2/18/2025 indicated Resident #2 had not received treatment to the left foot 2nd toe on 2/9/2025, 2/10/2025, and 2/11/2025. <BR/>Record review of physician's progress note dated 2/6/2025 indicated: Patient here with her [family member] very concerned that her mother is not getting good care for her left second toe. She states the bandage is not changed initially .<BR/>During an observation and interview on 2/12/2025 at 10:10 AM with Resident #2's family member said she was concerned that Resident #2 was not getting wound per the physician's orders. She said on 2/12/2025 Resident #2's dressing to the left foot 2nd toe had not been changed since 2/9/2025. She said Resident #2's dressing changes had not been getting changed daily as ordered. She said she had addressed the issue with the ADON previously. Observation of Resident #2's left foot 2nd toe revealed a dressing dated 2/9/25. <BR/>During an interview on 2/19/2025 at 1:23 PM the DON said she did not know why Resident #2's treatment to her left 2nd toe had not been done. She said by not having her treatment done per the physician's orders could cause the residents wound to become worse. <BR/>During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for all wound care to be done as per the physician's orders. He said it just was not done on Resident #2. He said he was told the treatment nurse was out sick but the charge nurse should have completed the wound care. He said by not receiving the wound care per physician orders and the care plan it could cause the wound to become worse.<BR/>During an interview on 2/19/2025 at 3:15 PM the ADON said she did not know why the wound care had not been completed on Resident #2. <BR/>Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident # 18) reviewed for dialysis. <BR/>The facility failed to ensure Resident #18 had a physician order for dialysis. <BR/>This failure could place residents at risk for not receiving appropriate care and treatment services.<BR/>Findings included:<BR/>Record review of a Resident #18's face sheet, dated 04/26/2023, indicated a [AGE] year-old-female who admitted on [DATE] with diagnoses including chronic kidney disease stage 5 (kidney cease functioning on a permanent basis) with dependence on renal (kidney) dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).<BR/>Record review of Resident #18's admission MDS, dated [DATE], indicated he was understood and understood others. Resident #18 had a BIMSs (Brief Interview for Mental Status) score was 14 indicated she had intact cognition. The MDS indicated in Section O (special treatments, procedures, and programs) Resident #18 received dialysis.<BR/>Record review of Resident #18's comprehensive care plan, created on 04/18/2023, indicated Resident #18 needed hemodialysis related to renal failure. The care plan indicated Resident #18 was encouraged to attend the scheduled dialysis appointments. <BR/>Record review of Resident #18's order summary report, dated 04/26/2023, indicated there was no order for hemodialysis.<BR/>During an observation and interview on 04/25/2023 at 8:30 a.m., Resident #18 said she received hemodialysis in a dialysis center outside the facility three times a week on Monday, Wednesday, and Friday. Resident #18 said she had to restart hemodialysis due to her kidney transplant failing. <BR/>During an interview on 04/26/2023 at 2:31 p.m., LVN A said he was unaware Resident #18 did not have a physician's order for hemodialysis. LVN A said all procedures including hemodialysis required a physician's order. LVN A said Resident #18 not having an order for hemodialysis placed her, at risk for missing her dialysis treatment.<BR/>During an interview on 04/26/2023 at 2:46 p.m., the DON said Resident #18 should have had an order for dialysis, but she did not. The DON said not having the physician's order for dialysis placed Resident #18 at risk for not receiving her scheduled dialysis treatments. The DON said she was responsible for reviewing the admission orders. <BR/>During an interview on 04/26/2023 at 3:01 p.m., the Administrator said she expected Resident #18 to have an order for hemodialysis. The Administrator said a physician's order was needed for all care. The Administrator said by not having a physician's order for dialysis Resident #18 was at risk for not receiving her services. The Administrator said admission orders were reviewed by the nursing managers.<BR/>Record review of the facility's policy and procedure titled Physician's Orders dated 2015 indicated the purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.4. The receiving nurse will contact any other department, or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #42) residents reviewed for care plan revisions. <BR/>The facility failed to ensure Resident #42's care plan was updated to reflect he was receiving end of life hospice care. <BR/>This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.<BR/>Findings included:<BR/>Record review of Resident #42's face sheet dated 04/26/2023, indicated an [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory) and cardiomyopathy (a disease of the heart muscle, making it hard for the heard to deliver blood to the body).<BR/>Record review of Resident #42's quarterly MDS dated [DATE], indicated he was sometimes understood and usually understood others. Section O, (special treatments, procedures, and programs) reflected Resident #42 received hospice care.<BR/>Record review of Resident #42's order summary report dated 04/26/2023, indicated he had a physician's order to admit to hospice on 08/31/2022.<BR/>Record review of Resident #42's comprehensive care plan dated 09/13/2022 failed to indicate he was receiving hospice services.<BR/>During an interview on 04/25/2023 at 1:43 p.m., the ADON of Resident #42's hospice provider indicated he was receiving hospice services at this time.<BR/>During an interview on 04/26/2023 at 2:10 p.m., the MDS nurse said she was responsible for updating Resident #42's care plan when he elected to receive hospice services. The MDS nurse said Resident #42 was at risk of not receiving the care he desired. The MDS nurse said the morning meetings was where she received information regarding updating the comprehensive care plans.<BR/>During an interview on 04/26/2023 at 2:46 p.m., the DON said she expected the care plan to reflect the needs of Resident #42. The DON said Resident #42 was receiving hospice services. The DON said nursing staff were responsible for updating the care plan during the morning meetings, during care plan meetings, and as needed. The DON said the care plan ensured Resident #42 received his desired services.<BR/>During an interview on 04/26/2023 at 2:56 p.m., the Administrator said she expected Resident #42's care plan to reflect his desired care for hospice services. The Administrator said the care plan should reflect a picture of the resident's care needs. The Administrator said the nursing managers and the MDS nurse, were responsible for updating and monitoring the care plan for needed revisions. <BR/>Record review of an undated Comprehensive Care Planning policy indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 12 residents reviewed in sample (Resident # 247).<BR/>The facility failed to have resident medications stored and locked in an area not accessible to other staff, residents, or visitors. <BR/>This failure could place residents at risk of injury by eating or drinking medications. <BR/>Findings included: <BR/>Record review of Resident #247 face sheet dated 03/09/2022 revealed that resident was a 73year old male who admitted to the facility on [DATE] with the diagnosis of Respiratory failure (lung disorder), pneumonia (lung infection), and Hypertension (high blood pressure). <BR/>Record review of Resident #247 admission nursing assessment dated [DATE] revealed that Resident #247 required limited to extensive assist with activities of daily living and resident is alert and oriented to person, place, and time with no memory problems. <BR/>Record review of Resident #247 Physician Orders dated March 2022 revealed that Resident #247 had an order dated 03/09/2022 for medication Diclofenac 1% gel to apply to joints and back QID (four times a day) PRN (as needed) for pain. <BR/>Observation on 03/07/22 at 09:35 AM revealed that Resident #247 was in his room and had medication Diclofenac 1% cream was on his bedside dresser. <BR/>Observation on 03/08/22 at 09:54 AM revealed that Resident was in bed resting. Said he did not sleep well night before. diclofenac 1% gel was on his bedside dresser. <BR/>Observation on 03/09/22 at 08:34 AM revealed that Resident was in bed finishing up breakfast. Diclofenac 1% gel and pain cream was on his bedside dresser.<BR/>Interview on 03/09/2022 at 01:50 PM with Resident #247 revealed that resident said he had medications brought to him, by his nephew, three days after he admitted (03/28/2022). He said he used it three times a day on his knees and back. Resident #247 said he did not know he could not keep medication in his room.<BR/>Interview on 03/09/2022 at 02:11 PM with LVN H revealed that LVN H was unaware that Resident #247 had medications in his room. LVN H removed medications. LVN H said she would call doctor and get order for medication found in room and call the family to notify. LVN H said she knew that residents could not keep any medication in the room, and it must be locked in cart for nurse to administer. LVN H was not aware of a policy that residents can administer their own medications on a nursing facility. <BR/>Interview on 03/09/2022 at 02:16 PM with DON revealed that DON said residents should not have medications in their rooms. All medications should be in the med room or carts locked. DON said families bring things into the facility that we are not aware of. What about that? She then walked off. <BR/>Interview on 03/09/2022 at 02:20 PM with Administrator revealed that administrator said she was not aware of any resident self-medicating, so medications should not be in resident rooms. Medications should be in carts. She said she expected all nurses to check medications they bring in when residents admit and ensure orders are in place. Administrator said all medications should be given by the nurse. This could be a hazard to all residents. <BR/>Policy for Storage of Medications dated April 2007, stated .The facility shall store all drugs and biologicals in a safe, secure, orderly manner.