BROOKDALE GALLERIA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to accurately document Resident #1's dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS. This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status: none of the; nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions, so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow, so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis was retrieved from hospital paperwork, doctors visits, and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS, and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Certifying Accuracy of Resident Assessments with no revision date revealed, Policy Statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation: 1. Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse. There was no reference to the accuracy of assessments.

**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, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for comprehensive care plans. - The facility failed to develop a care plan for Resident #1's diagnosis of dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status: nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. All previous orders to crush appropriate medications/open capsule if not contraindicated were discontinued. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis is retrieved from hospital paperwork, doctor's visits and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, on the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Comprehensive Care Plan revised November 2017 revealed, Policy Overview: A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. Policy Detail: A. A person centered, comprehensive care plan will be developed and implemented in accordance with the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults. 4. Each resident's comprehensive care plan will describe: a. Resident goals for care and desired outcomes b. Identified resident issues, conditions, risk factors and safety issues c. The resident's unique characteristics and strengths.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices 1 of 5 residents (Resident #1) reviewed for quality of care.<BR/>-The facility failed to enter orders for blood sugar monitoring for Resident #1, who had type 2 diabetes, upon admission and as a result the resident's blood sugar was not assessed for over 22 hrs. (01/17/24 at 02:50 PM to 01/18/24 at 01:11 PM) after admission.<BR/>This failure could place residents at risk of delayed identification/treatment of acute health conditions and hospitalization.<BR/>Findings Include:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels.<BR/>Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM.<BR/>Record review of Resident #1's admission assessment dated [DATE] at 06:07 PM and signed by LVN A revealed, a diagnosis of type 2 diabetes and there was no documented blood sugar level on admission.<BR/>Record review of Resident #1's Order Summary Report dated 01/17/24 printed by LVN A and signed by the MD revealed, no orders for blood sugar monitoring.<BR/>Record review of Resident #1's Order Summary Report dated 01/23/24 revealed, check blood sugars before meals and at bedtime entered on 01/18/24 and started on 01/18/24 at 09:00 AM, over 12 hours after admission to the facility.<BR/>Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM.<BR/>- 311 mg/dL on 01/18/24 01:11 PM documented by LVN B.<BR/>- 207 mg/dL on 01/18/24 05:52 PM documented by LVN D.<BR/>- 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D.<BR/>An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted she did not have her blood sugar checked even though she ate meals. Resident #1 said the day after she admitted was the first day she had her blood sugar check but she denied any symptoms or side effects of high blood sure.<BR/>In an interview on 01/23/24 at 02:35 PM, the DON said when a resident arrives at the facility, they were immediately placed in a room with the staff assisting the paramedics. She said the admitting nurse then completed a head-to-toe assessment, collected vitals (including BS for diabetics) reconciled medications and then contacted the physician to approve all medications and care records. The DON said per the EMR Resident #1 admitted to the facility at 02:50 PM and LVN A completed Resident #1's admission assessment after she arrived at her shift which usually starts between 4 and 5.<BR/>In an interview on 01/23/24 at 05:11 PM, LVN A said she had been in her role as the admission nurse for the past 3 years. She said when a resident admitted to the facility the nurse who received them was responsible for verifying the residents' medications/orders with the admitting physician and checking vitals which included blood sugar checks. LVN A said she saw Resident #1 when she arrived at her evening shift, the resident was primarily Spanish speaking and arrived at the facility with family. She said she was not the nurse who received the resident, and it was not her responsibility to enter the resident into the system, complete the admitting assessment or check the resident's vitals. LVN A said it was the responsibility of the actual nurse who admitted the resident and the unit manager to ensure all orders were entered and vitals like BS were checked. LVN A said even though she did not actually assess the resident or reconcile the medications/order with the physician, she helped enter the resident's admission assessment and orders a little after six. She said she did not know why she did not enter Resident #1's BS monitoring orders and failure to check blood sugars in a diabetic could place the resident at risk for unidentified hypo or hyperglycemia (low and high blood sugars).<BR/>In an interview on 01/24/24 at 09:35 AM, the DON said the nurse who received Resident #1 was responsible for checking vitals, which included blood sugars in diabetics, going over the medications and orders with the physician and then entering the orders in the system. The DON said after reviewing the chart, LVN B was the nurse who received Resident #1 but since the resident arrived during a shift change his unit manager should have been responsible for entering the resident's orders into the system. She said she could not determine which nurse reconciled the medications and orders with the physician from the records provided.<BR/>In an interview on 01/24/24 at 10:01 AM, LVN B said when resident arrived at the facility the admitting nurse was whoever received the resident. He said the admitting nurse was responsible for ensuring that the resident was comfortable, educated about the facility and collecting vitals, reconciling medications with the physician and then entering orders. LVN B said upon admission, the admitting staff must check a diabetic resident's blood sugars immediately to establish their baseline if they did not receive BS records from the discharging facility. He said facility's policy required all new admissions that arrived after 02:00 PM would be given to the unit manager and Unit Manager A was responsible for admitting Resident #1. LVN B said LVN A was the facility admission nurse, and her shift usually began between 04:00-05:00 PM and she would complete admissions of residents who arrived during her shift.<BR/>In an interview on 01/24/24 at 11:42 AM, Unit Manager A said she was the 2nd floor unit manager, and her shift was from 08:30- 05:00 PM. She said when a resident admitted into the facility, the admitting nurse was responsible for greeting the resident, reconciling medications, verifying orders with the physician and then entering the orders. Unit Manager A said all diabetic residents should have admitting orders to check their blood glucose and lab orders for A1c. She said failure to enter BS orders and check blood sugar upon admission could place the resident at risk for unknown low/high BS and a result in the failure to treat these uncontrolled blood sugars. Unit Manager A said after reviewing the EMR, Resident #1's order entry was her responsibility but LVN B, the admitting nurse, was responsible for checking the resident's BS since it was part of the vitals collected. Unit Manager A said she did not remember processing Resident #1's admission but due to the time the resident arrived it was her responsibility but she was not informed or provided any communication that she had to complete the resident's admission so that was why LVN A completed the admissions assessment and entered the medication orders. Unit Manager A said she could not remember any details regarding Resident #1's admissions.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said when Resident #1 admitted to the facility LVN B (the admitting nurse) was responsible for entering orders for BS monitoring and he should have checked the resident's BS upon admission. She said the DON was ultimately responsible for ensuring admissions orders are entered correctly but the responsibility is delegated to the unit managers. The DON said failure enter orders and monitor blood sugars in diabetics could result in a worsening of prognosis as well as hypo and hyperglycemia.<BR/>In an interview on 01/24/24 at 12:54 PM, LVN B said he did not check Resident #1's blood sugars upon admission or enter her blood sugar monitoring orders and he did not know whose responsibility it was since the resident arrived during a change of shift.<BR/>An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>Record review of the facility policy titled Blood Glucose Management revised 10/2016 revealed, program overview- charge nurses will provide blood glucose management per Health Care Provider's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 5 residents (Resident #2) reviewed for respiratory care. - The facility failed to ensure to change the water in Resident #1's oxygen concentrator (a machine that supplies concentrated oxygen) on 10/26/25 which resulted in the bottle being empty while the concentrator was in use and administering oxygen to the resident on 10/30/25. This failure could place residents at risk for dryness, irritation, nosebleeds, sore throats, thickened secretions, discomfort, and infection due to the dry oxygen. Findings include: Record review of Resident #2's Face Sheet dated 10/30/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: respiratory failure with hypoxia (low oxygen) and Hypercapnia (fast breathing), pneumonia (lung infection), COPD (group of breathing disorders that result in difficult breathing), and heart failure. Record review of Resident #2's admission MDS assessment dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, and receipt of oxygen while a resident at the facility. Record review of resident #2's undated care plan revealed, focus- has oxygen therapy r/t CHF; interventions: oxygen settings: the resident has o2 via nasal prongs/mask at 2 L/min PRN. Record review of Resident #2's Order Summary Report dated 10/30/25 revealed,- 10/03/25 Respiratory Orders: Oxygen at 2 liters per nasal cannula every shift for Hypoxia- 10/03/25 Respiratory Orders: Oxygen Tubing Change every night shift every Sun for Oxygen Tubing Change- 10/03/25 Respiratory Orders: Oxygen-with Humidifier Record review of Resident #2's October 2025 TAR revealed,- LVN A signed that she changed Resident #2's oxygen tubing on Sunday 10/26/25.- RN B signed that she checked on Resident #2's Respiratory orders on the night shift on 10/29/25.- LVN C signed that she checked on Resident #2's Respiratory orders on the evening shift on 10/29/25. Record review of Resident #2's Progress Notes from 10/03/25 to 10/30/25 revealed, no documented nasal irritation, or bleeding. An observation and interview on 10/30/25 at 10:17 AM revealed, Resident #2 lying in bed receiving oxygen at 2 L/min via Nasal Canula. The water bottle connected to the oxygen concentrator was empty and with a date of 10/20/25. Resident #2 said she had no problems breathing or dry/irritated/bleeding nostrils. In an interview on 10/30/25 at 10:20 AM, RN A said nursing staff were expected to check a resident's oxygen level frequently, at least per shift, and document it in their MAR. She said the water on the concentrator served to humidify the air being administered to prevent those receiving oxygen from experiencing dry nostrils that could lead to bleeding. RN A said when nurses signed off on O2 monitoring, they were to inspect the volume of oxygen being delivered, the placement of the tubing and the presence of water. She said she did not notice Resident #2 was out of water, and the nurse scheduled for the Sunday evening shift was responsible for changing the water. RN A said the water for the humidifier was changed along with the tubing and both activities are documented under the order to change the tubing. In and interview on 10/30/25 at 02:54 PM, LVN A said she worked with Resident #2 on Sunday 10/26/25. She said when a resident received oxygen, staff are expected to monitor the settings on the concentrator and the resident's o2 levels on each shift. She said the water is used to humidifier the oxygen delivered because oxygen can try out the nostrils. LVN A said if a resident's oxygen was not humidifier due to the bottle being empty they would be at increased risk for dry nostrils and bleeding. She said she changed the water weekly on the 11 PM- 7 AM shift along with the tubing for infection control/prevent contamination of the water and this task was documented under the change tubing task in the TAR. LVN A said she worked with Resident #2 over the weekend, and she thought she changed the oxygen with the tubing. She said if she documented it, she should have done it because she could not remember any issues with Resident #2's oxygen on the weekend of 10/26/25. She said failure to documents accurately, placed residents at risk of missed services or care and adverse reactions. In an interview on 10/31/25 at 10:22 AM, the Interim DON said O2 water and tubing should be changed every 7 days for infection control and to prevent contamination of the tubing and water She said failure to change the water and tubing could place residents at risk of infection and failure to humidify oxygen could result in drying of the nose, cracked and bleeding nostrils which result in discomfort. The Interim DON said when a nurse signed off on the MAR for changing the tubing they were also indicating that the water was changed, and when they signed off every shift they were signing off on checking that the humidifier had water, the tubing was in good shape, and oxygen being received was as ordered. The Interim DON said failure to document accurately could place residents at risk of inaccurate documentation, missed services/treatment, and care opportunities. In an interview on 10/31/25 at 10:41 AM, RN B said when she worked with Resident #2 overnight on 10/29/25, and the water for the humidifier was bubbling, so there was water in the bottle. She said Resident #2 did not have any issues with her nostrils or have any complaints of dry nose, cracking or bleeding. RN B said she missed the date on the water because she checked to ensure it was bubbling and the water and tubing were supposed to be changed every Sunday in the evening to prevent contamination and infection. In an interview on 10/31/25 at 11:47 AM, LVN C said when she worked with Resident #2 on the evening shift on 10/29/25. She said she monitored the resident's oxygen level, the settings on the tank and monitored the water. LVN C said the water for the humidifier was low, but it was still bubbling and functioning. She said the water was changed every Sunday but if it emptied sooner, nurses could change it. LVN C said she didn't notice the date on the water was 10/20/25, and Resident #2 reported no respiratory issues on her shift. Record review of the facility's policy Oxygen Management Policy revised September 2025 revealed, Policy Overview: This policy provides guidance for the safe storage and use of oxygen. B. Procedure 2. Oxygen Administration a. Verify that there is a physician's order for this procedure. Review the healthcare provider's orders or community protocol for oxygen administration. b. Review the resident's care plan to evaluate for any special needs of the resident. 3. Oxygen Use: b. The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. k. When humidifiers are used, they should be changed per the manufacturer's recommendation. Humidifiers should be checked periodically and changed as needed.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 2 of 2 floors (1st floor and 2nd floor) reviewed for required postings. - On 10/30/25, the facility failed to ensure the Daily Associate Posting included the name of the facility and was displayed in a prominent place readily accessible to residents, staff and visitors by hanging it on the corner wall of the nursing station located on one end of the hall on the 1st and 2nd floor.- On 10/31/25, the facility failed to ensure the Daily Associate Posting on the 1st and 2nd floor included the resident census. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings include: An observation on 10/30/25 at 10:29 AM revealed the facility's Daily Associate Posting hanging on a clip board on the corner of a wall across from the 1st floor nursing station. The name of the facility was not on the posting and the location of the posting was at the end of the left side of a T shaped hallway. An observation on 10/30/25 at 10:48 AM revealed, the facility Daily Associate Posting hanging on a clip board on the corner of a wall across from the 2nd floor nursing station. The name of the facility was not on the posting and the location of the posting was at the end of the left side of a T shaped hallway. In an interview on 10/30/25 at 10:55 AM, the Staffing Coordinator said she was responsible for the staffing schedule and the Daily Associate Posting. She said she did not know the CMS requirements for the Daily Associate Posting and she didn't receive any training prior to gaining the responsibility for creating the posting. She said she didn't know what was supposed to be included and she just completed the template. The Staffing Coordinator said the Daily Associate Postings were located on a clipboard on a corner wall across from the 1st and 2nd floor nursing stations and their purpose was to inform all visitors what staff were in the building. She said the location of the posting across from the nursing station at one end of the T-shaped hall was not in a place where everyone could see it, and it would only be seen by individuals who visited the nursing station located on one side of the hallway. In an interview on 10/30/25 at 02:44 PM, the Administrator said the Staffing Coordinator was responsible for the Daily Associate Posting. She said the posting must be displayed in a location visible to everyone, and it must be posted everyday and include the facility's name, date, census and the staffing for each shift. She said the location of the posting was only visible to anyone that comes in that direction and it was not visible to everyone who entered the facility. The Administrator said the Staffing Coordinator did not receive any training prior to completing the Daily Associate Posting and failure to have the posting in a location visible to all would result in visitors not knowing what the facility staffing was. An observation on 10/30/25 at 01:33 PM revealed the facility's Daily Associate Posting hanging on a clip board in the open sitting area before the hallway leading to 1st floor resident rooms. The facility name was on the posting but the resident census was not on the posting. An observation on 10/30/25 at 01:34 PM revealed, the facility Daily Associate Posting hanging on a clip board in the open sitting area before the hallway leading to 2nd floor resident rooms. The facility name was on the posting but the resident census was not on the posting. In an interview on 10/31/25 at 01:36 PM, the Staffing Coordinator said when she made the schedule on 10/31/25, she forgot to include the census because she forgot to update her premade schedules. She said failure to include the resident census would leave people unaware of the number of residents in the building. Record review of a blank Daily Associate Posting implemented 11/28/17 hanging on the clipboard on the 2nd floor revealed, the document was a photocopy and there was no location name on the form. Record review a SAMPLE Daily Associate Posting implemented 11/28/17, the original document read Location Name at the top left corner of the form. Record review of the facility's policy titled Benefits Improvement Protection ACT (BIPA) Daily Associate Posting revised 10/20/25 revealed, Policy Overview: A daily schedule of licensed and unlicensed nursing associates who are responsible for resident care, should be posted in a prominent location, allowing associates, residents and visitors to view this information. The schedule should include the number and categories of nursing associates scheduled for each shift as well as the total number of hours worked. Staffing is determined by resident population adhering to state and federal regulations. Clinical Services should complete the Clinical Services Sign-in Sheet on every shift. Policy Detail: 1. On a daily basis, a designated associate should post the community-specific number of direct caregivers scheduled for each shift in a 24-hour period by categories of nursing associates employed by the community, as well as the total number of hours worked by both licensed and unlicensed associates directly responsible for resident care. Direct care is interpreted as registered nurses, licensed practical/vocational nurses, and Certified Nursing Assistants (CNAs). 3. The designated associate member should post the community's name, current date and resident census, as well as the community specific shift schedule for a 24-hour period. The community decides when the 24-hour (daily) period for posting information begins and ends. 4. Data must be displayed in a clear and readable format and be posted in a prominent place readily accessible to residents and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #1) whose records were reviewed for resident identifiable records.<BR/>- The facility failed to completely and accurately document administration of medication to Resident #1 by documenting administration of Insulin Lispro that was not in the facility and did not occur,<BR/>This failure could place residents at risk of having incomplete or inaccurate records and inadequate care.<BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed,<BR/>- Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24.<BR/>Record review of Resident #1's 01/17/24 MAR revealed, <BR/>- Insulin Lispro was administered on of 01/18/24 for scheduled doses at 09:00 AM and 01:00 by LVN B.<BR/>Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed,<BR/>- Insulin Lispro was first administered on 01/18/24 at 01:11 PM for the doses scheduled at both 09:00 AM and 01:00 PM.<BR/>Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, <BR/>- Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send.<BR/>In observation on 01/24/24 at 12:14 PM, inventory of the nursing cart with LVN B revealed, an Insulin Lispro pen labeled for Resident #1 with the facility open date of 01/19/24 on both the pen and on the pharmacy label. Inspection of the 2nd floor medication room with LVN B revealed, no other insulin pens for Resident #1 in the fridge.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said staff were expected to document accurately and timely and any discrepancies should be documented in the progress notes. She said Resident #1's insulin arrived on 01/18/24 at 11:59 PM and based on the residents EMR it was not possible for LVN B to administer the 09:00 AM and 01:00 PM scheduled doses of Insulin Lispro to Resident #1 on 01/18/24 at 01:11 PM because the medication was not available in the pharmacy at that time and the facility did not have any insulin on-hand for emergency dispensing. The DON said failure to document accurately placed residents at risk for inaccurate medical records and unidentified missed doses.<BR/>In an interview on 01/24/24 at 12:54 PM, LVN B said to his knowledge Resident #1 did not have any insulin missing and he did not remember administering Resident #1's insulin late at 01:11 PM on 01/18/24 even though it was the documented time on the MAR. LVN B said the only insulin pen Resident #1 had was the pen observed in the nursing cart with an open dated of 01/19/24 and he could not explain where the insulin he documented as administered came from since the pen had not arrived at the facility at the documented time of administration. When asked about the requirement of accurate and timely documentation, LVN B could not provide an answer. He said he did not remember any specifics about Resident #1's Insulin Lispro pen and medication administration time and when asked how he documented the administration of medication that was not available he said I also want to know what happened with the medication and the documentation. He could not provide any details regarding the discrepancy between the documentation and the unavailability of the medication.<BR/>Record review of LVN B's Charge Nurse Orientation Checklist-Skilled Nursing signed on 04/24/22 by the ADON revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. <BR/>Record review of the facility policy titled Medication Administration revised 12/2020 revealed, after administering/observation of the client taking the medication the staff must sign for the scheduled assistance time and date for medications and if applicable, the associate should document the refusal or reason for not administering medication as ordered.<BR/>Record review of the facility policy titled Documentation for Skilled Services revised 05/2023 revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times.<BR/>Record review of the facility provided Skilled Documentation Guide with no revision date revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>- The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL.<BR/>This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization.<BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels.<BR/>Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM.<BR/>Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed,<BR/>- Cefdinir (an antibiotic) 300 mg- 1 capsule by mouth every 12 hours for 5 days, with a start date of 01/18/24.<BR/>- Metformin (an oral antidiabetic) 1000 mg- 1 tablet by mouth two times a day for diabetes with a start date of 01/18/24.<BR/>- Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24.<BR/>- Tresiba Insulin- Inject 30 units under the skin every 12 hours for type 2 diabetes with a start date of 01/17/24.<BR/>- Gabapentin 300 mg- 1 Capsule by mouth two times a day for nerve pain with a start date of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM.<BR/>- 311 mg/dL on 01/18/24 01:11 PM documented by LVN B.<BR/>- 207 mg/dL on 01/18/24 05:52 PM documented by LVN D.<BR/>- 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D.<BR/>Record review of Resident #1's 01/17/24 MAR revealed, <BR/>- Cefdinir 300 mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Gabapentin 300mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Metformin 1000mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Tresiba Insulin was not administered on 01/17/24 even though it was scheduled for 09:00 PM for reasons not documented.<BR/>- Insulin Lispro was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed,<BR/>- Metformin 1000 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Cefdinir 300 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Insulin Lispro was first administered on 01/18/24 at 01:11 PM.<BR/>- Tresiba Insulin was first administered on 01/18/24 at 01:11 PM.<BR/>- Gabapentin was first administered on 01/18/24 at 11:26 AM.<BR/>Record review of the facility automated dispensing machine inventory list presented on 01/23/24 revealed,<BR/>- the facility had 10 capsules of Cefdinir 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility had 6 capsules of Gabapentin 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility did not have Tresiba or Insulin Lispro on hand for emergency dispensing or newly admitted residents.<BR/>Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, <BR/>- Tresiba Insulin was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Metformin 1000mg was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Gabapentin 300 mg capsules was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send.<BR/>In an interview on 01/23/24 at 01:23 PM, the ADON said the facility received 3 different pharmacy deliveries. She said the pharmacy delivered medications to the facility in the early morning, mid-day and at night but there was always an option for a STAT delivery to be made within 2 hours for any urgent medications that the facility did not have in their automated dispensing system. The ADON said the facility did not have any insulin on hand for newly admitted or emergency medication orders.<BR/>An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted (01/17/24) she did not her medications. Resident #1 said she did not receive her antibiotic, Gabapentin and antidiabetic medications (Metformin and Insulins) on 01/17/24 but she did not suffer from any pain or signs/symptoms of uncontrolled blood sugars.<BR/>In an interview on 01/23/24 at 02:35 PM, the DON said per the EMR, Resident #1 admitted to the facility at 02:50 PM but her medication orders were not entered until after 06:00 PM. She said when a resident arrived at the facility their medication orders should be started immediately to avoid any missing doses based on the hospital discharge medication list. The DON said the facility had an automated dispensing system that could provide initial doses of medications for new admissions and any unavailable medications like insulin could be acquired within 2 hours from the pharmacy through a STAT order. She said if the pharmacy was unable to deliver the medication immediately, the resident's provider should be contacted for an alternative regimen and all medication issues should be documented in the resident's chart. The DON said failure to administer medications immediately upon admission could result in increased blood sugar, increased pain, as well as worsening of infection and hospitalization.<BR/>In an interview on 01/23/24 at 05:11 PM, LVN A said she has been in her role as the admission nurse for the past 3 years. She said when a resident arrived at the facility the nurse should reconcile the medications against the discharging facility medication lists and medications should be administered based on the last administered dose. LVN A said since Resident #1 arrived at 02:50 PM she should have received her first dose of medications starting that evening and did not know why she entered Resident #1's medications to start the next morning. She said the facility had an automated dispensing system that had the necessary oral medications on hand and the insulin could have been received within 2 hours through a STAT order from the pharmacy. LVN A said she did not know why she did not get the medication from the automated dispensing system, or from the pharmacy and she did not know why she did not document the issue in the resident's progress notes. LVN A said the doctor did not give her approval to delay the start of Resident #1's medications and failure to administer medications immediately upon admission could place residents at risk for uncontrolled health conditions, uncontrolled blood sugars, uncontrolled pain and hospitalization. She said Resident #1 should have received her first dose of medication the night she arrived at the facility.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said she was ultimately responsible for ensuring medications were started immediately upon admissions and administered as ordered but that responsibility was delegated to the managers who complete next day audits. She said to her knowledge no one had noticed that Resident #1 was not administered medications upon admissions and her first doses were administered late in the afternoon the next day. The DON said Resident #1, the resident's family as well as her doctor was notified of the missed medications and the resident reported no side effects and the physician did not give any new orders.<BR/>An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>Record review of LVN A's Charge Nurse Orientation Checklist-Skilled Nursing signed on 09/01/20 revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. <BR/>Record review of the facility policy titled Reconciliation of Medications od Admission/re-admission and Monthly Orders revised 03/2019 revealed, policy overview- the charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care, for the purpose of providing an accurate and current medication regimen. I(B)- Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process by: identifying the medications the resident needs and administering without interruption, the correct dosages and routes.<BR/>Record review of the facility policy titled Receipt of Interim/Stat/Emergency Deliveries revised 01/01/22 revealed, 1- facility should immediately notify pharmacy when facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions:<BR/>2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or<BR/>2.2 For Pharmacy delivery by contract courier, or<BR/>2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for expired foods.<BR/>The facility failed dispose of perishable foods after use in the walk-in fridge.<BR/>This failure could place residents at risk for consuming hazardous expired food and developing foodborne illnesses who received food from the kitchen.<BR/>Findings Included: <BR/>Observation on 06/17/2025 at 10:48 AM revealed the following:<BR/>*a bottle of Bay Leaves with use by date of 05/31/2025.<BR/>* a package of Pork with use by date of 06/14/2025;<BR/>*a package of Beef with use by date of 06/15/2025;<BR/>*a package of Beef Tips with use by date of 06/10/2025; <BR/>*a package of Brisket with use by date of 06/03/2025; and <BR/> *a container of Chocolate Fudge Icing with use by date of 04/27/2025.<BR/>An interview on 06/19/2025 at 11:22 AM with [NAME] A who revealed they have been trained on kitchen processes including discarding expired foods. [NAME] A stated that if there are expired foods in the facility it should be thrown away. [NAME] A stated there should not be any expired foods in the facility. [NAME] A stated a negative impact this could have on residents was the potential for illness. <BR/>An interview on 06/19/2025 at 11:45AM with DM who revealed he has received training on topics including kitchen storage. DM stated the process for checking expired foods was done two times a day, once in the morning and once in the evening. DM stated this was monitored by the DM and shift manager on duty. DM stated if there are expired foods it should be thrown away. DM stated a negative impact this could have on residents was the potential for illness. <BR/>An interview was conducted on 06/19/2025 at 12:00PM with DSD who revealed he has received training in topics including kitchen storage as well as labeling and dating system. DSD stated the process for checking for expired food was completed in the AM and PM. DSD stated if foods are expired, they should be thrown away. DSD stated a negative impact this could have on residents could be detrimental illness. <BR/>An interview was conducted on 06/19/2025 at 12:05PM with EC who revealed he has received training on topics including kitchen storage and labeling. EC stated the expectation for expired foods is to throw it out immediately. EC stated himself and the sous chef monitor the expiration of food items. EC stated a negative impact this could have on residents was it could make them sick. <BR/>An interview was conducted on 06/19/2025 at 1:15PM with ADM who revealed the dietary services manager provides the training to kitchen staff. ADM stated the policy for dated foods was to throw them away when they are expired. ADM stated the DSD was in charge of the functionality in the kitchen. ADM stated that the kitchen should be checking for expired foods two times a day, once in the AM and in the PM. ADM stated this could cause a negative impact on residents if they consumed the expired foods. <BR/>Record Review of facility policy titled Labeling Safety and Sanitization dated November 2024 stated, <BR/>1.Upon receipt from vendors, all non-perishable food items must be labeled with the received date (month and year) before putting in dry storage. This should be done even if the food item has a use by or sell by date marked by the manufacturer.<BR/>2.All prepared items must have a label with the name of item, date and time prepared, by whom, and discard/use by date. Discard/use by dates should be no more than 3 days for leftovers/hazardous foods and 7 days for all other prepared food. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.

**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 the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #105) reviewed for pressure ulcer in that:<BR/>-Facility staff failed to follow up with Wound Care Doctor's recommendation for left lateral forefoot/left medial foot wound care for Resident #105. <BR/>This failure could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care .<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Following order were entered on 02/22/23 in the resident's medical records: <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning orders recommended by Wound Care Doctor. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Observation and attempted interview on 02/21/23 at 9:23 a.m., revealed Resident #105 was resting on an air mattress. He was alert and well groomed. Resident did not respond to the questions asked about his pressure ulcer.<BR/>In an interview on 02/22/23 at 2:48p.m., with LVN A, she said Unit Manager rounded with the Wound Care Doctor weekly on Thursdays. She said the Unit Manager was responsible for updating wound care orders and reviewing the wound care doctor's evaluation. <BR/>In an interview on 02/22/23 at 3:04 p.m., with the DON, this Surveyor reviewed Resident #105's Wound Care Doctor's evaluation dated 02/16/23 and the physician orders. The DON said the wound care Doctor recommendation for the topical antibiotic were not followed. She said the Unit Manager was responsible for updating the wound care orders. <BR/>In an interview on 2/23/23 at 12:20 p.m., with the Medical Director, this Surveyor reviewed Resident #105's wound care evaluation and physician orders with the MD. The MD said Resident was receiving IV antibiotic for sepsis and infected sacral wound. Resident had a positive blood culture at the hospital. When asked if she was aware of Wound Care Doctor's recommendations for topical application from the wound care Doctor's evaluation dated 02/16/23 for left medial foot and left lateral forefoot. The MD said she reviewed the wound evaluation dated 02/16/23 because she needed to know the wound measurement. Size was the concerns for her to see if the wounds were Progressing or deteriorating. She said Wound Care Doctor's recommendation were supposed to be followed. She said recommendations were considered Wound Care Doctor's order. It should have been entered in PCC and treated like an order. She said, unfortunately I didn't look at the recommendations neither did the nurses or else it would have been in place. It was missed. <BR/>In an interview on 02/23/23 at 1:16p.m., with the DON, she said she talked to the WCD yesterday 02/22/23 and the WCD told her that my recommendations are my orders. She said UM was responsible for rounding with WCD and entering wound care orders in PCC I don't know why she didn't follow up with recommendations. The DON said she was responsible to oversee the Unit Managers. When asked how she monitored staff to ensure they were implementing care planned interventions. How did she monitor the resident's wound progress and how did she determine the appropriate interventions? The DON said she had not been spot-checking or reviewing the wound evaluations with the UM to make sure the orders were being followed. The DON said, I thought UM knew what she was doing. The DON said it was important to follow physician order to prevent wounds from deteriorating. At this time policy on following physician orders was requested.<BR/>In an interview on 02/23/23 at 1:48p.m., with the DON and the UM, the UM said she reviewed the wound care doctor's evaluations weekly and updated the orders in PCC. She said she failed to look at the WCD's recommendations.<BR/>In an interview on 02/23/23 at 3:10p.m., with the Wound Care Doctor, she said her recommendations were considered her orders. She said Resident#105's family member was concerned that the vascular doctor had prescribed topical antibiotic that was being used at the hospital and had been stopped intermittently while at the facility. WCD said it was important to complete the course of ABT. If not completed infecting bacterium would become resistant to the antibiotic and we do not want that to happen. It was imported to finish ABT. Therefore, she ordered the ABT. <BR/>Record review of facility's Wound Observation and Pressure Injury/Ulcer Staging Policy (Last revised: 05/2022) read in part: .Policy overview: All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers .<BR/>No policy regarding following physician order was provided prior to exit.

**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 6 residents (Resident #105) reviewed for infection control, in that: <BR/>-The facility failed to ensure LVN A performed hand hygiene when moving from a dirty to clean site, while performing Resident #105's wound care.<BR/>This failure could place residents at risk for or infections.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .<BR/>Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care.<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Resident#105's physician order, dated 02/11/2023 revealed an order for Cefepime HCL Solution 1 GM/50ML use 1 gram intravenously every 12 hours for infection for 14 days. <BR/>Record review of Resident#105's physician order, dated 02/09/2023, revealed an order to cleanse Right inner ankle with wound cleanser, pat dry, applied xeroform then covered with dry gauze and dry dressing every day shift.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse wound to sacrum with wound cleanser; pat dry; apply skin prep to Peri wound; apply Santyl to necrotic/slough tissue; cover with calcium alginate; cover with dry dressing daily and as needed if soiled. In the morning for wound healing until 03/17/2023 <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse pressure wound to right lower back with wound cleanser; pat dry; skin prep peri wound; apply Santyl; cover with calcium alginate and dry dressing in the morning for wound healing until 03/17/2023.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Observation on 02/22/23 at 2:35 p.m., revealed the LVN A performing wound care on Resident #105 assisted by CNA D. Resident #105 was assisted onto his left side revealing there was no dressing on the resident's back. The wounds were covered with dry gauge. Further observation revealed unstageable pressure ulcer to the sacral/coccyx area approximately 3 cm in diameter and a stage 3 pressure ulcer to the right lower wound area approximately 12 cm in diameter. LVN A looked at this Surveyor and said, I don't remember the orders do you mind if I go check the orders. LVN A removed her soiled gloves without sanitizing/washing her hands left the room. Returned after few minutes sanitized her hands, donned new gloves and continued the wound care treatment. LVN A removed right inner ankle dressing dated 02/21/23 observation revealed unstageable (had slough) right inner ankle area approximately 0.3 cm in diameter. LVN A cleansed the wound with normal saline, pat dried with the same soiled gloves applied xeroform, dry gauze and covered with dry dressing. With the same soiled gloves LVN A removed left medial foot /left lateral forefoot dressing (kerlix wrapped around the wound) left medial foot area approximately 4 cm in diameter. Left lateral forefoot area approximately 4 cm in diameter. LVN A cleansed both wounds with normal saline, pat dried, with the same soiled gloves applied betadine, xeroform, dry gauge and wrapped with kerlix. <BR/>In an interview on 02/22/23 at 3:04p.m., with the DON, she said she expected staff to follow standard infection control techniques; to perform handwashing before the treatment, between gloves change and after moving from dirty to clean site as it placed risk for infections. She said staff were provided mass infection control in service on COVID sign and symptoms, infection control and hand washing sometime in January 2023. She said to prepare for the annual survey Unit Mangers had been doing observations on staff providing care don't know how that fell through the cracks. She said she UM were eye bawling and did not have any documentations of the check off/spot checks. She said the potential risk to the resident, due to this failure, was cross contamination. At this time policy on infection control and hand hygiene were requested. <BR/>In an interview on 02/23/23 at 1:08 p.m., LVN A said she was not a certified wound care nurse and did not receive wound care training at this facility. She said she could not recall having wound care competency check with the DON/ADON/Unit Manager. She said she started working in April 2022 at this facility. She said upon hire she received 3 days training on the floor shadowing another nurse. She said that nurse did run down on how to clean the wound. She said she did not perform hand hygiene or changed gloves when moving from dirty area to clean because I thought we had to switch gloves when switching wound sites. She said, I should have changed my gloves, sanitized my hands before applying santyl and calcium alginate on the wound. While removing old dressing and cleaning the wound I contaminated my gloves. She said this failure placed risk for infections. She said the facility provided in-servicing on infection control sometime last month. She could not recall the exact date. <BR/>In an interview on 02/23/23 at 1:48 p.m., with the DON and the Unit Manager, UM said she tried to spot check nurses as much as possible at least once a week. She said she observed LVN A do the med pass last week and wound care two weeks ago. UM said it was a simple skin tear dressing change on another resident. She said she could not recall the name of that resident, but it was not on Resident# 105. <BR/>Record review of facility Wound Care Competency (revised 02/2020) revealed read in part: Skills: 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline. 12. Perform hand hygiene. 13. Apply treatment as indicated .<BR/>Record review of facility's Handwashing/Hand Hygiene policy (last revised: 01/2021) revealed read in part: .Policy Overview: This community considers hand hygiene the primary means to prevent the spread of infections. G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, and alcohol -based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 7. Before handling clean or soiled dressings, gauze pads, etc.; 8. Before moving from a contaminated body site to a clean body site during resident care; 11. After handling used dressings, contaminated equipment, etc.; 13. After removing gloves; I. The use of gloves does not replace hand washing/hand hygiene .<BR/>Record review of facility's Infection Prevention and Surveillance policy (Last revised: 01/20) revealed read in part: .Policy overview: The Nurse Leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infections .<BR/>Policy regarding infection control was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed physician notification. <BR/>Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later 2/20/2024.<BR/>An IJ was identified on 4/1/2024. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. <BR/>This failure could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life threatening infections, hospitalization, and worsening pressure ulcers.<BR/>Findings included:<BR/>Record Review of Resident #1's Face Sheet undated revealed an [AGE] year old female who was admitted to facility on 2/8/2024 with diagnoses of Other fracture of left femur (Bone that runs from hip to knee), subsequent encounter for closed fracture with routine healing (Unopen fracture), Encounter for other orthopedic after care (At facility for rehabilitation), Extended Spectrum Beta Lactamase (ESBL) resistance (Antibiotic resistant urinary infection), Urinary Tract Infection where urine is excreted), Morbid Severe Obesity due to excess calories, Type 2 Diabetes Mellites with Hyperglycemia (High blood sugar).<BR/>Record Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 9 indicating the resident was moderately cognately impaired, Resident #1 required extensive assistance with ADLs. Section I revealed fractures and other multiple traumas, urinary tract infection last 30 days, Swallowing Disorder . Risk of pressure injuries .yes, Unhealed pressure ulcers/Injuries yes .Unhealed pressure ulcers/injuries Yes .stage 1 .0 .Stage 2 .0, Stage 3 .0. Stage 4 .0 (No pressure injuries at admission) Unstageable deep tissue injury .1 .MASD (Moisture Associated Skin Damage). <BR/>Record review of Resident #1's Care Plan dated 2/9/2024 read in part .Resident #1 has potential/actual impairment to skin integrity . Interventions: Assist with turning and reposition as needed. Reduce friction and shearing with use of lift or transfer sheets 2/8/2024 .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc to MD. 2/8/2024 . <BR/>Record Review of Resident #1's Comprehensive Nursing notes dated 2/16/2024, 2/18/2024 and 2/19/2024 read no new or worsening skin conditions. <BR/>Record review of Resident #1's orders dated 2/20/2024 read . Cleanse sacrococcygeal ulcer (Area above and center of buttocks) with NSS (normal saline), Pad Dry, apply calcium alginate (Fabric) and med honey (medication for healing) and cover with sacral dressing (area at top and center of buttocks) qd (daily). <BR/>Record Review of Resident #1's BD Weekly Wound Data Collection Flow Sheet dated 2/20/2024 revealed wound 6.5x14.0 depth, unstageable.<BR/>Record Review of Resident #1's Change of Condition dated 2/20/2024 read in part . Skin status evaluation .pressure ulcer injury .Sacrum .unstageable pressure wound. <BR/>3/2/2024 Family Member #1 removed Resident #1 from the skilled nursing facility and took her to the hospital due to the pressure wound on her sacrum.<BR/>Record Review of Resident #1's hospital records dated 3/2/2024 to 3/11/2024 revealed Resident #1 was admitted to the hospital with diagnoses of Infected decubitus ulcer (Infection at buttocks), unspecified ulcer stage. 8.0 x 10.0 x Unstageable due to 80% adherent necrotic tissue. Resident underwent Incision and drainage of sacral wound on 3/5/2024, intraoperative cultures grew Protease mirabilis (Bacteria in Urine infections), ESBL E. coli MDR (Harder to treat with antibiotics) and Enterococcus faecalis Pan sensitive (Bacteria found in the intestine). Resident #1 was discharged with orders for IV Meropenem (Intravenous antibiotic) every 8 hours for 21 days. <BR/>Interview 3/13/2023 at 10:30am the Assistant Director Clinical Services said if a nurse found a wound and the skin was broken the expectations were to clean it, put a dry dressing on it and contact the Nurse Practitioner or Doctor for the findings and get and order for wound care. If that was not done the wound could have possibly deteriorated even more. She said they wanted staff to put in nursing interventions and needed them to offload from the wound. She said looking back they saw there was no notification to the physician and no orders for wound care for 2 days. She said they did rounds with the wound care physician so when the wound was found, they put interventions in place, making sure the wound care physician was notified, made sure the proper treatments were in place and notified the family. <BR/>Interview 3/13/2024 at 10:44am with Family Member #1 he said he had to take his Resident #1 out of the nursing facility himself as the facility transportation would not take him to the hospital of his choice and he wanted Resident #1 to go to a particular hospital for her wound. He said he had to initiate the transfer as the facility said Resident # 1 did not need to go to the hospital. He said Resident #1 was in the hospital for nine days for her infected bedsore and she had been discharged the previous day to another nursing facility.<BR/>Interview on 3/13/2024 at 1:20pm with LVN A she said she worked on 2/18/2023 in the evening. She said the weekend supervisor told her Resident #1 had a wound on her sacrum. She said she thought the weekend supervisor was going to manage everything. She said she did not necessarily say she was going to manage everything, she said she thought they were going to handle the wound together. She said she guessed it was her fault the physician was not called about the wound even the CNAs were telling her they were reporting it to previous nurses the day before on 2/17/2024. They said there were bandages on the wound already and there were bandages in the room. She said the CNAs that told her they were from the weekend shifts. They said the bandage fit on the specific part for the sacrum. She said the CNAs had been putting the bandage on the wound and said they had been reporting it to previous nurses. She said the weekend supervisor looked at the wound. She said she thought the supervisor was going to call the doctor. She said she had not worked at the facility in 2 or 3 weeks. She said she talked to the DON and ADON about the wound and they asked how it looked at the time, they wanted to know if it looked black at that time. She said the wound was large. She said no one had previously reported a wound to the sacrum. No one had reported a wound on Saturday. She said she had been a nurse for one year, worked at the facility for one month, and was in-serviced on wound care in February 2024.<BR/>Interview on 3/13/2024 at 2:00pm, CNA K said she remembered Resident #1. She said she came back from 5 days off and had her as a patient and when she was changing her, she saw she had redness and told her nurse. She said from then on, they started turning Resident #1 every 2 hours to get her off her bottom. She said this was on Wednesday February 21, 2024. She said when she saw the wound it was very large, very tender, obvious it had been there for a few days. She said the skin was broken. She said it was very vibrant colored, so she reported it to LVN B. She said she had been a CNAs for 10 months and worked at the facility for 5 months. She said prior to this happening she was in-serviced on wounds at a retirement home and was reminded at this facility. She said the facility had done an in-service . She said they had shown them how to add notes so they could have said they told the nurse about wounds and so the residents could have gotten treatment.<BR/>Interview on 3/13/2024 at 2:50pm CNA L said she worked on Sunday 2/18/2024. She said she had only worked with Resident #1 a handful of times, and she was dead weight. She said when she got to Resident #1, she noticed a wound with no covering on her back side (2/16/2024). She said another CNA said she noticed it the day before on 2/17/2024, but she did not remember who it was. She said this had to have happened about a month ago if not more. She said the skin was broken off at the back and butt crack and she told the nurse but could not remember who on the morning shift. She said the wound looked pretty bad and looked like it would have stung. She said it was medium to large. She said they should have known about the wound if the CNA noticed it before her. She said it was a Sunday. She said she did not really know some of the nurses. She said she had worked at facility 7 months and been a CNA for 3 years. She said she was last in-serviced on skincare the prior weekend, and before that 3 months ago.<BR/>Interview on 3/13/2024 at 3:55pm CNA M she said she was not at the facility at first but when she came back on 2/16/2024, she saw Resident #1 had a wound to her buttocks. She said she told the nurse it needed to be cleaned and it had an odor. She said the wound was open, large and had an odor. She said the skin was off the wound. She said she told the nurse LVN C about the wound, but she did not do anything about it because after that she got a call from the DON asking about the wound and when it started.<BR/>An interview with LVN C could not be conducted as she was in the hospital.<BR/>Record review of Resident #1's Braden Scale for predicting pressure ulcer risk dated 2/15/2024 read Resident #1 had slightly limited sensory perception, was bedfast, occasionally moist, made frequent though slight changes in body or extremity position independently, friction or shear was a potential problem, and the total score was above 16. (Mild risk for pressure ulcers). <BR/>Interview on 3/14/2024 at 2:55pm with the Assistant Director Clinical Services she said they did investigations with the staff to figure the gaps on Resident #1's wound. She said she looked herself and the skin initially was intact. She said even the week prior the evening nurse showed on the 14th it was intact. She said it was Resident #1's positioning, nutrition, and incontinence, and it was a combination that caused the wound. She said she knew they were putting zinc on the wound. She said on Sunday 2/20/2024, the CNA had identified and informed the off going nurse on the 3 to 11shift of the wound and she looked at it and told RN S. She said LVN A told RN S Resident #1 had skin breakdown and could she look at it look at it let her know. She said RN S said she would help LVN A if she needed it. The Assistant Director Clinical Services stated according to the RN S she told the nurse to get the information and call the doctor. LVN A said she would call the doctor and get the order. The Assistant Director Clinical Services stated It was he said she said situation. She said she had not heard anything about February 16th and when she did her weekly assessment on the 14th it was ok and there was no breakdown on the sacral area. She said the reason the resident had a sacral wound was because she had not been repositioned. She said when residents get sacral wounds, they can become infected. <BR/>Interview on 3/14/2024 at 2:55pm with the ADON she said she did not know a CNA had reported skin breakdown to LVN C on 2/16/2024. She said on 2/18/2024 LVN A and RN S told her it was the others responsibility to call the physician. She said LVN C told her RN S would call the physician for orders and RN S said LVN A would call the physician for orders. She said RN S should have called the physician for orders for wound care as she was the person who reported to the oncoming staff.<BR/>On 3/13/2024 at 11:05am outreached RN S who had been terminated by the facility for not contacting the physician for wound care orders, and she refused the interview.<BR/>Interview on 3/15/2024 at 8:30am with the ADON she said the failure with Resident #1's wound was a combination of timely identification of the wound and not getting timely treatment in place. She said Resident #1 was being treated for ESBL (Antibiotic Resistant bacteria) and E. coli (Intestinal bacteria) in urine. She said Resident #1 had a slight decrease in mobility and it was their job to have repositioned her, to have been timely in reporting the wound, and she said the reason Resident #1 developed the wound was because she was not repositioned enough. She said she had been a part of the QAPI (Quality Assurance and Performance Improvement) subcommittee, with KPI (report to look at metrics and pressure ulcers) were worked on this year, she said this issue was disheartening, she said they had identified wounds and they had multiple sessions with the nurses. She said she thought the failure was communication regarding Resident #1. She said they educated the staff so when they saw something to report it. She said staff were to report skin breakdown instead of someone assuming it had already been reported. She said Resident #1 did not really want to be turned and Resident #1 could have gotten the wound by not being turned, she said Resident #1 needed assistance with turning. She said what should have happened was as soon as anything was different with Resident #1's skin, they should have reported to the charge nurse starting at the stage 1. She said staff should have notified charge nurse, notified wound care physician, and gotten orders for wound care.<BR/>Interview on 3/15/2024 at 6:46am CNA N said she worked the night shift last night. She said she had worked at the facility for 10 years and been a CNA for 20 plus years. She said she worked on the first floor. She said she saw Resident #1's wound. She said she saw her wound, but she was not assigned to her, but she did see it, she said she assisted with turning. She said when Resident #1 needed changing she would assist with changing her. She said Resident #1 would call and let us know when she was ready to be changed. She said Resident #1 was with it and she was coherent. She said she saw the bedsore and saw the wound as medium sized, she said they would have patches on it, they would clean it and put patches on it. She said she told the nurse about the wound, and they had so many since then she did not know the name of the nurse, she reported it to. She said she did not know if the ADON knew about the wound. She said she was sure she did, she said you can tell nurses about a wound but after that you do not know what happens. She said if a resident was not turned, they could have gotten a bedsore and it could have gotten larger. She said it could have gotten infected. She said she did not know how Resident #1 got the bedsore but had been shocked to hear about it and said she saw it when it was smaller.<BR/>Interview on 3/15/2024 7:31am with LVN D she said she had worked at the facility for about 5 weeks. She said she had been a nurse for 2 years. She said she saw the wound on Resident #1's sacrum. She said the wound was unstageable when she saw it. She said it was red around the perimeter and black on the inside. She said she did not believe the CNA reported the wound. She said she believed there was a dressing on the wound on Friday 2/16/2024. She said she did not know it had not been reported to the physician as they each had a list of comprehensive nursing notes to write, and she had not documented on her. She said the CNA told her there was a wound and it was not dirty. She said she did not call the physician. She said they do skin checks on the 7 to 3 and 3 to 11 shifts so they would have called and received an order as she worked nights. She said she found a wound on Resident #1's inner thigh the following week and called the wound care physician and received an order for that. She said if a resident had a bedsore, they could get an infection and have pain. She said she did not know how long Resident #1's sacral wound had been there. <BR/>Interview on 3/15/2024 at 7:33am with CNA O she said she had worked at the facility since October 2023, she said she would have been a CNA for a year in May 2024. She said she had seen the wound on Resident #1's sacrum and reported it to the nurse. She said she reported it to LVN D because the bandage was soiled, and she took it off so that LVN D could replace it. She said LVN D came in and replaced the bandage. She said she saw the wound after Valentines Day . She said she did not work on weekends, so it was on Thursday 2/15/2024, or Friday 2/16/2024. She said it was not the week of 2/23/24. She said if a resident was not turned, they could have gotten a bedsore, the bedsore could have gotten worse, and the resident could have gotten an infection.<BR/>Record Review of facilities policy titled, Skin Observation and Wound Prevention Protocol dated 10/2022 read in part . Charge nurses should observe the condition of the resident's skin on admission and on a routine basis.<BR/>Record Review of facilities policy titled, Change of Condition for Skilled Nursing Communities dated 8/2023 read in part .An associate should communicate information about a residents status change to appropriate licensed personnel upon observation .or observing a difference in the residents usual physical .the licensed nurse should .notify the HCP (Healthcare provider) of observations and relevant change of condition information .Implement treatment interventions, received orders and document HCP recommendations as indicated .<BR/>Record Review of Facility In-Service dated 2/2/2024, 2/3/2024 and 2/7/2024 .Topic .Annual Charge Nurse Check-off Training read in part . Importance of pressure wound prevention .Doctors, On-call, Telehealth.<BR/>Record Review of Facility In-Service dated 2/20/2024 .Topic . Offloading/Repositioning read in part .Repositioning patients throughout shift to offload bony prominences .offload areas at risk for breakdown .<BR/>Record Review of Facility In-Service dated 2/21/2024 .Topic .Infection Control read in part . Signs and Symptoms of wound infection: Swelling, Redness, Slight odor, increased pain at wound site .<BR/>Record Review of Facility In-Service dated 3/13/2024 .Topic .Reporting New or Progression of Wound read in part .CNA to report New or Worsening wounds too Charge nurse immediately .Document Change in Skin Condition in PCC using Stop-N-Watch Tool .Charge Nurse to report New or Worsening wounds to Physician/NP to receive wound care orders immediately .Charge Nurse should place call to DCS (Director Clinical Services) or ADCS (Associate Director Clinical Services) to inform of New or Worsening wound identified. <BR/>An IJ was identified on 4/1/2024 and the facility administrator was notified at 7:00pm. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. <BR/>On 4/3/2024 at 4:40pm the following Plan of Removal was accepted.<BR/> Plan of Removal<BR/>Brookdale Galleria - April 2, 2024<BR/>F580 Notifications of Changes<BR/>Immediate Action:<BR/>On 2/19/2024, an impromptu Quality Assurance Performance Improvement (QAPI) Meeting was completed with the Healthcare Administrator (HCA), Director of Clinical Services, Assistant Director of Clinical Services (ADCS), and Medical Director via the phone related to the Skin Management Process related to Resident # 1 skin documentation. The additional actions included re-education to Certified Nursing Assistance (C.N.As) and Licensed Nurses on repositioning and abuse neglect reporting. Re-education for Licensed Nurses on skin assessments, Skin observation protocol (which includes notification of healthcare provider), repositioning, and wound prevention. These Inservices were completed on 2/20 by the ADCS.<BR/>On 2/20/2024, the ADCS and Attending Physician assessed the wound to Resident #1's sacrum and new orders received by the attending physician for medical honey and calcium alginate, supplements, and a low air loss mattress. <BR/>On 2/22/2024 the Third Party Wound Doctor assessed the wound, orders were updated to include Santyl. The Third Party Wound Doctor discussed the skin management plan of care with the resident # 1 representative at bedside. <BR/>On 2/22/24, the ADCS performed wound rounds on current residents with wounds. No new pressure concerns were noted.<BR/>On 3/2/24, Resident # 1 discharged from the community. <BR/>On 3/13/24, an Impromptu QAPI Meeting held with the HCA, ADCS, Regional Director of Clinical Services (RDCS), and the Medical Director via the phone related to the Skin Management Process. The additional actions included the ADCS or designee to extend the audits of 5 residents dressing to be completed weekly for 90 days, review residents that would benefit from a Low Air Loss Mattress, complete skin checks on current residents, and re-education to C.N.A's and Licensed Nurses to notify the DCS or ADCS on new pressure ulcers. The regional support nurse conducted an audit on 3/14 no additional findings relating to physician notification were noted.<BR/>On 3/13-3/14/24, the ADCS and designee completed skin checks on current residents. No new pressure concerns were noted.<BR/>On 3/14/24, a Registered Nurse (RN) performed a remote Skin Documentation Audit. The audit included the following items. The audit was documented on an audit form. <BR/>o <BR/>Weekly Skin Integrity Review form to verify every resident had either the weekly skin form or the section completed in the Nursing admission Data Collection form, if newly admitted . <BR/>o <BR/>That every resident had a weekly skin integrity review activated schedule to be completed weekly in PCC. Form scheduled as needed in PCC.<BR/>o <BR/>Weekly Wound Data Collection form if completed, the date, and information in the form. <BR/>o <BR/>Third Party Wound Care MD notes in PCC Miscellaneous tab with notes on wounds (location, etc.)<BR/>o <BR/>Third Party Wound Care MD orders from their notes on wounds from bullet above.<BR/>o <BR/>Physician orders written in PCC for wounds or anything related to skin. <BR/>o <BR/>Care Plans related to wounds. <BR/>Plan for Compliance:<BR/>From 3/13/- 3/16/2024, the DCS or designee re-educated all Licensed Nurses on change of condition documentation which includes notifying physician and representative, skin documentation, obtaining orders for any wounds, reviewing and addressing clinical alerts on skin concerns from C.N.A's, notifying provider as indicated, professional standards of wound care, that the C.N.A can't apply a treatment, Braden Scale which includes preventative measures. Licensed nurses not available between 3/13/2024 to 3/16/2024 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/2024. Competency validated with a post test. From 4/1 -4/3 the DCS or designee re-educated nurse on physician notification of new skin issues, change of condition documentation, aides performing dressing changes, skin observation and wound prevention protocol. Licensed nurses not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test.<BR/>Starting 3/14/24, the Licensed Nurses will initiate the wound data collection sheets on any new pressure ulcers. The RAI or designee will update resident care plans as needed as new pressure concerns arise. The Licensed Nurse will review the clinical alerts in the dashboard periodically through the shift to verify that any new skin concerns communicated by the C.N.A are addressed. The ADCS or designee overseeing will complete the weekly wound data collections for residents with new pressure ulcers until pressure ulcer is resolved or the resident is discharged . Order listing report, progress notes, weekly skin and wound documentation is reviewed during daily standup for any new or worsening pressure ulcers.<BR/>From 3/13- 3/16/24, the ADCS or designee re-educated all C.N.A.s on communication of changes in skin integrity with the licensed nurse and DCS or ADCS, documentation of any new skin concerns in the electronic medical record every shift including the stop and watch, what to do if dressing falls off the resident's wound, moisture barriers, and turning and repositioning. The C.N.A may complete a Stop and Watch Alert that there is a Change in skin color or condition as indicated. These alerts display on the licensed nurse clinical alert dashboard in the electronic medical record. The C.N.A will also communicate verbally to the licensed nurse what they documented in the electronic medical record related to new skin concerns. The C.N.A. will contact the DCS, ADCS, or the Healthcare Administrator to report new skin issue for additional follow up. C.N.As not available between 3/13- 3/16/23 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/24. Competency validated with a post test. From 4/1 to 4/3 C.N.A. were re-educated on C.N.A. not performing dressing changes and are allowed to apply barrier cream, reporting changes in skins and wound prevention. Aides not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test.<BR/>For 90 days, the DCS or designee will review clinical alerts in stand-up meeting five days a week, to determine if there is documentation of new skin concerns noted by a C.N.A. and verify that appropriate follow up and documentation was completed by a licensed nurse as indicated. The licensed nurses will review clinical alerts including the stop and watch periodically through their shifts daily, to assist with identification of new skin concerns documented by the C.N.A's. <BR/>For 90 days, the ADCS or designee will audit the weekly skin integrity review for 5 residents a week to verify completion, validate accuracy with a head-to-toe skin check, confirm that appropriate skin care orders are in place as applicable, and notification of the Healthcare was completed as applicable if skin concerns identified. These audits will be documented on an audit form.<BR/>For 90 days, the ADCS or designee will audit 5 residents' wound care orders a week to verify treatments were completed per physician orders. These audits will be documented on an audit form and reported in the next morning stand up meeting.<BR/>For 90 days, the DCS or designee will review the audits monthly at the QAPI meeting.<BR/>Compliance date: 4/3/2024<BR/>An IJ was identified on 4/1/2024 and the facility was notified at 7:00pm. The IJ template was provided to the facility on 4/2/2024 at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance.<BR/>The surveyor monitoring was from 4/1/2024 to 4/4/2024.<BR/>Immediate Jeapordy monitoring included:<BR/>Record review on 3/13/2024 revealed a QAPI sign in sheets for 2/19/2024, 3/13/2024, 3/15/24, 3/20/2024, 3/27/2024 with sign in sheets in IJ book by Administrator, Infection preventionist/ADON, Medical Director (3/15/2024).<BR/>Record review on 3/13/2024 of nurse's notes dated 2/20/2024 revealed the physician was notified immediately on 2/20/2024 at 1:51pm and orders implemented for wound care and wound care physician consulted.<BR/>Record review on 3/13/2024 revealed staff in-services 2/20/2024 for Abuse and Neglect, the facility provided a copy of policy, Offloading and Repositioning, Skin observation and repositioning, 2/21/24 In-service included Hand Hygiene, Incontinent Care Cleansing, Signs and Symptoms of wound infection, Cleansing of Shared equipment, Handouts: Charge nurse responsibilities, Nursing Forms, Shift Report, Patient appointments and facility provided policy on infection control. Inservice 3/1/2024 Charge nurse responsibilities, 3/13/2024 Reporting new or progression of wound, 3/21/2024 Wound care paperwork, 3/25/2024 Infection Control. Facility provided policy. 3/25/24 Order Confirmation from Physician/NP.<BR/>Record review on 3/13/2024 revealed wound care physician visit on 2/22/2024<BR/>Record review on 3/13/2024 of physician orders dated 2/23/2024 15:00 were updated to include Santyl Ointment as part of the residents wound care regimen.<BR/>Record review on 3/13/2024 revealed staff were in-service 3/13/2024 Reporting New or Progression of Wound: CNAs t report new or worsening wounds to charge nurse immediately, Charge nurse to report new or worsening wounds to Physician/NP to receive wound care orders immediately, Charge nurse should place call to Director of Clinical Services or Assistant Director of Clinical Services to inform of New or worsening wound identified. <BR/>Record review on 3/13/2024 revealed skin assessments performed on 2/21/2024 to 2/23/2024 and 3/13/2024.<BR/>Record review 4/3/2024 revealed Woundcare Orders and Treatment audit for March 2024<BR/>Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 and 4/3/2024 for Physician notification for new skin issue, change of condition documentation, and CNAs and dressing changes. In-service included CNAs should never apply Zinc oxide to patients' body, change a wound dressing and if the dressing comes off during a shower or bath the CAN needed to notify the nurse to put a new dressing on the wound. The in-service was followed by a post test for CNA's.<BR/>Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 for Skin observation/Wound prevention; facility provided policy.<BR/>Record review on 4/3/2024 revealed audits on 4/2/2024 for residents admitted within the last 30 days for new pressure ulcers and notification to healthcare provider. Audit consisted of reviewing the weekly skin integrity forms, admission assessment and weekly wound data forms. Wound physician progress notes as indicated. No additional findings.<BR/>Record review on 4/3/2024 revealed weekly skin integrity reviews for February 2024 and March 2024 revealed no new or worsening wounds.<BR/>Observation of wound care on 4/3/2024 11:45am on Resident #6. Resident #6 noted to be on a low air loss mattress. Nurse washed hands, donned gloves, removed dressing, removed gloves, applied hand sanitizer .donned gloves, wiped wound from inside to outside with gauze impregnated with wound cleanser, removed gloves, hand sanitizer, donned gloves, patted are around wound for adhesion, removed gloves, hand sanitizer, applied calcium alginate and bordered dressing. Dated. Noted wound was healthy and healing, It appeared sacral wound had been larger at one time but now wound small, healthy red with granulation tissue.<BR/>In an interview on 4/2/2024 at 12:47pm LVN E said she had been in-serviced a few times on wounds and wound care, she said she had been in-service the previous night on reporting new wounds to the physician, letting the unit manager and ADON know, calling the physician for orders and letting them know about changes in condition and weekly skin data. <BR/>Interview on 4/2/2024 at 12:53pm CNA P said she was not supposed to change dressings on a resident, she said she was supposed to report missing or damaged dressings to the charge nurse or DON and document in the system who she told. Se said she would have reported skin breakdown to the charge nurse or DON, she said she had been in-service today, last week on wounds, change of condition, not to use zinc oxide and moisture barrier. <BR/>Interview on 4/2/2024 1:00pm CNA Q said he had been in-service on wounds and wound care that morning. He said reporting wounds, new skin issues, not to change dressings, role as a CNAs, and when he saw redness or wounds to report and document in the system. He said he would have reported to the nurse and ADON.<BR/>Interview on

**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 the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #105) reviewed for pressure ulcer in that:<BR/>-Facility staff failed to follow up with Wound Care Doctor's recommendation for left lateral forefoot/left medial foot wound care for Resident #105. <BR/>This failure could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care .<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Following order were entered on 02/22/23 in the resident's medical records: <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning orders recommended by Wound Care Doctor. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Observation and attempted interview on 02/21/23 at 9:23 a.m., revealed Resident #105 was resting on an air mattress. He was alert and well groomed. Resident did not respond to the questions asked about his pressure ulcer.<BR/>In an interview on 02/22/23 at 2:48p.m., with LVN A, she said Unit Manager rounded with the Wound Care Doctor weekly on Thursdays. She said the Unit Manager was responsible for updating wound care orders and reviewing the wound care doctor's evaluation. <BR/>In an interview on 02/22/23 at 3:04 p.m., with the DON, this Surveyor reviewed Resident #105's Wound Care Doctor's evaluation dated 02/16/23 and the physician orders. The DON said the wound care Doctor recommendation for the topical antibiotic were not followed. She said the Unit Manager was responsible for updating the wound care orders. <BR/>In an interview on 2/23/23 at 12:20 p.m., with the Medical Director, this Surveyor reviewed Resident #105's wound care evaluation and physician orders with the MD. The MD said Resident was receiving IV antibiotic for sepsis and infected sacral wound. Resident had a positive blood culture at the hospital. When asked if she was aware of Wound Care Doctor's recommendations for topical application from the wound care Doctor's evaluation dated 02/16/23 for left medial foot and left lateral forefoot. The MD said she reviewed the wound evaluation dated 02/16/23 because she needed to know the wound measurement. Size was the concerns for her to see if the wounds were Progressing or deteriorating. She said Wound Care Doctor's recommendation were supposed to be followed. She said recommendations were considered Wound Care Doctor's order. It should have been entered in PCC and treated like an order. She said, unfortunately I didn't look at the recommendations neither did the nurses or else it would have been in place. It was missed. <BR/>In an interview on 02/23/23 at 1:16p.m., with the DON, she said she talked to the WCD yesterday 02/22/23 and the WCD told her that my recommendations are my orders. She said UM was responsible for rounding with WCD and entering wound care orders in PCC I don't know why she didn't follow up with recommendations. The DON said she was responsible to oversee the Unit Managers. When asked how she monitored staff to ensure they were implementing care planned interventions. How did she monitor the resident's wound progress and how did she determine the appropriate interventions? The DON said she had not been spot-checking or reviewing the wound evaluations with the UM to make sure the orders were being followed. The DON said, I thought UM knew what she was doing. The DON said it was important to follow physician order to prevent wounds from deteriorating. At this time policy on following physician orders was requested.<BR/>In an interview on 02/23/23 at 1:48p.m., with the DON and the UM, the UM said she reviewed the wound care doctor's evaluations weekly and updated the orders in PCC. She said she failed to look at the WCD's recommendations.<BR/>In an interview on 02/23/23 at 3:10p.m., with the Wound Care Doctor, she said her recommendations were considered her orders. She said Resident#105's family member was concerned that the vascular doctor had prescribed topical antibiotic that was being used at the hospital and had been stopped intermittently while at the facility. WCD said it was important to complete the course of ABT. If not completed infecting bacterium would become resistant to the antibiotic and we do not want that to happen. It was imported to finish ABT. Therefore, she ordered the ABT. <BR/>Record review of facility's Wound Observation and Pressure Injury/Ulcer Staging Policy (Last revised: 05/2022) read in part: .Policy overview: All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers .<BR/>No policy regarding following physician order was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices 1 of 5 residents (Resident #1) reviewed for quality of care.<BR/>-The facility failed to enter orders for blood sugar monitoring for Resident #1, who had type 2 diabetes, upon admission and as a result the resident's blood sugar was not assessed for over 22 hrs. (01/17/24 at 02:50 PM to 01/18/24 at 01:11 PM) after admission.<BR/>This failure could place residents at risk of delayed identification/treatment of acute health conditions and hospitalization.<BR/>Findings Include:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels.<BR/>Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM.<BR/>Record review of Resident #1's admission assessment dated [DATE] at 06:07 PM and signed by LVN A revealed, a diagnosis of type 2 diabetes and there was no documented blood sugar level on admission.<BR/>Record review of Resident #1's Order Summary Report dated 01/17/24 printed by LVN A and signed by the MD revealed, no orders for blood sugar monitoring.<BR/>Record review of Resident #1's Order Summary Report dated 01/23/24 revealed, check blood sugars before meals and at bedtime entered on 01/18/24 and started on 01/18/24 at 09:00 AM, over 12 hours after admission to the facility.<BR/>Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM.<BR/>- 311 mg/dL on 01/18/24 01:11 PM documented by LVN B.<BR/>- 207 mg/dL on 01/18/24 05:52 PM documented by LVN D.<BR/>- 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D.<BR/>An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted she did not have her blood sugar checked even though she ate meals. Resident #1 said the day after she admitted was the first day she had her blood sugar check but she denied any symptoms or side effects of high blood sure.<BR/>In an interview on 01/23/24 at 02:35 PM, the DON said when a resident arrives at the facility, they were immediately placed in a room with the staff assisting the paramedics. She said the admitting nurse then completed a head-to-toe assessment, collected vitals (including BS for diabetics) reconciled medications and then contacted the physician to approve all medications and care records. The DON said per the EMR Resident #1 admitted to the facility at 02:50 PM and LVN A completed Resident #1's admission assessment after she arrived at her shift which usually starts between 4 and 5.<BR/>In an interview on 01/23/24 at 05:11 PM, LVN A said she had been in her role as the admission nurse for the past 3 years. She said when a resident admitted to the facility the nurse who received them was responsible for verifying the residents' medications/orders with the admitting physician and checking vitals which included blood sugar checks. LVN A said she saw Resident #1 when she arrived at her evening shift, the resident was primarily Spanish speaking and arrived at the facility with family. She said she was not the nurse who received the resident, and it was not her responsibility to enter the resident into the system, complete the admitting assessment or check the resident's vitals. LVN A said it was the responsibility of the actual nurse who admitted the resident and the unit manager to ensure all orders were entered and vitals like BS were checked. LVN A said even though she did not actually assess the resident or reconcile the medications/order with the physician, she helped enter the resident's admission assessment and orders a little after six. She said she did not know why she did not enter Resident #1's BS monitoring orders and failure to check blood sugars in a diabetic could place the resident at risk for unidentified hypo or hyperglycemia (low and high blood sugars).<BR/>In an interview on 01/24/24 at 09:35 AM, the DON said the nurse who received Resident #1 was responsible for checking vitals, which included blood sugars in diabetics, going over the medications and orders with the physician and then entering the orders in the system. The DON said after reviewing the chart, LVN B was the nurse who received Resident #1 but since the resident arrived during a shift change his unit manager should have been responsible for entering the resident's orders into the system. She said she could not determine which nurse reconciled the medications and orders with the physician from the records provided.<BR/>In an interview on 01/24/24 at 10:01 AM, LVN B said when resident arrived at the facility the admitting nurse was whoever received the resident. He said the admitting nurse was responsible for ensuring that the resident was comfortable, educated about the facility and collecting vitals, reconciling medications with the physician and then entering orders. LVN B said upon admission, the admitting staff must check a diabetic resident's blood sugars immediately to establish their baseline if they did not receive BS records from the discharging facility. He said facility's policy required all new admissions that arrived after 02:00 PM would be given to the unit manager and Unit Manager A was responsible for admitting Resident #1. LVN B said LVN A was the facility admission nurse, and her shift usually began between 04:00-05:00 PM and she would complete admissions of residents who arrived during her shift.<BR/>In an interview on 01/24/24 at 11:42 AM, Unit Manager A said she was the 2nd floor unit manager, and her shift was from 08:30- 05:00 PM. She said when a resident admitted into the facility, the admitting nurse was responsible for greeting the resident, reconciling medications, verifying orders with the physician and then entering the orders. Unit Manager A said all diabetic residents should have admitting orders to check their blood glucose and lab orders for A1c. She said failure to enter BS orders and check blood sugar upon admission could place the resident at risk for unknown low/high BS and a result in the failure to treat these uncontrolled blood sugars. Unit Manager A said after reviewing the EMR, Resident #1's order entry was her responsibility but LVN B, the admitting nurse, was responsible for checking the resident's BS since it was part of the vitals collected. Unit Manager A said she did not remember processing Resident #1's admission but due to the time the resident arrived it was her responsibility but she was not informed or provided any communication that she had to complete the resident's admission so that was why LVN A completed the admissions assessment and entered the medication orders. Unit Manager A said she could not remember any details regarding Resident #1's admissions.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said when Resident #1 admitted to the facility LVN B (the admitting nurse) was responsible for entering orders for BS monitoring and he should have checked the resident's BS upon admission. She said the DON was ultimately responsible for ensuring admissions orders are entered correctly but the responsibility is delegated to the unit managers. The DON said failure enter orders and monitor blood sugars in diabetics could result in a worsening of prognosis as well as hypo and hyperglycemia.<BR/>In an interview on 01/24/24 at 12:54 PM, LVN B said he did not check Resident #1's blood sugars upon admission or enter her blood sugar monitoring orders and he did not know whose responsibility it was since the resident arrived during a change of shift.<BR/>An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>Record review of the facility policy titled Blood Glucose Management revised 10/2016 revealed, program overview- charge nurses will provide blood glucose management per Health Care Provider's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>- The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL.<BR/>This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization.<BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels.<BR/>Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM.<BR/>Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed,<BR/>- Cefdinir (an antibiotic) 300 mg- 1 capsule by mouth every 12 hours for 5 days, with a start date of 01/18/24.<BR/>- Metformin (an oral antidiabetic) 1000 mg- 1 tablet by mouth two times a day for diabetes with a start date of 01/18/24.<BR/>- Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24.<BR/>- Tresiba Insulin- Inject 30 units under the skin every 12 hours for type 2 diabetes with a start date of 01/17/24.<BR/>- Gabapentin 300 mg- 1 Capsule by mouth two times a day for nerve pain with a start date of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM.<BR/>- 311 mg/dL on 01/18/24 01:11 PM documented by LVN B.<BR/>- 207 mg/dL on 01/18/24 05:52 PM documented by LVN D.<BR/>- 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D.<BR/>Record review of Resident #1's 01/17/24 MAR revealed, <BR/>- Cefdinir 300 mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Gabapentin 300mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Metformin 1000mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Tresiba Insulin was not administered on 01/17/24 even though it was scheduled for 09:00 PM for reasons not documented.<BR/>- Insulin Lispro was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed,<BR/>- Metformin 1000 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Cefdinir 300 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Insulin Lispro was first administered on 01/18/24 at 01:11 PM.<BR/>- Tresiba Insulin was first administered on 01/18/24 at 01:11 PM.<BR/>- Gabapentin was first administered on 01/18/24 at 11:26 AM.<BR/>Record review of the facility automated dispensing machine inventory list presented on 01/23/24 revealed,<BR/>- the facility had 10 capsules of Cefdinir 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility had 6 capsules of Gabapentin 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility did not have Tresiba or Insulin Lispro on hand for emergency dispensing or newly admitted residents.<BR/>Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, <BR/>- Tresiba Insulin was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Metformin 1000mg was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Gabapentin 300 mg capsules was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send.<BR/>In an interview on 01/23/24 at 01:23 PM, the ADON said the facility received 3 different pharmacy deliveries. She said the pharmacy delivered medications to the facility in the early morning, mid-day and at night but there was always an option for a STAT delivery to be made within 2 hours for any urgent medications that the facility did not have in their automated dispensing system. The ADON said the facility did not have any insulin on hand for newly admitted or emergency medication orders.<BR/>An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted (01/17/24) she did not her medications. Resident #1 said she did not receive her antibiotic, Gabapentin and antidiabetic medications (Metformin and Insulins) on 01/17/24 but she did not suffer from any pain or signs/symptoms of uncontrolled blood sugars.<BR/>In an interview on 01/23/24 at 02:35 PM, the DON said per the EMR, Resident #1 admitted to the facility at 02:50 PM but her medication orders were not entered until after 06:00 PM. She said when a resident arrived at the facility their medication orders should be started immediately to avoid any missing doses based on the hospital discharge medication list. The DON said the facility had an automated dispensing system that could provide initial doses of medications for new admissions and any unavailable medications like insulin could be acquired within 2 hours from the pharmacy through a STAT order. She said if the pharmacy was unable to deliver the medication immediately, the resident's provider should be contacted for an alternative regimen and all medication issues should be documented in the resident's chart. The DON said failure to administer medications immediately upon admission could result in increased blood sugar, increased pain, as well as worsening of infection and hospitalization.<BR/>In an interview on 01/23/24 at 05:11 PM, LVN A said she has been in her role as the admission nurse for the past 3 years. She said when a resident arrived at the facility the nurse should reconcile the medications against the discharging facility medication lists and medications should be administered based on the last administered dose. LVN A said since Resident #1 arrived at 02:50 PM she should have received her first dose of medications starting that evening and did not know why she entered Resident #1's medications to start the next morning. She said the facility had an automated dispensing system that had the necessary oral medications on hand and the insulin could have been received within 2 hours through a STAT order from the pharmacy. LVN A said she did not know why she did not get the medication from the automated dispensing system, or from the pharmacy and she did not know why she did not document the issue in the resident's progress notes. LVN A said the doctor did not give her approval to delay the start of Resident #1's medications and failure to administer medications immediately upon admission could place residents at risk for uncontrolled health conditions, uncontrolled blood sugars, uncontrolled pain and hospitalization. She said Resident #1 should have received her first dose of medication the night she arrived at the facility.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said she was ultimately responsible for ensuring medications were started immediately upon admissions and administered as ordered but that responsibility was delegated to the managers who complete next day audits. She said to her knowledge no one had noticed that Resident #1 was not administered medications upon admissions and her first doses were administered late in the afternoon the next day. The DON said Resident #1, the resident's family as well as her doctor was notified of the missed medications and the resident reported no side effects and the physician did not give any new orders.<BR/>An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>Record review of LVN A's Charge Nurse Orientation Checklist-Skilled Nursing signed on 09/01/20 revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. <BR/>Record review of the facility policy titled Reconciliation of Medications od Admission/re-admission and Monthly Orders revised 03/2019 revealed, policy overview- the charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care, for the purpose of providing an accurate and current medication regimen. I(B)- Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process by: identifying the medications the resident needs and administering without interruption, the correct dosages and routes.<BR/>Record review of the facility policy titled Receipt of Interim/Stat/Emergency Deliveries revised 01/01/22 revealed, 1- facility should immediately notify pharmacy when facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions:<BR/>2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or<BR/>2.2 For Pharmacy delivery by contract courier, or<BR/>2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #1) whose records were reviewed for resident identifiable records.<BR/>- The facility failed to completely and accurately document administration of medication to Resident #1 by documenting administration of Insulin Lispro that was not in the facility and did not occur,<BR/>This failure could place residents at risk of having incomplete or inaccurate records and inadequate care.<BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed,<BR/>- Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24.<BR/>Record review of Resident #1's 01/17/24 MAR revealed, <BR/>- Insulin Lispro was administered on of 01/18/24 for scheduled doses at 09:00 AM and 01:00 by LVN B.<BR/>Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed,<BR/>- Insulin Lispro was first administered on 01/18/24 at 01:11 PM for the doses scheduled at both 09:00 AM and 01:00 PM.<BR/>Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, <BR/>- Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send.<BR/>In observation on 01/24/24 at 12:14 PM, inventory of the nursing cart with LVN B revealed, an Insulin Lispro pen labeled for Resident #1 with the facility open date of 01/19/24 on both the pen and on the pharmacy label. Inspection of the 2nd floor medication room with LVN B revealed, no other insulin pens for Resident #1 in the fridge.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said staff were expected to document accurately and timely and any discrepancies should be documented in the progress notes. She said Resident #1's insulin arrived on 01/18/24 at 11:59 PM and based on the residents EMR it was not possible for LVN B to administer the 09:00 AM and 01:00 PM scheduled doses of Insulin Lispro to Resident #1 on 01/18/24 at 01:11 PM because the medication was not available in the pharmacy at that time and the facility did not have any insulin on-hand for emergency dispensing. The DON said failure to document accurately placed residents at risk for inaccurate medical records and unidentified missed doses.<BR/>In an interview on 01/24/24 at 12:54 PM, LVN B said to his knowledge Resident #1 did not have any insulin missing and he did not remember administering Resident #1's insulin late at 01:11 PM on 01/18/24 even though it was the documented time on the MAR. LVN B said the only insulin pen Resident #1 had was the pen observed in the nursing cart with an open dated of 01/19/24 and he could not explain where the insulin he documented as administered came from since the pen had not arrived at the facility at the documented time of administration. When asked about the requirement of accurate and timely documentation, LVN B could not provide an answer. He said he did not remember any specifics about Resident #1's Insulin Lispro pen and medication administration time and when asked how he documented the administration of medication that was not available he said I also want to know what happened with the medication and the documentation. He could not provide any details regarding the discrepancy between the documentation and the unavailability of the medication.<BR/>Record review of LVN B's Charge Nurse Orientation Checklist-Skilled Nursing signed on 04/24/22 by the ADON revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. <BR/>Record review of the facility policy titled Medication Administration revised 12/2020 revealed, after administering/observation of the client taking the medication the staff must sign for the scheduled assistance time and date for medications and if applicable, the associate should document the refusal or reason for not administering medication as ordered.<BR/>Record review of the facility policy titled Documentation for Skilled Services revised 05/2023 revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times.<BR/>Record review of the facility provided Skilled Documentation Guide with no revision date revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 28 opportunities, which involved 2 of 6 residents (Resident #8, Resident #42) reviewed for medication errors.<BR/>1-LVN A failed to administer medications as physician ordered to Resident #8 as by not administering Esomeprazole Magnesium delayed release 40mg on 04/23/2024. The original order for Esomeprazole 40mg twice a day was dated 3/13/2024.The order status was on hold because the medication was out of stock on 04/23/2024.<BR/>2-LVN B failed to administer medications as ordered to Resident #42 as by administering Vitamin B12 with Folate instead of the physician order for Vitamin B12 without folate on 4/23/2024.<BR/>These failures could place residents at risk of not receiving the desired therapeutic effect of their medications.<BR/>Findings included:<BR/>1.Record review of Resident #8's Diagnoses sheet dated 04/23/2024 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: GERD (gastro-esophageal reflux) and personal history of digestive system disease.<BR/>Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 has an alteration in gastro-intestinal status r/t cholangitis (inflammation of the bile duct). Interventions included: give medications as ordered. Focus - Resident had GERD. Interventions included: give medications as ordered.<BR/>Record review of Resident #8's April 2024 MAR (medication administration records) revealed, on 04/23/2024 the 9:00 AM dose of Esomeprazole Magnesium delayed release 40mg was not given but was put on hold.<BR/>Record review of Resident #8's nursing progress note dated 4/23/2024 at 9:06 AM, LVN A wrote that the Omnicell was checked for Esomeprazole 40mg, and the medication was not present. Contacted the pharmacy to check on status of order and that it was refilled. The NP was notified, no new orders and holding medication until medication arrives.<BR/>Record review of Resident #8's Order Summary Report received from the DON dated 04/24/2024 at 11:37 AM revealed, Esomeprazole Magnesium oral capsule delayed release 40mg, give every morning and at bedtime, start date 03/13/2024. The order status was on hold.<BR/>An observation and interview on 04/23/24 at 08:12 AM revealed, LVN A preparing medication for administration to Resident #8. LVN A administered all ordered 9:00 AM medications by 8:33 AM except for Esomeprazole. LVN A stated she would check the Omnicell for the Esomeprazole 40 mg and that it just may be out of stock. LVN A stated she did not know why it was not available.<BR/>In an interview on 04/24/2024 at 9:19 AM, LVN A stated Resident #8 has a personal history of acid reflux and if she did not receive Esomeprazole as physician ordered then heart burn could begin.<BR/>2.Record review of Resident #42's Diagnoses sheet dated 04/04/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a fracture to the right thigh bone, heart disease, and unstageable pressure ulcer to the sacrum.<BR/>Record review of Resident #42's undated Care Plan revealed, focus- Resident had altered cardiovascular status. Interventions included administer medications as ordered. Focus - Resident had Unstageable pressure ulcer to sacrum. Interventions included: Vitamin C and multivitamins with minerals for wound healing. Further review did not include Vitamin B12 and Folic Acid.<BR/>Record review of Resident #42's Order Summary Report dated 04/24/2024 revealed an order for Vitamin B12 1000 mcg, give 1 tablet daily for Vitamin insufficiency, order start date was 04/05/2024. Further review revealed an order for Folic acid 1mg, give daily for vitamin insufficiency, order start date 04/05/2024.<BR/>Record review of Resident #42's April 2024 MAR dated 04/23/2024 at 10:59 AM, revealed LVN B documented she administered Vitamin B12 1000mcg on 04/23/2024 on arising (between 7:00 AM and 10:00 AM). <BR/>An observation on 04/23/24 at 09:09 AM revealed, LVN B preparing medication for administration to Resident #42. LVN B administered 2 tablets of Vitamin B12 with folate 500 mcg and Folic acid 1 mg tablet.<BR/>In an interview on 04/23/2024 at 11:30 AM, LVN B stated she gave Resident #42 Vitamin B12 from the bottle with the label Vitamin B12 with folate 500mcg because she did not have Vitamin B12 without folate in her cart. LVN B stated she was not aware that it contained folate (folic acid) and that the resident also received folic acid 1 mg tablet. When asked if she gave the correct medication as physician ordered she stated she would check to see if there was stock Vitamin B12 bottles and would call the NP to ask for the order to be changed.<BR/>In an interview on 04/24/2024 at 10:50 AM, the DON stated the nurses were responsible for reordering the Esomeprazole through the online electronic health record system, before they run out for sure at least 3 days prior. The DON stated the night shift nurses were responsible for auditing the medication rooms and medication carts but not individual medications. The DON stated she would have to trust the nurses to be aware of when medications run low.<BR/>Record review of the facility policy titled General dose Preparation and Medication Administration, dated 12/01/2007 read in part: .4.1 Facility staff should: .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>- The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL.<BR/>This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization.<BR/>Findings Included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24.<BR/>Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia.<BR/>Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital.<BR/>Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels.<BR/>Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM.<BR/>Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed,<BR/>- Cefdinir (an antibiotic) 300 mg- 1 capsule by mouth every 12 hours for 5 days, with a start date of 01/18/24.<BR/>- Metformin (an oral antidiabetic) 1000 mg- 1 tablet by mouth two times a day for diabetes with a start date of 01/18/24.<BR/>- Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24.<BR/>- Tresiba Insulin- Inject 30 units under the skin every 12 hours for type 2 diabetes with a start date of 01/17/24.<BR/>- Gabapentin 300 mg- 1 Capsule by mouth two times a day for nerve pain with a start date of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM.<BR/>- 311 mg/dL on 01/18/24 01:11 PM documented by LVN B.<BR/>- 207 mg/dL on 01/18/24 05:52 PM documented by LVN D.<BR/>- 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D.<BR/>Record review of Resident #1's 01/17/24 MAR revealed, <BR/>- Cefdinir 300 mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Gabapentin 300mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Metformin 1000mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>- Tresiba Insulin was not administered on 01/17/24 even though it was scheduled for 09:00 PM for reasons not documented.<BR/>- Insulin Lispro was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM.<BR/>Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed,<BR/>- Metformin 1000 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Cefdinir 300 mg was first administered on 01/18/24 at 11:26 AM.<BR/>- Insulin Lispro was first administered on 01/18/24 at 01:11 PM.<BR/>- Tresiba Insulin was first administered on 01/18/24 at 01:11 PM.<BR/>- Gabapentin was first administered on 01/18/24 at 11:26 AM.<BR/>Record review of the facility automated dispensing machine inventory list presented on 01/23/24 revealed,<BR/>- the facility had 10 capsules of Cefdinir 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility had 6 capsules of Gabapentin 300 mg capsules on hand for emergency dispensing or newly admitted residents.<BR/>- the facility did not have Tresiba or Insulin Lispro on hand for emergency dispensing or newly admitted residents.<BR/>Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, <BR/>- Tresiba Insulin was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Metformin 1000mg was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Gabapentin 300 mg capsules was first delivered to the facility on [DATE] at 11:59 PM.<BR/>- Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send.<BR/>In an interview on 01/23/24 at 01:23 PM, the ADON said the facility received 3 different pharmacy deliveries. She said the pharmacy delivered medications to the facility in the early morning, mid-day and at night but there was always an option for a STAT delivery to be made within 2 hours for any urgent medications that the facility did not have in their automated dispensing system. The ADON said the facility did not have any insulin on hand for newly admitted or emergency medication orders.<BR/>An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted (01/17/24) she did not her medications. Resident #1 said she did not receive her antibiotic, Gabapentin and antidiabetic medications (Metformin and Insulins) on 01/17/24 but she did not suffer from any pain or signs/symptoms of uncontrolled blood sugars.<BR/>In an interview on 01/23/24 at 02:35 PM, the DON said per the EMR, Resident #1 admitted to the facility at 02:50 PM but her medication orders were not entered until after 06:00 PM. She said when a resident arrived at the facility their medication orders should be started immediately to avoid any missing doses based on the hospital discharge medication list. The DON said the facility had an automated dispensing system that could provide initial doses of medications for new admissions and any unavailable medications like insulin could be acquired within 2 hours from the pharmacy through a STAT order. She said if the pharmacy was unable to deliver the medication immediately, the resident's provider should be contacted for an alternative regimen and all medication issues should be documented in the resident's chart. The DON said failure to administer medications immediately upon admission could result in increased blood sugar, increased pain, as well as worsening of infection and hospitalization.<BR/>In an interview on 01/23/24 at 05:11 PM, LVN A said she has been in her role as the admission nurse for the past 3 years. She said when a resident arrived at the facility the nurse should reconcile the medications against the discharging facility medication lists and medications should be administered based on the last administered dose. LVN A said since Resident #1 arrived at 02:50 PM she should have received her first dose of medications starting that evening and did not know why she entered Resident #1's medications to start the next morning. She said the facility had an automated dispensing system that had the necessary oral medications on hand and the insulin could have been received within 2 hours through a STAT order from the pharmacy. LVN A said she did not know why she did not get the medication from the automated dispensing system, or from the pharmacy and she did not know why she did not document the issue in the resident's progress notes. LVN A said the doctor did not give her approval to delay the start of Resident #1's medications and failure to administer medications immediately upon admission could place residents at risk for uncontrolled health conditions, uncontrolled blood sugars, uncontrolled pain and hospitalization. She said Resident #1 should have received her first dose of medication the night she arrived at the facility.<BR/>In an interview on 01/24/24 at 12:40 PM, the DON said she was ultimately responsible for ensuring medications were started immediately upon admissions and administered as ordered but that responsibility was delegated to the managers who complete next day audits. She said to her knowledge no one had noticed that Resident #1 was not administered medications upon admissions and her first doses were administered late in the afternoon the next day. The DON said Resident #1, the resident's family as well as her doctor was notified of the missed medications and the resident reported no side effects and the physician did not give any new orders.<BR/>An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left.<BR/>Record review of LVN A's Charge Nurse Orientation Checklist-Skilled Nursing signed on 09/01/20 revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. <BR/>Record review of the facility policy titled Reconciliation of Medications od Admission/re-admission and Monthly Orders revised 03/2019 revealed, policy overview- the charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care, for the purpose of providing an accurate and current medication regimen. I(B)- Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process by: identifying the medications the resident needs and administering without interruption, the correct dosages and routes.<BR/>Record review of the facility policy titled Receipt of Interim/Stat/Emergency Deliveries revised 01/01/22 revealed, 1- facility should immediately notify pharmacy when facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions:<BR/>2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or<BR/>2.2 For Pharmacy delivery by contract courier, or<BR/>2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to personal privacy including medical treatment for 2 (Resident #1 and Resident #4) of 11 reviewed for respect and dignity.<BR/>-The facility failed to place Resident #1's Foley Cather bag inside of a privacy bag on 12/07/23.<BR/>-The facility failed to place Resident #4's Foley Cather bag inside of a privacy bag on 12/09/23.<BR/>This failure placed residents at risk of embarrassment and lower self-esteem.<BR/>Findings: <BR/>Record review of Resident #1's face sheet reveled an 88year old female admitted to the facility on [DATE] with the diagnoses that included the following: osteomyelitis (inflammation of the brain cause by infection) of vertebra (back bone), sacral (portion of the spine between your lower back and tailbone) and sacrococcygeal region (joint between the sacrum and the tailbone), pressure ulcer of the sacrum, long term current use of antibiotics, elevated white blood cell count, moderate protein deficiency, muscle weakness, hyperlipidemia (elevated cholesterol), dementia (memory loss and judgement), hypertension (elevated blood pressure), retention of urine, and pneumonia (infection in the lungs).<BR/>Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 12 indicating resident cognition was intact.<BR/>Record review of Resident #1's Physician orders included the following order:<BR/>-Dated 11/08/23 Catheter care for indwelling catheter<BR/>Record review of Resident #1's care plan dated 11/08/23 revealed that resident was being care planned for an indwelling Foley Catheter with an intervention privacy bags at all times.<BR/>Observation on 12/07/23 at 9:20AM Resident #1 was resting in bed on an air mattress. Further observation of was made of resident having an indwelling foley catheter with the bag not inside of a privacy bag. Resident #1's door was open with Foley bag in view. Resident was alert to name but not place and time. <BR/>Interview on 12/07/23 at 9:25AM LVN A regarding Resident #1 said resident Foley bag should be inside of a privacy bag for dignity and privacy. LVN A said he was Resident #1's nurse and would ensure that resident foley bag was placed inside of a privacy bag. <BR/>Interview on 12/07/23 at 10:25AM CNA B said she was Resident#1's CNA. CNA B said Resident #1's Foley catheter bag should be inside of a privacy bag for privacy reasons. CNA B said she was not aware that Resident #1's Foley catheter bag was not inside of a privacy bag. CNA B said when she arrived to work, she immediately started taking the residents vital signs and after that start passing out the resident breakfast trays. CNA B said the nurses were supposed to be making their rounds on the residents as well making sure the residents were okay.<BR/>Interview on 12/07/23 at 11:45AM the DON said residents who had an indwelling Foley catheter, the Foley bag needed to be inside of a privacy bag to promote dignity for the resident (s) as well as privacy. <BR/>Resident #4<BR/>Record review of Resident #4's face sheet revealed an 93year old female admitted to the facility originally 07/15/23 and again on 11/08/23 with the following diagnoses that included: acute respiratory failure, heart failure, atelectasis (collapse of the whole lung or an area of the lung), vascular dementia (memory loss in older adults), urinary tract infection, hypertension (elevated blood pressure), muscle weakness, insomnia (difficulty sleeping), cardia pacemaker (small battery powered device that prevents the hear from beating too slow), and cerebral infarction (disruption of blood flow to the brain).<BR/>Record review of Resident #4's MDS dated [DATE] revealed that resident BIMS score was 12 indicating that resident cognition was intact.<BR/>Record review of Resident #4's Physician Orders revealed the following:<BR/>-Dated 11/08/23 Apply dignity bag for placement each shift<BR/>Record review of Resident #4's care plan dated 11/08/23 revealed that resident was not being care planned for Foley Catheter.<BR/>Observation on 12/09/23 at 2:20PM Resident #4 was in bed resting quietly on an air mattress. Resident #4 had an indwelling Foley Catheter that was draining clear yellow urine. Resident Foley catheter bag was not inside of privacy bag. Resident privacy bag was hanging on the bed beside the Foley bag. Resident door was open with the Foley bag in view.<BR/>Interview on 12/09/23 at 2:23PM LVN P said she was Resident #4's nurse. LVN P said resident Foley bag were supposed to be inside of a privacy bag to promote privacy. LVN P said the CNA had been busy. <BR/>Observation on 12/09/23 at 2:23PM with staff members sitting at the nurse station as well as CNA U standing at the nurse station.<BR/>Interview on 12/09/23 at 2:30pm CNA U said she was Resident #4's CNA. CNA U said she had forgotten to place Resident #4's Foley bag inside of the privacy bag. CNA U said Foley catheter bags were supposed to placed inside of a privacy bag to promote privacy for the resident.<BR/>Record review of the facility Policy on Urinary Catheter Care revised January 2016 revealed in part:<BR/> .The drainage collection bag should be placed in a privacy bag for dignity purposes .<BR/>Record review of the facility policy on Quality of Life---Dignity revised 10/22 revealed in part:<BR/> .Residents should be cared for in a manner that promotes and enhance their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Demeaning practices and standards of care that compromise dignity are prohibited. Associates should promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered .<BR/>

**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, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for comprehensive care plans. - The facility failed to develop a care plan for Resident #1's diagnosis of dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status: nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. All previous orders to crush appropriate medications/open capsule if not contraindicated were discontinued. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis is retrieved from hospital paperwork, doctor's visits and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, on the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Comprehensive Care Plan revised November 2017 revealed, Policy Overview: A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. Policy Detail: A. A person centered, comprehensive care plan will be developed and implemented in accordance with the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults. 4. Each resident's comprehensive care plan will describe: a. Resident goals for care and desired outcomes b. Identified resident issues, conditions, risk factors and safety issues c. The resident's unique characteristics and strengths.

**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 the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #105) reviewed for pressure ulcer in that:<BR/>-Facility staff failed to follow up with Wound Care Doctor's recommendation for left lateral forefoot/left medial foot wound care for Resident #105. <BR/>This failure could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care .<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Following order were entered on 02/22/23 in the resident's medical records: <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning orders recommended by Wound Care Doctor. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Observation and attempted interview on 02/21/23 at 9:23 a.m., revealed Resident #105 was resting on an air mattress. He was alert and well groomed. Resident did not respond to the questions asked about his pressure ulcer.<BR/>In an interview on 02/22/23 at 2:48p.m., with LVN A, she said Unit Manager rounded with the Wound Care Doctor weekly on Thursdays. She said the Unit Manager was responsible for updating wound care orders and reviewing the wound care doctor's evaluation. <BR/>In an interview on 02/22/23 at 3:04 p.m., with the DON, this Surveyor reviewed Resident #105's Wound Care Doctor's evaluation dated 02/16/23 and the physician orders. The DON said the wound care Doctor recommendation for the topical antibiotic were not followed. She said the Unit Manager was responsible for updating the wound care orders. <BR/>In an interview on 2/23/23 at 12:20 p.m., with the Medical Director, this Surveyor reviewed Resident #105's wound care evaluation and physician orders with the MD. The MD said Resident was receiving IV antibiotic for sepsis and infected sacral wound. Resident had a positive blood culture at the hospital. When asked if she was aware of Wound Care Doctor's recommendations for topical application from the wound care Doctor's evaluation dated 02/16/23 for left medial foot and left lateral forefoot. The MD said she reviewed the wound evaluation dated 02/16/23 because she needed to know the wound measurement. Size was the concerns for her to see if the wounds were Progressing or deteriorating. She said Wound Care Doctor's recommendation were supposed to be followed. She said recommendations were considered Wound Care Doctor's order. It should have been entered in PCC and treated like an order. She said, unfortunately I didn't look at the recommendations neither did the nurses or else it would have been in place. It was missed. <BR/>In an interview on 02/23/23 at 1:16p.m., with the DON, she said she talked to the WCD yesterday 02/22/23 and the WCD told her that my recommendations are my orders. She said UM was responsible for rounding with WCD and entering wound care orders in PCC I don't know why she didn't follow up with recommendations. The DON said she was responsible to oversee the Unit Managers. When asked how she monitored staff to ensure they were implementing care planned interventions. How did she monitor the resident's wound progress and how did she determine the appropriate interventions? The DON said she had not been spot-checking or reviewing the wound evaluations with the UM to make sure the orders were being followed. The DON said, I thought UM knew what she was doing. The DON said it was important to follow physician order to prevent wounds from deteriorating. At this time policy on following physician orders was requested.<BR/>In an interview on 02/23/23 at 1:48p.m., with the DON and the UM, the UM said she reviewed the wound care doctor's evaluations weekly and updated the orders in PCC. She said she failed to look at the WCD's recommendations.<BR/>In an interview on 02/23/23 at 3:10p.m., with the Wound Care Doctor, she said her recommendations were considered her orders. She said Resident#105's family member was concerned that the vascular doctor had prescribed topical antibiotic that was being used at the hospital and had been stopped intermittently while at the facility. WCD said it was important to complete the course of ABT. If not completed infecting bacterium would become resistant to the antibiotic and we do not want that to happen. It was imported to finish ABT. Therefore, she ordered the ABT. <BR/>Record review of facility's Wound Observation and Pressure Injury/Ulcer Staging Policy (Last revised: 05/2022) read in part: .Policy overview: All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers .<BR/>No policy regarding following physician order was provided prior to exit.

**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 6 residents (Resident #105) reviewed for infection control, in that: <BR/>-The facility failed to ensure LVN A performed hand hygiene when moving from a dirty to clean site, while performing Resident #105's wound care.<BR/>This failure could place residents at risk for or infections.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .<BR/>Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care.<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Resident#105's physician order, dated 02/11/2023 revealed an order for Cefepime HCL Solution 1 GM/50ML use 1 gram intravenously every 12 hours for infection for 14 days. <BR/>Record review of Resident#105's physician order, dated 02/09/2023, revealed an order to cleanse Right inner ankle with wound cleanser, pat dry, applied xeroform then covered with dry gauze and dry dressing every day shift.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse wound to sacrum with wound cleanser; pat dry; apply skin prep to Peri wound; apply Santyl to necrotic/slough tissue; cover with calcium alginate; cover with dry dressing daily and as needed if soiled. In the morning for wound healing until 03/17/2023 <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse pressure wound to right lower back with wound cleanser; pat dry; skin prep peri wound; apply Santyl; cover with calcium alginate and dry dressing in the morning for wound healing until 03/17/2023.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Observation on 02/22/23 at 2:35 p.m., revealed the LVN A performing wound care on Resident #105 assisted by CNA D. Resident #105 was assisted onto his left side revealing there was no dressing on the resident's back. The wounds were covered with dry gauge. Further observation revealed unstageable pressure ulcer to the sacral/coccyx area approximately 3 cm in diameter and a stage 3 pressure ulcer to the right lower wound area approximately 12 cm in diameter. LVN A looked at this Surveyor and said, I don't remember the orders do you mind if I go check the orders. LVN A removed her soiled gloves without sanitizing/washing her hands left the room. Returned after few minutes sanitized her hands, donned new gloves and continued the wound care treatment. LVN A removed right inner ankle dressing dated 02/21/23 observation revealed unstageable (had slough) right inner ankle area approximately 0.3 cm in diameter. LVN A cleansed the wound with normal saline, pat dried with the same soiled gloves applied xeroform, dry gauze and covered with dry dressing. With the same soiled gloves LVN A removed left medial foot /left lateral forefoot dressing (kerlix wrapped around the wound) left medial foot area approximately 4 cm in diameter. Left lateral forefoot area approximately 4 cm in diameter. LVN A cleansed both wounds with normal saline, pat dried, with the same soiled gloves applied betadine, xeroform, dry gauge and wrapped with kerlix. <BR/>In an interview on 02/22/23 at 3:04p.m., with the DON, she said she expected staff to follow standard infection control techniques; to perform handwashing before the treatment, between gloves change and after moving from dirty to clean site as it placed risk for infections. She said staff were provided mass infection control in service on COVID sign and symptoms, infection control and hand washing sometime in January 2023. She said to prepare for the annual survey Unit Mangers had been doing observations on staff providing care don't know how that fell through the cracks. She said she UM were eye bawling and did not have any documentations of the check off/spot checks. She said the potential risk to the resident, due to this failure, was cross contamination. At this time policy on infection control and hand hygiene were requested. <BR/>In an interview on 02/23/23 at 1:08 p.m., LVN A said she was not a certified wound care nurse and did not receive wound care training at this facility. She said she could not recall having wound care competency check with the DON/ADON/Unit Manager. She said she started working in April 2022 at this facility. She said upon hire she received 3 days training on the floor shadowing another nurse. She said that nurse did run down on how to clean the wound. She said she did not perform hand hygiene or changed gloves when moving from dirty area to clean because I thought we had to switch gloves when switching wound sites. She said, I should have changed my gloves, sanitized my hands before applying santyl and calcium alginate on the wound. While removing old dressing and cleaning the wound I contaminated my gloves. She said this failure placed risk for infections. She said the facility provided in-servicing on infection control sometime last month. She could not recall the exact date. <BR/>In an interview on 02/23/23 at 1:48 p.m., with the DON and the Unit Manager, UM said she tried to spot check nurses as much as possible at least once a week. She said she observed LVN A do the med pass last week and wound care two weeks ago. UM said it was a simple skin tear dressing change on another resident. She said she could not recall the name of that resident, but it was not on Resident# 105. <BR/>Record review of facility Wound Care Competency (revised 02/2020) revealed read in part: Skills: 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline. 12. Perform hand hygiene. 13. Apply treatment as indicated .<BR/>Record review of facility's Handwashing/Hand Hygiene policy (last revised: 01/2021) revealed read in part: .Policy Overview: This community considers hand hygiene the primary means to prevent the spread of infections. G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, and alcohol -based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 7. Before handling clean or soiled dressings, gauze pads, etc.; 8. Before moving from a contaminated body site to a clean body site during resident care; 11. After handling used dressings, contaminated equipment, etc.; 13. After removing gloves; I. The use of gloves does not replace hand washing/hand hygiene .<BR/>Record review of facility's Infection Prevention and Surveillance policy (Last revised: 01/20) revealed read in part: .Policy overview: The Nurse Leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infections .<BR/>Policy regarding infection control was not provided prior to exit.

**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 the necessary treatment and services, to promote healing and prevent infection for 1 of 3 residents (Resident #105) reviewed for pressure ulcer in that:<BR/>-Facility staff failed to follow up with Wound Care Doctor's recommendation for left lateral forefoot/left medial foot wound care for Resident #105. <BR/>This failure could place residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care .<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice: continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Following order were entered on 02/22/23 in the resident's medical records: <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning orders recommended by Wound Care Doctor. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; apply mixture of three Linezolid caps plus 9 pumps bassogel to wound base after cleansing, cover with one layer of Xeroform, dry gauze and secured with kerlix and once daily and as needed in the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed every day shift discontinue this order once antibiotic mixture arrive. <BR/>Observation and attempted interview on 02/21/23 at 9:23 a.m., revealed Resident #105 was resting on an air mattress. He was alert and well groomed. Resident did not respond to the questions asked about his pressure ulcer.<BR/>In an interview on 02/22/23 at 2:48p.m., with LVN A, she said Unit Manager rounded with the Wound Care Doctor weekly on Thursdays. She said the Unit Manager was responsible for updating wound care orders and reviewing the wound care doctor's evaluation. <BR/>In an interview on 02/22/23 at 3:04 p.m., with the DON, this Surveyor reviewed Resident #105's Wound Care Doctor's evaluation dated 02/16/23 and the physician orders. The DON said the wound care Doctor recommendation for the topical antibiotic were not followed. She said the Unit Manager was responsible for updating the wound care orders. <BR/>In an interview on 2/23/23 at 12:20 p.m., with the Medical Director, this Surveyor reviewed Resident #105's wound care evaluation and physician orders with the MD. The MD said Resident was receiving IV antibiotic for sepsis and infected sacral wound. Resident had a positive blood culture at the hospital. When asked if she was aware of Wound Care Doctor's recommendations for topical application from the wound care Doctor's evaluation dated 02/16/23 for left medial foot and left lateral forefoot. The MD said she reviewed the wound evaluation dated 02/16/23 because she needed to know the wound measurement. Size was the concerns for her to see if the wounds were Progressing or deteriorating. She said Wound Care Doctor's recommendation were supposed to be followed. She said recommendations were considered Wound Care Doctor's order. It should have been entered in PCC and treated like an order. She said, unfortunately I didn't look at the recommendations neither did the nurses or else it would have been in place. It was missed. <BR/>In an interview on 02/23/23 at 1:16p.m., with the DON, she said she talked to the WCD yesterday 02/22/23 and the WCD told her that my recommendations are my orders. She said UM was responsible for rounding with WCD and entering wound care orders in PCC I don't know why she didn't follow up with recommendations. The DON said she was responsible to oversee the Unit Managers. When asked how she monitored staff to ensure they were implementing care planned interventions. How did she monitor the resident's wound progress and how did she determine the appropriate interventions? The DON said she had not been spot-checking or reviewing the wound evaluations with the UM to make sure the orders were being followed. The DON said, I thought UM knew what she was doing. The DON said it was important to follow physician order to prevent wounds from deteriorating. At this time policy on following physician orders was requested.<BR/>In an interview on 02/23/23 at 1:48p.m., with the DON and the UM, the UM said she reviewed the wound care doctor's evaluations weekly and updated the orders in PCC. She said she failed to look at the WCD's recommendations.<BR/>In an interview on 02/23/23 at 3:10p.m., with the Wound Care Doctor, she said her recommendations were considered her orders. She said Resident#105's family member was concerned that the vascular doctor had prescribed topical antibiotic that was being used at the hospital and had been stopped intermittently while at the facility. WCD said it was important to complete the course of ABT. If not completed infecting bacterium would become resistant to the antibiotic and we do not want that to happen. It was imported to finish ABT. Therefore, she ordered the ABT. <BR/>Record review of facility's Wound Observation and Pressure Injury/Ulcer Staging Policy (Last revised: 05/2022) read in part: .Policy overview: All licensed nurses should follow established guidelines and protocols to observe, describe tissue, evaluate, measure wounds and stage of pressure injuries/ulcers .<BR/>No policy regarding following physician order was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #105) of 3 residents reviewed for pain management.<BR/>-The facility staff failed to stop a wound care treatment and provide Resident #105 with pain reduction care when the resident cried and yelled out from pain he experienced during the wound care treatment. <BR/>This failure placed residents who received pain medications at risk for unmanaged pain during treatments.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .Focus: (Resident #105) is experiencing pain. OA, L2 compression fx, DVT LLE, urinary retention, multiple pressure and diabetic ulcers. <BR/>Goal: The resident will not have an interruption in normal activities due to pain through the review date. Interventions: Anticipate the resident's need for pain relief, provide pain interventions and follow up for effectiveness of interventions . <BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Section J: J0100: Pain Management-A. Received scheduled pain medication regimen? Coded-No. B. Received PRN pain medications OR was offered and declined: coded- Yes. C. Received non-medication intervention for pain: Coded-No. J0200. Should pain Assessment interview be conducted? Coded-Yes. J0300. Pain Presence: Coded-Yes. J0400. Pain Frequency: Coded-Frequently. J0500: Pain Effect on Function: Coded-No. J0600. Pain Intensity-Coded- 06.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse wound to sacrum with wound cleanser; pat dry; apply skin prep to Peri wound; apply Santyl to necrotic/slough tissue; cover with calcium alginate; cover with dry dressing daily and as needed if soiled. In the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse pressure wound to right lower back with wound cleanser; pat dry; skin prep peri wound; apply Santyl; cover with calcium alginate and dry dressing in the morning for wound healing until 03/17/2023. <BR/>Record review of Resident#105's physician order, dated 02/09/2023, revealed a traMADol HCL oral tablet 50 MG (Tramadol HCL pain medication) Give 1 tablet by mouth every 6 hours as needed for Mild Pain. <BR/>Record review of Resident #105's MAR dated February 2023 revealed the resident received PRN Tramadol tablet 50mg by mouth every 6 hours for mild pain on the following dates: 2/10/23 pain level -7, 2/11/23 pain level -3, 2/12/23 pain level -8, 2/12/23 pain level -8, 2/15 /23 pain level- 9, 2/16/23 pain level -9, 2/17/23 pain level -8, 2/18 /23 pain level -5, 2/19/23 pain level -5, 2/20/23 pain level- 6, 2/21/23 pain level -9, 2/22/23 pain level- 5.<BR/>Record review of Resident #105's Nurses Notes dated February 2023 revealed there was no documentation that the resident was receiving medication or non-pharmacological intervention for pain prior to wound care daily or that the physician was contacted to address pain management for the resident.<BR/>Following Surveyor's questioning physician orders were entered in the Resident's medical record: <BR/>Record review of Resident#105's physician order, dated 02/22/2023, revealed an order Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth in the morning for pain Give 30 minutes before wound care is done. <BR/>Record review of Resident#105's physician order, dated 02/23/2023, revealed an order for Lidoderm patch 5% (Lidocaine) Apply to lower back keep it on during day-time and off at bedtime. <BR/>Observation on 02/22/23 at 2:35 p.m., revealed LVN A performing wound care on Resident #105 assisted by CNA D. Resident #105 was assisted onto his left side revealing there was no dressing on the resident's back. The wounds were covered with dry gauge. Further observation revealed unstageable pressure ulcer to the sacral/coccyx area approximately 3 cm in diameter and a stage 3 pressure ulcer to the right lower wound area approximately 12 cm in diameter. LVN A cleaned the center of the sacral wound the resident cried out in pain and said, it hurts. LVN A cleaned the perimeter of the wound and the resident yelled again ahhhhh. At this time, Resident #105 family member ran in the room and said, are you okay dad. LVN A said, I know it hurts sorry and continued with the treatment. When LVN A dried sacral wound with a dry 4 x 4-inch gauze, the resident cried out in pain. Then, LVN A cleaned the center of the right lower wound the resident cried out in pain. LVN A cleaned the perimeter of the wound and the resident yelled again. LVN A did not ask the resident if he was in pain and continued with the treatment. When the LVN A dried the area with a dry 4 x 4-inch gauze, the resident cried out in pain. LVN A said out loud, I am almost done. LVN A looked at this Surveyor and said, I don't remember the orders do you mind if I go check the orders. LVN A removed her soiled gloves without sanitizing/washing her hands left the room. Returned after few minutes sanitized her hands, donned new gloves and continued the wound care treatment. The resident was seen flinching when LVN A applied skin prep, Santyl and calcium alginate to the sacral and right lower wounds. The resident yelled out in pain when the dry dressing was applied. This surveyor asked the resident if he was in pain and the resident said, yes. LVN A said, he always yells in pain when I do his wound care. When I ask him where he is hurting, he says everywhere. LVN A said he received his prn tramadol earlier this morning. She said resident did not have any break thru pain meds other than the tramadol. She said it was either every 6 hours or every 8 hours was not sure she would have to go and look at his orders. <BR/>In an interview on 02/22/23 at 3:04 p.m., with the DON, she said Resident #105 was able to verbalize pain. She said the nurse should have stopped, medicated or repositioned the resident, covered the wound with a dressing, and continued the treatment when the pain was managed. <BR/>In an interview on 02/23/23 at 1:08p.m., with LVN A, she said Resident #105 was given prn tramadol earlier that morning. She said, he always yells when I do his wound care. It's a stage 3 when you touch it. It's not going to hurt. But I should have addressed the pain when he said ahhh! He was verbalizing that he was in pain. He also moved his body away each time I touched the wound. She said she was in serviced on pain management sometime last month. She could not recall the exact date. <BR/>In an interview on 2/23/23 at 11:04a.m., with the Medical Director, MD reviewed Resident #105's physician orders with the Surveyor. MD said Resident came with Tramadol 50 mg q6hrs order from the hospital. MD said I thought Tramadol was controlling the pain. It was not brought to my attention prior to today that resident was unable to tolerate pain during wound care. She said she saw her NP was in the facility yesterday 2/22/23 and wrote an order for Tylenol 30 minutes prior to wound care. She said Stage 3 was superficial and painful because of the nerves. She said she also ordered the Lidoderm patch today to apply to the lower back for pain.<BR/>Record review of facility's Pain Management policy (last revised: 10/22) revealed read in part: .Policy Overview: the purpose of the policy is to identify, treat and manage the resident's pain levels. The program should provide a systematic approach to data collection using objective measurements of the wound level in effectiveness of the pain relief medication. Policy Detail: 2. If resident is having pain, the level of pain is measured using one of the following scales: a) using a scale of 0-10: zero (0) being the least pain, and ten (10) being the most severe pain. b) If a resident is unable to verbally communicate, or does not understand English, the resident should be given Faces Pain Intensity Pictures which when pointed to, will indicate the severity of the resident's current pain level. c) A verbal descriptive scale. d) PAINAD scale is used in advance dementia, utilizing observation techniques (e.g., facial expressions, breathing, body language, negative vocalization, and consolability). 3. Pain Management Strategies: a) non-pharmacological interventions may be appropriate alone or in conjunction with medications. b) Pharmacological Medications (i.e., analgesics) may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (e.g., drowsiness, increased risk of falling; loss of appetite). i. Identify the level of pain and document effectiveness as indicated .

**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 6 residents (Resident #105) reviewed for infection control, in that: <BR/>-The facility failed to ensure LVN A performed hand hygiene when moving from a dirty to clean site, while performing Resident #105's wound care.<BR/>This failure could place residents at risk for or infections.<BR/>Findings included:<BR/>Record review of the admission sheet for Resident #105 revealed he was [AGE] year-old male admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 3 (skin injuries that occur in the sacral region of the body, near the lower back and spine), non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity (result from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus) and peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). <BR/>Record review of Resident#105's care plan, initiated 02/09/23 and revised on 02/22/2023, revealed the following read in part: .<BR/>Focus: (Resident#105) has infection of the wound. <BR/>Goal: The resident will be free from complications related to infection through the review date.<BR/>Interventions/Tasks: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care.<BR/>Record review of Resident#105's Comprehensive MDS assessment, dated 02/16/2023, revealed a BIMS score of 10 out of 15 indicating moderately impaired cognitively. Resident required extensive assistance from staff for dressing, toilet use and personal hygiene. Resident had indwelling catheter and frequently incontinent of bowel. Further review M0150. Risk of Pressure Ulcers/Injuries revealed Resident #105 was at risk of developing pressure ulcer or injuries. M0210. Unhealed Pressure ulcers/injuries. Coded- yes. M0300. C. Stage 3: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth the tissue loss. May include undermining and tunneling. M0300. G. Unstageable-Deep tissue injury: 2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry: Coded-1. <BR/>Record review of Resident#105's physician order, dated 02/11/2023 revealed an order for Cefepime HCL Solution 1 GM/50ML use 1 gram intravenously every 12 hours for infection for 14 days. <BR/>Record review of Resident#105's physician order, dated 02/09/2023, revealed an order to cleanse Right inner ankle with wound cleanser, pat dry, applied xeroform then covered with dry gauze and dry dressing every day shift.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse wound to sacrum with wound cleanser; pat dry; apply skin prep to Peri wound; apply Santyl to necrotic/slough tissue; cover with calcium alginate; cover with dry dressing daily and as needed if soiled. In the morning for wound healing until 03/17/2023 <BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order cleanse pressure wound to right lower back with wound cleanser; pat dry; skin prep peri wound; apply Santyl; cover with calcium alginate and dry dressing in the morning for wound healing until 03/17/2023.<BR/>Record review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left lateral forefoot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>review of Resident#105's physician order, dated 02/17/2023, revealed an order Cleanse left medial foot with wound cleanser, pat dry; apply Betadine to wound base; cover with one layer of xeroform, dry gauge and secured with kerlix and tape once daily and as needed in the morning orders recommended by Wound Care Doctor. The order was discontinued on 02/22/23. <BR/>Record review of Initial wound evaluation & Management Summary dated 2/16/2023 revealed read in part: .Focused Wound Exam (Site 1) Unstageable DTI Sacrum Full Thickness wound size (L x W x D): 3.7 x 4.5x0.1 cm. Surgical excisional debridement procedure: surgically excise 7.49cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 2) Stage 3 Pressure wound of the right lower back full thickness wound size (L x W x D): 12.2 x 3.7 x 0.1 cm. Site 2: Surgical excisional debridement procedure: surgically excise 16.25cm&sup2; of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Focused Wound Exam (Site 3) Arterial wound to the left, medial foot partial thickness wound size (L x W x D): 4.1 x 5.0 x Not Measurable cm. Recommendations: Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily. Focused Wound Exam (Site 4) Arterial wound to the left, lateral foot partial thickness wound size (L x W x D): 4.3 x 3.4 x Not Measurable cm. Recommendations Off-load wound; Consult outside specialist: follow up w/ vascular surgery as outpatient; Antibiotic choice : continue topical application of linezolid (2 caps) with bassagel qdaily .<BR/>Observation on 02/22/23 at 2:35 p.m., revealed the LVN A performing wound care on Resident #105 assisted by CNA D. Resident #105 was assisted onto his left side revealing there was no dressing on the resident's back. The wounds were covered with dry gauge. Further observation revealed unstageable pressure ulcer to the sacral/coccyx area approximately 3 cm in diameter and a stage 3 pressure ulcer to the right lower wound area approximately 12 cm in diameter. LVN A looked at this Surveyor and said, I don't remember the orders do you mind if I go check the orders. LVN A removed her soiled gloves without sanitizing/washing her hands left the room. Returned after few minutes sanitized her hands, donned new gloves and continued the wound care treatment. LVN A removed right inner ankle dressing dated 02/21/23 observation revealed unstageable (had slough) right inner ankle area approximately 0.3 cm in diameter. LVN A cleansed the wound with normal saline, pat dried with the same soiled gloves applied xeroform, dry gauze and covered with dry dressing. With the same soiled gloves LVN A removed left medial foot /left lateral forefoot dressing (kerlix wrapped around the wound) left medial foot area approximately 4 cm in diameter. Left lateral forefoot area approximately 4 cm in diameter. LVN A cleansed both wounds with normal saline, pat dried, with the same soiled gloves applied betadine, xeroform, dry gauge and wrapped with kerlix. <BR/>In an interview on 02/22/23 at 3:04p.m., with the DON, she said she expected staff to follow standard infection control techniques; to perform handwashing before the treatment, between gloves change and after moving from dirty to clean site as it placed risk for infections. She said staff were provided mass infection control in service on COVID sign and symptoms, infection control and hand washing sometime in January 2023. She said to prepare for the annual survey Unit Mangers had been doing observations on staff providing care don't know how that fell through the cracks. She said she UM were eye bawling and did not have any documentations of the check off/spot checks. She said the potential risk to the resident, due to this failure, was cross contamination. At this time policy on infection control and hand hygiene were requested. <BR/>In an interview on 02/23/23 at 1:08 p.m., LVN A said she was not a certified wound care nurse and did not receive wound care training at this facility. She said she could not recall having wound care competency check with the DON/ADON/Unit Manager. She said she started working in April 2022 at this facility. She said upon hire she received 3 days training on the floor shadowing another nurse. She said that nurse did run down on how to clean the wound. She said she did not perform hand hygiene or changed gloves when moving from dirty area to clean because I thought we had to switch gloves when switching wound sites. She said, I should have changed my gloves, sanitized my hands before applying santyl and calcium alginate on the wound. While removing old dressing and cleaning the wound I contaminated my gloves. She said this failure placed risk for infections. She said the facility provided in-servicing on infection control sometime last month. She could not recall the exact date. <BR/>In an interview on 02/23/23 at 1:48 p.m., with the DON and the Unit Manager, UM said she tried to spot check nurses as much as possible at least once a week. She said she observed LVN A do the med pass last week and wound care two weeks ago. UM said it was a simple skin tear dressing change on another resident. She said she could not recall the name of that resident, but it was not on Resident# 105. <BR/>Record review of facility Wound Care Competency (revised 02/2020) revealed read in part: Skills: 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline. 12. Perform hand hygiene. 13. Apply treatment as indicated .<BR/>Record review of facility's Handwashing/Hand Hygiene policy (last revised: 01/2021) revealed read in part: .Policy Overview: This community considers hand hygiene the primary means to prevent the spread of infections. G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, and alcohol -based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 7. Before handling clean or soiled dressings, gauze pads, etc.; 8. Before moving from a contaminated body site to a clean body site during resident care; 11. After handling used dressings, contaminated equipment, etc.; 13. After removing gloves; I. The use of gloves does not replace hand washing/hand hygiene .<BR/>Record review of facility's Infection Prevention and Surveillance policy (Last revised: 01/20) revealed read in part: .Policy overview: The Nurse Leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infections .<BR/>Policy regarding infection control was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 6 residents (Resident #3) reviewed for medications in that:<BR/>-The facility failed to ensure Resident #3 did not have medications clotrimazole cream 1% (a medicated antifungal skin cream. It treats certain kinds of skin fungal or yeast infections) and zinc oxide ointment (a medicated ointment that treats or prevents skin irritation like cuts, burns or diaper rash) in her room.<BR/>This failure could affect residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization.<BR/>Findings include:<BR/>Record review of the admission sheet (undated) for Resident #3 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included hypertension (blood pressure that is higher than normal), anemia (A condition in which the blood doesn't have enough healthy red blood cells) and metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural brain disease).<BR/>Record review of Resident #3's Comprehensive MDS assessment, dated 01/16/2023 revealed BIMS score of 11 out of 15 indicating moderately impaired cognitively. She required extensive assistance from staff for dressing, personal hygiene, transfers and bed mobility. She required total dependence from staff for toilet-use. <BR/>Record review of Resident #3's care plan, dated 11/08/2022 and revised on 02/11/2023, revealed the following care plan: <BR/>Focus: (Resident #3) has impaired cognitive function/or impaired thought processes metabolic encephalopathy. Goal: The resident will be able to communicate basic needs on a daily basis through the review date. Interventions/Tasks: Approach resident in calm, gentle manner. Explain care and procedures to resident prior to beginning. Resident #3 was not care planned for having meds at bedside. <BR/>During an observation and attempted interview on 02/21/2023 at 9:32 a.m. of Resident #3, in her room, revealed a bottle of zinc oxide ointment on top of the dresser across from resident's bed, a tube of clotrimazole cream 1% sitting on top of the side table. Resident #3 mumbled for 5 minutes, while being interviewed, and did not respond appropriately to the questions asked about meds at bedside.<BR/>During an observation and attempted interview on 02/22/2023 at 9:18 a.m. of Resident #3, in her room, revealed a tube of clotrimazole cream 1% sitting on top of the side table. Resident #3 mumbled for 5 minutes, while being interviewed, and did not respond appropriately to the questions asked about meds at bedside.<BR/>Record review of Resident #3's physician's order revealed Resident #3 was not prescribed the above-mentioned medication. There were no orders for self-administration.<BR/>During an observation and interview on 02/22/23 at 11:39a.m., with LVN A, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. She said she threw away the bottle of zinc oxide ointment after using it on the resident this morning because it was empty. At that time, LVN A took the Clotrimazole Cream 1% out of the resident's room and placed it in the treatment cart. LVN A said, I don't know what this cream is used for. I know resident has a wound and the evening shift nurse was assigned to do the wound care on Resident#3. Evening shift nurse might have left it in the room. <BR/>In a later interview and record review on 02/22/23 at 12:05p.m. with LVN A. This Surveyor reviewed Resident #3's physician orders with the Surveyor. LVN A said the resident did not have an order for zinc oxide and clotrimazole cream. She said, I was not aware resident had meds in her room. She said nurses needed to call the doctor and get an order. <BR/>In an interview on 02/22/23 at 3:04p.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said Resident #3 was not deemed safe to have medications in her room. DON said Resident was not supposed to have meds at her bedside. She said if med was not identified and not in physician orders the nurse should have not placed it in the treatment cart. She said nurses, cnas, unit manager made rounds and were responsible for checking the rooms for medications. She said risk for leaving meds at bedside was not safe med administration, could have adverse effect, unidentified meds could interact with prescribed meds. She said she was not aware of Resident #3 having meds at bedside. <BR/>Record review of facility's medical Management Overview- MED-1 policy (last revised 03/2019) read in part: .Policy Detail: A. Medication management services include but are not limited to: keeping medications in a locked and safe place, inaccessible to persons other than employees responsible for their supervision .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for 1 of 12 residents (Resident #4) reviewed for resident assessments was assessed using the quarterly review instrument not less frequently than once every 3 months, in that:<BR/>- <BR/>Resident #4's EHR showed her quarterly MDS assessment was due for completion by 4/10/2024 but was not done by time of record review on 04/24/2024.<BR/>This failure placed residents at risk of not receiving adequate care.<BR/>Findings included:<BR/>Record review of Resident #4's face sheet, dated, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with vascular dementia, Parkinson's disease and protein calorie malnutrition. <BR/>Record review of Resident #4's last comprehensive MDS, revealed it was dated 01/09/2024.<BR/>Record review of Resident #4's EHR revealed the resident's quarterly ARD was due by 4/10/2024.<BR/>In an interview with the MDS Nurse on 04/24/24 at 1:41PM, she stated assessment for admission assessments, quarterly assessments and discharge assessments are all completed within 14 days and the DON then has 7 days to sign off on the assessment and transmit the MDS to CMS . She stated follows the guidance as stated in the RAI manual. She stated she was not aware that she had missed Resident #4's quarterly MDS. She stated she forgot to complete Resident #4's MDS and, as of 04/24/2024, her MDS should have been completed since it was already beyond the 3-month period since her last MDS was completed. <BR/>In an interview with the DON, on 04/24/24 at 2:52PM, she stated she signed MDS assessments when they were due, but she was not involved in auditing the MDS Nurse's work. She stated she expected the MDS to be completed on time and knew that it could affect billing and updates in resident care plans.<BR/>Record review of the RAI Manual, dated 2019, revealed a quarterly MDS must be completed within 14 calendar days after ARD and a discharge MDS must be completed within 14 days after discharge date .