Haven Of Saguaro Valley

Based on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure transmission-based precautions and proper hand hygiene was implemented during incontinence care.

Findings include:

An observation of incontinence care was conducted with a certified nurse assistant (CNA/staff#60) and a licensed practical nurse (LPN/staff #91) on October 18, 2023 at 4:45 p.m. The LPN performed pericare and brief change while the CNA assisted the resident on her right side. During the observation, the LPN donned a clean pair of disposable gloves and then touched the resident. However, the LPN did not perform hand hygiene prior to donning of gloves. The LPN then removed the wet incontinent brief, placed it in a trash bag and cleaned the resident's perineal area. The LPN then proceeded to apply the new and clean incontinent brief on the resident using the same pair of gloves she used for pericare and handling of the soiled incontinent brief. The LPN continued to wear the same pair of gloves and adjusted the resident's clothing and positioned the resident in bed. The LPN then removed her gloves and disposed them in the trash, exited the resident's room, went to the nurses' station, washed and dried her hands.

An interview was conducted on October 19, 2023 at 12:32 p.m. with CNA (staff #50) who stated the procedure of performing pericare included washing of hands and applying gloves before initiating resident care.

In an interview with LPN (staff #84) conducted on October 19, 2023 at 12:52 p.m., the LPN said that staff were to wash their hands before and after applying gloves on, discarding soiled gloves or linens or incontinent briefs and resident care. However, that LPN said that he has not received any training from the facility regarding pericare.

During an interview with the Director of Nursing (DON/staff #3) on October 19, 2023 at 1:10 p.m., the DON stated that staff were expected to follow the facility policy/procedure when performing pericare. The DON stated that he policy was to wash and dry hands thoroughly, to put on gloves before beginning procedure, to remove gloves after completing pericare prior to putting on clean brief and repositioning the bed covers, and after task was completed to wash and dry hands thoroughly prior to leaving the room.

The facility policy on Handwashing/Hand Hygiene dated August 2015 revealed that all persons shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy stated that an alcohol-based hand rub was to be used before moving from a contaminated body site to a clean body site during resident care and after contact with blood or bodily fluids.

Review of the facility policy on Perineal Care dated October 2010 included that staff were to wash hands and apply gloves before initiating resident care. Once completed with perineal care, staff were to remove gloves and wash hands prior to repositioning bed covers, making the resident comfortable, placing the call light, and cleaning the wash basin and bedside stand. Staff were to again wash hands prior to leaving resident room.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident was free from abuse. The deficient practice could result in further resident abuse.

Findings include:

Resident #2 was admitted on February 17, 2022 with diagnoses of dementia, cardiomegaly, weakness, heart failure and type II diabetes.

The admission MDS (Minimum Data Set) assessment dated February 23, 2022 revealed a BIMS (brief interview for mental status) score of 12 indicating the resident had intact cognition.

Review of the clinical record revealed the resident will require 24/7 supervision upon discharge; and that, the resident will be discharge to an assisted living.

The physician's history and physical revealed the resident had an increase need of assistance with activities of daily living such as continence care and medical assistance such as medication administration.

The social services progress note dated March 11, 2022 revealed that there had been an ongoing issue between the resident and the family related to resident's placement or going home. Per the documentation, the resident decided to go to an assisted living facility and this had upset the resident's family who came to the facility on March 11, 2022. Per the documentation, the family was asked to leave and staff attempted to remove the resident from the situation. The documentation also included this escalated the situation and the family ran to the resident's room and grabbed the resident "from behind in a choke hold." It also included that the family was "subsequently arrested on domestic violence assault" and the resident was discharged to the assisted living of her choice.

The facility's self-report dated March 11, 2022 included that the resident was in the process of discharge to an assisted living facility on March 11, 2022 at 10:15 a.m. when a staff found the resident in her room and her family had her in a head-lock. Per the documentation, the police were called and the family was escorted out from the facility.

The facility's reportable event record/report dated March 14,2022 included that the family came to the facility on the evening of March 10, 2022 to take his mother home against medical advice; and that, the family was asked to leave the facility. Per the report, the following morning (March 11, 2023), the family returned, would not listen to instructions "and instead made a bolt" for the resident's room. The documentation included that a certified nurse assistant (CNA/staff #60) witnessed the family putting the resident into a head lock type position; and that, the environmental services director (EVS/staff #41) and another staff intervened and removed the family's grip from the resident. The report also included that the family was arrested by the local police. The facility concluded in their report that the incident of physical abuse of the resident by her family was substantiated.

In an interview conducted on October 18, 2023 at 4:40 p.m., the CNA (staff #60) stated the same account of events as described in facility's self-report.

An interview was conducted with the EVS on October 19, 2023 at 11:00 a.m. The EVS provided the same account of events as described in facility's self-report.

The facility policy on Abuse included an objective is to provide a safe haven for their residents through preventative measures that protect every resident's right to freedom from abuse.

Based on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure transmission-based precautions and proper hand hygiene was implemented during incontinence care. The sample size was one. The deficient practice could result in transmission of infections to residents.

Findings include:

An observation of incontinence care was conducted with a certified nurse assistant (CNA/staff#60) and a licensed practical nurse (LPN/staff #91) on October 18, 2023 at 4:45 p.m. The LPN performed pericare and brief change while the CNA assisted the resident on her right side. During the observation, the LPN donned a clean pair of disposable gloves and then touched the resident. However, the LPN did not perform hand hygiene prior to donning of gloves. The LPN then removed the wet incontinent brief, placed it in a trash bag and cleaned the resident's perineal area. The LPN then proceeded to apply the new and clean incontinent brief on the resident using the same pair of gloves she used for pericare and handling of the soiled incontinent brief. The LPN continued to wear the same pair of gloves and adjusted the resident's clothing and positioned the resident in bed. The LPN then removed her gloves and disposed them in the trash, exited the resident's room, went to the nurses' station, washed and dried her hands.

An interview was conducted on October 19, 2023 at 12:32 p.m. with CNA (staff #50) who stated the procedure of performing pericare included washing of hands and applying gloves before initiating resident care.

In an interview with LPN (staff #84) conducted on October 19, 2023 at 12:52 p.m., the LPN said that staff were to wash their hands before and after applying gloves on, discarding soiled gloves or linens or incontinent briefs and resident care. However, that LPN said that he has not received any training from the facility regarding pericare.

During an interview with the Director of Nursing (DON/staff #3) on October 19, 2023 at 1:10 p.m., the DON stated that staff were expected to follow the facility policy/procedure when performing pericare. The DON stated that he policy was to wash and dry hands thoroughly, to put on gloves before beginning procedure, to remove gloves after completing pericare prior to putting on clean brief and repositioning the bed covers, and after task was completed to wash and dry hands thoroughly prior to leaving the room.

The facility policy on Handwashing/Hand Hygiene dated August 2015 revealed that all persons shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy stated that an alcohol-based hand rub was to be used before moving from a contaminated body site to a clean body site during resident care and after contact with blood or bodily fluids.

Review of the facility policy on Perineal Care dated October 2010 included that staff were to wash hands and apply gloves before initiating resident care. Once completed with perineal care, staff were to remove gloves and wash hands prior to repositioning bed covers, making the resident comfortable, placing the call light, and cleaning the wash basin and bedside stand. Staff were to again wash hands prior to leaving resident room.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident was free from abuse.

Findings include:

Resident #2 was admitted on February 17, 2022 with diagnoses of dementia, cardiomegaly, weakness, heart failure and type II diabetes.

The admission MDS (Minimum Data Set) assessment dated February 23, 2022 revealed a BIMS (brief interview for mental status) score of 12 indicating the resident had intact cognition.

Review of the clinical record revealed the resident will require 24/7 supervision upon discharge; and that, the resident will be discharge to an assisted living.

The physician's history and physical revealed the resident had an increase need of assistance with activities of daily living such as continence care and medical assistance such as medication administration.

The social services progress note dated March 11, 2022 revealed that there had been an ongoing issue between the resident and the family related to resident's placement or going home. Per the documentation, the resident decided to go to an assisted living facility and this had upset the resident's family who came to the facility on March 11, 2022. Per the documentation, the family was asked to leave and staff attempted to remove the resident from the situation. The documentation also included this escalated the situation and the family ran to the resident's room and grabbed the resident "from behind in a choke hold." It also included that the family was "subsequently arrested on domestic violence assault" and the resident was discharged to the assisted living of her choice.

The facility's self-report dated March 11, 2022 included that the resident was in the process of discharge to an assisted living facility on March 11, 2022 at 10:15 a.m. when a staff found the resident in her room and her family had her in a head-lock. Per the documentation, the police were called and the family was escorted out from the facility.

The facility's reportable event record/report dated March 14,2022 included that the family came to the facility on the evening of March 10, 2022 to take his mother home against medical advice; and that, the family was asked to leave the facility. Per the report, the following morning (March 11, 2023), the family returned, would not listen to instructions "and instead made a bolt" for the resident's room. The documentation included that a certified nurse assistant (CNA/staff #60) witnessed the family putting the resident into a head lock type position; and that, the environmental services director (EVS/staff #41) and another staff intervened and removed the family's grip from the resident. The report also included that the family was arrested by the local police. The facility concluded in their report that the incident of physical abuse of the resident by her family was substantiated.

In an interview conducted on October 18, 2023 at 4:40 p.m., the CNA (staff #60) stated the same account of events as described in facility's self-report.

An interview was conducted with the EVS on October 19, 2023 at 11:00 a.m. The EVS provided the same account of events as described in facility's self-report.

The facility policy on Abuse included an objective is to provide a safe haven for their residents through preventative measures that protect every resident's right to freedom from abuse.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that the responsible party was notified of a fall with injury for one resident (#186). The deficient practice could result in required decisions regarding treatment and care not made timely.

Findings include:

Resident #186 was admitted on October 1, 2021 with diagnoses of malignant neoplasm of the brain, anxiety disorder, schizophrenia and auditory hallucinations.

A face sheet included that this resident had a Power of Attorney (POA) for financial and care.

A care plan dated September 30, 2022 included that the resident was at risk for falls and injury

An incident note dated November 2, 2022 included that the resident was on the floor with small pool of blood from a small cut to the right eyebrow. Per the documentation, pressure was and a small band-aid was applied to injury; and that, the director of nursing (DON) and the unit manager (UM) were notified of fall.

Further review of the clinical record revealed no evidence that the resident's family or POA was notified of the fall or injury until November 6, 2022.

An interdisciplinary team (IDT) review dated November 6, 2022 included that the responsible party was notified of the resident's fall.

An attempt to contact the nurse providing care was made on April 12, 2022 at 9:27 AM and April 13, 2023 at 2:30 PM, however no return call or answer was received.

An interview was conducted on April 11, 2023 at 10:06 a.m. with a registered nurse (RN/staff #12) who stated that unless a resident does not have anyone, staff need to inform contact family or a POA of resident's admission, change of condition such as transfer to the hospital or a fall.

In an interview with a licensed practical nurse (LPN/staff #80) conducted on April 12, 2023 at 1:03 p.m., the LPN said that when a resident falls she would tell the staff not to move the resident until the she assess the resident. The LPN said that if a resident is not alert and oriented she would do neuro-checks; and, after resident was assessed and neuro-checks had been started, she would inform the doctor, the family, administration and the supervisor and do a fall report.

During an interview with the Director of Nursing (DON) conducted on April 13, 2023 at 3:07p.m., the DON said that when a resident had a fall incident, the facility would investigate how the fall happened, assist the patient, notify provider and family and then put the intervention in place. She said that it did not meet her expectations that staff waited days to notify the POA of resident #186. The DON stated that notification should be done right away. A review of the clinical record was conducted with the DON who stated that she was not able to find documentation that resident's family or POA had been notified of the resident's fall on November 2, 2022.

The facility policy on Accidents and Incidents - Investigating and Reporting revealed that the date/time the injured person's family was notified and by whom will be included on the report of incident/accident. This document included that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a report of incident/accident and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.

Based on clinical record review, staff interviews and review of policy, the facility failed to ensure intervention was implemented to prevent a fall for one resident (#29). The sample size was 19. The deficient practice may result in avoidable accidents.

Findings include:

-Resident #29 admitted on February 17, 2023 with diagnoses of COVID-19, weakness and unspecified lack of coordination.

The baseline care plan dated February 17, 2023 included the resident was at risk for falls related to weakness and history of falls; and, was at risk for ADL (activities of daily living) self-care performance. Goal included that the resident will be free of falls and will safely perform ADLs. Interventions included following facility fall protocoal and call light within reach.

The history and physical note dated February 20, 2023 included the resident subsequently fell twice, the most recent fall was 3 days ago; and that, the resident reported that he was losing his balance easily and his legs were giving in even though he was using a walker.

Review of the Admission 5-day MDS assessment dated February 23, 2023 revealed the resident had a BIMS (brief interview for mental status) score of 14 indicating resident had intact cognition. The assessment included that required extensive assistance with 2-person physical assist bed mobility, toilet use and dressing.

The daily skilled evaluation note dated February 23, 2023 included the residnt was alert and oriented to person, place, time and situation, was able to make his needs known and was a 1-2 person assist with ADLs.

The daily skilled evaluation dated February 28, 2023 included the resident was alert and oriented x 4. was able to make his needs known and was incontinent of bowel and bladder.

The incident note dated March 11, 2023 included that the resident was being changed by a certified nurse assistant (CNA/staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head and sustained an abrasion on the left side of the eyebrows. Per the documentation the provider was notified and the resident was sent to the hospital.

The fall risk evaluation dated March 11, 2023 included a fall risk score of 10 indicating the resident was moderate risk for fall. The evaluation included that the resident had a history of 1-2 falls within the last 6 months and had a decrease in muscle coordination.

A nursing note dated March 12, 2023 revealed the resident returned from the hospital. The documentation included the resident had a band-aid to his forehead; and that, the resident's head CT (computed tomography) was clear.

The IDT (interdisciplinary team) fall review and report dated March 12, 2023 included that the resident had a fall with minor injury on March 11, 2023 at 10:45 p.m. Per the documentation, the resident was being changed by a CNA (staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head. The documentation included that the resident sustained an abrasion on the left side of the eyebrows; and that, the resident was sent out to the hospital for CT scan. New interventions included use of pool noodle to help identify the bed parameters.

An interview with a licensed practical nurse (LPN/staff #73) was conducted on April 12, 2023 at 12:54 p.m. The LPN stated that the CNA (staff #105) called her into the resident's room around 10:00 p.m. and told her that resident #29 had a fall. The LPN stated that resident #29 told her that while he was being changed by staff #105, he fell off the bed and hit his head. The LPN said that resident #29 normally lay over on his side because he has a pressure ulcer; and, staff #105 reported that she was rolling the chux from under the resident who got too close to the edge and fell off the bed. The Lpn said that she assessed the resident and called the doctor who recommended for the resident to sent out for a CT scan.

An interview was conducted on April 12, 2023 at 2:10 p.m. with a CNA (staff #50) who stated that end of shift report will tell her whether a resident requires 1 or 2 two person assist in report; and, she may also ask therapy staff, if needed. She stated that for a resident who requires extensive assistance, she would anticipate having 2 or more CNAs fto assist that resident. Staff #50 also said that for a larger resident with an air mattress, she would think that the resident would require a 2-person assist at all times. Regarding resident #29, she stated that the resident was always a 2-person assist. Staff #50 stated that there are usually 2 CNAs and a nurse on on each hall, so there is always someone around to help if she needs it.

In an interview with the alleged CNA (staff #105) conducted on April 13, 2023 at 8:06 a.m., staff #105 stated that she was only 4'8" tall; and that, she should have gotten some help when she assisted resident #29 on the day of the incident. Staff #105 said that on the evening of March 11, 2023, she turned resident #29 on his side to provide incontinence care, and the resident rolled out of the bed. She stated she was standing on the opposite side of the bed, with the resident's back facing her. She stated that she had rolled all of the chux up underneath him, then pulled the draw sheet back towards her body but, the resident continued to roll out of the bed. Staff #105 said that she was able to grab his arm to keep him from falling, but that there was no restraining him after that; and that, the resident bumped his head and got a little scratch. Further, staff #105 said that she did not mean for it to happen and she was really sorry.

During an interview conducted with the director of rehabilitation (DOR/staff #98) on April 13, 2023 at 9:15 a.m., the DOR stated that, functionally, resident #29 still needed a lot of assistance. She stated that resident #29 was able to roll from left to right with moderate assistance and that meant someone needed to hold onto him. She stated that resident #29 was able to do about 25% of the rolling on his own, but that he definitely needed help. Further, the DOR said that the resident definitely needed two persons to assist with incontinence care. In addition, the DOR stated that the air mattress the resident had could also make the surface less stable for him.

In an interview conducted with the director of nursing (DON/staff #32) on April 13, 2023 at 1:15 p.m., the DON stated that if a resident had been assessed to require 2-person assistance, then the expectation was that 2 staff would provide care to the resident. The DON said that on November 16, 2022, staff were in-serviced on falls; however, staff #105 was not able to attend the in-service because staff #105 worked the night shift and had a day off the following day.

The facilty policy on Activities of Daily Living (ADLs), Supporting revised March 2018 included that residents will be provided with care, treatment and service as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care.

The Fall Prevention Program included that the Falling Leaf Program (FLP) has been designed to assist facility staff in this development. Steps include: review and determination of at-risk residents, prevention through addressing risks, appropriate fall respone, and initiation of effective interventions.

Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 66 and the sample was 17. The deficient practice could result in resident not provided with advanced care activities to meet their needs.

Findings include:

The Facility Assessment with completion dated of February 1, 2023 revealed tan average daily census range of 90-105. Staffing planning included one FT (full time) DON (director of nursing), wound nurse, admission nurse, unit manager; and, two FT MDS (minimum data set) nurses. Per the assessment there should be at least one RN per 24-hour period; individual nursing staff assignments was based on patient care needs and individual staff needs/training; and that, nursing shifts are twelve hours with a goal of consistent assignments.

Review of facility punch detail for registered nurses for March and April 2023 revealed no evidence of RN coverage on the following dates:
-March 11, 16, 17, 18, 23, 24, 25 and 30; and,
-April 6 and 7.

An interview was conducted with the DON (staff #32) and staffing Coordinator (staff #111) on April 13, 2023 at 10:24 a.m. The DON stated that if a registered nurse (RN) was not available to provide the RN coverage that the DON would assume the role of an RN floor nurse. She stated that the risk could include simultaneous demands on both roles and not being able to fully fulfill one or the other.

A request for the "staffing policy" was submitted on April 10, 2023, a policy regarding "posting direct care daily staffing numbers" with a revision date of August 2006 was provided noting the following "Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to resident."

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#11) was free from unnecessary pain medications. The deficient practice could result in residents experiencing adverse side effects.

Findings Include:

Resident #11 was admitted on October 20, 2022 with diagnoses of pubic fracture, pulmonary embolism and hypertension.

The care plan dated January 19, 2023 revealed the resident was on opiate medication related to pelvic fracture. Interventions included to administer medications as ordered and to monitor for side effects.

Review of the physician order revealed for oxycodone (opioid narcotic) 5 mg (milligram) 1 tablet by mouth every six hours as needed for pain on a scale of 6-10.

The MAR (Medication Administration Record) for February and March 2023 included that oxycodone was administered outside of the ordered pain parameter on the following dates:
-February 11 at 8:18 p.m. for pain scale of 2;
-February 18 at 8:23 p.m. for pain scale of 3;
-March 24 at 8:50 p.m. for pain scale of 5; and,
-March 25 at 9:03 p.m. for pain scaled of 0.

The progress notes from February through March 2023 revealed documentation that on several occasions, resident #11 requested for oxycodone for her pain. However, the documentation did not that the physician was notified that medication was given outside of the ordered parameters.

An interview was conducted on April 13, 2023 at 2:27 p.m., with a licensed practical nurse (LPN/staff #110) who stated that pain medications are given based on the resident's level of pain. The LPN said that medications like Tylenol (analgesic) would be given for a pain scale of 1-5, and stronger controlled medications such as oxycodone would be given for a scale of 6-10. The LPN said that if the resident's current medication was not adequate she would notify a provider to get an alternative order or make changes as necessary. Further, the LPN stated that giving medications outside the prescribed parameters could lead to side effects, such as lethargy, dependence, or being overmedicated.

During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 3:54 p.m., the DON stated reported that medications with parameters should be strictly followed; and that, her expectation was for pain medications to be given according to the ordered parameters by the physician. The DON stated that administering medications outside the ordered parameters could result in over sedation or pain not being controlled.

A review of facility policy on Administering Medications revised on December 2012 included that medications must be given in accordance with the physician's orders.

Based on observations, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medications were not available for resident use. The census was 85. The deficient practice may result in ineffective treatments and/or in residents receiving the expired medications.

Findings include:

An observation of the #100 medication room was conducted on April 13, 2023 at 2:04 p.m. with a licensed practical nurse (LPN/staff #80). There was a quadrivalent flucelvax (influenza vaccine) 2022-2023 formula, with an open date of March 8, 2023 written on the side of the box; and, two bags of 1000 ml (milliliters) 0.9% sodium chloride injection with a label that listed a resident who had been discharged from the facility in June, 2022. In an interview conducted with staff #80 immediately following the observation, the LPN stated that the influenza vaccine was good for 28 days after opening and should have been thrown out. The LPN also stated the two bags of sodium chloride injections should have been sent back to the pharmacy.

An observation of the #200 medication room on April 13, 2023 at approximately 2:20 p.m. was conducted with staff #80. There was a package of daptomycin (antibiotic) 450 mg (milligrams) 4.128 mg/mL, with an expiration date of April 9, 2023.

An interview was conducted on April 13, 2023 at approximately 2:30 p.m. with staff #80 who stated that the night nurses and central supply are responsible for checking the supply rooms for any expired supplies. She stated that expired supplies should be discarded and that pharmacy items would be sent back to the pharmacy.

During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 2:47 p.m., the DON stated that the expectation was that nursing staff would return expired medications and/or biologicals to the pharmacy for destruction. She stated that the administration of an expired product may cause side-effects and/or may be less potent.

The facility policy on Storage of Medications revised April 2007 revealed that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that the responsible party was notified of a fall with injury for one resident (#186).

Findings include:

Resident #186 was admitted on October 1, 2021 with diagnoses of malignant neoplasm of the brain, anxiety disorder, schizophrenia and auditory hallucinations.

A face sheet included that this resident had a Power of Attorney (POA) for financial and care.

A care plan dated September 30, 2022 included that the resident was at risk for falls and injury

An incident note dated November 2, 2022 included that the resident was on the floor with small pool of blood from a small cut to the right eyebrow. Per the documentation, pressure was and a small band-aid was applied to injury; and that, the director of nursing (DON) and the unit manager (UM) were notified of fall.

Further review of the clinical record revealed no evidence that the resident's family or POA was notified of the fall or injury until November 6, 2022.

An interdisciplinary team (IDT) review dated November 6, 2022 included that the responsible party was notified of the resident's fall.

An attempt to contact the nurse providing care was made on April 12, 2022 at 9:27 AM and April 13, 2023 at 2:30 PM, however no return call or answer was received.

An interview was conducted on April 11, 2023 at 10:06 a.m. with a registered nurse (RN/staff #12) who stated that unless a resident does not have anyone, staff need to inform contact family or a POA of resident's admission, change of condition such as transfer to the hospital or a fall.

In an interview with a licensed practical nurse (LPN/staff #80) conducted on April 12, 2023 at 1:03 p.m., the LPN said that when a resident falls she would tell the staff not to move the resident until the she assess the resident. The LPN said that if a resident is not alert and oriented she would do neuro-checks; and, after resident was assessed and neuro-checks had been started, she would inform the doctor, the family, administration and the supervisor and do a fall report.

During an interview with the Director of Nursing (DON) conducted on April 13, 2023 at 3:07p.m., the DON said that when a resident had a fall incident, the facility would investigate how the fall happened, assist the patient, notify provider and family and then put the intervention in place. She said that it did not meet her expectations that staff waited days to notify the POA of resident #186. The DON stated that notification should be done right away. A review of the clinical record was conducted with the DON who stated that she was not able to find documentation that resident's family or POA had been notified of the resident's fall on November 2, 2022.

The facility policy on Accidents and Incidents - Investigating and Reporting revealed that the date/time the injured person's family was notified and by whom will be included on the report of incident/accident. This document included that the Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a report of incident/accident and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#11) was not administered with unnecessary narcotic pain medication.

Findings Include:

Resident #11 was admitted on October 20, 2022 with diagnoses of pubic fracture, pulmonary embolism and hypertension.

The care plan dated January 19, 2023 revealed the resident was on opiate medication related to pelvic fracture. Interventions included to administer medications as ordered and to monitor for side effects.

Review of the physician order revealed for oxycodone (opioid narcotic) 5 mg (milligram) 1 tablet by mouth every six hours as needed for pain on a scale of 6-10.

The MAR (Medication Administration Record) for February and March 2023 included that oxycodone was administered outside of the ordered pain parameter on the following dates:
-February 11 at 8:18 p.m. for pain scale of 2;
-February 18 at 8:23 p.m. for pain scale of 3;
-March 24 at 8:50 p.m. for pain scale of 5; and,
-March 25 at 9:03 p.m. for pain scaled of 0.

The progress notes from February through March 2023 revealed documentation that on several occasions, resident #11 requested for oxycodone for her pain. However, the documentation did not that the physician was notified that medication was given outside of the ordered parameters.

An interview was conducted on April 13, 2023 at 2:27 p.m., with a licensed practical nurse (LPN/staff #110) who stated that pain medications are given based on the resident's level of pain. The LPN said that medications like Tylenol (analgesic) would be given for a pain scale of 1-5, and stronger controlled medications such as oxycodone would be given for a scale of 6-10. The LPN said that if the resident's current medication was not adequate she would notify a provider to get an alternative order or make changes as necessary. Further, the LPN stated that giving medications outside the prescribed parameters could lead to side effects, such as lethargy, dependence, or being overmedicated.

During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 3:54 p.m., the DON stated reported that medications with parameters should be strictly followed; and that, her expectation was for pain medications to be given according to the ordered parameters by the physician. The DON stated that administering medications outside the ordered parameters could result in over sedation or pain not being controlled.

A review of facility policy on Administering Medications revised on December 2012 included that medications must be given in accordance with the physician's orders.

Based on observations, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medications were not available for resident use.

Findings include:

An observation of the #100 medication room was conducted on April 13, 2023 at 2:04 p.m. with a licensed practical nurse (LPN/staff #80). There was a quadrivalent flucelvax (influenza vaccine) 2022-2023 formula, with an open date of March 8, 2023 written on the side of the box; and, two bags of 1000 ml (milliliters) 0.9% sodium chloride injection with a label that listed a resident who had been discharged from the facility in June, 2022. In an interview conducted with staff #80 immediately following the observation, the LPN stated that the influenza vaccine was good for 28 days after opening and should have been thrown out. The LPN also stated the two bags of sodium chloride injections should have been sent back to the pharmacy.

An observation of the #200 medication room on April 13, 2023 at approximately 2:20 p.m. was conducted with staff #80. There was a package of daptomycin (antibiotic) 450 mg (milligrams) 4.128 mg/mL, with an expiration date of April 9, 2023.

An interview was conducted on April 13, 2023 at approximately 2:30 p.m. with staff #80 who stated that the night nurses and central supply are responsible for checking the supply rooms for any expired supplies. She stated that expired supplies should be discarded and that pharmacy items would be sent back to the pharmacy.

During an interview conducted with the Director of Nursing (DON/staff #32) on April 13, 2023 at 2:47 p.m., the DON stated that the expectation was that nursing staff would return expired medications and/or biologicals to the pharmacy for destruction. She stated that the administration of an expired product may cause side-effects and/or may be less potent.

The facility policy on Storage of Medications revised April 2007 revealed that the facility shall store all drugs and biologicals in a safe, secure and orderly manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on clinical record review, staff interviews and review of policy, the facility failed to ensure intervention was implemented to prevent a fall for one resident (#29).

Findings include:

-Resident #29 admitted on February 17, 2023 with diagnoses of COVID-19, weakness and unspecified lack of coordination.

The baseline care plan dated February 17, 2023 included the resident was at risk for falls related to weakness and history of falls; and, was at risk for ADL (activities of daily living) self-care performance. Goal included that the resident will be free of falls and will safely perform ADLs. Interventions included following facility fall protocoal and call light within reach.

The history and physical note dated February 20, 2023 included the resident subsequently fell twice, the most recent fall was 3 days ago; and that, the resident reported that he was losing his balance easily and his legs were giving in even though he was using a walker.

Review of the Admission 5-day MDS assessment dated February 23, 2023 revealed the resident had a BIMS (brief interview for mental status) score of 14 indicating resident had intact cognition. The assessment included that required extensive assistance with 2-person physical assist bed mobility, toilet use and dressing.

The daily skilled evaluation note dated February 23, 2023 included the residnt was alert and oriented to person, place, time and situation, was able to make his needs known and was a 1-2 person assist with ADLs.

The daily skilled evaluation dated February 28, 2023 included the resident was alert and oriented x 4. was able to make his needs known and was incontinent of bowel and bladder.

The incident note dated March 11, 2023 included that the resident was being changed by a certified nurse assistant (CNA/staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head and sustained an abrasion on the left side of the eyebrows. Per the documentation the provider was notified and the resident was sent to the hospital.

The fall risk evaluation dated March 11, 2023 included a fall risk score of 10 indicating the resident was moderate risk for fall. The evaluation included that the resident had a history of 1-2 falls within the last 6 months and had a decrease in muscle coordination.

A nursing note dated March 12, 2023 revealed the resident returned from the hospital. The documentation included the resident had a band-aid to his forehead; and that, the resident's head CT (computed tomography) was clear.

The IDT (interdisciplinary team) fall review and report dated March 12, 2023 included that the resident had a fall with minor injury on March 11, 2023 at 10:45 p.m. Per the documentation, the resident was being changed by a CNA (staff #105) who pulled the chuck from underneath the resident who rolled out off the bed on the other side and hit his head. The documentation included that the resident sustained an abrasion on the left side of the eyebrows; and that, the resident was sent out to the hospital for CT scan. New interventions included use of pool noodle to help identify the bed parameters.

An interview with a licensed practical nurse (LPN/staff #73) was conducted on April 12, 2023 at 12:54 p.m. The LPN stated that the CNA (staff #105) called her into the resident's room around 10:00 p.m. and told her that resident #29 had a fall. The LPN stated that resident #29 told her that while he was being changed by staff #105, he fell off the bed and hit his head. The LPN said that resident #29 normally lay over on his side because he has a pressure ulcer; and, staff #105 reported that she was rolling the chux from under the resident who got too close to the edge and fell off the bed. The Lpn said that she assessed the resident and called the doctor who recommended for the resident to sent out for a CT scan.

An interview was conducted on April 12, 2023 at 2:10 p.m. with a CNA (staff #50) who stated that end of shift report will tell her whether a resident requires 1 or 2 two person assist in report; and, she may also ask therapy staff, if needed. She stated that for a resident who requires extensive assistance, she would anticipate having 2 or more CNAs fto assist that resident. Staff #50 also said that for a larger resident with an air mattress, she would think that the resident would require a 2-person assist at all times. Regarding resident #29, she stated that the resident was always a 2-person assist. Staff #50 stated that there are usually 2 CNAs and a nurse on on each hall, so there is always someone around to help if she needs it.

In an interview with the alleged CNA (staff #105) conducted on April 13, 2023 at 8:06 a.m., staff #105 stated that she was only 4'8" tall; and that, she should have gotten some help when she assisted resident #29 on the day of the incident. Staff #105 said that on the evening of March 11, 2023, she turned resident #29 on his side to provide incontinence care, and the resident rolled out of the bed. She stated she was standing on the opposite side of the bed, with the resident's back facing her. She stated that she had rolled all of the chux up underneath him, then pulled the draw sheet back towards her body but, the resident continued to roll out of the bed. Staff #105 said that she was able to grab his arm to keep him from falling, but that there was no restraining him after that; and that, the resident bumped his head and got a little scratch. Further, staff #105 said that she did not mean for it to happen and she was really sorry.

During an interview conducted with the director of rehabilitation (DOR/staff #98) on April 13, 2023 at 9:15 a.m., the DOR stated that, functionally, resident #29 still needed a lot of assistance. She stated that resident #29 was able to roll from left to right with moderate assistance and that meant someone needed to hold onto him. She stated that resident #29 was able to do about 25% of the rolling on his own, but that he definitely needed help. Further, the DOR said that the resident definitely needed two persons to assist with incontinence care. In addition, the DOR stated that the air mattress the resident had could also make the surface less stable for him.

In an interview conducted with the director of nursing (DON/staff #32) on April 13, 2023 at 1:15 p.m., the DON stated that if a resident had been assessed to require 2-person assistance, then the expectation was that 2 staff would provide care to the resident. The DON said that on November 16, 2022, staff were in-serviced on falls; however, staff #105 was not able to attend the in-service because staff #105 worked the night shift and had a day off the following day.

The facilty policy on Activities of Daily Living (ADLs), Supporting revised March 2018 included that residents will be provided with care, treatment and service as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care.

The Fall Prevention Program included that the Falling Leaf Program (FLP) has been designed to assist facility staff in this development. Steps include: review and determination of at-risk residents, prevention through addressing risks, appropriate fall respone, and initiation of effective interventions.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on April 11, 2023, revealed the following;

1) the door between the kitchen and the dining room failed to close. The door caught on the floor tile
2) the door from the service hall to the soiled linen passageway and oxygen storage room had excessive gap on the lower handle side. This area was damaged. The door would not stop smoke from traveling.
3) the door from the soiled linen passageway and oxygen storage to the laundry room had excessive gap on the lower handle side. The door would not stop smoke from traveling.
4) room 101 had a 1/4 gap on the upper handle side.
5) room 206 had a 1/4 gap on the upper handle side.
6) room 212 had a 1/4 gap on the upper handle side.
7) room 218 had a 1/4 gap on the upper handle side.
8) room 305 failed to latch secure when tested three of three times
9) the soiled linen room in the 300 hall had a 1/4 gap on the upper handle side.
10) room 311 had a 1/4 gap on the upper handle side.

During the exit conference conducted on April 11, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to ensure a protected covering over exposed wires. Failure to have the appropriate protection around exposed wires could cause harm to the patients and/or staff in an emergency.

NFPA 101, 2012 Edition Chapter 19. "19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1" " 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."

Findings include:

Observations made while on tour on April 11, 2023, revealed the facility failed to provide proper covering under the dish wash sink in the kitchen. The wiring was in a waterproof conduit but the conduit was approximately 6 inches short to total enclose the wiring. The wires were covered in black tape.

During the exit conference on April 11, 2023, the above findings were again acknowledged by the management staff. .

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#12) received care and services to promote the prevention, healing, and prevent the development of additional pressure ulcers/injury consistent with professional standards of practice. The sample size was 3. The deficient practice increases the risk of pain, infection, and rehospitalization.

Findings include:

Resident #12 readmitted to the facility on 02/17/23 with diagnoses including COVID-19, type 2 diabetes mellitus and adult failure to thrive.

The baseline risk for skin impairment care plan dated 02/17/23 related to bowel and bladder incontinence, weakness and a pressure ulcer present upon admission had a goal to have intact skin. Interventions included to follow facility policies and protocols for the prevention and treatment of skin breakdown.

A Weekly Skin check and Wound Assessment dated 02/17/23 revealed a popped blister with foam dressing had been identified on the resident's sacrum. However, a complete assessment of the wound was not identified in the clinical record.

Review of Pressure Ulcer Documentation and Weekly Assessment dated 02/20/23 revealed a Deep Tissue Injury to the resident's right heel. However, the wound to the resident's sacrum was not identified or addressed.

On 02/22/23 the Weekly Skin check and Wound Assessment revealed a skin break, Moisture Associated Skin Damage (MASD), and fragile skin surrounding the lesion. Review of the note section of the assessment included that barrier cream was being applied to the coccyx and buttocks on every brief change. However, further review of the clinical record provided no evidence that a complete evaluation of the lesion had been provided.

The 5-Day Minimum Data Set assessment dated 02/23/23 indicated the resident had admitted with one stage 3 pressure ulcer and one unable to be determined.

A physician's order dated 02/25/23 included an air mattress for the prevention of skin breakdown.

An alert progress note dated 02/25/23 at 11:15 p.m. included that while providing care to the resident, blood was noted in the resident's brief. Upon assessment of the area, an open area to the resident's sacrum was identified. The note indicated the area had deep purple non-blanching tissue to approximately 40% of the wound bed. The remaining wound bed was described with smooth, pink moist tissue with serosanguinous drainage. The note indicated that the writer had cleansed the area well and a silicone dressing was placed to protect the area. The note stated the Director of Nursing (DON) was notified.

A wound note dated 02/27/23 at 2:23 p.m. included the resident's coccyx and surrounding area noted with a stage 3 pressure area. The wound bed was described with 20% slough, 10% eschar and 70% granulation. The surrounding area was observed with MASD. The note indicated that new orders were implemented. However, review of the clinical record provided no evidence that a complete wound evaluation had been performed.

A physician ' s order dated 02/27/23 revealed cleansing the coccyx with normal saline, application of Medihoney (antibacterial/autolytic) and covering with a foam dressing. Change 3 times per week and as needed for saturated/dislodged dressing.

However, review of the February 2023 Wound Administration Record did not include documentation to indicate whether or not dressing changes had been completed.

The Pressure Ulcer Documentation and Assessment completed on 03/01/23 revealed a stage 3 pressure ulcer at the sacrum which measured 6 centimeters (cm) x 6 cm x 0.1 cm with serous drainage. The worst type of tissue noted was identified as eschar. Treatment included Medihoney and a foam dressing.

A physician's order dated 03/01/23 revealed wound care to the sacrum which included cleansing with normal saline, application of Medihoney, and covering the wound with a foam dressing. Change 3 times weekly and as needed.

The March 1, 2023 Wound Administration Record included a code "9", which indicated "Other/See Nurse Notes." However, review of the nursing progress notes did not provide documentation of the rationale for not performing the dressing change.

Review of the Weekly Skin check and Wound Assessment dated 03/08/23 revealed an unstageable pressure ulcer to the resident's sacrum. Measurements included 10.0 cm x 7.0 cm x 0.2 cm. Per the notes, the wound presented with 40% eschar, 40% granulation and 20% slough, with no undermining or tunneling present to the wound bed. A moderate amount of serous drainage was noted with no signs or symptoms of infection present.

A physician's order dated 03/09/23 included to cleanse the sacrum with normal saline, apply Santyl (exogenous bacterial enzyme) ointment, and cover with a foam dressing. Change 3 times weekly and as needed for wound care.

On 03/16/23 a Weekly Skin check and Wound Assessment noted a stage 3 pressure ulcer to the resident's sacrum which measured 9.5 cm x 6.5 cm x 0.1 cm. According to the documentation, the wound presented with irregular shape. The wound bed was described as 20% slough, 40% eschar and 40% red granulation with some intact skin throughout. A large amount of serous drainage was observed with no signs or symptoms of infection, tunneling or undermining.

An interview was conducted on 03/21/23 at 11:11 a.m. with a Certified Nursing Assistant (CNA/staff #70). She stated that she assists residents in preventing skin breakdown by rotating their position in the bed, helping them to get out of bed, if possible, and if they are incontinent, she will change them frequently. She stated that she reports skin breakdown to the nurse.

During an interview conducted on 03/21/23 at 11:20 a.m. a Licensed Practical Nurse (LPN/staff #90) stated that when a CNA tells her that a resident has an open wound, she would go and observe the wound herself. She stated that she would immediately notify the wound nurse.

On 03/21/23 at 11:32 a.m. an interview was conducted with the wound nurse (staff #40). She stated that when she is notified that a resident has an open wound, she will go and take a look at it immediately. She stated that she will take the DON along with her to stage the wound. She stated that after determining the type of wound, she would obtain orders and update the resident's care plan. She stated that if the wound is determined to be MASD, they would continue to apply barrier cream to the area. She stated that if the wound is assessed to be a pressure ulcer, it will be measured weekly. She stated that components of wound assessment include wound measurements, a description of the wound bed, signs or symptoms of infection, type and amount of drainage, and whether or not the resident is compliant with wound care. She stated that weekly skin checks and pressure ulcer assessments have been combined into one form.

An interview was conducted on 03/21/23 at 12:00 p.m. with the DON (staff #96). She stated that preventative measures included educating the nursing staff, frequent skin checks, frequent turning/repositioning, a low air loss mattress, and skin checks while changing the resident's brief. She stated that when skin breakdown has been identified, her expectation includes notification of the nurse, the wound nurse and/or they would let her know. She stated that she expects that the provider will be notified and that orders will be obtained for treatment. She stated that the wound would be assessed and staged as soon as possible after discovery. She stated that she expects wounds to be assessed on a weekly basis and as needed. She stated that MASD is moisture-associated, but that the skin would not be open. She stated that if the skin opens then the wound would be staged. She stated that it did not meet her expectations for wound care and treatmen

Based on clinical record review, staff interviews, and policy, the facility failed to ensure that 2 out of 3 residents reviewed (#7 and #13) received care and services to prevent and/or treat urinary tract infections. The deficient practice may increase the risks for pain, infection and rehospitalization.

Findings include:

-Resident #7 readmitted to the facility 07/06/22 with diagnoses including paroxysmal atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms and other obstructive and reflux uropathy.

An indwelling catheter care plan dated 06/24/22 related to other obstructive and reflux uropathy had a goal to remain free from catheter-related trauma. Interventions included to monitor/record/report to MD signs or symptoms of UTI, including: blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse/temperature, change in behavior and change in eating patterns.

A physician's order dated 06/24/22 at 2:19 p.m. included catheter care with soap & water or wipes every shift.

A nursing progress note dated 07/26/22 at 3:00 a.m. indicated that the resident had a Foley catheter in place that was patent and draining amber yellow urine at that time. The note included that the resident was encouraged to drink more water due to his [lack of] output and the color of the urine. However, review of the resident's progress notes did not reveal that the provider had been notified of the changes.

On 07/27/22 at 12:47 a.m. a nursing progress note indicated that the resident had a Foley that was patent and draining amber yellow urine. The note stated that the resident was encouraged to drink more water due to his output and the color of urine. However, the nursing progress notes provided no evidence that the provider had been notified.

The physician progress note dated 07/27/22 at 3:13 p.m. revealed the resident had no new complaints.

A late entry system note dated 07/28/22 at 12:47 a.m. revealed that the resident appeared to be more fatigued that shift, had not been able to use his whiteboard to answer questions, and that he had not eaten any dinner. The note included that the resident's Foley was in place and patent and that no signs of pain or discomfort were noted. However, there was no indication that the provider had been notified of the changes in the resident's status.

Review of the July 7 - 28, 2022 Treatment Administration Record revealed catheter care was provided as ordered.

On 07/29/22 at 6:50 a.m. an alert charting note revealed a change of condition in the resident's status. According to the note, the resident had a temperature of 102.3 F, blood pressure of 110/50, respirations of 26, pulse of 100, and an oxygen saturation level of 87% on room air. The note indicated that the resident was placed on oxygen and the provider was notified. An order to send the resident to the ER was obtained.

The discharge Minimum Data Set assessment dated 07/29/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive assistance for most activities of daily living, and he had an indwelling catheter.

At 10:20 on 07/29/22 a nursing progress note stated the resident was transferred to the hospital and admitted to the ICU.

A late entry History and Physical note dated 08/26/22 at 6:24 p.m. included that the resident had been admitted to the ICU for hypotension and septic shock. The note indicated that the resident had a bacteremia with pseudomonas and enterococcus faecalis, a UTI and cystitis. The resident also tested positive for COVID-19. According to the note, the resident was in acute renal failure upon presentation which had been resolved during his stay.

-Resident #13 readmitted to the facility on 01/27/23 with diagnoses including acute and chronic respiratory failure with hypoxia, Parkinson's disease and obstructive and reflux uropathy, unspecified.

A functional bladder incontinence care plan initiated 05/26/22 related to bladder incontinence had a goal to remain free from skin breakdown due to incontinence and brief use. Interventions included to monitor/document for signs and symptoms of UTI, including: pain, burning, increased pulse, change in behavior, altered mental status and change in eating patterns.

A review of the resident's vitals records dated 01/12/23 at 7:10 a.m. revealed the resident's blood pressure at 101/67, a pulse of 72, and a temperature of 96.9F. No respiratory documentation was identified on that date.

Review of an alert progress note dated 01/12/23 at 6:38 p.m. included that the resident's daughter had requested that a urinalysis (UA) be obtained due to the resident's increased lethargy and decreased appetite. According to the note, the resident had a past history of frequent UTIs. The provider was notified and orders were received to obtain a UA with culture and sensitivity, if indicated, via straight catheterization.

A physician's order dated 01/12/23 included straight catheterization to obtain UA with C&S, if indicated, one time only for lethargy.

On 01/14/23 at 7:10 a.m. review of the resident's vitals records revealed a blood pressure of 98/60, pulse of 110, respirations of 16, and a temperature of 97.3F. However, review of the resident's progress notes did not indicate that the provider had been notified of the change in the resident's status.

Per the lab results reported on 01/15/23 at 1:27 p.m., the culture and sensitivity (C&S) revealed for escherichia coli >100,000 colony-forming unit per milliliter (CFU/mL) and proteus mirabilis 10,000 - 50,000 CFU/mL - indicative of UTI.

On 01/16/23 at 9:16 a.m. an alert nursing progress note included that the resident was fatigued and eating less than baseline. The note indicated that fluids were encouraged and that the UA C&S results report was in and had been reported to the provider. According to the note, nursing was awaiting further instruction at that time.

A physician's order dated 01/16/23 at 2:54 p.m. revealed ampicillin (antibiotic) 500 milligrams (mg). Give 1 capsule three times a day for UTI.

Review of the January 2023 Medication Administration Record revealed ampicillin was administered beginning at 10:00 p.m. on 01/16/23.

On 01/17/23 at 7:02 a.m. the resident's vitals included a blood pressure of 113/64, pulse of 91, respirations of 20, and a temperature of 98.2F.

An infection progress note dated 01/17/23 at 8:53 a.m. included that the resident was on antibiotics for a UTI, that she continued to complain of fatigue and loss of appetite. Per the note, no nausea, vomiting, diarrhea or shortness of breath was identified.

A physician's progress note dated 01/17/23 at 10:52 a.m. revealed the resident had a recent UTI that week and that she was taking ciprofloxacin (antibiotic). However, review of the physician's orders did not include ciprofloxacin.

On 01/18/23 at 9:18 a.m. a discharge summary note included that the resident had been transferred to the hospital via ambulance due to decreased level of consciousness per a provider's order.

Review of the clinical record revealed the resident was readmitted to the facility on 01/27/23 at 3:00 p.m.

According to the physician's progress note dated 02/21/23 at 2:46 p.m., the resident was on routine Hospice after hospitalization for septicemia/respiratory failure. Per the note, the resident was readmitted with nephrolithiasis with a right kidney stone and a nephrostomy tube.

On 03/21/23 an interview was conducted with a Certified Nursing Assistant (CNA/staff #70). She stated that she provides catheter care and that she empties the catheters. She stated that signs and symptoms of a UTI would include confusion and fever. She stated that a darker urine color and/or less urinary output would be red flags for a UTI. She stated that she would

Based on clinical record review, staff interviews, and facility policies and procedures, the administrator failed to ensure one resident (#12) received services that assist in the resident to maintain their highest practicable well-being according to the resident comprehensive assessment related to pressure ulcers, and two residents (#7 and #13) received services that assist in the resident to maintain their highest practicable well-being according to the resident comprehensive assessment related to urinary tract infections.

Findings include:

Regarding pressure ulcers:

-Resident #12 readmitted to the facility on 02/17/23 with diagnoses including COVID-19, type 2 diabetes mellitus and adult failure to thrive.

The baseline risk for skin impairment care plan dated 02/17/23 related to bowel and bladder incontinence, weakness and a pressure ulcer present upon admission had a goal to have intact skin. Interventions included to follow facility policies and protocols for the prevention and treatment of skin breakdown.

A Weekly Skin check and Wound Assessment dated 02/17/23 revealed a popped blister with foam dressing had been identified on the resident's sacrum. However, a complete assessment of the wound was not performed.

Review of Pressure Ulcer Documentation and Weekly Assessment dated 02/20/23 revealed a Deep Tissue Injury to the resident's right heel. However, the wound to the resident's sacrum was not identified or addressed.

On 02/22/23 the Weekly Skin check and Wound Assessment revealed a skin break, Moisture Associated Skin Damage (MASD), and fragile skin surrounding the lesion. Review of the note section of the assessment included that barrier cream was being applied to the coccyx and buttocks on every brief change. However, further review of the clinical record provided no evidence that a complete evaluation of the lesion had been provided.

The 5-Day Minimum Data Set assessment dated 02/23/23 indicated the resident had admitted with one stage 3 pressure ulcer and one unable to be determined.

A physician's order dated 02/25/23 included an air mattress for the prevention of skin breakdown.

An alert progress note dated 02/25/23 at 11:15 p.m. included that while providing care to the resident, blood was noted in the resident's brief. Upon assessment of the area, an open area to the resident's sacrum was identified. The note indicated the area had deep purple non-blanching tissue to approximately 40% of the wound bed. The remaining wound bed was described with smooth, pink moist tissue with serosanguinous drainage. The note indicated that the writer had cleansed the area well and a silicone dressing was placed to protect the area. The Director of Nursing (DON) was notified.

A wound note dated 02/27/23 at 2:23 p.m. included the resident's coccyx and surrounding area noted with a stage 3 pressure area. The wound bed was described with 20% slough, 10% eschar and 70% granulation. The surrounding area was observed with MASD. The note indicated that new orders were implemented. However, review of the clinical record provided no evidence that a complete wound evaluation had been performed.

A physician's order dated 02/27/23 revealed cleansing the coccyx with normal saline, application of Medihoney (antibacterial/autolytic) and covering with a foam dressing. Change 3 times per week and as needed for saturated/dislodged dressing.

However, review of the February 2023 Wound Administration Record did not include documentation to indicate whether dressing changes had been completed.

The Pressure Ulcer Documentation and Assessment completed on 03/01/23 revealed a stage 3 pressure ulcer at the sacrum which measured 6 centimeters (cm) x 6 cm x 0.1 cm with serous drainage. The worst type of tissue noted was identified as eschar. Treatment included Medihoney and a foam dressing.

A physician's order dated 03/01/23 revealed wound care to the sacrum which included cleansing with normal saline, application of Medihoney, and covering the wound with a foam dressing. Change 3 times weekly and as needed.

The March 1, 2023 Wound Administration Record included a code "9", which indicated "Other/See Nurse Notes." However, review of the nursing progress notes did not provide documentation of the rationale for not performing the dressing change.

Review of the Weekly Skin check and Wound Assessment dated 03/08/23 revealed an unstageable pressure ulcer to the resident's sacrum. Measurements included 10.0 cm x 7.0 cm x 0.2 cm. Per the notes, the wound presented with 40% eschar, 40% granulation and 20% slough, with no undermining or tunneling present to the wound bed. A moderate amount of serous drainage was noted with no signs or symptoms of infection present.

A physician's order dated 03/09/23 included to cleanse the sacrum with normal saline, apply Santyl (exogenous bacterial enzyme) ointment, and cover with a foam dressing. Change 3 times weekly and as needed for wound care.

On 03/16/23 a Weekly Skin check and Wound Assessment noted a stage 3 pressure ulcer to the resident's sacrum which measured 9.5 cm x 6.5 cm x 0.1 cm. According to the documentation, the wound presented with irregular shape. The wound bed was described as 20% slough, 40% eschar and 40% red granulation with some intact skin throughout. A large amount of serous drainage was observed with no signs or symptoms of infection, tunneling or undermining.

An interview was conducted on 03/21/23 at 11:11 a.m. with a Certified Nursing Assistant (CNA/staff #70). She stated that she assists residents in preventing skin breakdown by rotating their position in the bed, helping them to get out of bed, if possible, and if they are incontinent, she will change them frequently. She stated that she reports skin breakdown to the nurse.

During an interview conducted on 03/21/23 at 11:20 a.m. a Licensed Practical Nurse (LPN/staff #90) stated that when a CNA tells her that a resident has an open wound, she would observe the wound herself. She stated that she would immediately notify the wound nurse.

On 03/21/23 at 11:32 a.m. an interview was conducted with the wound nurse (staff #40). She stated that when she is notified that a resident has an open wound, she will go and take a look at it immediately. She stated that she will take the DON along with her to stage the wound. She stated that after determining the type of wound, she would obtain orders and update the resident's care plan. She stated that if the wound is determined to be MASD, they would continue to apply barrier cream to the area. She stated that if the wound is assessed to be a pressure ulcer, it will be measured weekly. She stated that components of wound assessment include a description of the wound bed, signs or symptoms of infection, type and amount of drainage, and whether or not the resident is compliant with wound care. She stated that weekly skin checks and pressure ulcer assessments have been combined into one form.

An interview was conducted on 03/21/23 at 12:00 p.m. with the DON (staff #96). She stated that preventative measures included educating the nursing staff, frequent skin checks, frequent turning/repositioning, a low air loss mattress, and skin checks while changing the resident's brief. She stated that when skin breakdown has been identified, her expectation includes notification of the nurse, the wound nurse and/or they will let her know. She stated that she expects that the provider will be notified and that orders will be obtained for treatment. She stated that the wound would be assessed and staged as soon as possible after discovery. She stated that she expects wounds to be assessed on a weekly basis and as needed. She stated that MASD is moisture-associated, but that the skin would not be open. She stated that if the skin opens then the wound would be staged. She stated th