Life Care Center Of Scottsdale

Based on review of personnel files, staff and resident interviews, and policy review, the facility failed to ensure one Registered Nurse ' s (RN/#33) personnel records were maintained and included copies of a current and valid Fingerprint Clearance Card. The deficient practice could result in potential harm to residents due to a lack of safety and security.

Findings include:

Review of the personnel files for staff #33 on September 10, 2024 revealed that staff #33 was hired on May 2, 2023, and she did not have a current and valid Fingerprint Clearance Card. Further review of the personnel files revealed that staff #33 was denied a Fingerprint Clearance Card by the Arizona Department of Public Safety on August 20, 2024, and she applied for a Good Cause Exception on September 1, 2024.

Review of the punch details for staff #33 on September 10, 2024 revealed she worked 14 shifts from August 24, 2024 to September 8, 2024 without a current and valid fingerprint card.

Review of the Fingerprint Clearance Card denial letter on September 11, 2024 revealed that "a residential care institution, nursing care institution or home health agency shall not allow a person to continue to provide direct care, home health services, or supportive services if the person has been denied a Fingerprint Clearance Card pursuant to Arizona Revised Statutes (ARS) 41-12-3.1 and 36-411 unless they meet the requirements of 36-411(F)".

At 9:19 a.m. on September 9, 2024, an interview was conducted with resident #339 who stated there was a cruel nurse (RN/#33) who could be mean and made resident #339 upset and uncomfortable.

On September 10, 2024, a follow-up interview was conducted with resident #339 who stated that the nurse (RN/#33) gave her a shower in the evening and was left alone with her. Resident #339 stated that the nurse she was referring to was a nurse manager or supervisor who was older, and resident #339 stated it was staff #33.

At 10:42 a.m. on September 11, 2024, an interview was conducted with the Executive Director (ED/Staff#102) who stated that staff may or may not have a fingerprint clearance card when they were onboarded, but they should have a fingerprint clearance card if they work on the floor. She stated that the risk of staff not having a current and valid fingerprint card was that the facility would not know the background of that staff, causing the resident to be at a potential risk for harm. Staff #102 also stated that the majority of the facility ' s concern would depend upon if staff was denied a fingerprint card.

Review of the Arizona Revised Statutes (ARS) 41-12-3.1 and 36-411 and requirements of 36-411(F) revealed that "an employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card."

Review of the facility policy titled "Employment File Guidelines" was given to the survey team with "Fingerprint Policy" handwritten on the top, and the document revealed that the employee files should contain state specific fingerprints, if applicable.

Based on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure one of one sampled resident's (#148) and/or their representatives were informed of the resident's care and treatment when requested.

Findings include:

Resident #148 was admitted on March 23, 2023 with diagnoses that included subdural hemorrhage, cognitive communication deficit, and atrial fibrillation.

Review of a Health Care Power of Attorney, dated March 15, 2006, included the resident's signature and indicated that her son was designated as her agent for all matters relating to her healthcare.

Review of the admission information dated March 23, 2023, revealed that Resident #148 was her own responsible party, and her emergency contact was her son, Chad Emerson.

A care plan initiated on March 24, 2023, revealed a focus on rehospitalization, with interventions that included discuss with resident/family history of hospitalization.

Review of a nursing alert note dated March 25, 2023, revealed that the Resident's daughter-in law called requesting information regarding the resident's plan of care, medication list and health in general, and requested a call from a case manager as soon as possible (ASAP). The note further revealed that Resident #148 gave verbal consent agreeing for her son and daughter-in-law to receive information regarding her care/treatment.

Further review of clinical record revealed no evidence that a case manager returned the call to the resident's family per their request.

A Health Status Note dated March 25, 2023 at 13:17, revealed that the resident's son called and was upset that no one reached out to him regarding his mother's care plan. The nurse called the resident's son back and left a message that included setting up a care conference with the interdisciplinary team (IDT).

Review of the clinical record revealed an IDT late entry dated March 26, 2023, indicating a team of qualified clinicians met to determine the patient's usual performance during the look-back period.

Further review of the clinical record revealed no evidence that the resident's son/family had been included in the IDT meeting, or attended the meeting, per their request.

Review of an Event Note dated March 27, 2023 at 10:37, revealed that the resident's daughter-in-law and the resident requested nursing interventions, and "demanded" that the resident be transferred to a higher level of care, related to a decline in cognition.

Review of a 5-day Medicare Minimum Data Set (MDS) assessment dated March 27, 2023, revealed no evidence of a Brief Interview for Mental Status (BIMS) assessment. A Cognitive Skills for Daily Decision Making assessment indicated that Resident #148, was independent with decisions regarding daily life, with decisions consistent/reasonable.

An interview was conducted on September 10, 2024, with a Licensed Practical Nurse, Case Manager (LPN/staff #52), who stated that resident's and their representatives are invited to meet for IDT meetings. She further stated that IDT meetings include the Director of Nursing (DON), Executive Director (ED), social services, rehabilitation and case management. The LPN also stated that this meeting would also include the resident's family/emergency contact, even if the resident is their own responsible party (unless the patient states otherwise). She stated that the IDT meeting would be documented in a progress note, along with the attendees. The LPN stated that a progress note should be completed when case management contacts a resident's representative. The LPN reviewed Resident #148's clinical record and stated there was no evidence that the resident's care plan had been reviewed with the resident or her representative. She further stated that there was no evidence in the clinical record that a case manager had called the representative back on March 25, 2023, after he had requested a call. The LPN stated the risk of not keeping representatives up dated on patient care/treatment, and not returning representatives calls could result in families/representatives being upset.

An interview was conducted on September 10, 2024 at 09:54, with the Health Information Management (HIM) Director (HIM/staff #63), who reviewed the clinical record and stated that there was no evidence that the resident's family had been informed of an IDT meeting, or attended the meeting on March 26, 2023, and that there was no evidence that case management called the Resident's son back after his request. She stated that she would expect that the case manager would have returned the call with the Resident's son and document the call in the clinical record. The HIM Director further stated that since it was not documented there is no way to tell if the call had been returned. She stated that there should be a progress note regarding the IDT care conference. She further stated that there was no evidence of case management progress notes or social service notes or Admission Care Conference notes that the family had been contacted regarding their concerns. She also stated that the risk of not keeping representatives/family updated on resident's care/treatment could result in a determent to the resident's health.

An interview was conducted on September 11, 2024 at 10:37 AM with the DON (staff #51), who stated that she expected case management to call resident representatives/families back if requested, and to document the call in the clinical record. She reviewed the clinical record and stated that there was no evidence that Resident #148's family member had been contacted by case management as requested on March 25, 2023, and that this was not "OK". She further stated that there was no evidence in the clinical record that the resident or her representative were part of the March 26, 2023, IDT care plan meeting and that this did not meet her expectations, stating that it needs to be documented. She stated the risk could result in the family member not being aware of the plan of care for the Resident.

Review of a facility policy titled, Family Involvement and Alternative Means of Communication, revealed family involvement in the resident's life is promoted and maintains the resident's support network. The policy also revealed that the facility should encourage the family to be involved in planning and implementation of the resident's care. The Social Services Director, as a member of the facility interdisciplinary team, designs, supports, and advocates facility systems that promote family involvement by providing information to the family to keep them informed of the resident's status (ie:, progress, changes, etc.).

Based on closed record review, staff interviews, and review of facility policy, the facility failed to ensure care and services were provided to prevent pressure ulcers from developing and worsening for one (#144) of one resident.

Findings include:

Resident #144 was admitted to the facility on April 18, 2023 with diagnoses including major depressive disorder, paraplegia, and multiple sclerosis.

Review of the care plan revealed a focus dated April 18, 2023 that the resident was at risk for breaks in skin integrity. The goal of this area was to maintain intact skin with no skin breaks, and interventions including weekly skin checks.

Review of the Admission/Readmission Collection Tool completed on April 18, 2023 revealed that on admission, the resident had an open wound to the left heel and blanchable redness to the coccyx. These were the only skin impairments documented in this tool.

Review of physician orders revealed an order dated April 18, 2023 that instructed daily wound care for the resident's left heel wound.
There is no mention of wound care for any other wounds, indicating the left heel was the only open wound at this time.

Further review of physician orders revealed an order dated April 19, 2023 that instructed to complete a weekly skin assessment every Tuesday night.

Review of the Minimum Data Set (MDS) dated April 21, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS also revealed that the resident needed maximal assistance to roll and to move from sitting to lying, indicating the resident was largely reliant on staff for repositioning. Further review of the MDS revealed the resident had one unstageable pressure injury present at admission, and he was at risk at developing pressure ulcers. Treatments in place included pressure reducing device for bed, pressure ulcer care, and application of dressings to feet.

Further review of the care plan revealed a focus dated April 24, 2023 that indicated the resident had an impairment to skin integrity on the left heel due to pressure. One of the interventions for this focus included weekly treatment documentation, which included measurement of each area of skin breakdown and any other notable changes. There was no mention in the care plan of any other wounds or pressure ulcers.

Review of the task "Turn and Reposition" revealed opportunities to chart turning or repositioning a resident every two hours. Review of this task revealed lapses in documentation of turning/repositioning. For example, on April 24, 2023, there was no evidence of the resident being turned or repositioned past 4:00PM, no evidence of turning or repositioning on April 25, 2023, and no evidence of turning or repositioning until 6:00 AM on April 26, 2023. This documentation reflects that the resident was not turned or repositioned from approximately 4:00PM on April 24, 2023 until approximately 6:00AM on April 26,2024.

Further review of physician orders revealed an order dated April 29, 2023 that instructed wound care twice a day for a right heel blister.

Further review of physician orders revealed an order dated May 1, 2023 to apply barrier cream to the resident's buttocks/coccyx for prevention of skin breakdown every shift and as needed. Additionally, an order was added on May 2, 2023 to apply Triad paste twice a day and as needed to the sacrum. On May 8, 2023, orders were added for daily wound care to the sacrum, including cleansing with normal saline and applying a wound-dressing paste.

Review of the Wound Observation Tools dated May 8, 2023 revealed first observations of acquired unstageable pressure ulcers on the sacrum and right heel, in addition to the left heel unstageable pressure ulcer on the left heel. The sacral wound at this time was 8 centimeters in length and 10 centimeters in width. The right heel wound at this time was 1.5 centimeters in length and 3 centimeters in width.

Further review of the task "Turn and Reposition" revealed no evidence of the resident being turned from 6:00AM on May 8, 2023 until 6:00M on May 9, 2023. Additionally, review of tasks revealed no evidence of bed mobility, locomotion, dressing, or transferring on May 8, 2023.

Review of the MDS dated May 16, 2023 revealed that the resident had three unstageable pressure ulcers with slough and/or eschar, with only one of these present upon admission to the facility.

Review of the discharge summary created May 16, 2023 revealed that the skin condition section was documented as "skin intact".

Review of the nursing progress note dated May 16, 2023 revealed an entry that was stated to be a "correction in documentation". This note revealed that the patient had a pressure ulcer on the sacrum that was 10 centimeters by 4 centimeters, and stage 1 pressure ulcers on both heels at time of discharge.

An interview was conducted on September 10, 2024 at 8:20AM with the resident's son, who stated that at the time of admission, the resident only had a "red hotspot" on his bottom and the area was not open. He states that on discharge from the facility, the discharge paperwork stated "skin intact". The son at this time saw the wounds on his father, and demanded the discharging nurse to assess and change the documentation. The son goes on to state that the facility knew about the extent of the wounds, as the wounds were dressed at the facility. Once discharged to the receiving facility, the son states that the nurse director took photos of the wounds, noting four wounds on the resident's bottom and one on each heel. The son states that the nurse director described the wounds as clearly stageable, with one wound being stage 4. When asked if he felt the facility worked to prevent his father's wounds, the son stated that the facility turned his father but not very often. He describes that his mother would have to often ask the staff to turn the resident, as it was not being done enough.

An interview was conducted with the Director of Nursing (DON/Staff #51) on September 10, 2024 at 12:52PM who stated that the expectation of her staff on admission is to complete a head-to-toe skin assessment, documenting any impairments and measurements. From there, weekly skin assessments should be completed, and the wound nurse will come behind nurses for wound assessments Monday through Friday. The DON elaborates that weekly skin checks should be completed for every resident, and skin integrity should be documented, including any new skin issues and pre-existing wounds. The DON goes on to explain that if redness is found on a resident's bottom, it should be reported to the nurse, and then to the doctor and family. The nurse should ensure treatment is ordered.

An interview was conducted with a Registered Nurse (RN/Staff #59) on September 12, 2024 at 8:20AM who stated that nurses conduct a full skin assessment on admission and are assessed periodically thereafter. She stated that if new skin breakdown is noticed, it should be reported to the physician and family. A change of condition assessment should be completed at this time, and interventions should be put in place, including new treatments ordered by the doctor.

Review of the facility policy titled "Skin Integrity & Pressure Ulcer/Injury Prevention and Management" indicates that any changes in a resident's skin or any open areas should be reported to the nurse, who will complete further inspection and provide treatment as needed.

Based on observation, staff interviews, and facility policy, the facility failed to ensure that refrigerated food was not expired.

During the initial tour of the kitchen on September 09, 2024 at 8:39AM, conducted with the Dietary Manager (Staff #9), during an observation of the refrigerator, one container of Horseradish was labeled with a received date of 11/8/2023 and opened on 11/10/23. Further observed revealed that the best used by date from the manufacture was April 06, 2024. The Dietary Manager stated that they can use the Horseradish condiment after the used by the date for up to a year. The Dietary Manager immediately throw the horseradish condiment into a trashcan.

An interview was conducted on September 11, 2024 at 09:12 AM with the Dietary Manager (Staff #9) and Consultant Dietitian (Staff #185). The Consultant Dietitian stated that the facility process for the expired food is that it should be discarded and thrown away. She further stated that the food can be used after the "best if used by/before". The Consultant Dietitian also stated that the horseradish could be used after the used by date depending on quality and flavor. She further stated that she has not taste tested the flavor or the quality of the horseradish condiment. The Dietary Manager further stated that she does not know when the horseradish condiment was last used.

An interview was conducted on September 11, 2024 at 11:33 AM with the Administrator (Staff #102) . who stated that the facility process for expired food is to throw way after the expiration date. She also stated that she expects the Dietary Manager to follow the policy item on how long they should keep the food after the used by date. She further stated that she does not see horseradish condiment on the list and it should not have been used. She Stated that Horseradish condiment should been thrown away.

Review of the facility policy titled, Food Storage, revealed that "Best if Used By/before"-gives the recommended shelf life for best flavor or quality. The food can be used safely past this date." It has also revealed that "Date of pack or Manufacture Date refers to when the food was packed or processed for sale, these are not "use by date", however horseradish was not one of the items listed.

Based on clinical records, facility documents, staff interviews, and facility policy, the facility failed to ensure residents wounds were assessed and treated per professional standards for 3 residents. (#11, 4, 19). This deficient practice can result in significant increases in morbidity and mortality related to wounds.

Findings include:

Regarding Resident #11:
-Resident #11 was admitted to the facility on 6/30/2023 with diagnoses of osteomyelitis of the vertebra, sacral and sacrococcygeal region, paraplegia and encounter for surgical aftercare.

A care plan initiated 7/2/2023 included that the resident has a break in skin integrity with interventions to provide treatment as ordered and a pressure reducing mattress.

An admission Minimum Data Set (MDS) dated 7/20/2023 included this resident is cognitively intact, has 1 stage 4 pressure ulcer and a surgical wound.

A CAA(Care Area Assessment) Worksheet included "(Resident #11) has a (history of pressure injury) which has now been treated surgically with flap closure. She is at risk for skin break down (related to) decreased mobility and incontinence. Staff will educate on causative factors for skin breakdown and how to prevent it. Staff will assist within continent care as needed. Staff will perform routine skin assessments to ensure skin integrity. Staff will encourage (patient) to change position at least every two hours to help reduce risk for breakdown (information obtained from hospital notes, clinical note, MARs (Medication Administration Records) /TARs (Treatment Administration Records), and therapy notes added to record in look back period 6/30/2023-7/4/2023)."

A hospital record dated 6/30/2023 included that the "The patient may be discharged to (Skilled Nursing Facility) on a low air loss bed. Once transferred the patient is to remain in a lateral (side) or prone position. Follow up in wound clinic in 1 week for repeat exam and suture removal."

An admission collection tool dated 6/30/2023 included that the resident had "sutures to the back of left and right leg" and notes that the resident has a "surgical incision" but did not contain measurements.

Review of the physician's orders did not find an order for a low air loss bed.

Review of the clinical record did not find that a low air loss bed had been implemented.

A physician's order dated 7/1/2023 included Cleanse wound with normal saline. Apply Xeroform to wound and wrap with Kerlix every day shift for Wound Care which included that wound care was performed 5 times of 9 opportunities.

A physician's order dated 7/1/2023 included to complete weekly skin and Braden assessment UDAs every night shift every Saturday, which included that a skin assessment was performed 1 of 2 assessments.

A weekly skin integrity data collection dated 7/7/2023 included that this resident has a surgical incision, however no notes were made regarding the condition of the surgical incision.

Review of the clinical record did not find that an assessment was completed of the surgical repair of the stage 4 ulcer with measurements during the resident's stay.

An interview was conducted on 6/3/2024 at 3:11 P.M. with an RN (staff #7) who said that if there is nothing in the box on a Treatment Administration Record (TAR) it means it wasn't completed. This nurse said that the nurse that admits the resident is supposed to do measurements and descriptions of the wounds.

An interview was conducted on 6/4/2024 at 11:46 A.M with a RN (staff #59) who said that who said that the wound team comes Tuesdays and Thursdays and the floor nurses do it when they are not here. She said that the first skin check is done by the floor nurses. This nurse said that we definitely note where the wound is at, try to get some measurements, and try to note that in the skin tab and write it in a summary in the end. If it's something that the wound team should see we put it in their book, also we look in their chart and go over the history and physical. She said that for a non-pressure wound, she measures it and write down if it has staples or sutures, and get orders to keep dressing on or to change the dressing, the appearance of the surrounding tissue, and the drainage. This nurse reviewed the clinical record and said she did not see an order for a low air loss mattress and that the facility always has an order for a low air loss mattress if one is used. She said that she did not see measurements for the surgical wound.

Regarding Resident #4
-Resident #4 was admitted on 4/25/2024 with diagnoses of encounter for surgical aftercare following surgery on the circulatory system.

A 5 day MDS dated 4/28/2024 included this resident is cognitively intact, has a surgical wound and requires partial/moderate assistance to roll left to right.

A review of hospital records included this resident has 3 surgical wounds on the left shoulder, left medial elbow and left axilla, 2 which require dressings and the left axilla which is to be left open to air.

A wound observation tool with an effective date of 5/2/2024 included that a left arm surgical wound was well approximated, had no drainage and measured 1.7 x .5 x 0. However, no assessments of this wound were made from 4/25/24 until this assessment on 5/2/2024. No notes were found of the other surgical wounds.

An interview was conducted on 6/4/2024 at 11:46 A.M with a RN (staff #59) who said that she reviewed the clinical record for resident #4 and said the wound observation tool on 5/2/2024 was the first record that the wound was measured.

Regarding Resident #19:
-Resident #19 was admitted on 5/29/2024 with diagnoses of nondisplaced fracture of base of neck of right femur.

An admission MDS dated 6/1/2024 included this resident does not have memory issues and was independent for making decisions for daily life. This MDS was not completed in sections on M Skin Conditions or GG Functional Abilities and Goals

A care plan dated 5/29/2024 included that this resident had a right hip fracture related to a fall and included that the resident would be observed for infection at the surgical site.

Review of the clinical record did not find a wound assessment of the surgical site.

An interview was conducted with a Registered Nurse (RN/staff #7) on 6/3/2024 at 3:11 P.M. who said that a blank spot on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) meant that that was not completed. This nurse said that the nurse admitting the resident is supposed to assess the wounds which would include measuring them.

An interview was conducted on 6/4/2024 at 11:46 A.M. with a RN (staff #59). This nurse reviewed the clinical record for resident #19 and said that she was unable to find measurements for the surgical site.

An observation was conducted on 6/4/2024 at 9:27 A.M. with a RN (staff #7) who measured a surgical incision on the right hip which was 9 cm in length, fully epithelialized with clear tape over the incision which appeared to be the type applied during surgery.

An interview was conducted during the observation with staff #7 who said that wound orders should be in the TAR.

An interview was conducted on 6/4/2024 at 1:40 P.M with the Director of Nursing (DON/staff #8) who said that she has not had a wound nurse in a few years. She said that the wound assessment tool triggers from the description of the wound and from there they put a treatment in place until a specialist comes in to assess and recommend treatment. She said that initially the staff were not assessing surgical wounds and that they have started recently. She said that her expectation is that the admission staff describe the wound and we have the wound team come in and assess and apply a treatment. She said that the wound team comes Tuesdays and Thursdays. This DON said that wound pati

Based on clinical records, facility documents, staff interviews, and facility policy, the facility failed to ensure residents pressure wounds were assessed and treated per professional standards for 1 residents. (#19). This deficient practice can result in significant increases in morbidity and mortality related to wounds.

Findings include:

-Resident #19 was admitted on 5/29/2024 with diagnoses of nondisplaced fracture of base of neck of right femur.

Review of hospital records dated 5/29/2024 did not include pressure ulcers.

An admission MDS dated 6/1/2024 included this resident does not have memory issues and was independent for making decisions for daily life. This MDS was not completed in sections on M Skin Conditions or GG Functional Abilities and Goals.

A care plan dated 5/29/2024 did not include pressure ulcers or risk of developing pressure ulcers.

An Admission/Readmission Collection Tool included that the resident had a right heel intact clear blister. This note included that the resident was to be seen by the wound team.

A progress note dated 5/29/3024 5/29/2024 included that "Patient has large intact blister on right heel that daughter is aware of. Heels floated while in bed and she is to be seen by wound team."

A progress note dated 5/30/24 included "wound team here to see and eval R heel blister with new orders for Tx, medicated as prescribed"

However, review of the clinical record did not find an assessment or a physician's order for the treatment of the resident's wounds from admission until 6/4/2024. No notes were found regarding a blister/pressure ulcer on the left heel from 5/29/2024 until 6/4/2024. This would indicate that the blister on the left heel was facility acquired.


A physician's order dated 6/4/2024 for Saline Wound Wash Solution (Sodium Chloride) Apply to bilateral heel topically as needed for cleansing, then apply foam dressing and to apply protective dressing. This order included to change day shift every 3 days and for soiled or damaged dressing.

An observation was conducted on 6/4/2024 at 9:27 A.M. with a RN (staff #7) who greeted resident #19, explained the procedure, then removed wrapped gauze, and a bordered dressing from both heels. This nurse stated that orders should be in the Treatment Administration Record (TAR). This nurse measured a blister on the left heel at 4cm x 2.5cm and stated that it was a closed blister. This nurse then measured the right heel blister as 9cm x 4.5cm with small serosanguinous drainage. This resident's family was in the room during the measurement and stated that the resident's heel was not looked at since admission, however said that they had booties on one night. This nurse looked for the booties found in room and placed on residents' feet.

An interview was conducted with a Registered Nurse (RN/staff #7) on 6/3/2024 at 3:11 P.M. who said the nurse admitting the resident is supposed to assess the wounds which would include measuring them.

An interview was conducted on 6/4/2024 at 11:46 A.M with a RN (staff #59) who said that who said that the wound team comes Tuesdays and Thursdays and the floor nurses do measurements when they are not here. She said that the first skin check is done by the floor nurses. This nurse said that we definitely note where the wound is at, try to get some measurements, and try to note that in the skin tab and write it in a summary in the end. If it's something that the wound team should see we put it in their book, also we look in their chart and go over the history and physical.

An interview was conducted on 6/4/2024 at 11:46 A.M. with a RN (staff #59). This nurse reviewed the clinical record for resident #19 and said that she was unable to find any measurements, or any assessments.

An interview was conducted on 6/4/2024 at 1:40 P.M with the Director of Nursing (DON/staff #8) who said that she has not had a wound nurse in a few years. She said that pressure ulcer assessments are to be done promptly and a blister is a stage 2 pressure ulcer. She said that the wound assessment tool triggers from the description of the wound and from there they put a treatment in place until a specialist comes in to assess and recommend treatment. She said that her expectation is that the admission staff describe the wound and we have the wound team come in and assess and apply a treatment. She said that the wound team comes Tuesdays and Thursdays. This DON said that wound patients are reviewed during the NAR meeting to see if they are getting better or worse and that it would require measurements to assess if a wound was getting better or worse. She said that resident #19's first wound assessment was 6/4/2024 that included a description and measurements. She said that her expectations are that the staff do the wound tool to assess the resident, provide a description and get weekly assessments of skin integrity and that the staff should contact the physician to get an order for treatment.

A policy titled Area of Focus: Wound Assessment & Wound Report revised 11/30/2023 included Wound Management is a daily event not a weekly plan and occurs 7 days a week and that new admissions and new wounds need timely assessment/documentation and treatmentsnimplemented preferably at time of admission or within 24 hours, this may require havingmadditional nurses trained in HCA's CWC Certified Wound Champion Curriculum.

A policy titled Documentation & Assessment of Wounds reviewed 03/31/2023 revealed that based on the comprehensive assessment of a resident, the facility must ensure that 1. A resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing.

A policy titled Physician Orders revised 2/26/2024 revealed a physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.

Based on clinical records, facility documents, staff interviews, and facility policy, the facility failed to ensure residents wounds were assessed and treated per professional standards for 3 residents. (#11, 4, 19) and failed to ensure residents pressure wounds were assessed for 1 residents. (#19).

Findings include:

Regarding Resident #11:
-Resident #11 was admitted to the facility on 6/30/2023 with diagnoses of osteomyelitis of the vertebra, sacral and sacrococcygeal region, paraplegia and encounter for surgical aftercare.

A care plan initiated 7/2/2023 included that the resident has a break in skin integrity with interventions to provide treatment as ordered and a pressure reducing mattress.

An admission Minimum Data Set (MDS) dated 7/20/2023 included this resident is cognitively intact, has 1 stage 4 pressure ulcer and a surgical wound.

A CAA(Care Area Assessment) Worksheet included "(Resident #11) has a (history of pressure injury) which has now been treated surgically with flap closure. She is at risk for skin break down (related to) decreased mobility and incontinence. Staff will educate on causative factors for skin breakdown and how to prevent it. Staff will assist within continent care as needed. Staff will perform routine skin assessments to ensure skin integrity. Staff will encourage (patient) to change position at least every two hours to help reduce risk for breakdown (information obtained from hospital notes, clinical note, MARs (Medication Administration Records) /TARs (Treatment Administration Records), and therapy notes added to record in look back period 6/30/2023-7/4/2023)."

A hospital record dated 6/30/2023 included that the "The patient may be discharged to (Skilled Nursing Facility) on a low air loss bed. Once transferred the patient is to remain in a lateral (side) or prone position. Follow up in wound clinic in 1 week for repeat exam and suture removal."

An admission collection tool dated 6/30/2023 included that the resident had "sutures to the back of left and right leg" and notes that the resident has a "surgical incision" but did not contain measurements.

Review of the physician's orders did not find an order for a low air loss bed.

Review of the clinical record did not find that a low air loss bed had been implemented.

A physician's order dated 7/1/2023 included Cleanse wound with normal saline. Apply Xeroform to wound and wrap with Kerlix every day shift for Wound Care which included that wound care was performed 5 times of 9 opportunities.

A physician's order dated 7/1/2023 included to complete weekly skin and Braden assessment UDAs every night shift every Saturday, which included that a skin assessment was performed 1 of 2 assessments.

A weekly skin integrity data collection dated 7/7/2023 included that this resident has a surgical incision, however no notes were made regarding the condition of the surgical incision.

Review of the clinical record did not find that an assessment was completed of the surgical repair of the stage 4 ulcer with measurements during the resident's stay.

An interview was conducted on 6/3/2024 at 3:11 P.M. with an RN (staff #7) who said that if there is nothing in the box on a Treatment Administration Record (TAR) it means it wasn't completed. This nurse said that the nurse that admits the resident is supposed to do measurements and descriptions of the wounds.

An interview was conducted on 6/4/2024 at 11:46 A.M with a RN (staff #59) who said that who said that the wound team comes Tuesdays and Thursdays and the floor nurses do it when they are not here. She said that the first skin check is done by the floor nurses. This nurse said that we definitely note where the wound is at, try to get some measurements, and try to note that in the skin tab and write it in a summary in the end. If it's something that the wound team should see we put it in their book, also we look in their chart and go over the history and physical. She said that for a non-pressure wound, she measures it and write down if it has staples or sutures, and get orders to keep dressing on or to change the dressing, the appearance of the surrounding tissue, and the drainage. This nurse reviewed the clinical record and said she did not see an order for a low air loss mattress and that the facility always has an order for a low air loss mattress if one is used. She said that she did not see measurements for the surgical wound.

Regarding Resident #4
-Resident #4 was admitted on 4/25/2024 with diagnoses of encounter for surgical aftercare following surgery on the circulatory system.

A 5 day MDS dated 4/28/2024 included this resident is cognitively intact, has a surgical wound and requires partial/moderate assistance to roll left to right.

A review of hospital records included this resident has 3 surgical wounds on the left shoulder, left medial elbow and left axilla, 2 which require dressings and the left axilla which is to be left open to air.

A wound observation tool with an effective date of 5/2/2024 included that a left arm surgical wound was well approximated, had no drainage and measured 1.7 x .5 x 0. However, no assessments of this wound were made from 4/25/24 until this assessment on 5/2/2024. No notes were found of the other surgical wounds.

An interview was conducted on 6/4/2024 at 11:46 A.M with a RN (staff #59) who said that she reviewed the clinical record for resident #4 and said the wound observation tool on 5/2/2024 was the first record that the wound was measured.

Regarding Resident #19:
-Resident #19 was admitted on 5/29/2024 with diagnoses of nondisplaced fracture of base of neck of right femur.

An admission MDS dated 6/1/2024 included this resident does not have memory issues and was independent for making decisions for daily life. This MDS was not completed in sections on M Skin Conditions or GG Functional Abilities and Goals

A care plan dated 5/29/2024 included that this resident had a right hip fracture related to a fall and included that the resident would be observed for infection at the surgical site.

Review of the clinical record did not find a wound assessment of the surgical site.

An interview was conducted with a Registered Nurse (RN/staff #7) on 6/3/2024 at 3:11 P.M. who said that a blank spot on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) meant that that was not completed. This nurse said that the nurse admitting the resident is supposed to assess the wounds which would include measuring them.

An interview was conducted on 6/4/2024 at 11:46 A.M. with a RN (staff #59). This nurse reviewed the clinical record for resident #19 and said that she was unable to find measurements for the surgical site.

An observation was conducted on 6/4/2024 at 9:27 A.M. with a RN (staff #7) who measured a surgical incision on the right hip which was 9 cm in length, fully epithelialized with clear tape over the incision which appeared to be the type applied during surgery.

An interview was conducted during the observation with staff #7 who said that wound orders should be in the TAR.

An interview was conducted on 6/4/2024 at 1:40 P.M with the Director of Nursing (DON/staff #8) who said that she has not had a wound nurse in a few years. She said that the wound assessment tool triggers from the description of the wound and from there they put a treatment in place until a specialist comes in to assess and recommend treatment. She said that initially the staff were not assessing surgical wounds and that they have started recently. She said that her expectation is that the admission staff describe the wound and we have the wound team come in and assess and apply a treatment. She said that the wound team comes Tuesdays and Thursdays. This DON said that wound patients are reviewed duri

CPR

0322 Citation CPR

Based on personnel file reviews, staff interview and policy review, the facility failed to implement their policy by failing to ensure that one staff member (Staff #29) had documentation of cardiopulmonary resuscitation (CPR) training on file.

Findings include:

Staff #29, has an initial hire date of 12/20/21 and a rehire date of 05/05/2022. A review of the personnel file for staff #29 was conducted on 01/18/23 01:01 PM with Staff #45 and revealed evidence that staff #29 did not have proof of cardiopulmonary resuscitation training (CPR) on file and was verified by staff #45

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to establish and implement their policy by failing to ensure that code status was consistent in the medical record for two residents (#21 and #306).

Findings include:

-Resident #21 was admitted on January 5, 2023 with diagnoses of unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing, COVID-19, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes with diabetic neuropathy and anemia.

The physician order dated January 5, 2023 revealed a code status of do not resuscitate (DNR).

The baseline care plan dated January 5, 2023 revealed the resident had an advanced directive of DNR-do not resuscitate and had a signed DNR. Interventions included for advanced directives will be honored.

Continued review of the electronic clinical record revealed documentation that the resident had a DNR code status.

However, the code status signed by resident #21 on January 5, 2023 revealed the resident wanted cardiopulmonary resuscitation (CPR), intravenous administration of fluids, nutrition via feeding tube, hospital transfer, pain medication and antibiotic therapy.

The 5-day minimum data set (MDS) assessment dated January 9, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

There was no evidence found in the clinical record that the resident's code status was corrected to reflect the resident's wishes for a full code from January 5 through 17, 2023.

There was also no evidence found in the clinical record that the resident changed his code status.

A physician order dated January 18, 2023 revealed a code status of full code.

-Resident #306 was admitted on January 2, 2023 with diagnoses of COVID-19, infection and inflammatory reaction due to indwelling urinary catheter, muscle weakness (generalized), need for assistance with personal care and chronic diastolic (congestive) heart failure.

Review of the code status form signed by resident on January 2, 2023 included that the resident requested to receive CPR, nutrition, hydration, pain medication, hospital transfers and antibiotic therapy.

However, the physician order dated January 3, 2023 included the resident had a code status of DNR.

The baseline care plan dated January 3, 2023 revealed the resident had advanced directives DNR-do not resuscitate. Interventions included that the resident's advanced directives will be honored.

The 5-day MDS assessment dated January 6, 2023 revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact.

There was no evidence found in the clinical record that the resident's code status was corrected to reflect the resident's wishes for a full code from January 5 through 17, 2023.

There was also no evidence found in the clinical record that the resident changed his code status.

A physician order dated January 18, 2023 included for a code status of full code.

An advanced directive form dated January 18, 2023 revealed the resident's code status was modified from DNR to full code.

An interview was conducted with licensed practical nurse (LPN/staff #11) on January 18, 2023 at 12:03 pm. The LPN stated that in an emergency situation they could obtain the code status from the electronic medical record or an advanced directive form signed by the resident in the hard chart. The LPN stated that if there was an inconsistency between the electronic medical record she would follow the hard chart copy because that was signed by the resident. The LPN also stated that they could call the resident's family for verification; and that, the admitting nurse was responsible for obtaining the code status as part of the admission packet.

During an interview with the director of nursing (DON/staff #98) conducted on January 18, 2023 at 12:08 p.m., the DON stated that if it was an emergency situation they would look in the hard chart for the signed copy or the care plan in the electronic medical record. The DON said that if the hard chart was inconsistent with the electronic medical record, the DON would follow the treatment requested on signed form in the hard chart. The DON also stated they could also confirm the resident's wishes directly with the resident or family during the emergency if resident is able to answer questions. The DON stated it was a team approach to obtaining code status; and that, the floor nurse could obtain it, the admission nurse, assistant director of nursing (ADON) or DON could obtain it. According to the DON the facility strives to get the code status in the computer within twenty-four hours of admission.

The facility's policy advance directives and care plan reviewed September 30, 2022 states residents have the right to self-determination regarding their medical care. Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made in the care plan and an immediate entry is made in the medical record. With written reversals, the physician is notified and the plan is permanently adjusted. The physician must give an order for any changes in advance directives. Upon review of the electronic medical record and care plan, no data exists that resident #306 reversed their code status to DNR.

Based on closed record review, staff interviews, and review of facility policy and procedure, the facility failed to implement their policy by failing to ensure that all transfer/discharge notifications were made for one resident (#53).

Findings include:

Resident # 53 was admitted December 12, 2022 with diagnoses of unspecified nephritic syndrome with diffuse membranous glomerulonephritis, acute kidney failure, unspecified atrial fibrillation and dependence on renal dialysis.

A physician order dated December 18, 2022 revealed an order to send the resident to the acute care hospital.

The transfer to hospital form (interact) dated December 18, 2022 included the resident was sent to an acute care hospital on December 18, 2022 for respiratory arrest.

A progress note dated December 18, 2022 revealed the resident was sent to an acute care hospital and the MD (medical doctor) was notified.

Continued review of the clinical record revealed no further documentation related to this incident found.

There was no evidence found in the clinical record that the resident's representative/s or Ombudsman were notified of the resident's transfer to the hospital on December 18, 2022.

The discharge minimum data set (MDS) dated December 18, 2022 revealed that the resident's discharge was coded as a death in the facility. The MDS further revealed that the resident was deceased.

An interview with licensed practical nurse (LPN/staff #19) was conducted on January 19, 2023 at 8:46 a.m. The LPN stated that if a resident is sent to the hospital the provider, the front desk, Director of Nursing (DON) and Assistant Director of Nursing (ADON) are notified. She stated that an interact form is filled out; and the notes and notifications are documented in the progress notes. Further, the LPN stated that documentation in the progress note was very detailed.

In an interview with the MDS nurse conducted on January 19, 2023 at 9:06 a.m., she stated that a discharge MDS is completed if a resident goes to the hospital. She also said that if the resident expires at the hospital and does not return to the facility, a death in the facility MDS is completed for that resident.

During an interview with the director of nursing (DON/staff 98) conducted on January 19, 2023 at 9:06 a.m., the DON stated that if a resident goes out to the hospital emergent, the provider is contacted and an order is placed in the chart. All notifications are to be included in the progress notes. Regarding resident #53, the DON stated that the only notification documented in the clinical record was to the provider.

In a later interview on January 19, 2023 at 12:59 p.m., the DON stated that a review of the clinical record for resident #53 revealed no documentation of notifications of family or the Ombudsman of the resident's discharge. She further stated the facility does not notify the Ombudsman of resident transfers of discharges.

Review of the facility policy Notice of Transfers and Discharges dated August 16, 2022 revealed that a copy of the notice of transfer/ discharge will be sent to a representative of the office of the State Long-Term Care Ombudsman. In the case of an emergency transfer a copy of transfer notice is sent to the Ombudsman as soon as practicable. The policy further stated that an emergency transfer to an acute care facility the resident and resident representative should receive the notice of transfer as soon as practicable before the transfer.

Based on staff interviews, facility documentation and policy and the Centers for Medicare and Medicaid Services (CMS) interim final rule requirements, the facility failed to establish and implement their policy on infection control by failing to ensure twelve staff members (#91, #89, #75, #96, #70, #86, #78, #61, #63, #24, #31 and #29) were vaccinated for COVID-19.

Findings include:

Review of facility documentation revealed a staff list with COVID-19 vaccination information. On this list, 11 staff members did not have documentation indicating that they were fully vaccinated for COVID-19 or had vaccination exemptions or had an approved temporary delay of vaccination. According to the documentation, one staff (#29) was partially vaccinated and did not have documentation staff had vaccination exemptions or an approved temporary delay of vaccination.

An interview was conducted with the Infection Preventionist (staff #27) on January 19, 2023 at 11:54 am. She stated all staffs hired are required to have primary COVID-19 vaccination completed before they start working or should have exemption filled out. She stated that once the exemption form is filled out, it is sent to corporate for review and the corporate will notify if the exemption was approved or denied. Staff #27 stated that after the exemption is approved or the staff are fully vaccinated, the facility is able to get the staff on schedule. Further, she stated that verification for vaccination status are done during the hiring process.

In an interview with the Director of Nursing (DON/staff #98) conducted on January 19, 2023 at 1:58 p.m., the DON stated that all staff are required to be fully vaccinated or should have been granted exemption prior to working. Further, the DON stated she was not able to get vaccination status or exemption/delay information for the staff (#91, #89, #75, #96, #70, #86, #78, #61, #63, #24, #31 and #29) who were identified as not vaccinated.

Review of the facility's COVID-19 vaccination program policy for associates, revised January 5, 2023, revealed that the facility will ensure that associates have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by CDC (Centers of Disease Control and Prevention). The policy stated that the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for CODID-19. The policy included that staff are considered fully vaccinated for COVID-19 if has been 2 weeks or more since they completed a primary vaccination series for COVID-19 which includes the administrator of a single-dose vaccine, and the administrator of all required doses of a multi-dose vaccine. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. The policy also included that the facility will ensure that newly hired associates will have received at least a single-dose vaccine, or the first dose of a multi-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or has been identified as having a delay as recommended by the CDC.

Review of CMS (Centers for Medicare and Medicaid Services) interim final rule requirements regarding health care staff vaccination for COVID-19, revised dated April 5, 2022, revealed that all facility staff are to have received the appropriate number of doses by the timeframes specified unless exempted as required by law. The rule indicates that facility staff vaccination rates under 100% constitute non-compliance under the rule.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was consistent in the medical record for two residents (#21 and #306). The deficient practice could result in resident not receiving care consistent with their signed advance directive.

Findings include:

-Resident #21 was admitted on January 5, 2023 with diagnoses of unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing, COVID-19, chronic obstructive pulmonary disease with (acute) exacerbation, type 2 diabetes with diabetic neuropathy and anemia.

The physician order dated January 5, 2023 revealed a code status of do not resuscitate (DNR).

The baseline care plan dated January 5, 2023 revealed the resident had an advanced directive of DNR-do not resuscitate and had a signed DNR. Interventions included for advanced directives will be honored.

Continued review of the electronic clinical record revealed documentation that the resident had a DNR code status.

However, the code status signed by resident #21 on January 5, 2023 revealed the resident wanted cardiopulmonary resuscitation (CPR), intravenous administration of fluids, nutrition via feeding tube, hospital transfer, pain medication and antibiotic therapy.

The 5-day minimum data set (MDS) assessment dated January 9, 2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

There was no evidence found in the clinical record that the resident's code status was corrected to reflect the resident's wishes for a full code from January 5 through 17, 2023.

There was also no evidence found in the clinical record that the resident changed his code status.

A physician order dated January 18, 2023 revealed a code status of full code.

-Resident #306 was admitted on January 2, 2023 with diagnoses of COVID-19, infection and inflammatory reaction due to indwelling urinary catheter, muscle weakness (generalized), need for assistance with personal care and chronic diastolic (congestive) heart failure.

Review of the code status form signed by resident on January 2, 2023 included that the resident requested to receive CPR, nutrition, hydration, pain medication, hospital transfers and antibiotic therapy.

However, the physician order dated January 3, 2023 included the resident had a code status of DNR.

The baseline care plan dated January 3, 2023 revealed the resident had advanced directives DNR-do not resuscitate. Interventions included that the resident's advanced directives will be honored.

The 5-day MDS assessment dated January 6, 2023 revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact.

There was no evidence found in the clinical record that the resident's code status was corrected to reflect the resident's wishes for a full code from January 5 through 17, 2023.

There was also no evidence found in the clinical record that the resident changed his code status.

A physician order dated January 18, 2023 included for a code status of full code.

An advanced directive form dated January 18, 2023 revealed the resident's code status was modified from DNR to full code.

An interview was conducted with licensed practical nurse (LPN/staff #11) on January 18, 2023 at 12:03 pm. The LPN stated that in an emergency situation they could obtain the code status from the electronic medical record or an advanced directive form signed by the resident in the hard chart. The LPN stated that if there was an inconsistency between the electronic medical record she would follow the hard chart copy because that was signed by the resident. The LPN also stated that they could call the resident's family for verification; and that, the admitting nurse was responsible for obtaining the code status as part of the admission packet.

During an interview with the director of nursing (DON/staff #98) conducted on January 18, 2023 at 12:08 p.m., the DON stated that if it was an emergency situation they would look in the hard chart for the signed copy or the care plan in the electronic medical record. The DON said that if the hard chart was inconsistent with the electronic medical record, the DON would follow the treatment requested on signed form in the hard chart. The DON also stated they could also confirm the resident's wishes directly with the resident or family during the emergency if resident is able to answer questions. The DON stated it was a team approach to obtaining code status; and that, the floor nurse could obtain it, the admission nurse, assistant director of nursing (ADON) or DON could obtain it. According to the DON the facility strives to get the code status in the computer within twenty-four hours of admission.

The facility's policy advance directives and care plan reviewed September 30, 2022 states residents have the right to self-determination regarding their medical care. Residents may revise an advance directive either orally or in writing. With an oral reversal, charting is due immediately, the physician is notified immediately, an immediate notation is made in the care plan and an immediate entry is made in the medical record. With written reversals, the physician is notified and the plan is permanently adjusted. The physician must give an order for any changes in advance directives. Upon review of the electronic medical record and care plan, no data exists that resident #306 reversed their code status to DNR.

Based on closed record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that all transfer/discharge notifications were made for one resident (#53). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties.

Findings include:

Resident # 53 was admitted December 12, 2022 with diagnoses of unspecified nephritic syndrome with diffuse membranous glomerulonephritis, acute kidney failure, unspecified atrial fibrillation and dependence on renal dialysis.

A physician order dated December 18, 2022 revealed an order to send the resident to the acute care hospital.

The transfer to hospital form (interact) dated December 18, 2022 included the resident was sent to an acute care hospital on December 18, 2022 for respiratory arrest.

A progress note dated December 18, 2022 revealed the resident was sent to an acute care hospital and the MD (medical doctor) was notified.

Continued review of the clinical record revealed no further documentation related to this incident found.

There was no evidence found in the clinical record that the resident's representative/s or Ombudsman were notified of the resident's transfer to the hospital on December 18, 2022.

The discharge minimum data set (MDS) dated December 18, 2022 revealed that the resident's discharge was coded as a death in the facility. The MDS further revealed that the resident was deceased.

An interview with licensed practical nurse (LPN/staff #19) was conducted on January 19, 2023 at 8:46 a.m. The LPN stated that if a resident is sent to the hospital the provider, the front desk, Director of Nursing (DON) and Assistant Director of Nursing (ADON) are notified. She stated that an interact form is filled out; and the notes and notifications are documented in the progress notes. Further, the LPN stated that documentation in the progress note was very detailed.

In an interview with the MDS nurse conducted on January 19, 2023 at 9:06 a.m., she stated that a discharge MDS is completed if a resident goes to the hospital. She also said that if the resident expires at the hospital and does not return to the facility, a death in the facility MDS is completed for that resident.

During an interview with the director of nursing (DON/staff 98) conducted on January 19, 2023 at 9:06 a.m., the DON stated that if a resident goes out to the hospital emergent, the provider is contacted and an order is placed in the chart. All notifications are to be included in the progress notes. Regarding resident #53, the DON stated that the only notification documented in the clinical record was to the provider.

In a later interview on January 19, 2023 at 12:59 p.m., the DON stated that a review of the clinical record for resident #53 revealed no documentation of notifications of family or the Ombudsman of the resident's discharge. She further stated the facility does not notify the Ombudsman of resident transfers of discharges.

Review of the facility policy Notice of Transfers and Discharges dated August 16, 2022 revealed that a copy of the notice of transfer/ discharge will be sent to a representative of the office of the State Long-Term Care Ombudsman. In the case of an emergency transfer a copy of transfer notice is sent to the Ombudsman as soon as practicable. The policy further stated that an emergency transfer to an acute care facility the resident and resident representative should receive the notice of transfer as soon as practicable before the transfer.

Based on personnel file review and staff interview, the facility failed to ensure that staff #12 was compliant with the fingerprint clearance requirement.

Findings include:

Review of the personnel file for staff #12 had a hire dated of March 12, 2020. Further review of the personnel file revealed no evidence that staff #12 had a fingerprint clearance as required.

An interview was conducted with staff #45 was conducted on January 18, 2023 at 1:01 p.m. staff #45 stated that staff #12 did not have a fingerprint clearance card on record.

Based on personnel file review and staff interview, the facility failed to ensure two staff members (#29 and #49) have evidence of freedom from infectious tuberculosis (TB).

Findings include:

Review of the personnel file of staff #29 revealed a initial hire date of December 30, 2021 and a rehire date of May 5, 2022. Continued review of the personnel file revealed no evidence that staff #29 was free from infectious TB.

A review of the personnel file of staff #49 revealed an initial hire date of April 4, 2004 and a rehired date of April 7, 2022. Further, the personnel file revealed no evidence of TB screening or testing completed for staff #49

In an interview and a review of the personnel files was conducted on January 18, 2023 at 1:01 p.m. with staff #45 who stated that there was no evidence found in the personnel file that staffs #29 and #49 had a current TB screening or testing done.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to meet professional standards of practice by failing ensure a wound treatment solution was not left at bedside and available for use for one resident (#35). The deficient practice resulted in the resident improperly and inappropriately taking the medication.

Findings include:

Resident #35 was admitted on December 14, 2022 with diagnoses of osteomyelitis of vertebra, sacral and sacrococcygeal region, muscle weakness, need for assistance with personal care and difficulty in walking.

The care management note dated December 16, 2022 included the resident had a sacral wound.

A skilled note dated December 18, 2022 included the resident had osteomyelitis of the vertebra, sacral and sacrococcygeal region.

The minimum data set (MDS) assessment signed December 27, 2022 revealed the brief interview of mental status (BIMS) was not completed.

A physician order dated January 4, 2023 included for Dakin's \'bc strength-soaked gauze twice daily every shift

The care plan revealed the resident had a break in skin integrity and had a stage IV pressure ulcer to his sacrococcygeal region. The plan was to minimize the risk for symptoms of infection, educate resident and/or family regarding skin problem and treatment. Interventions included to provide treatment as ordered and weekly skin checks.

The event note dated January 6, 2023 included that the resident returned from dialysis and was thirsty. According to the documentation, the resident grabbed a cup containing Dakins solution that was left over his table; and that, the physician was notified and the resident was sent to the hospital.

An interview was conducted with a registered nurse (RN/staff #78) on January 19, 2023 at 09:58 a.m. The RN stated that if a wound care item such as Dakins solution was taken into the room, it would be left in the room for the next time wound care is performed. The RN said that if the wound care supplies are to be discarded, they are discarded in the garbage bin located on the wound care cart. Regarding resident #35, the RN stated that the resident receives wound care treatment daily. The RN said that wound care nurse is only in the building twice a week for wound care tasks; but, the floor nurses are expected to perform wound care if a wound care nurse was not present. The RN further stated that documentation could be found on the TAR; and that, staff keeps a bin full of wound care supplies in resident's room on a table out of the resident's reach. The RN further stated that Dakins solution was kept in a bottle with a lid on it and is clearly labeled as Dakin's solution.

On January 19, 2023 an interview was conducted with the director of nursing (DON/staff #98) who stated that leftover wound supplies, creams, solutions, etc. should be removed from the room after wound care treatment was performed as they are considered medications, unless the resident has a physician order that supplies may be kept at bedside. Regarding the incident on January 6, 2023, the DON said that it was not acceptable to have Dakins solution at bedside in an unlabeled container.

An interview was conducted with LPN (staff #48) who stated that they were not sure if wound care supplies were kept in resident's room but recalled that the resident had a box in his room with his personal wound vac supplies. The LPN stated that on January 6, 2023, they witnessed multiple cups used for water consumption on the resident's bedside table; and the Dakins solution was present in one of the cups. The LPN the cup with Dakins was within the resident's reach and access to consume. The LPN stated he thought the cup with Dakins solution was left behind by previous shift.

The facility's policy, Workplace Hazard Assessment Policy reviewed December 08,2022 states that the facility must ensure the resident environment remains as free of accident hazards as possible.

The facility policy on Self-Administration of Medication included that the facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location (e.g., medication cart or medication room) or the resident is able to safely store the medication in a sere area in their room and safely administer the medication as prescribed.

Based on clinical record review, resident and staff interviews, and policies and procedures, the facility failed to ensure one resident (#354) received ostomy care in accordance with professional standards of practice. The deficient practice could result in untimely waste removal and complications such as skin breakdown.

Findings include:

Resident #354 was admitted to the facility on November 29, 2022 with diagnoses of urinary tract infection, surgical aftercare following surgery on the digestive system and need for assistance with personal care.

The admission MDS (Minimum Data Set) assessment dated December 3, 2022 included the resident required extensive assistance with bed mobility, transfers and toilet use. The assessment also included that ostomy was coded.

The physician order summary included an order dated January 18, 2023 to cleanse the abdomen with NS (normal saline), lightly pack openings with 1/4 Dakins soaked iodoform packing and cover with dry dressing daily every day shift for wound care. However, there was no order for ostomy care.

Review of the care plan revealed that there was no intervention found related to ostomy care.

Review of the TAR (treatment administration record from December 1 2022 through January 17, 2023 revealed that ostomy care was not transcribed onto the TAR; and that, ostomy care was provided to the resident during this period.

There was also no evidence found in the clinical record that the resident was assessed and was determined to be capable of doing his own ostomy care.

There was no physician order found for ostomy care from November 29, 2022 through January 17, 2023.

On January 18, 2023, an ostomy treatment order was written.

During an interview conducted with resident #354 on January 18, 2023 at 9:01 a.m., the resident stated that he was not receiving any assistance with or maintenance of his ostomy care since his admission at the facility.

An interview was conducted on January 19, 2023 at 08:48 a.m. with a certified nursing assistant (CNA/Staff #87) who stated that resident #354 was admitted with the ostomy; and that, he had provided care of the ostomy for a couple of weeks. Staff #87 stated he no longer provides ostomy care for resident #354 as the resident now takes care his ostomy. The CNA stated that bowel and bladder care was documented in the electronic record. A review of the CNA documentation was conducted with staff #87 who stated that there was no documentation of bowel or ostomy care found prior to January 18, 2023.

In an interview conducted on January 18, 2023 at 08:59 a.m., the licensed practical nurse (LPN/Staff #48) stated he was the nurse providing care for resident #354; and that, he had not received any report from the night shift staff that the resident had a colostomy. During the interview, a review of the clinical record was conducted with the LPN who stated there were no orders for colostomy care prior to January 18, 2023 for resident #354. He stated that if the resident required ostomy care, this would need to be on the treatment plan of the resident. Further, the LPN stated that because there was no order for ostomy care for resident #354 since admission, the resident did not receive the required care; and, this could lead to possible irritation at the site or other complications.

An interview was conducted on January 19, 2023 at 10:51 a.m. with Director of Nursing, (DON/staff #98) who stated that there should be an order for ostomy care and this order is communicated with staff for patient care. The DON stated that she does not why the assessment of resident #354 was not completed correctly upon the resident's admission at the facility. During the interview, a review of the clinical record was conducted with the DON who stated there were no previous orders for ostomy care nor was there any documentation for care for resident #354 found; and that, this does not meet the facility policy. She also stated that there was conflicting documentation as to whether the resident has an ileostomy or colostomy. She further stated that the risk of not completing ostomy care could result in no assessment of the stoma and possible unidentified infection.

Review of the facility policy titled, Colostomy and Ileostomy Care, revealed that it was their policy that a physician's order will be obtained for ostomy care to include specific physician preference regarding appliance, skin barrier and skin care.

-Resident #35 was admitted to the facility on December 14, 2022 with diagnoses of acute and chronic respiratory failure with hypoxia, heart failure, morbid (severe) obesity due to excess calories and obstructive sleep apnea.

A review of admission/readmission dated December 14, 2022 revealed the resident was receiving 2 liters of oxygen via nasal cannula.

The physician order dated December 14, 2022 included for oxygen with CPAP (continuous positive airway pressure)/BIPAP (bilevel positive airway pressure), pressure setting of 14 at 3LPM of oxygen while sleeping at night and during naps every shift.

The care management note dated December 16, 2022 revealed the resident was admitted on continuous oxygen at 2 LPM (liters per minute) via NC (nasal cannula) and used CPAP at night.

Review of the 5-day MDS (minimum data set) assessment dated December 18, 2022 coded the resident received oxygen while a resident and while not a resident at the facility.

Review of the admission/readmission note dated December 19, 2022 included resident was admitted with respiratory failure and had an oxygen saturation of 92 on 2 liters of oxygen via NC.

An administration note dated December 21, 2022 revealed the resident was on oxygen with CPAP/BIPAP at 3 LPM while sleeping at night and during naps every shift for respiratory failure.

The alert note dated January 7, 2023 included resident was awake with no respiratory distress and had oxygen via NC.

Review of the TAR (treatment administration record) for December 2022 and January 2023 revealed the order for oxygen with CPAP/BIPAP pressure setting of 14, on 3 LPM oxygen while sleeping at night and during naps every shift for respiratory failure was transcribed. The TAR also included that it was marked as administered on the day shift.

Despite documentation that the resident was on oxygen during the day, the clinical record revealed no physician for its use during the day.

An observation was conducted on January 17, 2023 at 10:12 a.m. Resident #35 was awake in his room and had oxygen on via NC which was connected to an oxygen concentrator.

In an interview conducted on January 19, 2023 at 10:03 a.m., the LPN (staff #48) stated resident #35 was on oxygen and oxygen saturation was monitored every shift and as needed. The LPN stated there should be a physician order for oxygen to be administered.

An interview with LPN (staff #11) conducted on January 19, 2023 11:40 a.m., staff #11 stated you need a physician order for residents on oxygen; and that, the order can vary between residents and will indicated whether the oxygen is administered on continuous or on as needed basis. She stated that if the resident uses it continuously, the physician order will specify the number of liters per minute. A review of the clinical record was conducted with staff #11 during the interview. The LPN stated that there was no order for oxygen therapy in the day shift found in the clinical record for resident #35.

During an interview with the director of nursing (DON/staff #98) conducted on January 19, 2023 at 10:32 a.m., the DON stated a physician order for oxygen use is required prior to its administration as oxygen is a medication. However, the DON stated that in a medical emergency oxygen can be administered without a physician order based on nursing practices.

The facility policy on Oxygen Administration/Safety/Maintenance reviewed on October 2022 revealed that it is their policy oxygen will be administered in accordance with physician orders and current standards of practice.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that ongoing assessment and monitoring for complications pre and post-dialysis treatments was provided for one resident (#35). This deficient practice could result in complications with the fistula/shunt not identified and managed.

Findings include:

Resident #35 was admitted to the facility on December 14, 2022 with diagnoses of end stage renal disease ESRD and dependence on renal dialysis.

A physician order dated December 14, 2022 revealed to send resident to dialysis on Monday, Wednesday and Friday; medication orders had appropriate times of at least 2 hours prior to or after return from dialysis; and, pre-and post-dialysis vitals and weight every shift every Tuesday, Thursday and Saturday.

The care plan dated December 14, 2022 revealed resident had chronic renal failure related to kidney disease (ESRD). The goal was that the resident will have no signs or symptoms or complications related to fluid deficit. Interventions included to provide resident/family/caregiver teaching regarding importance of compliance with treatment plan, fluid restrictions, dietary restrictions, energy conservation, medications and possible side effects and dialysis treatment.

A health status note dated December 15, 2022 revealed the resident returned from dialysis.

The skilled note dated December 15, 2022 included the resident remained on dialysis for ESRD 3x per week.

A skilled note dated December 27, 2022 revealed resident remained on dialysis for ESRD 3x per week.

Review of the admission MDS (Minimum Data Set) assessment dated December 27, 2022 revealed dialysis was coded.

The nutrition/dietary note dated December 28, 2022 included the resident was receiving HD (hemodialysis) treatment related to ESRD.

A physician order dated December 30, 2022 revealed resident received dialysis and to not take BP (blood pressure) on the right arm with fistula/shunt.

Further review of the clinical record revealed no evidence that the dialysis vascular access site for presence or absence of bruits/thrills and for signs and symptoms of complications such as bleeding since admission of the resident at the facility.

An interview was conducted on January 17, 2023 at 10:10 a.m. with resident #354 who stated that the staff at the facility does not assess his hemodialysis site; and that, the nurse at the dialysis center was the only person that assesses it.

In an interview with a licensed practical nurse (LPN/staff #11) conducted on January 18, 2023 at 12:53 p.m., the LPN stated that pre- and post-dialysis assessments and vital signs are no longer charted on paper; and that, all pre-post dialysis charting is completed in the electronic record. The LPN stated that nurses receive a prompt from the TAR to perform the task of post-dialysis vital signs. The LPN stated that when assessing the dialysis site, she will look at the dressing for bleeding of fistulas and permcaths and will listen to presence or absence of the bruits and thrills.

During an interview conducted with the director of nursing (DON/staff #98) on January 19, 2023 at 10:31 a.m., the DON stated that it was an expectation that staff assess and document their assessment for residents on dialysis. The DON also said that it was also an expectation to have a physician order in the clinical record for assessing the bruits and thrills the dialysis vascular site and obtain vital signs. Further, the DON said that nurses are expected to document their assessment findings such as the fistula condition, signs of bleeding and vital signs in the resident's clinical record. The DON stated that assessments are documented in paper and electronically; however, paper documentation should be followed up on and scanned in the electronic clinical record.

Review of facility policy on Dialysis with revision date of August 18, 2022 included that the facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including ongoing assessment of resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The vascular access site shall be checked daily with physician notification for any known or suspected problem. General guidelines included to assess vascular access site for signs of clotting or bleeding each shift; monitor for complaints of pain or discomfort at vascular access site; and to document in the clinical record. Further, the policy included to monitor vascular access site on routine basis and to notify the physician if any unusual problems noted such as tenderness and bleeding.

Based on staff interviews, facility documentation and policy and the Centers for Medicare and Medicaid Services (CMS) interim final rule requirements, the facility failed to ensure twelve staff members (#91, #89, #75, #96, #70, #86, #78, #61, #63, #24, #31 and #29) were vaccinated for COVID-19. The facility census was 57 residents. The deficient practice could result in the spread of COVID-19 in the facility.

Findings include:

Review of facility documentation revealed a staff list with COVID-19 vaccination information. On this list, 11 staff members did not have documentation indicating that they were fully vaccinated for COVID-19 or had vaccination exemptions or had an approved temporary delay of vaccination. According to the documentation, one staff (#29) was partially vaccinated and did not have documentation staff had vaccination exemptions or an approved temporary delay of vaccination.

An interview was conducted with the Infection Preventionist (staff #27) on January 19, 2023 at 11:54 am. She stated all staffs hired are required to have primary COVID-19 vaccination completed before they start working or should have exemption filled out. She stated that once the exemption form is filled out, it is sent to corporate for review and the corporate will notify if the exemption was approved or denied. Staff #27 stated that after the exemption is approved or the staff are fully vaccinated, the facility is able to get the staff on schedule. Further, she stated that verification for vaccination status are done during the hiring process.

In an interview with the Director of Nursing (DON/staff #98) conducted on January 19, 2023 at 1:58 p.m., the DON stated that all staff are required to be fully vaccinated or should have been granted exemption prior to working. Further, the DON stated she was not able to get vaccination status or exemption/delay information for the staff (#91, #89, #75, #96, #70, #86, #78, #61, #63, #24, #31 and #29) who were identified as not vaccinated.

Review of the facility's COVID-19 vaccination program policy for associates, revised January 5, 2023, revealed that the facility will ensure that associates have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by CDC (Centers of Disease Control and Prevention). The policy stated that the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for CODID-19. The policy included that staff are considered fully vaccinated for COVID-19 if has been 2 weeks or more since they completed a primary vaccination series for COVID-19 which includes the administrator of a single-dose vaccine, and the administrator of all required doses of a multi-dose vaccine. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. The policy also included that the facility will ensure that newly hired associates will have received at least a single-dose vaccine, or the first dose of a multi-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or has been identified as having a delay as recommended by the CDC.

Review of CMS (Centers for Medicare and Medicaid Services) interim final rule requirements regarding health care staff vaccination for COVID-19, revised dated April 5, 2022, revealed that all facility staff are to have received the appropriate number of doses by the timeframes specified unless exempted as required by law. The rule indicates that facility staff vaccination rates under 100% constitute non-compliance under the rule.

Based on clinical record review, resident and staff interviews, and policies and procedures, the facility failed to maintain the highest practicable well-being by failing to provide ostomy care in accordance with professional standards of practice for one resident (#354); by failing to ensure ongoing assessment and monitoring for complications pre and post-dialysis treatments was provided for one resident (#35).

Findings include:

-Regarding ostomy care for resident #354

Resident #354 was admitted to the facility on November 29, 2022 with diagnoses of urinary tract infection, surgical aftercare following surgery on the digestive system and need for assistance with personal care.

The admission MDS (Minimum Data Set) assessment dated December 3, 2022 included the resident required extensive assistance with bed mobility, transfers and toilet use. The assessment also included that ostomy was coded.

The physician order summary included an order dated January 18, 2023 to cleanse the abdomen with NS (normal saline), lightly pack openings with 1/4 Dakins soaked iodoform packing and cover with dry dressing daily every day shift for wound care. However, there was no order for ostomy care.

Review of the care plan revealed that there was no intervention found related to ostomy care.

Review of the TAR (treatment administration record from December 1 2022 through January 17, 2023 revealed that ostomy care was not transcribed onto the TAR; and that, ostomy care was provided to the resident during this period.

There was also no evidence found in the clinical record that the resident was assessed and was determined to be capable of doing his own ostomy care.

There was no physician order found for ostomy care from November 29, 2022 through January 17, 2023.

On January 18, 2023, an ostomy treatment order was written.

During an interview conducted with resident #354 on January 18, 2023 at 9:01 a.m., the resident stated that he was not receiving any assistance with or maintenance of his ostomy care since his admission at the facility.

An interview was conducted on January 19, 2023 at 08:48 a.m. with a certified nursing assistant (CNA/Staff #87) who stated that resident #354 was admitted with the ostomy; and that, he had provided care of the ostomy for a couple of weeks. Staff #87 stated he no longer provides ostomy care for resident #354 as the resident now takes care his ostomy. The CNA stated that bowel and bladder care was documented in the electronic record. A review of the CNA documentation was conducted with staff #87 who stated that there was no documentation of bowel or ostomy care found prior to January 18, 2023.

In an interview conducted on January 18, 2023 at 08:59 a.m., the licensed practical nurse (LPN/Staff #48) stated he was the nurse providing care for resident #354; and that, he had not received any report from the night shift staff that the resident had a colostomy. During the interview, a review of the clinical record was conducted with the LPN who stated there were no orders for colostomy care prior to January 18, 2023 for resident #354. He stated that if the resident required ostomy care, this would need to be on the treatment plan of the resident. Further, the LPN stated that because there was no order for ostomy care for resident #354 since admission, the resident did not receive the required care; and, this could lead to possible irritation at the site or other complications.

An interview was conducted on January 19, 2023 at 10:51 a.m. with Director of Nursing, (DON/staff #98) who stated that there should be an order for ostomy care and this order is communicated with staff for patient care. The DON stated that she does not why the assessment of resident #354 was not completed correctly upon the resident's admission at the facility. During the interview, a review of the clinical record was conducted with the DON who stated there were no previous orders for ostomy care nor was there any documentation for care for resident #354 found; and that, this does not meet the facility policy. She also stated that there was conflicting documentation as to whether the resident has an ileostomy or colostomy. She further stated that the risk of not completing ostomy care could result in no assessment of the stoma and possible unidentified infection.

Review of the facility policy titled, Colostomy and Ileostomy Care, revealed that it was their policy that a physician's order will be obtained for ostomy care to include specific physician preference regarding appliance, skin barrier and skin care.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure two sampled residents (#40 and #35) had a physician order for oxygen use prior to its administration.

Findings include:

-Resident #40 was admitted on December 21, 2022 with diagnoses of COVID-19, pneumonia due to Coronavirus disease 2019 and asthma with acute exacerbation.

A review of the care plan dated December 22, 2022 revealed the resident had COVID-19 infection. Intervention included medication as ordered. However, the care plan did not include the use of oxygen with interventions.

A review of admission/readmission note dated December 22, 2022 included the resident was admitted with pneumonia and ESRD (end stage renal disease). Per the documentation, the oxygen saturation was 95 on 3 liters NC (nasal cannula).

Review of the order note dated December 22, 2022 revealed the resident desaturated to mid-70% while on 4L (liters) of oxygen during activity with therapy.

The BIMS (brief interview for mental status) note dated December 27, 2022 revealed a score of 9 indicating resident had moderate cognitive impairment.

The provider progress notes dated December 22 and 29, 2022 and January 5, 2023 included a plan for oxygen support as needed.

Review of skilled note dated January 3 and 5, 2023 revealed the resident continued on oxygen via NC.

Despite documentation that resident was using oxygen via NC, the clinical record revealed no evidence for a physician order for the use of oxygen.

During an observation conducted on January 17, 2023 at 9:52 a.m., the resident was receiving oxygen at 2 LPM (liters per minute) via nasal cannula via an oxygen concentrator.

In another observation conducted on January 18, 2023 at 1:25 p.m. the resident was on oxygen at 2 LPM via NC; and, the oxygen tubing was dated January 18, 2023.

An interview was conducted with a licensed practical nurse (LPN/staff #11) on January 18, 2023 at 1:57 p.m., the LPN stated that resident #40's oxygen saturation was 95% on 2 liters of oxygen via NC. She stated the amount of oxygen a resident can have is determined in the physician's order; and that, the oxygen order could be PRN (as needed) or continuous. The LPN stated a physician order for oxygen was needed for a resident using oxygen as oxygen was considered as medication and treatment. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no physician order for the use of oxygen and there should have been an order for oxygen because the resident was admitted with oxygen.

An interview with the Director of Nursing (DON/staff #98) was conducted on January 19, 2023 at 8:50 a.m. The DON stated there should be a physician order for oxygen use if the resident is using oxygen; and that, her expectation was for the nurses to follow the order. She further stated that oxygen is a prescribed medication therefore there should be a physician order for its use/administration.

The facility policy on Oxygen Administration/Safety/Maintenance reviewed on October 2022 revealed that it is their policy oxygen will be administered in accordance with physician orders and current standards of practice.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to meet professional standards of practice by failing ensure a wound treatment solution was not left at bedside and available for use for one resident (#35). The deficient practice resulted in the resident improperly and inappropriately taking the medication.

Findings include:

Resident #35 was admitted on December 14, 2022 with diagnoses of osteomyelitis of vertebra, sacral and sacrococcygeal region, muscle weakness, need for assistance with personal care and difficulty in walking.

The care management note dated December 16, 2022 included the resident had a sacral wound.

A skilled note dated December 18, 2022 included the resident had osteomyelitis of the vertebra, sacral and sacrococcygeal region.

The minimum data set (MDS) assessment signed December 27, 2022 revealed the brief interview of mental status (BIMS) was not completed.

A physician order dated January 4, 2023 included for Dakin's \'bc strength-soaked gauze twice daily every shift

The care plan revealed the resident had a break in skin integrity and had a stage IV pressure ulcer to his sacrococcygeal region. The plan was to minimize the risk for symptoms of infection, educate resident and/or family regarding skin problem and treatment. Interventions included to provide treatment as ordered and weekly skin checks.

The event note dated January 6, 2023 included that the resident returned from dialysis and was thirsty. According to the documentation, the resident grabbed a cup containing Dakins solution that was left over his table; and that, the physician was notified and the resident was sent to the hospital.

An interview was conducted with a registered nurse (RN/staff #78) on January 19, 2023 at 09:58 a.m. The RN stated that if a wound care item such as Dakins solution was taken into the room, it would be left in the room for the next time wound care is performed. The RN said that if the wound care supplies are to be discarded, they are discarded in the garbage bin located on the wound care cart. Regarding resident #35, the RN stated that the resident receives wound care treatment daily. The RN said that wound care nurse is only in the building twice a week for wound care tasks; but, the floor nurses are expected to perform wound care if a wound care nurse was not present. The RN further stated that documentation could be found on the TAR; and that, staff keeps a bin full of wound care supplies in resident's room on a table out of the resident's reach. The RN further stated that Dakins solution was kept in a bottle with a lid on it and is clearly labeled as Dakin's solution.

On January 19, 2023 an interview was conducted with the director of nursing (DON/staff #98) who stated that leftover wound supplies, creams, solutions, etc. should be removed from the room after wound care treatment was performed as they are considered medications, unless the resident has a physician order that supplies may be kept at bedside. Regarding the incident on January 6, 2023, the DON said that it was not acceptable to have Dakins solution at bedside in an unlabeled container.

An interview was conducted with LPN (staff #48) who stated that they were not sure if wound care supplies were kept in resident's room but recalled that the resident had a box in his room with his personal wound vac supplies. The LPN stated that on January 6, 2023, they witnessed multiple cups used for water consumption on the resident's bedside table; and the Dakins solution was present in one of the cups. The LPN the cup with Dakins was within the resident's reach and access to consume. The LPN stated he thought the cup with Dakins solution was left behind by previous shift.

The facility's policy, Workplace Hazard Assessment Policy reviewed December 08,2022 states that the facility must ensure the resident environment remains as free of accident hazards as possible.

The facility policy on Self-Administration of Medication included that the facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location (e.g., medication cart or medication room) or the resident is able to safely store the medication in a sere area in their room and safely administer the medication as prescribed.

Based on observation the facility did not assure that all parts of the sprinkler system were in accordance with NFPA 25. Failing to maintain sprinkler heads and keep the fusible links clean could allow a fire to burn longer before the sprinkler head will activate.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.
NFPA 25, 2011 Edition, Section 5.2.1 Sprinklers, Section 5.2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings include:

Observations made while on tour on January 19, 2023, revealed the sprinkler head in the mechanical closet in the service hall was wrapped in a white towel with the towel being secured with black tape.

During the exit conference on January 19, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to ensure rated doors could latch secure when closed. Failing to ensure properly latching doors could allow heat and/or smoke transfer to occur which will cause harm to the residents 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 January 19, 2023, revealed the following;

1) the rated door at the kitchen dry storage failed to latch secure
2) the rated doors separating the 300 hall and the service hall failed to latch
3) the rated doors separating the 300 hall and the 400 hall next to room 320 failed to latch
The above doors did not latch secure when closed 3 of 2 times

During the exit conference on January 19, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to fill penetrations in the smoke barriers of the facility. Failing seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made while on tour on January 19, 2023, revealed a 5 inch by 12 inch hole in the drywall of the smoke barrier above the 300 and 400 hall.

During the exit conference conducted on January 19, 2023, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure that staff did not plug appliances into a power strip. Appliances plugged into power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on January 19, 2023, revealed a microwave oven plugged into a power strip in the Health Information Management office.

During the exit conference conducted on January 19, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to secure (1) one E-type medical gas oxygen cylinder in a stand or cart. Failing to secure compressed medical gas cylinders could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations made while on tour on January 19, 2023, revealed (1) one unsecured medical gas oxygen cylinders E-type located in the oxygen storage room in the 300 hall.

During the exit conference on January 19, 2023, the above findings were again acknowledged by the management staff.