**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled, HLTC Advance Directives for Health Care Policy, the facility failed to establish mechanisms for documenting and communicating the resident's choices for code status (advanced directives) to staff responsible for the resident's care for one of 34 sampled residents (R) (R1). The deficient practice had the potential to prevent R1 from expressing her right to formulate an advanced directive.Findings include:A review of the facility policy titled HLTC Advance Directives for Health Care Policy revised [DATE], documented under Purpose: Support the resident's right, in accordance with Georgia law, to formulate Advance Directives, honor existing Advance Directives, and revoke Advance Directives. Under Policy and Procedure: 1. The facility will promote the resident's right to formulate an Advance Directive, including the right to accept or refuse medical or surgical treatment, and revise or revoke an existing Advance Directive at any time. Under Policy and Procedure: .7. The facility will inform direct care staff and the resident's physician of any Advance Directives or changed to Advance Directives.Review of R1's electronic medical record (EMR) revealed R1 was originally admitted to the facility with pertinent diagnoses including but not limited to, acute and chronic respiratory failure with hypoxia, acute kidney, chronic diastolic (congestive) heart failure, chronic systolic (congestive) heart failure, Alzheimer's disease, dysphagia, need for assistance with personal care, chronic kidney disease (stage 4, severe), and cognitive communication deficit.Review of R1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicates R1 had moderate cognitive impairment.Review of R1's care plan dated [DATE] indicated a focus of a Do Not Resuscitate (DNR) code status. Goals included but were not limited to R1's wishes to be observed during the review period and cardiopulmonary resuscitation (CPR) will not be performed in the event of cardiac or respiratory arrest. Interventions included but were not limited to a DNR status and to not initiate CPR in the event of cardiac or respiratory arrest and allow natural death.Review of R1's electronic medical record (EMR) on [DATE] revealed the main page of the resident's profile included the name of the resident, photo identification of the resident, and other identifiable information. The section marked Code Status did not indicate full code or do not resuscitate. An interview with Certified Nursing Assistant (CNA) BB on [DATE] at 1:39 pm revealed that to determine a resident's code status, staff used to look at code status on the EMR, but now she believed they had to dig through the care plan, as the code status section was no longer visible to CNAs. When asked what she would do in the event of an emergency code situation, she stated that she just knew which residents were full codes based on working with them for so long. When asked if there was any paper reference for code status, she stated that there may be something in the nurses' station, but it was not accessible to CNAs.An interview with CNA HH on [DATE] at 1:50 pm revealed that if a resident was coding, CNAs were to look at the kiosk, but she was not sure exactly where it was but would show this surveyor. When asked if there was any paper reference for code status, she re-stated that they would have to look at the kiosk. While showing the kiosk to this surveyor, CNA HH could not locate the code status on the CNA kiosk and stated that CNAs would have to ask the nurse. When asked what she would do in the event of an emergency and could not locate a nurse, she re-stated that she would have to ask the nurse. She stated that there were no paper references for resident code statuses.An interview with Licensed Practical Nurse (LPN), Unit Manager on [DATE] at 1:57 pm revealed she assisted CNA HH in looking for the code status on the CNA kiosk. She confirmed she could not find any CNA access to resident code statuses on the kiosk. When asked where nurses would determine resident code statuses, she stated that she would open the EMR to look for the code status on the main page of the resident's profile. She further stated she had no idea why the CNAs do not have access to that, but she thinks it has always been like that. She further stated there was no paper reference for code status to look at and confirmed that it was all on computer. While showing this surveyor R1's EMR, she confirmed the code status for R1 was not listed where it should be and was not sure what the code status was for R1. When asked whose responsibility it was to place the code status, she stated that it wast he responsibility of the nurses. She further stated that the code status may have been changed during her last hospitalization which was a few months ago. After searching through the EMR, she identified that R1's code status was do not resuscitate (DNR) effective [DATE]. LPN FF then updated the code status on the R1's EMR to reflect a DNR status. She stated that potential negative outcomes of not having the correct code status listed could lead to someone passing away when they should be full code or CPR would be performed on a DNR resident. An interview with the Director of Nursing (DON) on [DATE] at 9:52 am, she revealed that most CNAs were CPR certified and would perform as needed and as applicable. She was not aware if the code statuses were listed anywhere other than the EMR. She stated that the main page of the resident's profile on the CNA's kiosk should show the residents' allergies, code status, and any special instructions for care. She stated that yesterday she checked and confirmed code statuses were not visible for CNAs on their kiosk. She brought this issue to upper management and had the issue resolved yesterday. She stated that she expected residents' code statuses to be determined on admission, that social services will obtain any DNR forms as applicable as well as obtaining resident wishes, and that nursing staff would then put the orders in the EMR for staff to see, which was where the staff should find a resident's code status. The DON further stated that if no code status was listed, or if the incorrect code status was listed, potential negative outcomes could be the resident's wishes would not be honored and unexpected deaths could occur without the potential to perform CPR. An interview with the Social Services Coordinator (SSC) on [DATE] at 10:45 am revealed she would talk to cognitive residents to see where their mental status was to see if they could understand code status preferences. She would ask what their preference wasf or code status and would provide education on it as needed. She did not require an answer for code status at the time, but she would verify if residents were a full code or DNR. If they have an advanced directive, she would request a copy. They would discuss in the quarterly meetings if there were any changes in code statuses or preferences. She stated that she or the Business Office Manager could scan and upload advance directives in the EMR. She cannot make the code status change in the EMR, only the nurses did that.

Based on observations, resident and staff interviews, record review and review of the facility's policy titled, Care Planning, the facility failed to implement the care plan for risk of falls for one of 34 residents sampled (R) (R17). This deficient practice had the potential to place the resident at risk of decreasing the resident's practicable physical, mental and psychological well-being.Findings include:Review of the facility's policy titled Care Planning dated 11/1/2019, documented under Policy: .D. Care Plan Reviews.1. The resident's comprehensive care plan will be reviewed, revised, and updated on a PRN basis, as determined by new and/or temporary resident condition changes that do not meet the significant change MDS criteria, yet require care plan updates per policy.Review of care plan for R17 dated 11/2/2020 revealed that staff are to assist R17 with toileting and stay in attendance during toileting as indicated. An additional review of the care plan revealed that staff are to respond promptly to all requests for assistance.During an observation of R17 on 8/13/2025 at 10:14 am, R17 was noted to be sitting on the toilet unattended with the emergency alarm sounding and flashing. R17 alerted her call light and was waiting for assistance. During this observation, it was noted that Licensed Practical Nurses (LPN) and Registered Nurses (RN) were sitting at the nursing station while R17 call light continued to alarm. Certified Nursing Assistants (CNA) BB and CNA CC attended the alarm at 10:16 am.Interview with MDS Coordinator EE on 8/13/2025 at 11:50 am revealed that some care plans were revised daily when changes occurred or when new information was received about a resident during team meetings. MDS Coordinator EE revealed that nursing staff and CNA staff could update a resident's care plan if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure that staff used proper infection control practices as evidenced by staff not performing appropriate hand hygiene between glove changes during catheter and perineal care for one of four residents (R) (R3) with catheters. The deficient practice had the potential to transfer pathogens and increase the risk of infection transmission for R3.Findings include:Review of the facility's policy titled titled Hand Hygiene with a revision date of 3/20/2024 revealed under Policy:.A. Hand Hygiene.1. Hand hygiene will be performed by washing hands with soap (anti-microbial) or using alcohol-based hand rub (ABHR) on hands. 2. Healthcare personnel (HCP) will perform hand hygiene with ABHR or soap and water for the following clinical indications that include but are not limited to after removing gloves or other personal protective equipment. Review of the electronic medical record (EMR) for R3 revealed that he was admitted to the facility with diagnoses that included but were not limited to osteomyelitis of ankle and foot, methicillin resistant staphylococcus aureus infection (MRSA), acute respiratory failure with hypoxia, traumatic hemorrhage of the cerebrum, and neuromuscular dysfunction of bladder.Review of the physician's orders revealed that there was an order for indwelling Foley catheter for diagnoses of neurogenic bladder.Review of the Minimum Data Set (MDS) assessment dated [DATE] a Brief Interview for Mental Status (BIMS) score of 13, which means that he is cognitively intact. Review of section H (Bladder and Bowel) revealed that he has an indwelling catheter.Review of the care plan for R3 revealed that he is at risk for a multi-drug-resistant organism (MDRO) related to the presence of a foley catheter and Enhanced Barrier precautions (EBP) were implemented for that risk.An observation of perineal and catheter care occurred on 8/14/2025 at 11:11 am. Certified Nursing Assistant (CNA) AA provided catheter and perineal care for R3. CNA AA removed a soiled pair of gloves after cleaning the resident's perineal area. Without performing hand hygiene, she then put on a new pair of gloves and continued care by wiping and then disposing of the soiled cleaning wipes. She then removed her gloves a second time and donned (put on) another pair without performing hand hygiene. She concluded the procedure by adjusting the resident's incontinence brief and completed care without any visible hand hygiene between glove changes.An interview on 8/14/2025 at 10:25 am with CNA AA confirmed that she did not perform hand hygiene between glove changes.An interview with the Director of Nursing (DON) on 8/14/2025 at 10:35 am revealed that it was her expectation that hand hygiene was performed between glove changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) forms were completed for one of three sampled residents (R) (R27). Findings included: A review of a facility-completed worksheet Beneficiary Notice-Residents discharged Within the Last Six Months, revealed that R27 was discharged from a Medicare-covered Part A stay, still had benefit days remaining, and remained in the facility after their last covered day. A review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form for R27 indicated that services were initiated on 12/15/2023 and discharged from Medicare Part A services on 2/23/2024, and she remained in the facility with Part A benefit days remaining. An Advance Beneficiary Notice of Noncoverage was (ABN) was not completed for R27. A review of the Notice of Medicare Non-Coverage (NOMNC) indicated the effective date coverage of your skilled nursing facility services will end 2/23/2024. The notice indicated the resident/representative has the right to appeal against this decision and explains how to ask for an immediate appeal. The form was signed by R27's representative. A review of R27's Part A Discharge Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview of Mental Status (BIMS) score of four, which indicates severe cognitive deficient. During an interview on 4/10/2024 at 3:35 pm, the Business Office Manager (BOM) revealed she receives the NOMNC and the ABN's from the Certified Case Manager (CCM) when a resident is discharged from Medicare Part A. She indicated she doesn't do the actual forms. During an interview on 4/10/2024 at 4:45 pm, the CCM revealed she reviews the residents need for a NOMNC when they are going to be discharged off Medicare Part A services. She completes the NOMNC and contacts the resident and/or the resident representative to see if they agree to discharge, if they need an appeal, and assists them with discharge planning. She indicated she has only been completing an ABN for residents coming off Medicare Part B services. She was unaware she needed to complete an ABN for residents coming off Part A and staying in the facility.

Based on observations, staff interviews, and record review of the facility's policy titled Food Receiving and Storage with revised date of 2/22/2024, the facility failed to label and date open food items stored in the freezer. The census was 85. Findings included: The facility's policy titled Food Receiving and Storage revealed, Food shall be received and stored in a manner that complies with food and safe food handling practices. The policy further documented that all foods stored in the refrigerator or freezer would be covered, labeled, and dated with a used by date. An initial observation of the kitchen on 4/9/2024 at 8:55 am revealed the following were opened and not dated or labeled: frozen cookie dough (120 pieces), fish patties (10 pieces), beef patties (40 pieces), hash brown (1/2 bag), and fries (1/2 bag). During an interview on 4/9/2024 at 8:50 am, the Certificate Food Manager (CFM) revealed that he has only been working in current position for a few months. He stated that he was aware that the open food items in the refrigerator needed to be labeled and dated but he did not know that open food items in the freezer needed to be labeled and dated as well. He confirmed that the items listed above were open and not dated or labeled in the freezer. During an interview on 4/9/2024 at 9:20 am, the Registered Dietitian confirmed that the food in the freezer should be labeled and dated after being opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy review, the facility failed to consult with the resident's physician to obtain treatment orders for one of 19 sampled residents (R)(R#33) related to newly identified skin breakdown Findings include: A review of the facility policy titled, Change of Condition, dated 1/1/19, revealed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of R#33's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident had no pressure ulcers/injuries but was at risk for the development of pressure ulcers/injuries. Review of R#33's Care Plan, dated 1/4/22, revealed the resident was at risk for pressure and/or diabetic ulcers related to decreased mobility, periods of incontinence, diabetes, periods of decreased motivation/staying in bed, recurrent moisture associated skin damage to the sacrum, and sitting in a recliner for extended periods of time. An intervention indicated staff were to report changes in skin status, including appearance, color, signs/symptoms of infection, and signs of skin breakdown. During an interview with R#33 on 5/9/22 at 9:08 a.m., the resident stated he/she had breaking out to his/her bottom that would not go away and hurt to sit on. During a follow-up interview on 5/10/22 at 9:22 a.m., R#33 stated the areas were bleeding a little this morning. R#33 indicated the areas were about dime-sized, with one area on each side of the resident's bottom. The resident was further interviewed at 12:28 p.m. and stated he/she had told several staff members in the last two weeks that his/her bottom was hurting. The resident was unable to name the staff that he/she told and stated that on one occasion, a staff member brought cream to put on the resident's bottom. During an interview on 5/10/22 at 12:18 p.m., Certified Nursing Assistant (CNA) KK revealed she believed last Tuesday (on 5/3/22) was the last time she assisted R#33 with a shower. She stated she was aware R#33 had redness to the bottom, but she had not noticed any open areas. During an interview on 5/10/22 at 10:00 a.m., Registered Nurse (RN) JJ, the wound care nurse, stated R#33 had skin issues in the past, but did not have any current skin problems. During an observation on 5/10/22 at 11:33 a.m., RN JJ assessed R#33's skin, which revealed an open area on each buttock, approximately dime sized. RN JJ indicated that these areas looked like they were caused from friction. During the skin assessment, R#33 stated the areas had been bothering him/her for approximately two weeks. During an interview on 5/11/22 at 10:24 a.m., RN JJ stated she notified Medical Director UU of the open areas to R#33's bottom while he was in the facility on 5/10/22. She stated she also treated the areas with a barrier cream to protect against friction. She stated the resident should have had an order to use the cream as needed; however, after reviewing the resident's physician orders, RN JJ stated the cream was discontinued on 3/22/22. Review of the Clinical Physician Orders revealed that prior to 5/11/22, R#33 did not have an order for a skin/wound treatment, nor any orders to treat the resident's bottom. A review of a Total Body Skin Assessment note dated 5/11/22 revealed the resident had one New Wound. However, review of R#33's medical record revealed no documented evidence R#33's physician was notified of the open areas to the buttocks. During an interview on 5/11/22 at 10:40 a.m., Medical Director UU revealed he was not in the facility on 5/10/22 and had not been notified that R#33 had open areas to the buttocks. During an interview on 5/11/22 at 11:10 a.m., RN JJ revealed that she apparently did not notify the physician and stated she dropped the ball. During an interview on 5/12/22 at 8:16 a.m., Licensed Practical Nurse (LPN) Unit Manager DD indicated the physician should be notified when a resident had any new skin condition or open areas. According to LPN DD, if the change in a resident's skin condition was not urgent, the physician should at least be notified during that shift, but if it was urgent, then immediate notification to the physician was expected. During an interview on 5/12/22 at 10:52 a.m., interim Director of Nursing (DON) BB revealed that a resident's physician should be notified any time there was a change in condition or an order was needed. DON BB stated that a new, open area of the skin should be reported to the physician. During an interview on 5/12/22 at 11:10 a.m., Administrator AA reported he expected staff to follow the facility policy for physician notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and review of the facility policy titled Physician Services, the facility failed to ensure staff followed physician orders for one of 19 sampled residents (R)(R#1) related to the application of thrombo-embolus deterrent (TED) stockings. Findings include: A review of the facility policy, Physician Services dated 1/1/19, revealed: It is the policy of the facility to provide Physician Services in accordance to [sic] State and Federal regulations. 6. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record. During an interview and observation on 5/9/22 at 11:16 a.m., R#1 stated he/she was supposed to wear TED hose for edema. R#1 was observed to have socks and tennis shoes on both feet but did not have on TED hose. The resident stated that he/she was told by staff the TED hose had gone to the laundry, and the hose had not been seen since then. During an observation and interview on 5/10/22 at 8:25 a.m. revealed R#1 had socks on both feet but did not have on TED hose. The resident stated it had been probably two weeks since the TED hose went missing. R#1 stated the TED hose were needed, noting foot swelling resulted from not wearing TED hose. During an observation on 5/10/22 at 10:16 a.m. and at 12:45 p.m., R#1 was observed sitting in a wheelchair and had socks and tennis shoes on both feet. The resident did not have on TED hose. A review of a Physician Order for R#1 included: Active with revision date 3/02/22, Apply TED hose in AM and take off in PM, every day-shift. A review of the R#1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had moderately impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Per the MDS, the resident required extensive assistance with dressing, including applying TED hose. During an interview on 5/11/22 at 1:55 p.m., Certified Nursing Assistant (CNA) EE revealed she was assigned to R#1 that day to assist the resident with personal care, to include bathing, personal hygiene, and dressing. She stated CNA care plans were located at the nurses' station to address the specific needs of a resident, but she had not looked at R#1's care plan and she was not aware R#1 had orders to wear TED hose. Licensed Practical Nurse (LPN) DD, Unit Manager, stated during an interview on 5/11/22 at 2:20 p.m. that care plans were on the electronic kiosk for CNAs to review and that staff should be reviewing the plans every shift. She stated after a physician wrote an order, the order would be entered on the medication administration record (MAR), which ensured the nurse monitored and documented that physician orders were being followed. LPN DD said after review of the order for R#1's TED hose, it was apparent the nurse did not forward the order onto the MAR. LPN DD stated the order needed be placed in the electronic MAR to verify nurses were monitoring that the TED hose were applied and removed as per physician orders. During an observation on 5/11/22 at 2:35 p.m., LPN DD found an empty plastic bag labeled with the resident's name, COVIDIEN T.E.D Anti-Embolism Stockings, and the resident's prescribed size dated 03/07/2022 in the resident's bedside drawer. An interview on 5/12/22 at 9:45 a.m. with Environmental Services Director (EVS) CC revealed her oversight responsibilities included the laundry department. She stated all resident clothing and TED hose should be transferred to the laundry before wearing. EVS CC stated laundry staff placed labels with resident's names in resident clothing and on TED hose. Therefore, when the items were worn by the resident and sent to the laundry for washing, clothing and TED hose were returned to the correct residents. She said the laundry had lost and found items containing unlabeled clothing, socks, and TED hose. EVS CC proceeded to pull out a laundry basket which she said were unlabeled socks and TED hose. No TED hose in the basket were R#1's size. An interview on 5/11/22 at 3:10 p.m. with the Director of Nursing (DON) indicated when a nurse received a physician order for TED hose, the order should be placed on the MAR. Per the DON, the MAR would then trigger a pop up in the morning for the nurse to verify the TED hose had been put on the resident. The DON noted that, in the evening, another trigger would pop up on the MAR to remind the nurse to verify the TED hose had been taken off. The DON explained that the nurse who took off the order made a mistake and should have made sure it was on the MAR for nursing staff to monitor. An interview with the Administrator on 5/11/22 at 3:20 p.m. revealed if a nurse received a new physician order for a treatment or medication, the new order needed to be placed in the appropriate document to ensure the nurses provided monitoring of the order. The Administrator stated physician orders should always be followed. The Administrator noted the nurse who took off the order for R#1's TED hose should have forwarded the order to the MAR to ensure monitoring of compliance with the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of a facility policy titled, Pain Management,, the facility failed to ensure one two residents (R) (R#66) of reviewed for pain received an effective pain management program. Specifically, the facility failed to administer R#66's pain medication in a timely manner and ensure orders for pain medications were initiated in a timely manner. Findings include: A review of the facility's policy titled, Pain Management, dated 1/1/19, indicated, Assessment and Recognition 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Treatment/Management: 1. With input from the resident to the extent possible, the provider and staff will establish goals of pain treatment. 2. The provider will order appropriate non-pharmacologic and medication interventions to address the individual's pain. 3. As appropriate, staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage and the opportunity to talk about chronic pain. A review of the admission Minimum Data Set (MDS) dated [DATE], indicated R#66 had no cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Per the MDS, the resident required limited assistance for personal hygiene and extensive assistance for bed mobility and toilet use. A further review of the MDS indicated R#66 had occasional pain in the five days prior to the assessment date, rated six out of 10 on a 0-10 scale where zero equaled no pain and ten equaled the worst possible pain. The MDS noted the resident received scheduled and as needed (pro re nata; PRN) pain medication but did not receive non-pharmacologic interventions for pain. A review of the Care Plan dated 4/29/22, indicated R#66 was at risk for pain related to muscle weakness, decreased mobility, pain, current pressure ulcers, lips sores/mouth pain, and other medical diagnoses. Interventions listed on the care plan included: -Assess for verbal and non-verbal indicators of pain. -Encourage rest, proper positioning to enhance pain relief. Provide adjuvant treatments as needed. Darken room, cool cloth/warm pack. -Give pain medications as ordered. -Notify physician of unrelieved pain. The Care Plan was revised on 5/11/22 to include the outbreak of mouth ulcers. A review of the April and May 2022 Physician Orders indicated R#66 had the following orders for pain management: -Hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams (mg) give one tablet by mouth every four hours PRN for pain ordered 4/15/22, which was changed to every four hours routinely on 5/10/22 (during the survey) and was to be held if the resident was asleep or sedated. -Tylenol 8-hour Arthritis Pain extended release (ER) 650 mg give one tablet by mouth one time a day for pain, ordered 4/15/22 and discontinued on 5/10/22. -Gabapentin (a medication prescribed for nerve pain) 300 mg give one capsule by mouth three times a day for leg pain re-ordered 5/10/22. -Icy Hot original pain relief cream 10-30% apply to the bilateral lower extremities (BLE) topically four times a day for pain ordered 5/10/22. -Valacyclovir (an antiviral used to treat herpes) 500 mg give one tab by mouth three times a day for herpes blisters for 10 days ordered 5/10/22. A review of the May 2022 Medication Administration Record (MAR) indicated R#66 received the Tylenol Arthritis 650 mg every day at 8:00 a.m. until it was discontinued on 5/10/22 and received the hydrocodone-acetaminophen 5-325 mg two to four times a day from 5/1/22 through 5/9/22 except on 5/2/22 (none administered) and 5/3/22 (administered one time). The resident's pain was rated from a zero to an eight. A review of the Controlled Drug Records for R#66's hydrocodone-acetaminophen 5-325 mg indicated the resident was receiving one tablet of the pain medication two to four times a day, including twice on 5/2/22 and twice on 5/3/22 (even though these doses were not signed off as being administered on the MAR). Observation and interview with R#66 in their room on 5/10/22 at 12:11 p.m. revealed the resident had a complaint of pain to their legs and mouth. The resident's lips and outer mouth were caked with dry, crusted blood. The resident stated staff were aware of the findings. During an interview on 5/10/22 at 12:35 p.m. with Licensed Practical Nurse (LPN) VV, he stated the hospice nurse had been at the facility that morning and ordered medications for the resident's oral pain because they had herpes blisters on their lips that they had been picking at and was causing them to bleed. LPN VV stated he had also received an order for Icy Hot to be used on the resident's legs. When LPN VV was told the resident was complaining of pain, he stated he had just applied the Icy Hot to the resident's legs. During an interview on 5/10/22 at 2:33 p.m. with Resident Care Coordinator (RCC) TT, an LPN, she stated she thought hospice had ordered a topical medication for R#66's lips. She stated she would have the medication nurse give the resident some pain medication after being told of the resident's continued complaints of pain at 2:31 p.m. A review of an Interdisciplinary Team [IDT] Note dated 5/10/22, written by RCC TT at 9:48 a.m. indicated R#66 was seen by the hospice nurse. The hospice physician was contacted related to the outbreak of herpes blisters to the resident's mouth and bleeding. The note indicated new orders were received and confirmed with the primary care physician. An observation of wound care being provided to R#66 on 5/10/22 at 2:36 p.m. by Registered Nurse (RN) JJ revealed the resident complained of increased pain to the left heel during wound care and afterwards. RN JJ did not stop wound care and offer the resident any type of pain relief prior to proceeding. She did not treat the resident's lips or mouth. An observation and interview with R#66 on 5/10/22 at 3:21 p.m. revealed R#66 continued to complain of pain to his/her lips and the left foot, with the pain rated an eight out of 10. A review of the May 2022 MAR revealed R#66 had not received any PRN pain medications on 5/10/22. Further review of the MAR revealed the assessment for pain done every shift indicated the resident rated their pain a 5. The Orders-Administration Note indicated the pain was to both legs and lips. During an interview on 5/10/22 at 3:23 p.m. with Registered Nurse (RN) JJ, after being told during wound care that R#66 continued to have complaints of pain to their legs and mouth, she stated she would get the medication nurse to give the resident pain medication. During an interview on 5/10/22 at 3:35 p.m. with the Administrator and the Director of Nursing (DON) after entering R#66's room, they stated they were not aware of the condition of R#66's lips/mouth. The DON stated she was going to have the nurse call hospice to get the resident's pain medication changed to routine. LPN VV entered the room at 3:43 p.m. and stated he was giving the resident pain medication at that time. This was almost an hour from when staff was made aware of the resident's pain. A review of the May 2022 MAR revealed no evidence that R#66 received any PRN pain medication on 5/10/22. However, according to the Controlled Drug Record for R#66's hydrocodone-acetaminophen, one tablet was signed out on 5/10/22 at 4:00 p.m. by LPN VV. A review of R#66s record revealed no evidence of any type of non-pharmacological interventions being attempted to relieve the resident's pain. A review of a Nurse's Note dated 5/10/22 with an effective time of 3:00 p.m. (the note was a late entry created at 4:35 p.m.) indicated that at 7:10 AM, R#66's hospice had been contacted due to the resident's lips being swollen with dried blood due to the resident picking at them. The note indicated the hospice nurse came, contacted the hospice physician, and new orders were received. The new orders were confirmed with the RCC and reviewed with the resident and family. The note indicated the resident had denied pain and had not requested any hydrocodone for pain prior, but after receiving wound care, the resident requested a PRN pain pill and was given hydrocodone-acetaminophen 5-325 mg at 4:00 p.m. The note indicated the resident did not want a stronger pain medication that would make them feel sedated but agreed to having the hydrocodone-acetaminophen scheduled so hospice was notified. A new order was obtained to increase the medication. A review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 5/11/22 indicated a hospice physician order dated 5/5/22 for gabapentin (a medication for nerve pain) 300 mg one tablet by mouth three times a day for leg pain. However, this order was not added to R#66's physician orders at the facility and was not being administered to the resident. The resident was admitted to hospice on 5/1/22. A review of a Hospice Physician Order dated 5/5/22 revealed an order for gabapentin 300 mg one capsule by mouth three times a day for leg pain. According to a fax confirmation, the facility received the order on 5/5/22 via fax at 4:51 p.m. from R#66's hospice agency. During an interview on 5/11/22 at 4:02 p.m. with RCC TT, she stated whenever she got a faxed order from hospice, she would get approval from the resident's primary care physician and then put the order into the electronic health record (EHR). She stated all the faxed orders were then given to the DON for review, then to medical records. She stated if she was not at the facility, the nurse on the medication cart should get the faxed order and follow through with it. At 4:28 p.m. the RCC TT stated she never received the order for R#66's gabapentin on 5/5/22 from hospice and was not aware the resident was supposed to start the medications. During an interview on 5/12/22 at 9:14 a.m. with a member of R#66's hospice company, she stated if the hospice nurse got a physician's order while at the facility, the nurse would write the order and the office would print it up and send it to the facility via fax. She stated they kept a log of all orders that were faxed out and obtained a verification report with each fax sent. She stated the hospice nurse that had been going to the facility had reported to the hospice office discrepancies when checking orders at the facility. At 9:34 a.m., the hospice office provided copies of the verification that the order for gabapentin was faxed to the facility on 5/5/22. During an interview on 5/12/22 at 9:45 a.m. with the hospice nurse (HN) YY, he stated whenever he received orders from the hospice physician when he was at the facility, he would usually give the medication nurse a verbal order and then fax it over later, noting there were times that he had to print orders, take them back to the facility, and ask the facility to initiate the order because they had not followed through with orders that were faxed. HN YY stated he had gotten a call from LPN VV at the facility on 5/10/22 about the outbreak to the resident's lips. He stated he saw the resident that morning. He reported he contacted the hospice physician, received new orders, and called them into the facility. He stated while he was there, he had the facility pull up a list of the resident's medications and noticed that the order for gabapentin from 5/5/22 was not on the list, so he put in another order for it. During an interview on 5/12/22 at 10:11 a.m. with LPN RR, she stated a resident's pain should be assessed every shift and PRN, noting a tolerable level of pain was whatever the resident stated it was at the time. LPN RR stated non-pharmacological interventions included repositioning and using an ice pack if needed. She stated these interventions should be documented in a progress note whenever they were attempted. LPN RR stated in R#66's case, he/she had multiple wounds. LPN RR stated she would just give the resident pain medication and would not even attempt any non-pharmacological interventions because the resident was getting repositioned several times a day with care anyway. She stated after giving a PRN pain medication, she would usually follow up with the resident 45 minutes to an hour later to see if it was effective. If the medication was not effective, she stated the physician should be notified to get further orders. LPN RR stated if a resident was on hospice and the hospice nurse wanted to start new orders, the hospice nurse would contact the hospice physician and then hospice would fax the orders to the facility. She stated the RCC would usually check the fax machine and take care of any orders that came over the fax. Per LPN RR, if the RCC was not available, then the charge (medication) nurse would take care of it. She stated once the faxed order was put into the EHR, she thought the order was given to medical records to upload into the resident's record. During a second interview on 5/12/22 at 10:23 a.m. with RCC TT, she stated a resident's pain should be assessed twice a shift and PRN and a tolerable level of pain was what the resident stated it was. She stated non-pharmacological interventions for pain included repositioning, ice, and heat, which should be tried before giving a pain medication and documented in a progress note. RCC TT stated once a PRN pain medication was given, the nurse should follow up in 45 minutes to an hour to determine if it was effective and, if it was not, then the nurse should contact the physician. RCC TT stated again that if she was not available, the medication nurses should be checking the fax machine to ensure no orders had come through. RCC TT explained she was to receive a text message whenever there was a new order. She stated again that anytime hospice gave an order, she had to verify it with the primary care physician and then it was put into the EHR. She stated the order from hospice for the gabapentin must have been misplaced. During an interview on 5/12/22 at 12:54 p.m. with the Director of Nursing (DON), she stated she was the Assistant Director of Nursing (ADON) but was the interim DON while the DON was on maternity leave and vacation. She stated a resident's pain should be monitored every shift and PRN. She stated a resident's tolerable level of pain should be documented on a pain assessment. She stated non-pharmacological interventions included repositioning and warm or cold compresses and the use of these interventions should be documented in a progress note. The DON stated once a PRN pain medication was administered, the nurse should reevaluate the effectiveness within the hour and contact the physician if it was ineffective. She stated when a resident was on hospice, they usually received new orders over the phone or the fax machine. She stated these orders had to be approved by the primary care physician and it was the responsibility of the RCC and the medication nurses to follow up with these orders. During an interview on 5/12/22 at 2:43 p.m. with the Administrator, he stated a resident's pain should be managed in a timely manner.

Based on observations and interviews, the facility failed to ensure a homelike environment for five of 19 sampled residents (R) (R#34, R#36, R#50, R#59, and R#68) related to receiving meals from the kitchen on Styrofoam takeout containers and plastic utensils. Findings include: Observations on 5/9/22 at 1:05 p.m. of the meal service on the first-floor revealed residents were served their lunch in Styrofoam takeout containers with plastic utensils. During an interview on 5/9/22 at 10:06 a.m., R#59 stated that all meals were served in Styrofoam takeout containers with plastic utensils. The resident stated it would be much nicer to eat off a plate with real silverware. During an interview on 5/9/22 at 10:43 a.m., R#34 said the food was always cold because it was served on Styrofoam plates. During an interview on 5/9/22 at 1:30 p.m., R#68 revealed the facility had been serving meals in Styrofoam takeout containers for a long time. The resident said the plastic utensils and Styrofoam made it hard to deal with and cut food. During a Resident Council group interview on 5/11/22 at 10:54 a.m., R#36, who had intact cognition per a Brief Interview for Mental Status (BIMS) score of 15, and R#50, who had intact cognition per a BIMS score of 14, revealed they had been served meals in the Styrofoam takeout containers and using plastic utensils for a while. R#36 and R#50 stated they would prefer real plates for their meals. During an interview on 5/9/22 at 9:15 a.m., Dietary Aide (DA) WW stated that most resident food was served in Styrofoam takeout containers and with plastic utensils because there was not enough dietary staff in the facility to wash all the dishes from the meals. During an interview on 5/9/22 at 1:06 p.m., Certified Nurse Aide (CNA) ZZ stated the facility had originally started serving meals on Styrofoam during COVID-19 outbreaks, but they had been currently serving the meals on the Styrofoam because there were not enough staff to wash all the dishes from each meal. During an interview on 5/10/22 at 9:44 a.m., CNA KK stated the facility had been utilizing the Styrofoam takeout containers since the COVID-19 pandemic started. She said she had heard residents complaining about having to use plastic utensils. During an interview on 5/12/22 at 9:36 a.m. with the Administrator, he said the residents had been served using Styrofoam takeout containers with plastic utensils for a couple of months. He said the facility should be providing a homelike environment by serving the residents on plates with silverware. On 5/12/22 at 9:49 a.m., with the Director of Nursing (DON) a homelike environment policy was requested. An interview with the DON revealed the facility did not have a policy regarding a homelike environment that related to meal service. During an interview on 5/12/22 at 9:50 a.m. with Interim Director of Nursing (DON) BB, she said the facility had been using Styrofoam for a lengthy amount of time and it was not homelike for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of R#65's Quarterly MDS assessment dated [DATE], revealed the resident had a BIMS score of 11, which indicated moderately impaired cognition. The MDS revealed the resident was totally dependent on staff for personal hygiene (included shaving). According to the MDS, bathing did not occur during the assessment period (seven days). A review of R#65's care plan, dated 2/18/22, revealed the resident was at risk for a decline in ADLs. The facility developed interventions that included encouraging the resident to participate in ADL care and providing assistance as indicated with grooming and bathing. On 5/9/22 at 10:15 a.m., R#65 was observed lying in bed. R#65 appeared unkempt and unshaven. An interview with R#65 at that time revealed the resident thought it had been several days since the resident had received a shower. On 5/10/22 at 2:46 p.m., R#65 was again observed unshaven. A review of R#65's ADL-Bathing-Shower Schedule in the Electronic Medical Record (EMR) revealed the resident was totally dependent on staff for bathing/showers. According to the ADL-Bathing-Shower Schedule, R#65 received a shower on 4/7/22 and 5/7/22. Per the review, Not Applicable was checked on the schedule eight times from 4/9/22 through 5/7/22. According to the ADL-Personal Hygiene record, staff last provided personal hygiene for the resident on 5/7/22. During an interview on 5/10/22 at 2:50 p.m., CNA KK revealed R#65 did not refuse personal hygiene or bathing. During an interview on 5/11/22 at 2:39 p.m., CNA KK, who was the lead CNA on the hall where R#65 resided, stated she normally shaved R#65 on Tuesdays, but did not have time to shave the resident this past Tuesday (5/10/22). According to CNA KK, staff documented Not Applicable when they were not able to complete a task. During an interview with the Unit Manager LPN DD on 5/11/22 at 3:04 p.m., she stated when the facility admitted a resident, the admitting nurse should enter the resident's shower schedule in the EMR. Once entered, the task should pop up and alert staff when a bath/shower and personal hygiene was required. She stated R#65 should receive a shower/bath at least three times per week and the EMR should show that the resident required a shower on Tuesdays, Thursdays, and Saturdays. Upon review of the ADL-Bathing-Shower Schedule in the EMR, LPN DD identified that R#65's bath/shower was scheduled as needed and was not scheduled three times a week as required. As a result, the EMR was not alerting staff when bathing and personal hygiene care was to be provided. According to LPN DD, she did not monitor to ensure showers were completed. She stated unless she specifically looked at the EMR shower record, she would not know showers were not completed. During an interview on 5/12/22 at 4:15 p.m., the Interim Director of Nursing (DON) BB stated that the Unit Manager and other staff (not sure which staff) should initiate ADL tasks in the residents' EMRs. She stated the standard shower schedule was three times per week, but showers should also be provided per resident preference and as needed. According to DON BB, R#65 should receive a shower/bath three times a week and as requested. DON BB indicated residents should be shaved as often as needed but for sure on shower/bath days. DON BB reported her expectation was for residents to be clean and for bathing/shaving to be completed as scheduled. During an interview on 5/12/22 at 8:52 a.m. Administrator AA reported the expectation was for staff to follow facility policies and procedures. Based on observations, interview, record review, and review of the facility policy titled ADL Policy, the facility failed to provide Activities of Daily Living (ADL) care for three of five sampled residents (R)(R#47, R#48, and R#65) related to shaving, bathing, and fingernail care. Findings include: A review of a facility policy titled ADL Policy dated 1/1/19, revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). 1. A review of R#47's admission Record indicated the facility admitted R#47 with diagnoses including chronic diastolic (congestive) heart failure, Alzheimer's disease, and muscle weakness. A review of R#47's care plan, dated 1/14/22, revealed R#47 was at risk for ongoing changes, fluctuations, and a decline in ADLs related to muscle weakness and decreased mobility. The care plan interventions included to encourage the resident to participate in ADL care and to provide assistance as indicated (such as nail care, grooming bathing, dressing, eating, locomotion, transfers, toileting and oral hygiene). A review of R#47's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Further review of the MDS assessment revealed the resident required physical help in part of the bathing activity. A review of R#47's Documentation Survey Report V2, which documented ADLs provided, dated March 2022, April 2022, and May 2022, revealed 30 opportunities for scheduled showers from 3/1/22 to 5/9/2022. There were seven scheduled showers documented as completed in March 2022 with two showers documented on 3/1/22 and two on 3/15/22. The section titled Bathing Shower Schedule PRN [as needed] had documentation of 10 as-needed showers provided between 3/6/22 and 5/7/22. However, there were no scheduled showers documented after 3/15/22 in March 2022 and no scheduled showers documented as completed in April 2022 or May 2022. During an interview on 5/9/22 at 11:15 a.m., R#47 stated he/she had not had a shower in a week. During an interview on 5/10/22 at 12:41 p.m., R#47 stated he/she would like to get their showers every other day as scheduled. R#47 stated the facility did not have enough staff to provide bathing. R#47 stated, I begin to stink after a while. R#47 stated getting a bath made him/her feel better. During an interview on 5/10/22 at 11:00 a.m., Certified Nursing Assistant (CNA) FF stated the facility scheduled bathing for residents in A beds on Mondays, Wednesdays, and Fridays and residents in B on Tuesdays, Thursdays, and Saturdays. CNA FF stated the facility was understaffed and bathing needs were delayed. CNA FF stated bathing was documented in the resident's chart under ADLs. During an interview on 5/10/22 at 3:41 p.m., CNA QQ stated the shower aide quit about two weeks ago, which left the facility without a shower aide. CNA QQ stated the facility was understaffed and that showers and bathing sometimes would not get done. During an interview on 5/10/22 at 3:46 p.m., Licensed Practical Nurse (LPN) PP stated CNAs provided bathing and should document bathing in a resident's chart. LPN PP stated if a resident refused their showers, the staff should document the refusal and let the nurse know. During an interview on 5/11/22 at 7:07 a.m., LPN DD stated R#47 had a bath the previous day because the resident requested it before going to see a physician. LPN DD stated that, prior to yesterday, she did not know when bathing was last provided for R#47. LPN DD stated the last time bathing was documented for R#47 was on 4/25/22. During an interview on 5/11/22 at 7:10 a.m., CNA KK stated R#47 was not provided his/her bath/shower on Monday (5/9/22). CNA KK stated the resident wanted their shower at 8:00 a.m. CNA KK stated there was no way she could provide the shower at 8:00 a.m. because she was working by herself. CNA KK stated she did not feel like the facility had enough staff to provide bathing and confirmed that R#47 did not refuse showers. During an interview on 5/12/22 at 7:55 a.m., Interim Director of Nursing (DON) BB stated the expectation for staff was to follow the shower schedule. DON BB stated if a resident requested a bath, they should get a bath. DON BB stated she understood the documentation did not show R#47 was provided bathing. During an interview on 5/12/22 at 8:00 a.m., the Administrator stated bathing should be provided by staff according to the facility policy. The Administrator stated he would speak to staff about bathing documentation. 3. A record review revealed R#48's diagnoses included transient ischemic attack (TIA) and vascular dementia with behavioral disturbance. A review of a Significant Change MDS assessment, dated 4/6/22, revealed R#48's BIMS score was five, indicating severely impaired cognition. Per the assessment, the resident had verbal behavioral symptoms directed towards others which significantly interfered with the resident's care. The MDS noted R#48 required extensive assistance with dressing and hygiene, including combing hair, brushing teeth, and shaving. Additionally, the resident required physical help in part of the bathing activity. A review of a care plan, revised 4/14/22, indicated R#48 was at risk for ongoing unavoidable decline and fluctuations in ADL care related to muscle weakness, decreased mobility, potential medication side effects, TIA diagnosis, dementia with anticipated decline over time, rejection of care and meals at times, denial of care needs such as incontinence care, overall decline, and admission to hospice. Interventions included to encourage participation in ADL care and provide assistance as indicated (such as nail care, grooming, bathing, dressing, eating, locomotion, transfers, toileting, oral hygiene), to honor wishes for schedules such as naps/activity, and to encourage participation to the highest level possible. The care plan indicated R#48 was resistive to care and/or became agitated or combative. The interventions included If resists with ADLs, reassure, ensure safety, leave and return later to try again. A review of March 2022 through May 2022 Documentation Survey Report v2 documents revealed R#48 was scheduled to receive 30 showers between 3/1/22 and 5/9/22. However, the documentation indicated R48 only received five of the 30 scheduled showers. Further review of the documentation revealed the resident refused a total of four showers between 3/1/22 and 5/9/22. On 5/9/22 at 10:34 a.m., R#48 was observed sitting in a wheelchair in a common area near the nursing desk. R#48 was unshaven and had a moderate amount of facial hair. The resident stated, I need to shave. R#48's fingernails were observed to be long and jagged with a brown substance under the nails. On 5/10/22 at 9:46 a.m., R#48 was observed up in a wheelchair in a hallway. The resident was unshaven and had long, jagged nails with a brown substance under the nails. On 5/10/22 at 10:35 a.m., during an interview, Certified Nurse Aide (CNA) QQ stated the facility had a schedule for resident showers. CNA QQ stated R#48 usually received a shower. CNA QQ stated R#48 received hospice services and hospice staff would shower/bath R#48 if they got to the facility before the facility staff assisted R#48 with a shower/bath. CNA QQ stated hospice staff would report to the nurse what services were provided for the resident, and facility staff would document those services. CNA QQ stated assistance with shaving and nail care was provided while the resident was in the shower. CNA QQ then reported the facility sometimes had a shower team, but not always and CNAs who worked the floor usually did about 75 percent (%) of the showers. CNA QQ reported having 19 residents to care for that day with the help of a CNA in training who could not assist with transfers. CNA QQ reported they did their best to get resident showers completed in a 12-hour shift. Per CNA QQ, the facility used to have two CNAs on 500 and 600 Halls, one on 400, and two on the shower team, but that level of staffing had not happened in a while. CNA QQ stated today they had one CNA on 500 Hall, one CNA on 600 Hall, and one CNA on the 400 Hall. During an interview on 5/10/22 at 11:09 a.m., Registered Nurse (RN) CCC stated the documentation for R#48's shower/bath indicated R#48 had been shower/bathed on Saturday, 5/7/22. RN CCC reported she worked the day shift on 5/7/22 and had received in report that R#48 had been showered on the previous night shift. RN CCC reported staff usually did shaving and nails during showers. After looking at R#48, RN CCC stated the resident was probably not shaved and had not received nail care during the shower on 5/7/22. RN CCC reported R#48 needed nail care and shaving services. During an interview on 5/10/22 at 11:58 a.m., the Interim Director of Nursing (RN BB) stated the expectation was for staff to provide nail care and to shave residents during showers. On 5/10/22 at 12:19 p.m., Licensed Practical Nurse (LPN) DDD, a nurse with the resident's hospice agency, was interviewed. LPN DDD stated hospice did not provide CNA services for skilled facilities and did not provide CNA or ADL services for R#48. On 5/10/22 at 2:54 p.m., CNA QQ was shown the shower/bath sheets for R#48. CNA QQ stated if NA was documented on the shower sheet it meant the shower was not done. CNA QQ reported R#48 had received a bed bath that day (5/10/22). CNA QQ stated it was not the resident's scheduled day for a bath/shower, but it had been completed due to [R#48] looked so bad. CNA QQ reported R#48 had been shaved. CNA QQ reported R#48's fingernails were so thick the CNA might have to have the nurses cut the fingernails. On 5/10/22 at 3:00 p.m., LPN DD, Unit Manager, was interviewed. LPN DD stated if staff documented RR on the shower/bath ADL sheets, this meant the resident refused. LPN DD stated if a resident refused a shower/bath or ADL care, then staff were to re-attempt to provide care later or to get another staff to attempt care. LPN DD also stated R#48 was sometimes combative and refused care, was very hard of hearing, and had vision problems which made communication challenging. LPN DD stated NA on the shower/bath documentation meant the shower/bath was not completed on that shift. LPN DD reviewed R#48's shower/bath documentation and stated R#48 had received three showers in the month of March 2022, one shower in April 2022, and one shower in May 2022. LPN DD noted the facility policy called for residents to be bathed/showered three times a week, stating nurses should be checking in Point Click Care (PCC) to make sure bathing services were completed. LPN DD stated if a bath/shower was missed, it should be picked up by the end of the next day, noting shower/baths were given occasionally on night shift if they were missed. During an interview on 5/10/22 at 3:25 p.m., CNA KK stated she was assigned to care for 20 residents by herself that day. The CNA stated bath/showers were scheduled for residents residing in B beds that day, and CNA KK had not been able to be get showers done. CNA KK reported she had worked by herself quite often on Mondays, Tuesdays, and Wednesdays, noting it had been bad lately. CNA KK stated she did the best she could to complete resident showers, stating the unit manager was aware there was no shower team. During an interview on 5/10/22 at 3:30 p.m., CNA FF stated she usually worked the 500 Hall with one or two CNAs. If there was only one CNA on the 500 hall, CNA FF stated she first showered residents who had showers in their rooms. CNA FF stated when working alone, she was unable to get all the residents showers/baths completed. On 5/12/22 at 9:17 a.m., the Interim DON (RN BB) and the Administrator were interviewed. The Interim DON reported the unit manager should be monitoring resident care. They both reported they expected facility policies and procedures to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of facility policies titled, Skin Breakdown Prevention, Skin Integrity-Overview, and Skin, Wound and Pressure Ulcer Treatment-Overview, the facility failed to ensure treatment and services for prevention and management of pressure ulcers were provided in accordance with accepted standards of practice for three of four sampled residents (R) (R#33, R#65, and R#66) reviewed for pressure ulcers. Findings include: Review of the facility's policy titled, Skin Breakdown Prevention, dated 3/1/20, revealed the purpose of the policy was, To put measures in place to prevent residents from developing wounds/pressure ulcers, unless clinically unavoidable. According to the policy, The facility will utilize clinical information to determine appropriate and resident specific skin breakdown prevention measures needed. These may include, but not be limited to: Clinical assessments (admission/readmission assessments, MDS [Minimum Data Set], skin assessments and Braden Score). Review of the facility's policy titled, Skin Integrity-Overview, dated 3/1/20, revealed, 1. The facility will provide skin care and treatments consistent with professional standards of practice, to prevent resident wounds/pressure ulcers, unless the resident's clinical condition demonstrates that the wounds/pressure ulcers were clinically unavoidable. 2. The facility will provide skin care and treatments consistent with professional standards of practice, to a resident who has wounds/pressure ulcers, to promote healing, prevent infection and prevent new wound/pressure ulcers from developing, unless clinically unavoidable. 2. The facility will provide skin care and treatments consistent with professional standards of practice, to a resident who has wounds/pressure ulcers, to promote healing, prevent infection and prevent new wounds/pressure ulcers from developing, unless clinically unavoidable. 3. The facility's skin integrity program will consist of the following: - Assessment of each resident's skin integrity - Providing skin-breakdown prevention care and skin care treatments consistent with professional standards of practice - Accurately documenting skin concerns, care and treatments - Ongoing monitoring of resident's skin integrity and timely reporting of skin issues and concerns - Providing skin integrity education to residents, families and staff. Review of the facility's policy titled, Skin, Wound and Pressure Ulcer Treatment-Overview, dated 3/1/20, revealed, 1. The facility will implement skin, wound and pressure ulcer treatments that require a physician's order and those that may not require a physician's order, but determined by the resident's clinical information and care plan, as necessary to support and promote healing. 2. The facility will implement the following skin, wound and pressure ulcer treatments, as ordered by a physician, to promote healing: - Application and changes of wound dressings - Application of topical creams and lotions - Therapy services necessary to promote healing - Lymphedema management - Additional nutritional and hydration measures not included in current diet orders -Specialty devices and support surfaces that are paid under Part-B and or a third party and require a physician's order for payment. 3. The facility will implement the following skin, wound and pressure ulcer treatments, that do not require a physician's order, but determined by the facility as necessary to promote healing: - Topical barrier creams and moisturizers - Positioning devices and support surfaces that are not paid by Part-B or a third party - Incontinent briefs. 4. Application of treatments will follow professional standards of practice of wound care and infection control, as outlined in the Lippincott Manual of Nursing Practice. 1. Review of R#65's admission Record revealed the facility admitted the resident on 11/24/21 and readmitted the resident on 1/31/22 from an acute care hospital. The resident had diagnoses including osteomyelitis (an infection in the bone caused by bacteria or fungi) of vertebra - sacral and sacrococcygeal region (areas at the base of the spine) and pressure ulcer of unspecified site, stage four. Review of the admission Minimum Data Set (MDS), dated [DATE], and the admission/re-entry MDS dated [DATE], R#65 had a stage four pressure ulcer present on admission. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#65 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The MDS indicated the resident required extensive assistance of two or more people for bed mobility, transfers, dressing, and toilet use. The resident was at risk for pressure ulcers/injuries and had one stage four pressure ulcer that was present upon admission or reentry to the facility. According to the MDS, the resident had a pressure reducing device for the bed and was receiving pressure ulcer/injury care. Review of the Care Plan, dated 2/18/22, revealed R#65 was at risk for complications and delayed/non-healing of a stage four pressure ulcer to the sacrum and was at risk for further pressure ulcers due to declining health status and the presence of a long-term (years) stage four wound. Interventions included administering treatments as ordered and monitoring for effectiveness; avoiding positioning the resident on the sacrum; and reporting improvements and declines to the physician. Review of the wound and hyperbaric center's Progress Note Details, dated 4/4/22, revealed that since the last wound clinic visit, the resident had been hospitalized for a urinary tract infection. The note indicated the resident's family member reported the resident had a recent change in stool consistency (intermittent loose and semi-formed stools); that the wound often got contaminated; and that dressing adherence had been an issue. The wound assessment described the sacral wound as a chronic stage 4 pressure injury measuring 1.5 centimeters (cm) long, by 1 cm wide, by 2 cm deep. The wound bed was one to 25% slough with no granulation, eschar or epithelialization present. A review of the Clinical Physician Orders revealed R#65 had an order dated 4/22/22 to clean the wound with normal saline, apply skin prep to the peri-wound area, pack the wound loosely with calcium alginate AG (silver), and cover the wound with a hydrocolloid dressing. The treatment was to be provided every Monday, Wednesday, and Friday on day shift. Review of the wound and hyperbaric center's Progress Note Details and the Discharge Instructions Details, dated 5/2/22, indicated R#65's sacral wound measurements were 1 cm long, by 2 cm wide, by 2 cm deep, and that there had been no change noted in the wound progression. The treatment orders were as follows: Cleanse peri-wound with soap and water. Cleanse wound with normal saline. Apply Triad to peri-wound. Apply Triad impregnated gauze to wound bed. Cover with ABD (abdominal) pad, and secure with Medipore tape. Change dressing three times weekly and as needed for soilage or slippage. Further review of the Progress Note Details revealed the treatment plan included keeping weight off of the affected area and using a mattress overlay/specialty bed or mattress; however, the order for a mattress overlay or specialty mattress was not included on the Discharge Instructions Details. Observations on 5/10/22 at 4:35 p.m. revealed Certified Nursing Assistant (CNA) KK providing incontinent care to R#65. The resident did not have a dressing in place to the wound on the sacrum. CNA KK stated they had a hard time keeping the dressing in place due to the resident's bowel incontinence. During an interview at 4:45 p.m., CNA KK was asked how long the wound had been without a dressing. She stated she knew there was no dressing in place on the wound today or yesterday. She stated sometimes the nurses did not put a top dressing on, because the resident was incontinent, and the dressing got soiled and was hard to keep in place. Observations on 5/11/22 at 10:08 a.m. revealed Registered Nurse (RN) JJ, the wound care nurse, providing the pressure ulcer treatment to R#65's sacral wound. Based on the surveyor's observations, the wound had not increased in size or deteriorated since the most recent assessment at the wound clinic. During an interview on 5/11/22 at 11:11 a.m., RN JJ revealed it was challenging to keep R#65's dressing in place. RN JJ stated a specialty mattress had not been ordered for R#65. During further interview on 5/12/22 at 12:05 p.m., RN JJ revealed she had received the discharge orders (Discharge Instructions Details dated 5/2/22) but had not seen the Progress Note Details from that date and was not aware the wound care physician had ordered a specialty mattress. She stated she was unsure of the process for receiving the Progress Note Details. She stated she was aware when residents went to the wound clinic and watched for orders but had not been as concerned about the progress notes. At 12:06 p.m., RN JJ stated if a dressing came off or a staff member noticed a wound without a dressing, the nurse on the hall should replace the dressing. During an interview on 5/12/22 at 10:02 a.m., CNA HHH stated if she noticed a wound dressing was missing, she would tell the nurse. During an interview on 5/12/22 at 10:23 a.m., Resident Care Coordinator (RCC) TT stated if a wound dressing was not on a wound, the nurse should check the order and replace the dressing. During an interview on 5/12/22 at 12:54 p.m., interim Director of Nursing (DON) BB stated physician orders for pressure ulcer treatments should be followed and the wound should not be left uncovered. She stated if a dressing was not in place, the nurse should check the orders and replace it right away. DON BB reported the wound clinic orders were faxed the same or next day after the resident's appointment. She stated it could be a week before the facility received the progress notes. She stated documents from the wound clinic were placed on the treatment cart for staff to address. DON BB reported her expectations were for wounds to be treated per policy and consistently. 2. Review of R#33's admission Record revealed the resident had diagnoses including type 2 diabetes mellitus without complications and chronic diastolic heart failure. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was occasionally incontinent of bowel and bladder. The resident had no pressure ulcers/injuries but was at risk for the development of pressure ulcers/injuries and had pressure reducing devices for the bed and chair. Review of the Care Plan, dated 1/4/22, revealed R#33 was at risk for pressure and/or diabetic ulcers related to decreased mobility, periods of incontinence, diabetes, periods of decreased motivation/staying in bed, recurrent moisture associated skin damage to the sacrum, and sitting in a recliner for extended periods of time. Interventions included: - Report any changes in skin status: appearance, color, signs/symptoms of infection, signs of skin breakdown and treat per protocol/as ordered if noted. - Pressure reduction mattress and wheelchair cushion. Use positioning devices such as pillows as needed. Heel protection as indicated. During an interview on 5/9/22 at 9:08 a.m., R#33 revealed he/she had a skin issue/rash to his/her bottom that would not go away. The resident stated this hurt to sit on. During further interview on 5/10/22 at 9:22 a.m., R#33 stated the areas were dime-sized areas on each side of the resident's bottom. R#33 stated nursing staff did not assess the resident's skin. During an interview on 5/10/22 at 10:00 a.m., Registered Nurse (RN) JJ, the wound care nurse, indicated R#33 did not have any current skin conditions. RN JJ stated skin assessments were conducted weekly by RN JJ and/or the nurses assigned to the resident's care; however, on 5/10/22 when the surveyor reviewed the Skin and Wound-Total Body Assessments in the resident's electronic medical record, the most recent weekly skin assessment for R#33 was dated 1/25/22 (approximately four and one-half months prior to the survey). On 5/10/22 at 11:33 a.m., the surveyor observed RN JJ conducting a skin assessment for R#33. There was an approximately dime-sized, open area on each buttock. RN JJ indicated the areas looked like they were due to friction. During the skin assessment, R#33 stated the areas had been bothering him/her for approximately two weeks. On 5/11/22, the surveyor again reviewed the Skin and Wound-Total Body Assessments in R#33's electronic medical record, which revealed no documentation of the skin assessment RN JJ completed on 5/10/22. During an interview on 5/11/22 at 10:24 a.m., RN JJ reported she would call the open areas to R#33's buttocks a wound. She indicated she failed to document the assessment completed on 5/10/22 at 11:33 a.m. She reported that she also failed to obtain an order from the physician and document the treatment she had applied to the open areas. During an interview on 5/10/22 at 11:45 a.m., Licensed Practical Nurse (LPN) Unit Manager DD reported skin assessments should be completed for all residents weekly. LPN DD confirmed the last documented skin audit completed for R#33 was on 1/25/22. According to LPN DD, the facility was not able to complete skin assessments weekly due to due to staff turnover and the use of agency nurses. During an interview with LPN NN, an agency contract nurse, on 5/11/22 at 11:31 a.m., LPN NN did not know how often skin assessments were completed for the facility's residents. During an interview on 5/12/22 at 12:54 p.m., interim Director of Nursing (DON) BB revealed her expectation was for the facility's policies to be followed and skin assessments to be completed weekly.3. A review of the admission Record indicated the facility admitted R#66 on 4/15/22 with diagnoses which included Parkinson's disease, acute and chronic kidney disease, and monoclonal gammopathy (the presence of an abnormal protein in the blood that may cause rash). A review of the admission Minimum Data Set (MDS), dated [DATE], indicated R#66 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident required limited assistance of two or more people for personal hygiene and extensive assistance of two or more people for bed mobility and toilet use. The MDS indicated R#66 was occasionally incontinent of urine and always incontinent of bowel and was at risk of developing pressure ulcers/injuries. The MDS also revealed R#66 had one or more unhealed pressure ulcers/injuries, including one stage three pressure ulcer, one stage 4 pressure ulcer, and four unstageable pressure injuries that presented as deep tissue injuries, all of which were present upon admission. The MDS indicated the resident had a pressure-reducing device for the chair and bed and was receiving pressure ulcer/injury care. A review of the admission Note, dated 4/15/22, indicated R#66 had Allevyn (absorbent) dressings to both heels and ankles, right shoulder blade area, and sacrum due to skin breakdown. The note indicated the dressings were not removed for the assessment. A further review of the note indicated R#66 had redness to the skin at the perineum (the skin between the anus and the genitals). A review of the admission Skin Evaluation, dated 4/15/22, indicated R#66 had dressings present to the right heel, left heel, right scapula, and sacrum and had excoriation of the perineum. The evaluation indicated the interventions that were initiated included a pressure reduction mattress and turning/repositioning. There was no documentation to indicate the physician was contacted for wound treatment orders and no documentation the dressings were removed to allow assessment and measurement of the wounds. Review of the resident's medical record revealed no documentation of assessments of the wounds until 4/19/22, four days after admission. A review of the Skin and Wound Evaluations, dated 4/19/22, revealed the following wound assessments: -A deep tissue injury (DTI) to the coccyx measured 1.6 centimeters (cm) by 1.2 cm. The wound bed was 100% eschar. There was no exudate (drainage), and the peri-wound appeared flush with the wound bed. -A stage 3 pressure ulcer to the right ischial tuberosity measured 2.6 cm by 2.1 cm. A description the wound bed, peri-wound, and exudate was not provided. -A DTI to the left ischial tuberosity measured 3.3 cm by 1.8 cm. There was no documentation of the appearance of the wound bed, the peri-wound, or exudate. -A stage 4 to the left lower back measured 6.2 cm by 4.6 cm. The wound bed was 90% eschar. There was light serosanguineous exudate, and the edges of the wound appeared flush with the wound bed. -A DTI to the right heel measured 3.8 cm by 1.8 cm. There was no documentation of the appearance of the wound bed, exudate, or peri-wound. -A DTI to the left heel measured 2.4 cm by 3.9 cm. There was no documentation of a description of the wound bed, exudate, or peri-wound. There was no documentation to indicate what orders or treatments were in place for each wound at the time of this assessment, and there was no documentation of the physician being notified of the wounds on 4/19/22. During the survey, the surveyor requested a copy of this evaluation from the facility on two occasions but did not receive the requested copy as of the survey exit date. A review of the comprehensive care plan, last revised 5/2/22, indicated R#66 was at risk for additional pressure ulcers and infection to current skin breakdown and ulceration. Interventions included: -Assess risks as indicated. -Heel protection. -Observe for and report signs of pressure ulcer development. -Perineal care after incontinent episodes. -Pressure reduction/redistribution mattress and wheelchair cushion. -Reposition using a lift sheet if needed. -Turn and reposition frequently (encourage compliance if returning to prior position after turning). -Utilize positioning devices as needed. A review of the Physician Orders indicated R#66 had no treatment/wound care orders put in place until 4/20/22, five days after being admitted to the facility. The following wound orders were initiated on 4/20/22: -Active liquid protein two times a day for wound care, add to juice. -Clean pressure ulcer (PU) to left posterior rib area with normal saline (NS). Cover with foam dressing every day shift every 3 days for wound care and as needed. -Clean PU to coccyx with NS. Cover with foam dressing every day shift every 3 days for wound care and as needed. -Clean PU to right ischial with NS. Cover with foam dressing every day shift every 3 days for wound care and as needed. -Clean PU to left ischial with NS. Cover with foam dressing every day shift every 3 days for wound care and as needed. -Apply Iodine to DTI on right heel every dayshift for wound care. -Apply Iodine to DTI on left heel every dayshift for wound care. A review of the April 2022 and May 2022 Treatment Administration Records (TARs) revealed the order for treatment to the left posterior rib area was not transcribed onto the TAR and the treatment was not documented as being completed as ordered by the physician. A review of the Skin and Wound Evaluations, dated 4/25/22, revealed R#66 had the following wounds: -A deep tissue injury (DTI) to the coccyx that measured 1.9 cm by 0.8 cm. There was no documentation of a description of the wound bed and peri-wound, whether exudate was present, or the progress of the wound. -A stage 3 pressure ulcer to the right ischial tuberosity that measured 2.0 cm by 2.4 cm by 0.1 cm. The wound bed was 90% epithelial tissue and 10% granulation tissue, with the skin to the peri-wound attached. Three was no documentation as to whether exudate was present or of the progress of the wound. -A DTI to the left ischial tuberosity that measured 2.2 cm by 1.9 cm with no exudate present. There was no documentation of the appearance of the wound bed, the peri-wound, or the progress of the wound. -A stage 4 to the left lower back that measured 4.5 cm by 5.6 cm with 80% eschar and 20% granulation tissue. There was no documentation of the peri-wound, if exudate was present, or the progress of the wound. -A DTI to the right heel that measured 1.8 cm by 1.6 cm with 100% eschar. -A DTI to the left heel that measured 2.9 cm by 3.1 cm. There was no documentation of the wound bed, exudate, peri-wound, or progress of the wound. There was no documentation to indicate what orders or treatments were in place for each wound, and there was no documentation the physician was notified of the status of the wounds. A review of the record revealed no further documentation of assessments of any of the wounds from 4/25/22 until 5/11/22. A review of the May 2022 TAR revealed no documentation of R#66 receiving wound care as ordered by the physician to the left and right heels on 5/2/22 and 5/9/22 and no documentation of wound care being provided to the coccyx and left and right ischia on 5/1/22 and 05/7/22. Observations on 5/10/22 at 2:36 p.m. revealed the wound care nurse, Registered Nurse (RN) JJ, providing wound care to R#66. RN JJ revealed the right heel was healed, with no skin issue present. The left heel was a stage 2 open area, approximately 3 cm in diameter, with scant serosanguineous drainage noted on the pillowcase with which the resident's feet were being offloaded from the mattress. The resident complained of pain to the left heel during wound care. RN JJ cleansed the area, applied a small piece of Medi-honey over the wound bed, and covered it with a dressing. There were no dressings or open areas to the coccyx or ischial tuberosities. The coccyx and area to the left of the coccyx had slight redness present, and the area to the right of the coccyx was a fading DTI, approximately 1 cm in diameter. RN JJ cleansed the area and applied Triad cream to the entire area. There were no open areas to the right or left ischial tuberosities. A dressing to the left rib area on the resident's back was dated 5/5/22, five days prior to the observation. The dressing was removed, revealing a large wound with eschar present. The peri-wound was red and irritated. RN JJ cleaned the area with normal saline, patted it dry, applied a piece of Medi-honey over the wound bed, and covered it with a foam dressing. RN JJ stated this area was documented in the resident's record as the left lower back because that was the closest area that could be chosen on the electronic charting program she used. She stated the DTI to the right buttock was documented in the resident's record as the ischial tuberosity for the same reason. RN JJ stated she had changed the type of dressing used on the left heel because it was now open and had changed the type of dressing to the resident's back because the wound was not healing. RN JJ stated the wound care should have been done to R#66's wound on Sunday 5/8/22, since the dressing was dated 5/5/22. RN JJ stated wounds were measured weekly, either by herself or the other wound nurse. She stated measurements should have been obtained last week, but she was not here on the days the resident had wound care done, so it should have been done by the other nurse. Based on the surveyor's observations, several of the wounds had healed or were healing as compared with the most recently documented assessment, and the wound to the left rib area of the resident's back had not deteriorated since the last assessment. During an interview on 5/12/22 at 10:02 a.m., Certified Nurse Aide (CNA) HHH stated if she noticed a wound dressing was missing or old, she would tell the nurse. During an interview on 5/12/22 at 10:11 a.m., Licensed Practical Nurse (LPN) RR stated when a wound was identified, the wound care nurse and family were to be notified. She stated she would get a one-time order to cover the wound until the wound care nurse could look at it. LPN RR stated wounds were monitored daily. She stated if a resident was admitted with a wound and it was covered with a dressing, the nurse should remove the dressing, unless it had just been changed, to assess the wound. She stated if the wound nurse was in the facility, she would do the initial assessment and, if not, the nurse on the floor would do it. If the resident was not admitted with wound care orders, the physician should be contacted to get an order until the wound nurse could look at it. LPN RR stated all of R#66's wounds were present upon admission, but LPN RR was unsure of what the treatment was after admission. During an interview on 5/12/22 at 10:23 a.m., Resident Care Coordinator (RCC) TT stated when skin breakdown was identified, the nurse should notify the physician, power of attorney (POA), and the wound care nurse and document it on a progress note. If the resident was on hospice, then hospice should be notified as well. She stated if a dressing was not on a wound, the nurse should check the order and replace the dressing if the wound nurse was not available. RCC TT stated wounds were monitored three times a week and skin assessments were done monthly. She stated the CNAs monitored the residents daily and notified the nurse of any changes by filling out a form and verbally telling them. RCC TT stated the facility did not have a wound team, just a wound nurse, but they tried to do things as a team. She stated she tried to see all wounds with all new admissions and tried to work as a CNA occasionally. She stated she did not stage wounds but would measure them, and then the wound care nurse would come in and do the rest of the assessment because she had more experience. RC TT stated wound documentation should be a very detailed description with measurements. After reviewing R#66's record, RCC TT agreed that the wound assessments were not complete and did not describe the wounds. After review of the TAR and MAR, RCC TT agreed there were times the treatment was not documented as being completed. RCC TT stated she had not seen R#66's wounds. RCC TT stated if a resident was admitted to the facility without treatment orders, the nurse should contact the physician. She stated the facility also had a protocol the nurses could follow if the wound nurse was not present. She stated the physician should be notified immediately of any change to the status of a resident's wound, and it should be documented in a progress note. During an interview on 5/12/22 at 12:06 p.m., RN JJ, the wound nurse, stated when an area of skin breakdown was identified or if a resident was admitted with a wound, the nurse should write an order following the protocol, then notify RN JJ, either by submitting a slip or sending her a text. She stated if a dressing came off or a staff member noticed a wound without a dressing, the nurse on the hall should replace the dressing. RN JJ stated wounds were monitored at least weekly, which included taking measurements and documenting a description of the wound. She stated she monitored any complex ulcers or surgical wounds, depending on the treatment and what the physician orders were. She stated if she had a concern with a wound, she would call the wound clinic. Continuing the interview, RN JJ stated the wound physician was previously coming to the facility once a week to see those residents who needed to be seen, but he was not able to come into the facility for a while, so they now sent the residents out to the clinic. RN JJ stated she was responsible for the documentation of the wounds, which included the size of the wound, the peri-wound, drainage, and resident's pain level. She stated monitoring the effectiveness of a treatment was ongoing. She stated if she saw a wound had not responded to a treatment in a week or so, then she would try to change the order. She stated the facility had wound care protocols she followed. RN JJ also stated the physician should be notified within 24 hours if there was a negative outcome, and this should be documented. RN JJ stated if a resident was admitted to the facility with wounds, the nurse on the hall should do the skin assessment before their shift was over and they should remove any dressings in place to get a description of the wound. She stated R#66 was admitted with all their wounds, and after reviewing the record, she confirmed that R#66 did not have any treatment orders in place until five days after admission on [DATE]. She confirmed there was no documentation of the appearance of the wound until 4/19/22, four days after admission. RN JJ stated the admission nurse should have taken the dressings off and documented the size and appearance of all the wounds. She stated R#66's wounds were not measured the previous week (the week of 5/1/22) because she was not at the facility on the days that the treatments were due. She stated no one else in the facility was trained on how to use the wound documentation program. During an interview on 5/12/22 at 12:54 a.m., interim Director of Nursing (DON) BB stated if staff identified an area of skin breakdown, the nurse should notify the provider and get treatment orders, place the order in the electronic health record, schedule the treatment on the TAR, provide the treatment, document, and notify the family. She stated if a resident was admitted with a wound, the admission nurse should do a head-to-toe full body assessment and then, the following day, the wound nurse should go in and do a second assessment. She stated if there were dressings in place, they should be removed, and the nurse should document what they see. DON BB stated if the resident was admitted without wound orders, the nurse should contact the physician and get orders right away. She stated if a dressing was not in place, the nurse should check the orders and replace it right away. Continuing the interview, DON BB stated the wound nurse should be monitoring wounds weekly, with measurements and that this should include all pressure wounds, ulcers, DTIs, skin tears, and surgical wounds. She stated the wound nurse should be documenting the appearance of the wound, including if it was healing, if it had signs and symptoms of infection, what the peri-wound looked like, if there was drainage, and if the resident experienced pain during the treatment. She stated the facility used to do a weekly skin meeting but had not had one in several months. DON BB stated the physician should be notified of the wound status on a weekly basis or as needed, and this should be documented in a progress note, in the comment box on the assessments. During an interview on 5/12/22 at 2:43 p.m., Administrator AA stated wounds should be monitored, and it was his expectation that the staff follow policy and procedures and take the necessary steps to ultimately have a positive outcome.

Deficiency Text Not Available

Based on observation, record review, review of facility policy titled Medication Administration - General, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 33 medication opportunities were observed, and there were five errors for three of three residents (R) (R #29, R#56, R#34) for an error rate of 15.15%. Findings include: 1. A review of R#29's Orders, dated 2/17/22, directed staff to instill one drop of Restasis Multidose Ophthalmic Emulsion (chronic dry eye syndrome treatment) in each eye. An observation of medication pass with Registered Nurse (RN) LL on 5/9/22 at 9:49 a.m. for R#29 revealed RN LL administered one drop of Restasis in each of R#29's eyes. R#29 requested RN LL apply more drops. The surveyor observed RN LL instill an additional drop of Restasis into each eye. During an interview with RN LL on 5/9/22 at 9:56 a.m., RN LL erroneously stated the doctor's order for Restasis directed staff to administer two drops in each of R#29's eyes. 2. A review of R#56's Orders, dated 8/3/20, and the medication administration record (MAR) for the month of May 2022 indicated R#56 had an order directing staff to administer a scoop of MiraLAX powder (17 gram) mixed with four ounces of water by mouth every morning at 8:00 AM for constipation. A review of R#56's Orders, dated 4/22/22, and the MAR for the month of May 2022 indicated R#56 had a three-month order directing staff to orally administer one 324 milligram tablet of ferrous gluconate (iron supplement) two times a day for iron deficiency anemia, with one of the doses due at 8:00 a.m. An observation of medication pass with RN LL on 5/9/22 at 10:08 a.m. revealed RN LL administered 8:00 a.m. medications to R#56 to include hydrocodone-acetaminophen, allopurinol, carbidopa/levodopa, chewable aspirin, Plavix, Lasix, duloxetine, Lopressor, potassium, ropinirole hydrochloride, and Senna Plus that had been prepackaged by the pharmacy. RN LL indicated immediately after administering the medications that she had completed R#56's morning medication administration. However, RN LL failed to administer the ordered over-the-counter medications of MiraLAX powder and ferrous gluconate. On 5/12/22 at 10:49 a.m., a call made to RN LL to discuss the observation went unanswered and the call was not returned despite a voicemail request for a return call. 3. A review of R#34's Orders, dated 4/10/21, and the MAR for the month of May 2022 indicated R#34 had a physician's order directing staff to administer one spray of Flonase suspension in each nostril at 8:00 a.m. daily. A review of R#34's Orders, dated 11/4/21, and the MAR for the month of May 2022 directed staff to orally administer one puff of Breztri inhaler two times daily for chronic obstructive pulmonary disease, with the morning dose due at 8:00 a.m. An observation of medication pass with Licensed Practical Nurse (LPN) MM on 5/10/22 at 8:06 a.m. revealed LPN MM administered to R#34 enteric-coated aspirin, clopidogrel bisulfate, duloxetine hydrochloride, Lasix, gabapentin, methenamine hippurate, extended-release potassium chloride, Senna Plus, Thera-M with 9 milligram iron tablet, MiraLAX, and Levemir that had been prepackaged by the pharmacy. LPN MM did not administer the ordered Flonase or Breztri doses. During an interview on 5/10/22 at 11:16 a.m., LPN MM indicated she thought she had finished administering all of R#34's medications due at 8:00 a.m. but forgot to give the nose spray (Flonase). LPN MM also acknowledged she failed to administer the inhaler (Breztri) to R#34. She reported that the inhaler was not in the cart, so she had to order it from the pharmacy. During an interview on 5/11/22 at 8:33 a.m., LPN RR indicated that all medications should be given at the time ordered by the physician. She indicated that omitting medications was considered a medication error. During an interview with RN OO on 5/11/22 at 1:58 p.m., RN OO indicated that MARs and physician orders should be followed during medication administration. A review of the facility policy Medication Administration - General, with a last reviewed/revised date of 12/1/19, revealed, Purpose: To provide resident medication efficacy and safety by following established principles of medication administration. Policy: 2. All resident medications are administered as ordered by the prescriber. 3. It is the joint responsibility of the pharmacy and the nursing facility to ensure accurate medication administration. The RIGHT medication must be given to the RIGHT resident in the RIGHT does [sic] at the RIGHT time, using the RIGHT method of administration and the RIGHT process of documentation. During an interview on 5/11/22 at 4:15 p.m., the Director of Nursing (DON) indicated all medications should be given at the ordered time unless there was an order to hold the medication and noted there was a timeframe in which medications should be given. The DON indicated the expectation of the nursing staff was to follow physician orders. Per the DON, if a resident had a medication administration preference, a nurse should call the doctor to get an order to change the medication. The DON stated that medications were expected to be given and not omitted. During an interview on 5/11/22 at 8:33 a.m., the Administrator reported that his expectation for medication administration was for staff to follow policies, procedures, and protocols and give all medications as ordered.

Deficiency Text Not Available

Based on observations, interviews, and facility policy review, the facility failed to ensure staff members wore personal protective equipment (PPE), specifically face masks, in a manner that ensured the face masks fully covered staff members' noses and mouths in order to optimize source-control strategies and reduce the potential for COVID-19 transmission for one of two floors (second floor), for one of one facility entrance, and while in resident-care areas. Findings include: A review of the facility policy Required and Extended-Use Masking Policy for Healthcare Personnel (HCP) During COVID-19 Pandemic revealed, Effective Date: January 2022. Original Implementation Date: May 2020. Reference: CDC COVID-19, 'Your Guide to Masks'; Purpose: The virus is often spread before individuals begin experiencing symptoms; This policy is designed to protect against asymptomatic transmission and is recommended by the Centers for Disease Control and Prevention (CDC - 4/13/20); Procedure: 2. If employees/HCP have screened negative for fever/temperature 100.0 [degrees Fahrenheit], symptoms of COVID-19, they should enter the facility with a mask on; Mask Don'ts: don't wear the mask under your chin, don't wear the mask under your nose, don't wear it on the tip of your nose, don't wear it hanging on one of your ears; Mask Do's: do wear the mask so it covers your mouth and nose. During an observation on 5/9/22 at 8:30 a.m., outside the entrance to the facility, a sign posted on the entrance door of the facility revealed, Please put on a mask before entering the building. During an observation on 5/9/22 at 8:32 a.m., while the survey team members underwent COVID-19 screening at the front desk of the facility, Medical Records EEE stood in the front lobby of the facility without wearing a face mask. At that time, Medical Records EEE reported he/she was in the facility to report to work. During an observation on 5/9/22 at 9:02 a.m., Registered Nurse (RN) LL administered medications to residents in the Hall 500 without first ensuring the surgical face mask covered her nose and mouth. RN LL's face mask hung below the level of her nose and mouth. During an observation on 5/9/22 at 9:03 a.m., RN LL stood near the medication administration cart on Hall 500 with her nose and mouth exposed. RN LL's surgical face mask hung below the level of her nose and mouth. During an observation on 5/9/22 at 9:13 a.m., RN LL, with the surgical face mask below the level of her nose and mouth, walked down Hall 500 and conversed with the surveyor. During an observation on 5/9/22 at 9:22 a.m., RN LL conversed with a resident in Hall 500 while she administered medications to the resident in the resident's room. During the conversation between RN LL and the resident, the resident indicated he/she was not able to hear RN LL, and RN LL pulled her surgical face mask down and uncovered her nose and mouth when she spoke to the resident. During an observation on 5/9/22 at 10:17 a.m., RN LL stood in Hall 500 with a surgical face mask down below the level of her nose and mouth. During an observation on 5/9/22 at 10:30 a.m., RN LL, with the surgical face mask below the level of her nose and mouth, administered medications to and conversed with a resident in Hall 500. During an observation on 5/9/22 at 10:36 a.m., RN LL, with the surgical face mask below the level of her nose and mouth, stood in Hall 500 and conversed with another staff member. During an observation on 5/9/22 at 2:23 p.m., RN LL, with the surgical face mask below the level of her nose and mouth, administered a liquid supplement to a resident in Hall 500. On 5/9/22 at 4:45 p.m., the surveyor informed the Administrator and the Interim Director of Nursing (RN BB) of the observations of RN LL in resident care and communal areas without the surgical face mask covering her nose and mouth. The Administrator reported the issue would be addressed at once. During an interview on 5/10/22 at 9:23 a.m., Front Desk Clerk FFF indicated staff members needed to don a face mask prior to entering the building. Front Desk Clerk FFF indicated face masks and gloves were located outside the facility at one time, but the facility moved them inside due to rain and theft. Front Desk Clerk FFF stated, We probably need to have a [PPE] cart by the door. During an interview on 5/10/22 at 9:28 a.m., the Administrator indicated the facility expected staff members to wear face masks covering the nose and mouth when entering the building and while in the facility. On 5/11/22 at 8:30 a.m., during an observation, Dietary Manager GGG stood in a second-floor resident hallway without wearing a face mask. Dietary Manager GGG, during an interview, indicated that she attended an in-service earlier in the week regarding wearing face masks. Dietary Manager GGG reported she had been sitting in her office when she noticed staff members serving the lunch meal to residents. She stated, I jumped up from my chair and went into the resident hallway without thinking about my mask. I was going to help pass meal trays.