Az - Rio Vista Post Acute And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one (#4) of three sampled residents was provided respiratory care consistent with professional standards and highest practicability of care. The deficient practice could result in respiratory complications.
Findings include:
Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, hypertension, and heart failure with preserved ejection fraction.
Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.
Review of the care plan revealed no evidence of oxygen use or needs and no evidence of the resident having a focus related to respiratory issues.
Review of the progress notes revealed Physician and nurse practitioner (NP)/physician asssistant (PA) progress notes from November 2, 2024 to November 27, 2022 which recommended supplemental oxygen use to keep oxygen saturation (the amount of oxygen circulating in your blood) percent greater than ninety-two percent.
Review of the documented oxygen saturations revealed that all oxygen saturations documented included that the resident was on room air, indicating oxygen was not being administered during the reading. Additionally, the documentation revealed eight oxygen saturation readings that were less than or equal to ninety-two percent:
November 27, 2024 14:37 82.0% Room Air
November 27, 2024 06:55 91.0% Room Air
November 25, 2024 07:26 92.0% Room Air
November 21, 2024 07:37 92.0% Room Air
November 20, 2024 21:12 82.0% Room Air
November 20, 2024 06:50 86.0% Room Air
November 18, 2024 08:26 90.0% Room Air
November 17, 2024 21:13 80.0% Room Air
There was no evidence found that the staff re-checked oxygen saturation following these low oxygen saturation readings, or that oxygen was applied.
Further review of the nursing progress notes revealed multiple daily skilled notes (dated November 18, November 19, November 20, November 21, November 25, November 27 of 2024) which included vital signs for Resident #4. In these notes, the recorded oxygen saturation were less than ninety-two percent, and the note indicated that the resident was on room air. There was no evidence found that the provider was notified of these lower readings.
Review of provider orders revealed no evidence that oxygen was ordered for Resident #4.
Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2024 revealed no evidence that oxygen was ordered or administered to Resident #4.
A telephone interview was conducted on May 6, 2025 at 8:32AM with Resident #4's family member, who revealed that she had noticed on multiple occasions, during her stay, that Resident #4 had difficulty breathing. The family expressed that she would tell the staff about the respiratory issues the resident was having, but felt that the staff brushed her off. The family member stated that the facility did not provide Resident #4 with oxygen when Resident #4 was experiencing respiratory distress.
A interview was conducted on May 6, 2025 at 08:55AM with a Certified Nursing Assistant (CNA/Staff #7) who stated that if she noticed a resident was in respiratory distress, she would sit them upright to help them breathe better. She stated that if the resident had orders for oxygen, she would ensure the oxygen was on and did not fall off. The CNA stated that she would then call the nurse.
Interview was conducted on May 7, 2025 at 1:00PM with a Registered Nurse (RN/Staff #24), who stated that if a negative change in a resident's condition was noticed, he should notify the provider and colleagues. The RN further explained that if the change was emergent, such as one that disrupted the resident's vitals, this would require immediate intervention and he would call his supervisor for assistance.
A interview was conducted on May 7, 2025 at 4:10PM with the Director of Nursing (DON/Staff #18), who stated that she would expect that during a change of condition, the staff should notify the provider, who would give instruction on what to do next. She stated she would then expect the staff to follow any new orders, notify family, and document the change of condition. The DON also stated that if a resident needs oxygen therapy, the staff should call the provider, obtain an order, and administer oxygen per the order. The DON stated that oxygen should have an order to administer it. The DON also stated that if a resident's oxygen saturation is noted to be abnormally low, she would expect the staff to notify the nurse, who would then assess the patient. She stated she would then expect the nurse to call the provider for orders if the resident showed signs of distress and follow the orders. When reviewing the chart for Resident #4, the DON could not find evidence that the provider was contacted for the low oxygen saturation readings recorded. Additionally, no order was located for oxygen usage.
Review of the facility policy titled, Change of Condition Reporting (reviewed June 2024), revealed that all changes in resident condition will be communicated to the physician and resident representative and documented.
Review of the facility policy titled, Oxygen Administration (reviewed January 2025), revealed that oxygen therapy should be administered by a licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one (#2) of four residents reviewed for pressure ulcers was provided care and services to prevent and safely treat pressure ulcers. The deficient practice could result in the development and worsening of pressure ulcers.
Findings include:
Resident #2 was admitted to the facility on [DATE] with diagnoses that included (cystitis) inflammation of the bladder, Type two diabetes mellitus, and generalized muscle weakness.
Review of the nursing progress note dated April 8, 2025 revealed that on admission, the resident was noted to have a wound to the right heel, which had a clean dressing in place. There was no evidence of other wounds noted at this time.
Review of the Initial admission Record revealed that on April 9, 2025, the resident was observed to have a right heel wound. There was no evidence of any other wounds or skin impairments at that time.
Review of Resident #2's care plan revealed a problem focus, initiated on April 9, 2025, that revealed that the resident had a pressure ulcer or potential for pressure ulcer development. The goal in place for this focus was that the resident would have intact skin, free of redness, blisters, or discoloration through the review date. Interventions in place for this focus included: weekly head to toe skin assessments; informing the resident, family, and caregivers of any new areas of skin breakdown; and monitoring, documenting, and reporting to the Medical Doctor (MD) any changes in skin status.
Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.
Review of the nursing notes revealed a note dated April 20, 2025, which indicated that Resident #2 was noted to have a superficial popped out blister at the sacral area with redness on surrounding skin. The note revealed that the area was about one and a half inches in diameter. The nurse indicated that they had cleansed the area and applied a healing cream to avoid irritation. There was no evidence found in this note that the medical doctor (MD) had been notified or new orders were ordered to administer treatment. There was no evidence found to indicate what type of cream treatment was applied to the wound.
An interview was conducted on May 7, 2025 at 10:50AM with a Certified Nursing Assistant (CNA/Staff #16), who stated that if she noticed a new skin impairment on a resident, she would let the nurse know and contact the wound nurse to determine if it was a new skin impairment.
An interview was conducted on May 7, 2025 at 1:00PM with the Registered Nurse (RN/Staff #24) who initially noted the new skin impairment. The RN described that he had noticed on April 20, 2025, that Resident #2 had a sore on his bottom, which he described as a red open area with tearing skin, about a one-inch area. The RN stated that he had never seen a bed sore prior to this, but stated that he knew that they often started with a blister. The RN detailed that he had applied a cream to the wound when he noticed it. The RN could not identify the name of the cream he had used, but knew that the CNAs often used the cream for patients with bedsores. When asked if staff should obtain an order to apply a treatment to a wound, the RN explained that he did not think the treatment would require an order, as he believed this was a treatment he could begin and notify the MD after. The RN stated that he had spoken to his Director of Nursing (DON) about this case this morning, May 7, 2025, and understood that he had failed to follow protocol with this case.
An interview was conducted on May 7, 2025 at 2:34PM with the wound care Registered Nurse (RN/Staff #27), who stated that she was not aware of Resident #2's new skin impairment, which was noted on April 20, 2025. The RN explained that she was on vacation at that time, so the DON was covering her job at the time. The RN reviewed the nursing note in which the skin impairment was described, and the RN stated that the wound described could be a potential pressure ulcer or it could be a skin tear.
An interview was conducted on May 7, 2025 at 4:10PM with the Director of Nursing (DON/Staff #18), who stated that she would expect that if staff noticed a change of condition, the staff should notify the provider, who would give instruction on what to do next. She stated she would then expect staff to follow any new orders, notify family, and document the change of condition. When asked if she felt that Resident #2's new noted skin impairment on April 20, 2025 would be considered a change of condition, the DON stated it was potentially a change of condition, depending on what type of open area was discovered. When asked if she could determine what type of treatment was applied by the nurse, the DON stated that she would assume the nurse applied a protective barrier cream with zinc. The DON stated that the nurse should have notified the wound care nurse and put in a nursing note upon discovering the skin impairment. When asked if the DON felt this wound could have potentially been a pressure ulcer developing, the DON denied that this was a pressure ulcer, stating that the nurse had the skills to assess and determine the nature of the wound, though the wound nurse should have been notified.
Review of the facility policy titled, Wound Management (reviewed June 2024), revealed that once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area per the Physician's order. The policy also indicated that all wound or skin treatments should be documented in the resident's clinical record at the time they are administered.
Review of the facility policy titled, Change of Condition Reporting (reviewed June 2024), revealed that all changes in resident condition will be communicated to the physician and resident representative and documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one (#5) of three sampled residents' choices regarding personal hygiene care were considered and honored in regard to shower preferences. The deficient practice could result in residents not having their choice in personal preferences that are significant to them.
Findings include:
Resident #5 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, urinary tract infection, and end stage renal disease.
Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.
Review of the care plan revealed a problem focus initiated on September 10, 2024, which revealed that the resident could be resistive to care, such as refusing showers. Interventions in place included allowing the resident to make decision about treatment regime to provide a sense of control, providing consistency in care to promote comfort with Activities of Daily Living (ADLs) as much as possible, and providing the resident with opportunities for choice during care provision.
Review of the bathing charting in the Electronic Health Record (EHR) revealed that from April 7, 2025 to May 6, 2025, Resident #5 received one shower, two sponge baths, and one full-body bath. At that time period, there were three documented instances of the resident refusing, on April 9, April 16, and April 30 of 2025, which all were on Wednesdays.
Review of the provider order dated March 14, 2025 revealed that Resident #5 received dialysis three times a week on Monday, Wednesday, and Friday.
Review of the shower sheets for February 2025 through May 4, 2025 revealed that Resident #5 received six showers, nine bed baths, and refused ten showers. Of the ten documented refusals, eight of these were on Wednesdays, which was one of the resident's scheduled dialysis days. Review of the shower sheet dated Wednesday, April 2, 2025, revealed that the staff documented that the resident left before a shower could be completed. There was no evidence found that a shower was completed or attempted again until April 6, 2025. Additionally, review of the shower sheet dated April 9, 2025 revealed a comment from staff that indicated that the resident had refused her shower; and that, stated she did not want to go outside after shower because she was concerned about developing pneumonia.
Review of the progress notes revealed psychiatric notes, from December 2024 to the most recent note dated April 22, 2025. These notes revealed that the resident had been documented by staff to occasionally refuse showers. There was no evidence found in the progress notes that the resident had been asked about why she had refused.
An interview was conducted on May 6, 2025 at 10:07AM with Resident #5, who stated that she did not like her shower schedule. She explained that one of her scheduled shower days fell on Wednesdays, which was a day she was also scheduled for dialysis outside of the facility. The resident explained that she normally leaves for dialysis between 08:00AM and 9:00AM and she does not return to the facility until 3:00 or 4:00PM. The resident further explained that she does not want to go out to dialysis with wet hair, so she often denies a shower on Wednesday mornings when staff offer her a shower. The resident stated she had told multiple staff that she does not like showering on dialysis days, but claimed that none of the staff have done anything to change her shower schedule.
Interview was conducted on May 7, 2025 at 10:50AM with a Certified Nursing Assistant (CNA/Staff #16), who confirmed that Resident #5's shower days were Sundays and Wednesdays during the day shift. The CNA stated that Resident #5 could take showers, but had lately been preferring to do bed baths instead. The CNA also stated that staff attempt to shower Resident #5 before dialysis because she is often tired after dialysis. The CNA stated that Resident #5 will sometimes say that she does not want to shower before going to dialysis because she does not want to get sick with pneumonia again. The CNA then stated that the resident is particular in her wants, as she will often deny her shower before dialysis, but she almost always gets up for her smoke breaks. The CNA stated that she felt there was time to complete Resident #5's showers before dialysis, as her transportation does not arrive until around 0830AM, however Resident #5 often does not want to get up or she gets cold. When asked what is done for a resident that is frequently refusing baths, the CNA explained that the staff will attempt to talk to the resident and offer to do a bed bath instead. The CNA stated that a shower is always offered first, and if the resident refuses, the staff should document on the shower sheets that a shower was offered and the resident chose a bed bath instead. The CNA also explained that each room is assigned a shower date and time, though staff attempt to accommodate if the residents have preferences. She also stated that if a shower is missed due to an appointment, staff would attempt to complete later that day or the following day.
An interview was conducted on May 7, 2025 at 11:35AM with a Licensed Practical Nurse (LPN/Staff #33) who stated that Resident #5 decides what she wants to do regarding her care, including showers. The LPN stated that the resident will often be tired the day of and the day after dialysis. The LPN explained that Resident #5's shower times were Sundays and Wednesdays between 6:00AM and 2:00PM. She stated that the resident's transportation normally arrives between 08:30AM and 09:30AM. The LPN explained that staff attempt to provide showers before her dialysis. The LPN also stated that the resident will sometimes refuse, stating that she does not want her hair to be wet when going to dialysis. The LPN stated that she had attempted to tell the resident that she could get a shower without wetting her hair, but the resident did not accept.
Interview was conducted on May 7, 2025 with the Director of Nursing (DON/Staff #18) who stated that resident preferences are considered when implementing the facility shower schedule. The DON also stated that some residents may have dialysis or appointments on their shower days, and if this was the case, staff discuss with the resident if they would like their shower moved to another day. The DON stated that if a resident was noted to frequently refuse showers, staff would discuss with the resident to ask for the resident's preferences, and staff would see if the preferences could be accommodated. When asked if she was aware of Resident #5's preference to not have showers on dialysis days, the DON stated she was unsure if the concern had been brought up to any management, but stated that staff did not bring up shower concerns during the weekly interdisciplinary team (IDT) rounds.
Review of the facility policy titled, ADL's - hygiene, grooming, toileting, bathing, oral care, dressing, grooming, mobility, transfers, ambulation, etc. (Revised July 2025), revealed that residents should be involved in decision making and given choices related to ADL activities as much as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and facility policy, the facility failed to ensure medication were not left unsecured at bedside for two sample residents (#105 & #67). The deficientpractice of unattended medications does not align with accepted professional standards of practice and may result in undesirable medication-induced harm.
Findings include:
-Resident #105 was admitted on [DATE] with diagnoses of alcoholic cirrhosis of liver, depression, opioid abuse, and anxiety disorder.
Review of resident #105 medical records revealed a significant change Minimum Data Set (MDS) completed December 08, 2024 when admitted on to hospice. He had a Brief Interview for Mental Status (BIM) score of 15/15 which means he has no cognitive impairment.
Review of medical records did not reveal an assessment to allow self-administration nor to allow storage of medications or treatment at bedside.
On April 01, 2025 at 10:19 AM, during initial observation, a beige color asthma mist inhaler unit was observed on the bed side cabinet and an uneaten meal tray on the over the bed table. The resident #105 was asleep with a head-set on. A later observation conducted on April 01, 2025, at 1:46 PM revealed the inhaler in the same location.
Review of the resident's care plans revealed an intervention: allow to make decisions about treatment regime, to provide sense of control, but did not include a care plan to allow storage of medications or treatments in a secured location at bedside, nor a care plan for self-administration.
Review of physician's orders revealed that the resident did not have an order for an inhaler treatment nor include an order for self-administration.
An interview was conducted on April 03, 2025, at 1:09 PM, with resident #105 who was lying in bed, awake. Resident #105 stated that he had an inhaler brought in because he believed that his severe edema has traveled from his feet into his chest and been feeling pressure making it difficult to breathe, but the inhaler did not resolve that feeling.
- Resident #67 was re-admitted [DATE] with diagnosis myeloma, plasmacytoma, atrial fibrillation, chronic obstructive pulmonary disease, colostomy, depression, and insomnia. His April 02, MDS Quarterly had a BIM score of 15/15 that means he is cognitively intact.
Review of care plan revealed that the resident #67 had shortness of breath treatment to, Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. The care plans did not include resident to allow storage of medications or treatments at bedside, nor a related care plan for self-administration of nasal decongestion spray (oxymetazoline). Review of this resident's medical records did not reveal an assessment to allow secured storage of medications or to have treatments at bedside, nor self-administration of nasal spray.
Although review physician's orders revealed an order dated February 07, 2025 treatment to have, Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligram/3milliliter) 0.083% (Albuterol Sulfate) 3 milliliter inhale orally via nebulizer every 4 hours as needed for SOB/ wheezing, and a nasal spray order dated February 06, 2025, Narcan Nasal Liquid 4 milligram/0.1milliliter (Naloxone HCI) 1 spray in nostril as needed for Opioid Reversal, may repeat every 2-3 min until patient responds. The physician's orders did not reveal an order for nasal spray treatment nor include an order for self-administration of a nasal spray.
On April 01, 2025 at 09:59 AM, during initial observation, resident #67 had an box with the label Afrin sitting on top of his bedside table.
On April 02, 20250 at 07:26 AM, a follow-up interview was conducted with resident #67. He stated that he had allergies and used an inhaler and the nasal spray.
An interview was conducted on April 04, 2025 at 08:42 AM with a Licensed Nursing Assistant (LNA/Staff #175) who stated that the residents are not supposed to have medications nor vitamins within their rooms; and that, if she sees any type of medication or vitamin container in a resident's room, she would inform the nurse. Staff #175 stated that the residents can keep medications in their room, but has to be locked-up, and mentioned that the nurses will let the nursing assistants know who had medications in their room and that those medication have to be locked up when not in use. Staff #175 stated that having medications out in the open within a resident's rooms creates a risk of an overdosing by a wandering resident. Staff #175 stated that her expectations was that all nursing aides and staff will let the nurse know when they see medications in a resident room area.
An interview was conducted on April 04, 2025 at 08:57 AM with Certified Nursing Assistant (CNA/Staff #179) who stated that had the responsibility to let her nurse know when there are medications in a resident's room; and that, there is a risk of wanders taking the item and that medication becomes a risk of of misuse. Staff #179 stated that some of the rooms have lock boxes, and she expects that all new CNAs confirm with the nurse if it is safe for that resident to have those or medications in their room.
An interview was conducted on April 04, 2025 at 10:22 AM with (CNA/Staff #81) who stated that medications should not be in a resident's room, and that she would inform the nurse, who would expect a nurse to go into that room with her, and remove the item. Staff #81 stated that the nurse
would let the rest of the nursing staff know who can keep their meds within room, but those meds are to be placed in a lock box.
An interview was conducted on April 04, 2025 at 09:37 AM with the Licensed Practical Nurse (LPN/Staff #150) who stated whenever a medication is found, first procedure would be to make sure that resident had an order for that medication, and second to assure that the resident had an
assessment and had an order to be allowed to have medication at bedside in a secured box. The nurse stated that the risk of unsecured medications could be other patients getting a hold of the medication and overdosing. Staff #150 stated that the expectation is that staff notify her whenever any type of unsecured medication is within a resident's room.
An interview was conducted on April 04, 2025 at 10:41 AM with an (LPN/Staff #139) who stated that she will remove the medication or hazard items from the room, after talking to the resident or family on the risks, and call the provider. She confirmed that the nurses keep inhalers inside locked medication carts. Staff #139 stated that she had no residents that can keep medications at bedside, but the policy requires that bedside medications have to have a lock box, have to have an order, and a care plan.
Staff #139 stated that the risk of unsecure medication was overdose; and that, the over use of an inhaler could affect the breathing. Staff #139 stated that the expectation would be that staff will check that the patient's lock box is secured and report items to the nurse that are left out.
An interview was conducted on April 04, 2025 at 11:20 AM with the Director of Nursing (DON/Staff #1) who stated that the facility's policy and procedures are primarily focused on keeping medications, including over the counter medications, safely locked up in the medication cart, otherwise the process to keep medications in a resident's room are within a locked box. DON stated that residents are assessed to see if they can manage their own treatment, consult with the provider on the situational risks who makes the final decision, and then nursing staff will create a care plan
and inform staff. DON stated that the risk of unsecured medication is the potential of someone wandering into the room. The DON stated that she expected staff to inform her of medications including over the counter medications brought in by family, and those items are given to the nurse; and that, the nurse will call and consult with the provider.
Review of the facility's policy titled, Nursing Clinical (revised July 2024), revealed should a resident's medications be kept at bedside, it shall be placed in a secure container. Resident's requesting to keep medications at bedside may be assessed for the safety to self-administer medications, if approved by the medical provider. Resident found to have brought in medications from outside of the facility will be asked if the medications can be stored in a secure location. If the resident agrees to have medications removed, they will be removed to a secure area until family can pick up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line was discontinued when not required prior to, or at time of, discharge for one of three Residents (#1). The deficient practice could result in residents utilizing the PICC line inappropriately or getting infection if not prope.
Findings include:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included sepsis, psychoactive substance abuse, depression, and anxiety.
An order was initiated on January 23, 2025 to flush the PICC line right upper extremity (RUE) before and after use of intravenous IV medications.
An order was initiated on January 23, 2025 to do PICC line care and dressing changes.
An order initiated on January 24, 2025 revealed that Resident #1 ' s opioid risk was high risk.
An order initiated on January 24, 2025 revealed that upon discharge, the facility should have removed the negative pressure wound therapy (NPWT) dressing and discarded it, as well as removed the canister from the device and placed the device in a clear plastic bag to be placed in the med room.
There was no evidence of an order to remove Resident #1 ' s PICC line in the clinical record.
An assessment utilizing the opioid risk tool was conducted on January 24, 2025 which revealed that Resident #1 had a personal history of substance abuse of illegal drugs.
A care plan initiated on January 24, 2025 revealed a focus on the potential for an adverse outcome from opioid use because of her history of opioid abuse or other substance abuse. The care plan also revealed a focus on IV antibiotic therapy with an intervention for RUE PICC line care as ordered with no evidence of a revision to that intervention. The care plan revealed focuses on fall risk, pain, dehydration, ADL self care performance deficit, the risk for impaired cognitive function or impaired thought processes, and the potential for a psychosocial well-being problem all due to opioid dependency, psychoactive substance abuse, depression, and homelessness. The care plan also revealed a focus on the resident ' s wish to be discharged to their home.
A weekly skin assessment conducted on January 30, 2025 at 6:39 p.m. indicated that the resident had a wound vac on her left foot and a PICC RUE line.
A progress note dated January 31, 2025 revealed that the resident was discharged on January 31, 2025 at 2:30 p.m. via wheelchair, and that she left without signing her discharge summary. It was revealed that the resident left with the wound vaccuum in place and that the resident was alert and oriented and could communicate her needs well.
The Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview for Mental Status (BIMS) score was 14, which indicated intact cognition.
A Discharge summary dated [DATE] and signed by the Director of Nursing (DON/Staff#22) revealed that the resident was discharged to a shelter. The skin assessment portion of the discharge summary remained blank and indicated not available na for the need for ongoing treatment, treatment ordered, and other treatments or skin care. The discharge summary revealed that discharge instructions were given to the resident and her personal belongings were sent with her, the resident needed to follow up with wound care, and that her insurance ended on January 31, 2025.
An interview was conducted on February 5, 2025 at 11:54 a.m. with a social worker at the hospital (Hospital Social Worker/Staff#507) who stated that a patient came into the emergency room on February 2, 2025 after being homeless following her discharge from the facility. The social worker stated that the resident was discharged from the facility with a PICC line and a history of substance abuse, including methadone. The social worker stated that when they asked Resident #1 about the PICC line she stated the facility did not remove it, and she still had it in.
An interview was conducted on February 5, 2025 at 12:37 p.m. with an emergency room physician (emergency room Physician/Staff#398) who stated that she was the physician working at the hospital at the time the resident came into the emergency room on February 2, 2025 and that she did the initial assessment of Resident #1. The physician stated that Resident #1 claimed she was discharged to a shelter from the facility and that they did not have space for her when she arrived. The physician stated that the nurses witnessed and documented a PICC line in the right upper extremity of Resident #1 upon her admission to the hospital.
An interview was conducted on February 5, 2025 at 2:18 p.m. with a Licensed Practical Nurse (LPN/Staff#57) who stated that on the day of discharge, the PICC line would be removed from residents with a PICC line. The LPN further stated that residents would not be discharged with a PICC line in place.
An interview was conducted on February 5, 2025 at 2:25 p.m. with the Director of Case Management (DOCM/Staff#77) who stated that when a resident ' s coverage would run out she would try to find a discharge location that works for them, and if a resident had substance abuse problems she would try to get placement. Staff #77 stated that when the facility discharged residents to shelters, they would look at whether or not a resident was alert and oriented because they wouldn't know if there would be a spot at the shelter when they were discharged and there was no way to communicate with the shelter. Staff #77 stated that in Resident #1's case, her coverage was ending on January 31, 2025, the doctor changed the antibiotics from IV antibiotics to PO (by mouth), and that the facility could not send residents with a wound vac if they did not have a place to live. Staff #77 stated that they changed Resident #1 from IV to PO antibiotics because they, would have had to keep her if they did not. Staff #77 stated that it would be dangerous to discharge a resident with a PICC line who had a history of drug abuse. Staff #77 stated that if a resident was discharged with a PICC line left in place, it would indicate an unsafe discharge.
An interview was conducted on February 5, 2025 at 2:32 p.m. with a Registered Nurse (RN/Staff#23) who stated that a resident being discharged would need their PICC line removed by a registered nurse before discharging.
A telephonic interview was conducted on February 5, 2025 at 3:48 p.m. with a License Practical Nurse (LPN/Staff#66) who stated that his role in the discharge process was to check for wounds, sign the discharge summary, initiate a discharge progress note, document the time the resident left and what they signed, document if the resident took prescriptions, who was taking the resident, and how they left. Staff #66 stated that if he removed a PICC line he would document in the progress note that it was removed. The LPN also stated that there needed to be an order to remove the PICC line. The LPN stated that he had removed a PICC line before, but never at this facility and he stated that it was important to remove a PICC line to avoid problems with infection and to prevent residents from using it for their own purposes like drug abuse. The LPN further stated that he worked with Resident #1 the morning she was to be discharged and he was unsure of why she was moved from IV to PO antibiotics. The LPN relayed that when he got to Resident #1's room to discharge her, she was nowhere to be found, but he did not want to say she was lost. He further stated that at that time he spoke with a staff member at the front desk who stated that they witnessed the resident leaving with the wheelchair and getting into a vehicle. The LPN stated that he does know if the resident left against medical advice because, someone told me (Staff #66) she (the resident) was smoking downstairs by the chapel. Staff #66 further stated that he did not report it to anyone because his, schedule was busy that day, and he did not tell anyone that Resident #1 left without a skin assessment. The LPN stated that he did not remove Resident #1's PICC line prior to her discharge and that he would call it an unsafe discharge if a resident discharged into the community with a PICC line in place and a history of substance abuse.
An interview was conducted on February 5, 2025 at approximately 4 p.m. with the Director of Nursing, (DON/Staff#22), who confirmed that the resident was discharged with a PICC line. The DON stated that the nurse let Resident #1 know she would be discharging and that she needed to come back to see him. The DON stated that the facility knew Resident #1 left with the PICC line in place because she was on IV antibiotics at the facility. The DON further stated that the facility did have patients who would leave against medical advice in the past; and that, the process would be to call the police, but the police told the facility they are, no longer taking those calls. DON stated that the discharge for Resident #1 was considered a completed discharge and was not considered an against medical advice (AMA) discharge. The DON stated that the facility called the resident a ride for transportation to the shelter, and that they don't know if Resident #1 got into the vehicle. The DON stated that discharging Resident #1 with a PICC line would be a safe discharge because she was alert and oriented, and could leave if she chose to. The DON then stated that you cannot safely discharge to the community a resident with history of drug abuse with a PICC line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #66 was admitted on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, aphasia, epilepsy unspecified, type 2 diabetes mellitus, atrial fibrillation, unspecified dementia and anxiety disorder.
The care plan initiated on October 21, 2021 included that resident was on anticoagulant therapy related to atrial fibrillation. Interventions included to take/give medication at the same time each day.
The current comprehensive care plan included an intervention to administer medications as ordered and to monitor/document for side effects and effectiveness.
Review of the physician orders revealed the following morning medications:
-Aspirin (nonsteroidal anti-inflammatory) 81 mg (milligrams) give 1 tablet by mouth one time a day for DVT (deep vein thrombosis) prophylaxis;
-Tramadol (narcotic analgesic) 50 mg give 1 tablet by mouth every 6 hours as needed for pain 1-10;
-Acetaminophen (analgesic) 325 mg give 2 tablets by mouth every 6 hours as needed for generalized discomfort;
-Amiodarone (antiarrhythmic) 200 mg give 1 tablet by mouth one time a day for Atrial fibrillation;
-Apixaban (anticoagulant) 5 mg give 1 tablet by mouth two times a day for Atrial fibrillation;
-Clonidine (anti-hypertensive) 0.1 mg give 1 tablet by mouth every 8 hours for hypertension;
-Diltiazem (calcium-channel blocker) 30 mg give 1 tablet by mouth two times a day for hypertension; and,
-Famotidine (antacid) 20 mg give 1 tablet by mouth two times a day for GERD (gastro-esophageal reflux disease).
These medications were transcribed onto the MAR for August 2022.
However, review of the MAR revealed that these medications were neither documented as administered or not administered as ordered on August 26, 2022; and that, the boxes for these medication on this date were blank.
The clinical record revealed no evidence why these medications were not administered as ordered; and that, the physician was notified.
An interview with licensed practical nurse (LPN/staff #156) was conducted on May 26, 2023 at approximately 10:00 a.m. The LPN stated that staff were supposed to document if the resident took the medication or refused; and, inform the physician if the medication was not given or the resident refused. The LPN also stated that a nurse was expected to document administration/non-administration of medication and/or refusal of medication at time of administration in the clinical record. The LPN stated that she was unable to answer why there was no documentation that medications were administered or not administered to resident #66; or. the resident refused medications on August 26, 2022; and that, nursing staff probably failed to document administration. The LPN also stated that nurses worked 12 hour shifts and it was weird that charting of administration was not present in the electronic clinical record. Further, the LPN said if a nurse fails to document administration could result in a possible or definite medication error because the nurse may be unsure if the medication was given or not. The LPN also said that if a medication was not given it could pose harm to the resident.
During an interview with the Director of Nursing (DON/staff #27) on May 26, 2023 at approximately 10:30 a.m., the DON stated that if a resident was administered with a medication, the staff would document the administration on the medication administration record (MAR) and/or if the medication was refused staff would document the refusal in the clinical record (MAR or progress note) and contact the provider. The DON stated that her expectation was for nurses to document in the clinical record whether or not the resident had received the medication. She stated that the risk to a resident could be a complication or change in condition due to the administration or lack of administration; and that, the nurse managing the change in condition would not know if the change in condition was related to the administration or lack of administration of the medication. Further, the DON stated that all resident refusal of medications is passed along in shift report.
According to facility policy titled Administration of Drugs revised August 2022, it is their policy that medications shall be administered as prescribed by the attending physician. The policy included the seven rights of medication administration are as follows to ensure safety and accuracy of administration: right resident, right time, right medication, right dose, right route, right documentation and right diagnosis. Further, right documentation was defined as documentation of administration or refusal of medication after the administration or attempt and note any concerns. Further, the policy included that medications must be administered in accordance with the written orders of the attending physician; and that, Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer and record the administration of medications.
Based on observations, clinical record reviews, staff interviews and facility policy review, the facility failed to ensure that medications were not left at bedside and readily available for use for one resident (104) and, the facility failed to ensure medications were administered to one resident (#66) as ordered by the physician. This deficient practice could result in residents not receiving medications as ordered by the physician and could result in increased risk of side effects.
Findings include.
Resident #104 admitted on [DATE] with diagnoses of necrotizing fasciitis, sepsis, acute respiratory failure and type 2 diabetes mellitus with diabetic neuropathy.
A review of the clinical record revealed no documentation of a physician order for any eye drops.
During an observation of the resident's (#104) room conducted on May 22, 2023, revealed the following eye drop bottles were found at the bedside: Refresh (ocular lubricant), Latanoprost (eye pressure lowering agent) and Brimonidine Tartrate (alpha adrenergic agonist).
In another observation conducted on May 25, 2023 at 10:24 a.m., the abovementioned eye drop medication bottles continued to be found at bedside of resident #104.
An interview with certified nursing assistant (CNA/staff #114) was conducted on May 25, 2023 at 10:39 a.m. The CNA she had never observed medications in resident rooms; and that, residents are not allowed to keep medications in their rooms. The CNA also said that she had not seen a resident self administer medications; and, had only seen a nurse give medications. The CNA also stated if she finds medications in a resident room, she would remove the medications and give them to the nurse on shift.
In an interview with registered nurse (RN/staff #63) conducted May 25, 2023 at 10:32 a.m., the RN stated that residents were not allowed to administer their own medications; and that, if she enters and finds medications in the resident room, she would ask the resident when the last time he/she took the medication, would remove the medications and would check if there was an order for them. The RN also said that she would compare the medication/s with the physician order or MAR (medication administration record) transcribed; and, would notify the provider and follow directive/orders. During the interview, a review of the clinical record with the LPN who stated that resident #104 did not have physician orderd for the eye drops found at bedside in the resident's (#104) room.
During an interview conducted with Director of Nursing (DON/staff #27) on May 25, 2023 at 10:44 a.m., the DON stated the residents are allowed to self administer medications, prescribed or OTC (over the counter) if the residents were assessed and approved by the provider. The DON stated that there were no residents in the facility that were assessed and approved to self administer medication. Further, the DON said that residents were not allowed to keep medications in their room unless they were approved for self administration of the medication. She stated that if there was medication in the resident room that was not approved for self administration, it will be removed and the provider orders will be reviewed to see if there was an order for the medication. The DON also said that if there was no order for resident self administration, the nurse will store and administer the medication; and that, if there was no order for the medication, the provider will be notified and obtain an order to continue or discontinue the medication. The DON stated that residents will always be educated regarding medication and facility policy; and that, risk/benefits of the medication will be discussed with the resident as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that assessments consistently identified and accurately described the skin condition for one resident (#2). The deficient practice could result in resident not receiving the appropriate care and services according to their needs.
Findings Include:
Resident #2 was readmitted on [DATE] with diagnoses of abscess of bursa to right shoulder, cellulitis of right upper limb, end stage renal disease (ESRD), type 2 diabetes and anemia.
The care plan dated February 17, 2023 included the resident had potential for pressure ulcer development related to right shoulder abscess, s/p (status post-surgical debridement, morbid obesity, and had a wound to the right shoulder. Interventions included to follow facility policies/protocol for the prevention/treatment of skin breakdown; to monitor/document/report to physician as needed changes in skin status such as appearance, color, wound healing, signs/symptoms of infection, wound size and stage; and weekly head to toe skin at risk assessment.
The physician progress note dated March 6, 2023 revealed the resident was alert and awake, had warm and dry skin with no rash noted. Assessments included chronic issue of shoulder pain; and that, the resident was informed 2 weeks ago that she may have a pus pocket in her shoulder which on examination looked to be at baseline; and that there may be fluid collection or inflammatory reaction palpated in the right shoulder. Plan included checking the area using an ultrasound; and, preventive skin measures per nursing/facility.
Despite documentation that the resident had skin issue identified, the shower skin assessment dated [DATE] included shower was provided and there were no old/new skin issues identified and documented.
The soft tissue ultrasound result dated March 8, 2023 included 8.5 cm (centimeters) in greatest diameter of hypoechoic vascular area seen on the right shoulder which could represent bony deformity versus soft tissue mass. Impression was an 8.5 cm mass.
The shower skin assessment dated [DATE] included that bed/sponge bath was provided and there were no old/new skin issues identified and documented.
A nurse practitioner (NP) progress note dated March 15, 2023 included the resident was alert and awake and skin was warm and dry with no rashes noted. Per the documentation, the surface of the shoulder looked to at baseline; and that, there may be a fluid collection or inflammatory reaction palpated in the right shoulder.
The daily skilled note dated March 15, 2023 included resident was alert and oriented x 4; and there were no active symptoms affecting the integumentary system observed and no new issues reported. The documentation did not mention description of the right shoulder.
The shower skin assessments dated March 14, 16 and 19, 2023 included resident refused shower or bed/sponge bath.
The weekly skin evaluations dated March 9 and 21, 2023 revealed the skin was intact, had skin discoloration to buttocks and back of thighs and some scattered bruising to the left arm and to the top of the left foot. However, it did not document description of wound to the right shoulder.
The shower skin assessment dated [DATE] included bed/sponge bath was provided; and that, there was nothing new to report related to old/new skin issues.
The weekly skin evaluation dated March 29, 2023 included skin was intact, warm to touch and had no areas of concerns noted. It did not include description of wound to the right shoulder.
Review of the clinical record revealed that succeeding skin assessments dated April 5, 12 and 19, 2023 revealed skin was intact and there were no issues noted related to the right shoulder.
Further, the clinical record revealed no documentation of the wound to the right shoulder from march 7 through April 22, 2023.
The skin assessment dated [DATE] revealed an abscess was noted to the front of the right shoulder; and that, there was redness, warmth and tenderness to touch noted. Per the documentation, there was no drainage noted.
The nursing note dated April 24, 2023 included resident had abscess, raised, soft, reddened right shoulder. Per the documentation resident was requesting to go to the hospital for evaluation.
Another nursing note dated April 24, 2023 revealed that resident was transported to the hospital in stable condition.
Further review of the clinical record revealed no documentation that the wound to the right shoulder was monitored; and that, treatment was provided from March 6 through April 24, 2023.
Review of hospital physician progress note dated April 27, 2023 included that I&D (incision and drainage) was completed; and that, the resident had a large necrotizing soft tissue infection of the right shoulder.
An interview with resident #2 was conducted on May 22, 2023 at 10:30 a.m., she stated the pain on right shoulder was worsening each day and she wanted to be seen by a skin specialist. Resident #2 stated her family came to visit one day and saw how bad her skin looked and had informed the nurses to examine her skin. Resident #2 stated the facility and the nurse at that time did not want to send the resident out to the hospital; however, her family got upset and demanded the facility to send resident #2 out to the nearest hospital. Resident #2 stated she had told the nurses about the bruising, redness and swelling to her right shoulder but the nurses told resident #2 that they will just continue to monitor.
In an interview with the Director of Nursing (DON/staff #27) conducted on May 24, 2023 at 12:26 p.m., the DON stated that skin assessments are done on the day it prompts the nurses on the TAR (treatment administration record); and that, skin assessments are done weekly. The DON said that the expectation was for nurses to complete a thorough assessment of the skin and document any area that needs to be treated. She stated that if there were new skin issues and it was not on the day of the skin assessment, the expectation was for the nurse to document it in a progress note. The DON said that the wound nurse would be consulted; and that, the best time to notice any new skin issues is during the resident's shower days. She stated the CNA does not complete the skin assessment but if anything abnormal was noticed and was noted before, then the CNA was to notify the bedside nurse.
In another interview with the DON (staff #27) conducted on May 24, 2023 at 3:40 p.m., the DON stated that skin assessment was completed for resident #2; and that, the physician note dated March 6, 2023 documented a pocket of puss to the right shoulder from an appointment the resident went outside of the facility. The DON said that the facility physician reported a mild boggy sensation on the resident arm; and that, she did not know why the skin assessments completed by staff did not mention skin issue regarding the pocket pus identified by the facility physician. Further, the DON said that the facility physician did not say the resident had pocket pus as this was a description documented by a physician who saw the resident during an out-of-facility appointment.
An interview with corporate staff and the DON (staff #27) was conducted on May 25, 2023 approximately between 12:00 p.m. and 1:00 p.m. Both the corporate staff and the DON stated that proper interventions were followed for resident #2 and explained that an abscess could be internal and in the case of resident #2, there was not much the nurses could document in their skin assessment.
Review of the facility policy on Skin and Wound Monitoring and Management included that a licensed nurse must assess/evaluate a resident's skin on admission and each pressure injury and/or non-pressure injury that exists on the resident. The assessment t/evaluation should align with the scope of practice and include but not limited to: measuring the skin injury; staging the skin injury (when the cause is pressure); describing the nature of the injury (e.g., pressure, stasis, surgical incision), describing the location and characteristics of the skin alteration. A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as a new findings) must be documented in the nursing notes or on appropriate weekly assessment form. (Skin Pressure Ulcer Weekly, Skin Ulcer Non-Pressure Weekly, or Skin Evaluation - PRN/Weekly). The policy further included that once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per physician's order. Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessment/evaluation weekly/PRN (as needed) form. All residents will have a head to toe skin check performed at least weekly by a licensed nurse who should document the findings. Any skin issues identified as a result of weekly skin check should be documented and responded to.

Based on personnel file review, staff interviews and facility documentation and policy review, the facility failed to ensure that evidence of training to safely and effectively carry out the functions of the food and nutrition services were not expired for two staff members (#92 and #132). The deficient practice could result in dietary not having the appropriate skills to carry out their functions and responsibilities.
Findings include:
-Regarding the dietary aide (staff #92)
The personnel file of dietary aide (staff #92) revealed a hire dated of November 14, 2019. The file also included a completion of a Food Handler Card Training dated November 12, 2019 and was valid through November 12, 2022.
However, there was no evidence found that the food handler card training was renewed and completed after November 12, 2022.
Review of the punch details for staff #92 revealed that staff #92 worked more than 50% of the time after November 12, 2022.
-Regarding dietary aide/cook (staff #132)
The personnel file of dietary aide/cook (staff # 132) revealed a hire date of April 13, 2022. The file included that staff #132 did not complete food handler card training within 30 days of the hire date.
The unsigned and undated job description for staff #132 revealed that education and experience requirement for a job title of a cook included a current food handler's permit as required by State regulation. However, there was no evidence found that staff #132 had food handler card training from April 13 through May 21, 2023.
The personnel file revealed that food handler card training was issued for staff #132 on May 22, 2023.
During an interview with the Human Resource (HR) Director (staff #46) who stated the onboarding process was done once an offer letter is sent out and signed by the new hire employee; and that, a sit down is done with HR and all the required documents are done in the office. Staff #46 said that orientation is set up for the new hire and they are to complete online training through corporate, and two in-person orientation as well. Further, staff #46 stated training is scheduled through the department head and the staffing coordinator also helps out with onboarding. The HR director said that they use a payroll system call Workday and all the license information is entered into that system. She said she runs a report monthly and will send a detailed email to each department head for any upcoming renewal license or expired license or certifications.
Regarding the dietary aide (staff #92), the HR director stated that the food handlers' card for staff #92 expired on November 12, 2022 and there no renewal completed.
Regarding the dietary aide/cook (staff #132), the HR director said that staff #132 did not have a food handler card training completed within 30 days of hired date; and, did not have a food handler card training until May 22, 2023.

Based on observation, staff interviews and review of facility documentation, policies and procedures, the facility failed to ensure that staff were consistently screened for COVID-19 upon entry to the facility and prior to working their shift. The deficient practice could result in the spread of infection to residents and staff.
Findings include:
During an observation conducted on February 28, 2022 at 8:00 a.m., the receptionist instructed the staff and visitors waiting in the lobby to wear a mask and perform hand hygiene using the alcohol-based hand rub (ABHR) also located in the lobby. At the corner of the lobby, there was an I-Pad which the receptionist directed the staff and visitors to go for COVID-19 screening questions. The electronic screening questions included signs and symptoms of COVID-19, recent travel, COVID-19 exposure, and temperature. A laminated poster with information on handwashing and precautionary measures for symptomatic staff and visitors was also posted on the door as you entered the lobby.
Review of the Labor Hours Reports dated February 19, 20 and 21, 2022 revealed the following staff punched in and worked their entire shifts on the following dates:
-February 19: registered nurse (RN/#170); laundry staff (#24); dietary aide (#22);
-February 20: dietary aide (staff #22); licensed practical nurse (LPN/#38); registered nurse (RN/#149); certified nursing assistant (CNA #147); and,
-February 21: laundry staff (#97) and dietary aide (#56)
A review of the screening documents dated February 19 through 21, 2022 revealed documentations of COVID-19 screening for staffs #24 and #22 only for February 19.
Further review of facility documentation revealed no evidence that staffs #38, #56, #97, #147, #149, and #170 were screened for COVID-19 prior to or at the beginning of their shifts on February 19, 20 and 21, 2022.
An interview was conducted on February 28, 2022 at 1:42 p.m. with a certified nursing assistant (CNA/staff #142) who stated that the staff screening area is located at the front lobby or the back of the facility by the time clock. Staff #142 stated that staff performs self-screening prior to working and once completed, staff can clock in and sign-in by the computer.
In an interview conducted with the Infection Control Preventionist (ICP/ staff #125) on March 1, 2022 at 1:14 p.m., the ICP stated an in-service training on self-screening prior to entry to resident care areas was provided to all staff; and that, Human Resources (HR) maintained screening completed for all staff.
However, during an interview conducted on March 2, 2022 at 9:22 a.m., the Director of Nursing (DON/ staff #150) stated that only two (staff #24 and 22) out of 8 sampled staff completed the screening prior to entering the resident's care area; and that, she could not find any documentation that staffs #38, #56, #97, #147, #149, and #170 were screened prior to their shifts. She stated her expectation was for every staff to complete a COVID-19 screening prior to entering the resident's care area; and that, staff who do not comply with the facility's screening policy will not be allowed to enter the building. The DON further stated moving forward, the employee entrance will have a staff monitor 24/7 to ensure this deficient practice does not occur again.
The facility policy on Infection Control and Prevention, stated that it is their policy to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. The policy included healthcare personnel be screened on a daily basis, and monitored for COVID-19 symptoms and fever.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure an ongoing activity was provided based on the comprehensive assessment and preferences for one resident (#462). The deficient practice could result in the not having meaningful activities based on the resident's interest and preferences.
Findings Include:
Resident #462 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare, unilateral primary osteoarthritis, left hip and presence of left artificial hip joint.
A nursing progress note dated February 16, 2022 revealed the resident was alert and oriented x 4 and was able to make needs known.
An activity admission evaluation dated February 17, 2022 revealed the resident was alert and oriented to person, place and time with adequate communication and cognition skills. Activity interests included card games, computer games, puzzles, exercise groups, music, reading, walking and wheeling outdoors, sewing and watching television (TV).
The activities care plan dated February 17, 2022 included the resident was dependent on staff for activities, cognitive stimulation and social interactions related to physical limitations such as left hip fracture. The goal was that the resident will attend and participate in activities of choice. Interventions included preferred activities such as computer games, logic puzzles, classical music, [NAME] King books, sitting outside, TV, sewing, pet visits and current events. Further, the care plan included the resident needed one to one bedside/in-room visits and activities if unable to attend out of room.
The NP (nurse practitioner) progress note dated February 18, 2022 included the resident was alert and awake and had multiple complaints about food, room and TV (television).
The social service summary note dated February 21, 2022 revealed the resident was alert and oriented x 3 and was able to make needs known.
Review of the Activities log from February 17, 2022 through March 1, 2022 revealed the resident was documented as active in independent activity of watching TV and meal/food/or snack. According to the documentation, there was no one on one activity provided. The log also revealed the resident was marked as not available for the following activities:
-Creative activity in February 20 and 27;
-Mental activity on February 24; and,
-Social activity on February 26.
An observation was conducted on February 28, 2022 at 11:43 a.m., revealed resident #462 was in her room, lying in bed and the activity calendar was posted on the wall to the left of the resident. An interview was conducted immediately following the observation. Resident #462 stated that when she got admitted at the facility, the activity calendar was posted on a different side of the wall where she could not see it; and that, she had to ask for it to be posted closer to her so she could read it. Resident #462 stated she would have gone to activities and she would like to do activities but she did not know how. She stated that there was no posting of activity for February available in her room and the calendar posted at the time of interview was already for the month of March. Further, resident #462 stated that no one from activities had spoken with her to discuss any activity options.
An interview was conducted on March 1, 2022 at 12:57 p.m. with the activity director (staff #99) who stated she had been the activity director for a year. She stated each resident is interviewed regarding their activity preferences within three days of admission. Staff #99 said each resident is provided with their preferred activities; and that, all activities provided are documented in the clinical record and in the progress notes. She stated that for residents on transmission-based precautions, activities will be provided in the resident's rooms. Regarding resident #462, she stated she was familiar with the resident and was not aware the resident refused to participate in activities at any time. When asked about resident's preferred activities, staff #99 said she would have to check the resident's record.
An interview was conducted on March 3, 2022 at 12:48 p.m. with the Director of Nursing (DON/staff #35) who stated residents were restricted to activities in their rooms due to COVID-19 precautions in the building. The DON stated activity staff put a special focus on residents in the observation unit since they are not able to leave their rooms for activities. She stated the activity staff completes an assessment and provide resident activities according to their preferences. The DON stated the activity director and associates should be going into each resident's room to provide activities. Regarding resident #462, the DON said the resident was admitted in the observation unit and was placed on transmission-based precautions. Further, the DON stated she was not aware of any issues regarding the activity program.
The facility policy on Activities revealed that it is their policy to ensure that residents have the right to choose the types of activities and social events in which they wish to participate. Residents are encouraged to choose the types of activities and social events in which they prefer to participate. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure care and services were provided to prevent the development of pressure ulcer for one resident (#262) and failed to ensure the pressure ulcer was thoroughly assessed consistently. The deficient practice could result in residents developing pressure ulcers and has the potential for inadequate or inaccurate or inappropriate treatment and subsequent deterioration of pressure ulcer.
Findings include:
Resident #262 was admitted on [DATE] with diagnoses of unspecified low back pain, sciatica and generalized muscle weakness.
The skin integrity care plan dated December 6, 2021 revealed the resident having potential impairment for skin integrity related to incontinence, limited mobility, sciatica and severe pain. Interventions included weekly skin assessment; following facility protocols for treatment of injury; and, notifying the nurse immediately of any new areas of skin breakdown: redness, blisters, bruises or discoloration noted during bath or daily care.
The pressure ulcer care plan dated December 6, 2021 included the resident having a potential for pressure ulcer development related to incontinence, limited mobility, back pain and sciatica. Goal was that the pressure ulcer will show signs of healing. Interventions included wound care to be completed by the physician/NP (nurse practitioner); medications/treatment as ordered; weekly head to toes skin at risk assessment; and, to monitor/document/report to the physician as needed changes in skin status such as appearance, color, wound healing, wound size and shape.
Review of the Braden Scale dated December 6, 2021 revealed a score of 15 indicating the resident was at low risk for pressure ulcer.
A physician order dated December 6, 2021 included for encouraging turning and repositioning every shift, weekly Braden scale for 4 weeks on night shift (Monday) and weekly skin evaluation every night shift (Friday). The start date for the weekly skin evaluation was December 10, 2021.
The occupational therapy (OT) note dated December 7, 2021 included the resident required maximum assistance x 2 for sit to supine and repositioning; and maximum encouragement for participation due to pain level.
The nutritional care plan dated December 7, 2021 included the resident had a nutritional problem or potential related to alteration in skin integrity as evidenced by PI (pressure injury); and that, the resident had increased nutrient needs related to wound healing.
However, the skin/wound note dated December 7, 2021 revealed the resident was seen for initial skin evaluation and there were no pressure ulcers present. Per the documentation, the resident had generalized dry skin, was unable to demonstrate ability to turn side to side, unable to reposition self while in bed and unable to lift each leg off the surface due to severe pain.
A physician order dated December 8, 2021 revealed an order to apply house barrier cream topically to the buttocks/peri area every shift for skin care.
The shower sheet for December 9, 2021 revealed the resident was provided with a bed/sponge bath. The documentation did not indicate any old or new skin issues.
The daily skilled note dated December 11, 2021 included the resident was alert and oriented x 3, with skin described as warm, dry and intact and with fair turgor. Per the documentation, there were no active symptoms affecting the integumentary system observed; and that skin condition is not a new onset. The documentation did not include whether or not the resident had skin issues or wounds.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The assessment also included the resident at risk of developing pressure ulcers or injuries, had no pressure ulcer or injury and no skin tears or moisture related skin damage. Skin and ulcer treatments included pressure reducing devices for chair and bed. Further, the MDS revealed the resident was frequently incontinent and required extensive assistance with tasks such as personal hygiene and bathing.
The weekly skin evaluation dated December 13, 2021 revealed no new skin issues. However, the documentation did not include whether or not the resident had skin issues or wounds.
The shower sheet for December 13, 2021 revealed the resident was asked three times but refused a shower or bed/sponge bath.
A late-entry daily skilled note dated December 13, 2021 revealed a normal overall skin description and there were no active symptoms affecting the integumentary system observed; and that, skin condition is not a new onset. The documentation did not include whether or not the resident had skin issues or wounds.
The succeeding daily skilled notes from December 14 through 16, 2021 included skin was intact with no active symptoms affecting the integumentary system.
The shower sheet for December 16, 2021 revealed the resident was provided with a bed/sponge bath.
The weekly skin evaluation dated December 18, 2021 revealed skin was warm, dry and intact; and there were no open areas or lesions noted.
The shower sheet for December 19, 2021 revealed the resident was provided with a bed/sponge bath. The documentation did not indicate any old or new skin issues.
The shower sheet dated December 23, 2021 revealed the resident refused a shower or bed/sponge bath.
The daily skilled notes from December 18 through 25, 2021 revealed the skin was intact with no active symptoms affecting the integumentary system.
The weekly skin evaluation dated December 25, 2021 revealed no new skin issue. However, the documentation did not include whether or not the resident had existing skin issues or wounds.
The shower sheet dated December 26, 2021 revealed the resident refused a shower or bed/sponge bath; and that the resident was in too much pain.
A review of the certified nursing assistant (CNA) documentation from December 8 through 26, 2021 revealed the resident was turned and repositioned at least two to three times per day; except on December 24 and 25 when it was documented that the resident was repositioned only once in a 24-hour period.
Review of the treatment administration record (TAR) for December 2021 revealed that weekly Braden scale assessments and skin evaluations were completed as ordered. It also revealed that barrier cream to the buttocks/peri area was administered from December 8 through 25, 2021.
Continued review of the clinical record from December 6 through December 25, 2021 revealed no evidence the resident had any wound or skin issues identified.
However, review of the weekly pressure ulcer assessment dated [DATE] revealed an initial evaluation of an unstageable pressure ulcer to the sacrum which was not present on admission. It also included moderate serosanguineous exudate with slight odor, macerated wound edges, and wound bed had black/brown eschar.
The skin/wound note dated December 26, 2021 revealed the wound on the resident's sacrum that measured 9.5 centimeters (CM) x 13.6 cm with moderate eschar, minimal pink granulation and moderate serosanguineous drainage.
The Braden scale assessment dated [DATE] included a score of 12 indicating the resident was at high risk for pressure sore.
The pressure ulcer care plan was revised on December 26, 2021 to include wound to the sacrum.
The interdisciplinary team (IDT) review note dated December 26, 2022 revealed the resident's pressure ulcer on the sacrum was unavoidable because the resident had impaired mobility, bowel/bladder incontinence and serum albumin below 3.4 grams/deciliter (g/dl) or pre-albumin below 15 milligrams/deciliter (mg/dl). Risk factors included weight loss and muscle weakness. The following interventions were put in place: low air loss mattress (LALM), wheelchair cushion, frequent repositioning and dietary support. Recommendations included providing supplements and follow up with the wound team.
A physician order dated December 26, 2021 included to cleanse the sacral wound with wound cleanser or normal saline, apply Dakin's gauze to wound bed and cover twice daily and as needed.
This order was transcribed onto the TAR for December and was documented as administered as ordered.
Despite documentation the resident had an unstageable pressure ulcer to the sacrum, the daily skilled notes from December 26 through 28, 2021 documented skin was intact.
The skin committee IDT note dated December 30, 2021 included unstageable pressure ulcer to sacrum, with moderate eschar, minimal pink granulation and moderate serosanguineous drainage. The documentation did not include the measurement of the wound.
The weekly skin evaluation dated January 1, 2022 revealed skin was warm, dry, fair turgor and with sacral wound noted. The documentation did not include the type and stage, measurement and wound descriptions such as presence/absence of exudate, odor, tunneling, slough or eschar.
The daily skilled notes dated January 1 and 2, 2022 revealed the skin was warm, dry with a sacral wound; and, to refer to wound notes.
However, the clinical record revealed no evidence of wound notes for January 1 and 2, 2022.
The Braden scale assessment dated [DATE] revealed a score of 11 indicating the resident was at high risk for pressure sore.
The weekly pressure ulcer assessment dated [DATE] was signed as completed. However, there were no other areas answered except that it was a follow-up assessment. The sections regarding wound location, stage, measurement, exudate, description of wound bed/edges and surrounding tissue were blank.
The clinical record revealed no evidence the pressure ulcer to the sacrum was thoroughly assessed to include measurement and status of the wound from December 27, 2021 through January 3, 2022.
The daily skilled note dated January 4, 2022 revealed skin was warm to touch with new issues; and, to see wound nurse's notes.
However, the clinical record revealed no evidence of a wound note for January 4, 2022.
Further review of the clinical record revealed that on January 4, 2022, the resident was admitted to hospice services for a diagnosis of malnutrition.
The physician order dated January 4, 2022 included an order for discharge to a group home with hospice services.
The hospice nurse's initial assessment dated [DATE] revealed a stage IV pressure ulcer to the coccyx that measured 14 cm x 20 cm x 3 cm, with small serosanguinous drainage, red wound bed, attached wound edges, and intact surrounding tissue.
The Discharge summary dated [DATE] revealed the reason for discharge was that the resident's health had improved sufficiently and services of the facility were no longer required. The section on skin/wounds was blank.
The skin committee IDT note dated January 5, 2022 included unstageable pressure ulcer to sacrum, with loose black eschar loosely attached to wound edges, bone and tendon present, moderate serosanguineous drainage and with strong odor on exam. Per the documentation, the wound was staged by the wound care NP as stage IV sacral decubitus ulcer. However, the documentation did not include the measurement of the wound.
However, the discharge MDS assessment dated [DATE] revealed the resident had one unstageable pressure ulcer due to slough and/or eschar.
There was no documentation found in the clinical record from January 5 through 7, 2022 that the stage IV pressure ulcer to the sacrum noted on January 5 got worse and/or became an unstageable pressure ulcer.
The clinical record also revealed no evidence that a new unstageable pressure ulcer developed from January 5 through 7, 2022.
An interview was conducted on March 1, 2022 2:40 p.m., with a registered nurse (RN/staff#104) who stated a head to toe assessment is completed/documented in the electronic record upon resident's admission at the facility and succeeding skin assessments of all residents in the skilled unit are done every week, usually on a Thursdays. The RN stated showers are typically done twice a week by the CNAs who also assess the resident for any skin issues and are expected to advise the nurse of any concerns. She said the nurse would then document the concern and inform the wound nurse. Further, she said a wound doctor visits the facility at least weekly and will make rounds with the wound nurse to address resident skin concerns.
On March 2, 2022 at 8:54 a.m., an interview was conducted with a licensed practical nurse (LPN/ staff #127) who stated that skin assessments on all residents are done by nursing staff once a week. She said if there are any issues or concerns, the provider and wound care nurse are notified and the issue is documented in the electronic record. Staff #127 said skin assessments are ongoing and it is a standard of practice to always compare the assessments from current week to the prior week. She said an alert and oriented resident can also tell the nurse if they notice new skin issues. Further, staff #127 said that the weekly skin assessment found in the electronic record was the only document the staff use to document skin findings and/or wounds.
During the interview, a review of the clinical record was conducted with staff #127 who said resident #262 did not have a wound when she came in, had no skin issues noted on December 25, 2021; but, revealed a large wound on the coccyx on December 26, 2021. Further, staff #127 stated the progression and the size of the resident #262's wound would not have occurred in 24 hours. She said she does not know how a sudden change in skin condition would happen.
An interview was conducted with the wound care nurse (staff #102) on March 2, 2022 at 10:15 AM. Staff #102 stated she sees all new admissions within 24 hours to ensure all residents' skin integrity; follows treatment orders; and conducts rounds with the wound care doctor. Staff #102 also stated she also assesses for any potential risks for the development of pressure ulcers the resident may have and would put the needed interventions in place. Regarding resident #262, the wound nurse said the resident was bed-bound, very thin, in pain and was unable to reposition self because of sciatica. She said that because of these factors, wound or pressure ulcer development was probable. She said upon admission, a low air loss mattress was ordered for the resident to assist with repositioning. Additionally, staff #102 stated she conveyed to staff the importance of turning and repositioning for resident #262.
During the interview, a review of the clinical record was conducted with staff #102 who stated skin assessments were done on December 15 and 25, 2021 which revealed no new skin issues. Staff #102 said that according to the documentation on December 26, 2021 that she was notified by a nurse supervisor that the resident had a coccyx wound measuring 9.5 cm. X 13.6 cm. Staff #102 stated that in her opinion, it was impossible for a wound that size to develop within 24 hours. She said that from her experience, the wound probably took approximately 2 weeks to form; and that staff should have noticed skin changes much earlier. The wound nurse said that if resident #262 refused turning and repositioning because of pain, staff should have contacted the provider to address a possible change in pain medications. She said she was new to the role of a wound nurse; and that the previous wound nurse who was present at the time the resident was admitted no longer works at the facility. She further stated it was clear to her that the previous wound nurse was not aware of the resident's skin changes because there were no additional interventions put in place since resident's admission on [DATE] until the time when the wound was discovered on December 26, 2021.
In an interview with the Director of Nursing (DON/staff #35) on March 3, 2022 at 1:27 p.m., the DON stated her expectation was for skin assessments to be done completely and in a timely manner. She said the Braden scale and/or skin assessments are done by the nurses weekly and/or pressure ulcer wound assessments are done by the wound care team to determine and see the status/progression of the wound. She said skin should also be checked by the CNAs during showers and bed baths; and, the expectation was for the CNAs and/or shower aides to always fill out a shower sheet and include any skin issues found. The DON said that if a new wound is identified, the nurses should contact the wound nurse, write a progress and change of condition note (COC), and notify the family and provider. She said residents who are identified as at risk for developing pressure ulcers should have the following interventions: application of barrier cream, turning/repositioning, medications, discussing risk factors with the resident for refusal of care, and talking with and asking the family to help ensure resident compliance with the interventions. The DON said if a resident report that it was too painful to be turned and repositioned, the nurse should notify the provider for more pain medications or different medications. Additionally, she said that X-rays might be ordered to determine if any bone changes had occurred. Further, the DON stated the wound care nurse is responsible for completing the weekly pressure ulcer assessments. A review of the clinical record of resident #262 was conducted with the DON who said the follow up weekly pressure ulcer assessment dated [DATE] was not filled out, had no information at all and was signed by the floor nurse and not the wound nurse. She said that perhaps it was an error; however, she could not find in the clinical record a completed document by a wound nurse for January 2, 2022. She stated the resident's pressure ulcer in the sacrum should have been assessed and documented the week after it was found and before discharge on [DATE]. The DON stated the clinical record of resident #262 was lacking appropriate documentation; and, there was no evidence of any assessments of the resident's pressure ulcer to include measurements from December 26, 2021 through January 7, 2022. Further, she stated this was a problem because the wound nurses should have been measuring and documenting the wound carefully. She said the facility tracks and trends all wounds to establish progress; and, the lack of weekly wound measurement is a concern.
The facility policy Care and Treatment / Wound Management reviewed May, 2021 revealed that it is their policy that a resident does not develop pressure ulcers unless the individuals clinical condition or other factors determine that a pressure ulcer was unavoidable interventions included to stabilize, reduce or remove underlying risks, reposition the resident, use pressure relieving devices such as low air loss mattress, pillows and wedges and if the resident is incontinent provide regular peri care to ensure the residents skin remains clean and dry. The policy further revealed that a weekly head to toe skin assessment with follow up as applicable was to be completed.
The facility policy Documentation and Charting (reviewed July, 2020) revealed that it is the facility policy to provide a complete account of the residents' care, treatment, response to care, signs, symptoms etc., as well as the progress of the residents' care.
The facility policy Skin Assessment (revised May, 2007) revealed that the facility policy was to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown. If skin breakdown is present wound care will be followed and documentation is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews and facility policy and procedure review, the facility failed to ensure care and assistance with the use of hearing aids was provided to one resident (#65). The deficient practice could lead to the resident not able to hear and maintain hearing abilities resulting in difficulty in communication.
Findings include:
Resident #65 was readmitted on [DATE] with diagnoses of unspecified fracture of the shaft of the humerus, anxiety disorder and osteoarthritis.
The care plan dated August 11, 2020 revealed the resident was at risk for communication problem related to hearing deficit and had bilateral hearing aids. The goal was that the resident will be able to make needs known on a daily basis. Interventions included to anticipate and meet needs, and use of adaptive communication equipment, hearing aid.
A nursing progress note dated January 28, 2022 revealed the resident's hearing aids were delivered.
The hearing aid service note dated January 28, 2022 revealed that new rechargeable hearing aids were delivered with charging and cleaning instructions.
The NP (nurse practitioner) progress note dated February 3, 2022 included the resident reported getting her hearing aids.
The social service summary dated February 3, 2022 revealed the resident was alert and oriented with some forgetfulness and was hard of hearing.
The annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Per the assessment, the resident had adequate hearing with hearing aids.
A physician order dated February 9, 2022 revealed for hearing aids to be placed on the charger prior to the resident going to bed every night shift.
A psychiatric note dated February 15, 2022 revealed the resident was alert and oriented x 3 and can verbalize needs.
Review of the treatment administration records (TAR) and revealed that the hearing aids were placed on the charger every night as ordered from February 10, 2022 through March 1, 2022.
However, in an interview conducted on February 28, 2022 at 1:37 p.m., resident #65 stated she was having difficulty with hearing because she does not have her hearing aids on. She said that she received new hearing aids last month but no one has helped her to get them to work yet. She stated that without her hearing aids she cannot hear; and that, she needed staff assistance in putting them on. During the interview, an observation was conducted and revealed there were two hearing aids next to the charger on the bedside table.
An interview was conducted with a licensed practical nurse (LPN/staff #25) on March 2, 2022 at 11:58 a.m. The LPN stated she had worked on this unit for several years and the residents' hearing aids are locked in the cart at night. She stated the expectation was the nurse or CNA would help the residents in putting their hearing aids on in the morning. Regarding resident #65, the LPN stated the resident does not have any hearing aids; and that, the resident hears her without a problem. Further, the LPN stated that she was not aware that resident #65 has hearing aids; and that, there are no hearing aids in the medication cart for that unit.
During an interview with certified nursing assistant (CNA/staff #59). conducted on March 2, 2022 at 12:05 p.m., the CNA stated she works on the day shift and she assists the residents to get ready for the day. She said the process for residents with hearing aids included for the nurse to take them from the cart, give the hearing aid to the CNA and instruct the CNA to put them on the resident every day in the morning. Regarding resident #65, the CNA said she does not think the resident has hearing aids and was hard of hearing.
In another observation conducted on March 2, 2022 at 12:40 p.m., the hearing aids of resident #65 was next to the charger on the bedside table. Immediately following the observation an interview was conducted with the resident who stated she still has not had her hearing aid on because none of the staff has helped her put them on. She also said that in the past, there were two staff members who would always help her with her hearing aids. However, the resident said she does not see them anymore and no one helps her with her hearing aids even when she asks for help.
Review of the facility policy on Care of Hearing Aid with review date of May 2007 revealed that it is their policy to maintain the residents hearing aids in good order. The policy included a primary purpose of caring for a hearing aid is to maintain resident's hearing aid in good order.
The facility policy on Documentation and Charting reviewed on July 2020 revealed that it was their policy to provide a complete account of the residents' care, treatment, response to care, signs, symptoms etc. as well as the progress of the residents' care.
In their policy on Services to Carry Out Activities of Daily Living with review date of July 2020, it revealed that residents are to be given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with a written plan of care.