Acacia Health Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a minimum data set (MDS) assessment was completed accurately for one resident (#54) out of 68 sampled residents. The deficient practice could result in further incomplete MDS assessments.Findings include:Resident #54 was admitted on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, pain in right hip, and type 2 diabetes mellitus.A review of the Admission/Medicare-5 day MDS assessment dated [DATE] revealed that Resident #54 had a brief interview for mental status (BIMS) score of 15, which meant the resident was cognitively intact. MDS assessment revealed Resident #54 had received injections for 2 days during the last 7 days or since admission/entry or reentry if less than 7 days. Additionally, Section N0350 Insulin, had 2 days entered for Insulin injections, that were received during the last 7 days or since admission/entry or reentry if less than 7 days.A review of the care plan revealed no focus area for the diagnosis of diabetes or mention of insulin or other diabetic medications.An interview was conducted with Resident #54 on December 24, 2025 at 10:55 a.m. who stated was not diabetic, had not received insulin at the facility or prior to coming to the facility while in the hospital, and did not have any glucose monitoring of fingers. Resident #54 stated had received shots or injections, but not for diabetes.An interview was conducted with licensed practical nurse (LPN) Staff #5 on December 24, 2025 at 10:59 a.m. who revealed that there were no orders to check Resident #54's finger glucose checks; and that, no insulin was given or orders to give insulin to Resident #54.An interview was conducted with MDS coordinators Staff #155 and Staff #22 on December 24, 2025 at 11:05 a.m. who revealed that there were three MDS coordinators who performed the facility's MDS assessments. Two MDS coordinators were able to review Resident #54's assessment and confirmed that they (Staff #155 and Staff #22) did not perform the documented assessment. Staff #96 who was not present, did the assessment. Staff #22 revealed that they reviewed hospital records, read hospital information, review all the medications, treatments and do a good portion of the care plan, over the past 7 days and confirmed that the resident did get 2 injections, but not insulin. MDS coordinators (Staff #155 and Staff #22) confirmed that the mistake was an error. Staff #155 confirmed that Resident #54 received a flu shot. Staff #22 stated Resident #54 received a covid vaccine; and that, those were the only 2 injections.An interview was conducted with director of nursing (DON) Staff #191 on December 24, 2025 at 11:47 a.m. who revealed that the expectation with the resident assessment was to be completed thoroughly and accurately.Another medical record review of the MDS assessment was conducted on December 24, 2025 at 1225 p.m. which revealed that Staff #22 showed that the MDS was corrected and sent.Review of the job description for MDS Coordinator revealed that the MDS nurse was responsible for the overall supervision, coordination, maintenance and timely completion of the MDS, care plans and medical records for residents. Section: Principle duties, number 2. Assure accuracy and completeness of entire medical record.Review of the policy Resident Assessments version 2.0 (H5MAPL0755) revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews.

Based on observations, staff interviews, and facility policies, the facility failed to ensure food items were appropriately stored and labeled; and, failed to ensure that food was not expired. The deficient practice may result in the food items not kept according to professional standards for food service safety.Findings include:During initial observation of the kitchen conducted on December 22, 2025, at 8:23 am, with the Dietary Manager (Staff #215), items were found to be opened and not labeled. Observation revealed an open container of turkey base with an open date of November 27, and without a year or use by or expiration date. Two zested oranges unlabeled with a use by date. An open container of ketchup with an illegible open date behind an unopened container of ketchup. An opened bottle of maple syrup dated August 8, with no year and thick brown buildup on the inside walls of the bottle above the level of remaining syrup. A bag of potato pancakes was open to air with no open date, use-by date, or expiration date.An interview was conducted on December 22, 2025, at 8:31 am with Staff #215 who stated that the standard practice included that items should be used within 30 days of opening. Staff #215 stated that the expectation was that oranges used for zesting are discarded after use because they do not serve raw oranges to residents. A second interview was conducted on December 22, 2025, at 8:40am with Staff #215 who confirmed that the date on the ketchup container was smudged; and that, he could not read it. Staff #215 stated that the process for storing new products was to use the first-in, first-out method - the first product to come in is used first. He described the maple syrup found as having separation and stated food items should be discarded if there is no year marked. Staff #215 stated that food should be closed and labeled when it is going back in the freezer. An interview was conducted on December 24, 2025, at 8:59am with the Administrator (Staff #203), who stated that once items are opened they are dated, and discarded after seven days. Staff #203 stated that the expectation was that if something was opened, the it should be dated. Staff #203 stated that the risk involved with not labeling food is that the food could be potentially outdated and could be expired. Staff #203 further stated that the risk involved with giving residents expired food is that they could get sick. She did not want to expand upon this. Another observation of unit refrigerators and unit dry storage snacks was conducted on December 24, 2025, at 7:53 am, the following foods were found to be expired: 5 containers Special K Original Toasted [NAME] Cereal with an expiration date of December 7, 2025; 3 containers of Special K Original Toasted [NAME] Cereal with an expiration date of November 11, 2025; 4 containers of Cheerios Toasted Whole Grain Cereal with an expiration date of November 26, 2025; 1 container of Cheerios Toasted Whole Grain Cereal with an expiration date of November 21, 2025.Another interview was conducted on December 24, 2025, at 8:20 am with Staff #215 who stated the expectation was that staff look at each dried cereal package and discard it away if it is expired. Staff #215 stated that it was similar to the process for foods stored in the fridge and freezer if it has expired -- the practice is to discard it and the risk involved is potential foodborne illness.An interview was conducted on December 24, 2025, at 8:59 am with the Administrator (staff #203) who stated the process for expired foods was that they be discarded. The administrator further stated that the risk involved with a resident having expired food was that they could become sick.Review of the facility policy titled Food Storage and Datemarking revealed that old stock is always used first, with the first-in - first-out method and that the person designated to manage stock should be trained to rotate it properly. Additionally, leftover food items should be stored in covered containers or wrapped carefully, securely and clearly labeled, dated before being refrigerated, that leftover food should be used within seven days or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility documentation and policy the facility failed to ensure that medical records accurately documented skin impairments identified for resident #024. The deficient practice could result in medical records that do not accurately and completely reflect the care and services provided. The sample size was 3, and the facility census was 75. Findings Include:Resident # 024 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, and generalized muscle weakness. The resident was discharged from the facility on December 18, 2024. A provider's order dated November 22, 2024, directed staff to cleanse the right second toe with wound cleanser, apply betadine, and cover with a Band-Aid daily.A provider's order dated November 23, 2024, directed staff to cleanse the open area of the left knee with wound cleanser, apply a medical-grade honey dressing, cover with a petrolatum gauze dressing and gauze, and wrap with a rolled gauze dressing, secured with tape and a stockinette.A review of the admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Further review of the MDS indicated that Resident #74 had two venous/arterial ulcers and skin tears present. The MDS identified skin condition treatments included pressure-reducing devices for chair and bed, nutrition and hydration interventions, application of nonsurgical dressings, ointments or medications, and application of dressings to the feet with or without topical medications. The MDS also identified that the resident and representative were active participants in the assessment process and that the overall goal was discharge to the community.A provider's order dated December 16, 2024, directed staff to cleanse the right first toe with wound cleanser, pat dry, apply betadine, and leave open to air daily . A review of the Skin and Wound Evaluation dated December 16, 2024, revealed that the front of the left knee had a skin tear with complete tissue loss, and treatment orders were in place for the application of a medical-grade honey dressing.A review of the Skin and Wound Evaluation dated December 16, 2024, revealed the following: the arterial ulcer on the first digit of the left dorsum was treated with sodium hypochlorite, debrided with an autolytic, and covered with calcium alginate and foam dressings; and the arterial ulcer to the right first digit (hallux) was circular in shape and had an area with 70% slough and 30% non-granular tissue, that was circular in shape. A review of the Skin and Wound Evaluation dated December 16, 2024, described the arterial ulcer on the right dorsum as scabbed, circular in shape, with no surrounding redness. Further review revealed that the ulcer was cleansed with sodium hypochlorite and dressed with an antimicrobial dressing.A review of the Transition of Care and Discharge summary, dated [DATE], revealed that the discharge summary instructions received by the resident's representative and present in the electronic record were inconsistent with the resident's clinical record, due to omissions related to the resident's skin impairments.A provider's order dated December 17, 2024, directed staff to cleanse the left lateral hallux wound with wound cleanser.A review of the Home Health Care Referral Form dated December 17, 2024, revealed special instructions to include wound care.A review of the Health Services Concern and Comment form, dated February 28, 2025, indicated that the resident's representative expressed concern regarding the resident's wound care and the discharge wound care process. According to the document, the facility's investigation determined that incorrect documentation related to the resident's wound care was submitted on the discharge assessment. Further review of the document revealed that the facility provided education to licensed nursing staff regarding wound care documentation, discharge documentation, and communication.An interview was conducted on October 28, 2025, at 9:08 a.m., with the resident's representative. The representative expressed concern regarding insufficient communication from the facility to the consulting provider about the resident's wounds. The representative reported receiving written discharge instructions but indicated dissatisfaction that the discharge paperwork did not accurately reflect active skin impairments. The representative stated feeling equipped to manage the wounds but emphasized a desire that facility staff had communicated the condition of the wounds more accurately.An interview was conducted on October 28, 2025, at 9:42 a.m., with Certified Nursing Assistant (CNA) Staff #21. Staff #21 stated that any changes in a resident's skin integrity are immediately reported to the nurse. Additionally, Staff #21 explained that on resident shower days, it is their responsibility to document any abnormalities on the shower sheet and submit the completed form to the nurse. Staff #21 emphasized that accurate documentation and communication are essential to advocate for residents and ensure that floor staff receive effective nursing reports.An interview was conducted on October 28, 2025, at 9:55 a.m , with the dually titled Wound Care Nurse and Director of Nursing (DON). Staff # 01 revealed the resident foot wounds were classified as arterial ulcers in etiology. Regarding the right arterial ulcer, the nurse revealed on November 27, 2024 the area was scabbed over, but the wound area continued to receive therapy, as it is facility policy to continue. Staff #01 revealed providing weekly round reports to the medical director/ the resident's attending physician. Staff #01 stated reports directly to the attending provider, not the consultant provider unless instructed to do so by the attending/medical director. Staff #01 revealed that at discharge, the facility arranged for mobile wound clinic service to follow up with the resident.An interview was conducted on October 28, 2025, at 2:15 p.m. with Registered Nurse (RN/Staff #44). Staff #44 stated that proper documentation in the resident record is important to ensure that, if any issues arise in the future, accurate information is available regarding what actually occurred. Staff #44 further stated that inaccurate documentation can impact a resident's ability to receive appropriate treatment, such as in wound care. Staff #44 added that if the correct wound treatment is not properly documented, it may negatively affect the healing process.A follow-up interview was conducted on October 28, 2025, at approximately 2:55 p.m., with Staff #01. Staff #01 stated that preparing the discharge summary is a coordinated effort among nursing, social services, and dietary. Staff #01 explained that the facility ensures discharge information sent to the receiving provider is accurate, complete, and up to date by sending the most recent orders and relevant documentation. Staff #01 further stated that there is an expectation to verify that the discharge summary reflects the resident's most current clinical status, and the nurse completing the summary uses the most current records.Staff #01 mentioned that more than one nurse can work on the discharge assessment. Staff #01 explained that the facility's electronic record system highlights completed areas in green. Staff #01 provided an example in which a night shift nurse may begin the assessment and a day shift nurse completes it, so sections highlighted in green may not be rechecked, based on the assumption that the information entered is accurate and complete.Staff #01 revealed that following the discovery of omissions in the resident's discharge summary during a conference with the resident's representative, the facility identified the staff responsible for the incorrect documentation and provided re-education. Staff #01 stated that the re-education included ensuring the accuracy of skin condition documentation and reviewing the specific sections of the assessment being signed off on to prevent future errors.Review of the Discharge Summary and Plan policy, Revised December 2016, revealed that the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information as permitted by the resident. The policy further states that a copy of the discharge summary will be provided to the resident and receiving facility, and a copy will be filed in the resident's medical records. Review of the Transfer or Discharge Documentation policy, Revised December 2016, revealed that when a resident is transferred or discharged from the facility , the following information will be documented in the medical record: A summary of the resident's overall medical, physical, and mental condition.