Every finding on record at Avina of Mayville

Based on interview, record review, and policy review, the facility failed to ensure a Resident (R5) was free from physical abuse by Resident Representative (RR 2). RR2 slapped R5. Findings include: Review of the facility's undated policy and procedure titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revealed physical abuse included hitting and slapping. The policy indicated the facility would identify and intervene in situations in which abuse of a resident was likely to occur or had occurred. The policy also revealed, under Procedure for Response, that staff should remove the accused/perpetrator from the resident's care area. Staff were to respond to the needs of the resident and protect the resident from further incidents. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 02/01/25, revealed physical abuse included hitting and slapping. Under the section Protection of Resident: It indicated the facility will Make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to; A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examining the alleged victim for any signs of injury, including a physical examination or psychosocial assessment if needed. Review of R5's admission Record located under the Profile tab of the electronic medical record (EMR) indicated that he was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia, cognitive communication deficit, and need for assistance with personal care. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/26 and located under the MDS tab of the EMR indicated a Brief Interview for Mental Status (BIMS) score of zero out of 15, indicating severe cognitive impairment. The assessment also revealed the resident was dependent on others for eating and required staff or a family member to feed him. Review of R5's EMR Care Plan, located under the Care Plan tab and revised on 06/05/26, indicated the resident had an activity of daily living (ADL) self-care performance deficit and limited physical mobility related to Parkinson's disease and dementia. Care plan interventions included that R5 required assistance of one person for eating and should eat in the dining room. R5 also had a care plan for impaired cognitive function/dementia, which indicated the resident had an active healthcare surrogate and power of attorney. The goal of the care plan was for the resident to be able to communicate basic needs daily. An intervention was to discuss concerns about confusion and the disease process with the family member. Review of the facility's Initial Report, dated 06/03/26 and provided by the facility, revealed R5 was eating dinner in the facility dining room. R5's family member, RR2 (Resident Representative), was sitting with the resident and assisting him with eating. A staff member in the dining room at the time indicated R5 grabbed RR2 by the hand/wrist. RR2 yelled, Oww! Stop it! You are hurting me! Before the staff member could intervene to assist RR2, RR2 reached up with her other hand and slapped R5 in the face. R5 then let go of RR2's hand/wrist and asked RR2 why she hit him. RR2 responded that R5 was hurting her. R5 made a comment about RR2 hitting him in his ear, and RR2 said she did not hit his ear; she was trying to get him to let go of her wrist. The staff member stated she monitored R5 and RR2 until the end of the meal to ensure R5 was safe. RR2 left after the meal. During an interview on 06/16/26 at 1:51 PM, RR2 stated she was sitting in the dining room with R5, assisting him with his meal, when he suddenly grabbed her wrist, squeezed it very hard, and would not let go. RR2 stated she yelled and told him he was hurting her, but he still did not let go. RR2 stated he was gripping her wrist so hard that he had a grimacing look on his face. RR2 stated, I then instinctively, like a jerk response, reached up and slapped him across the face, hoping it would startle him so he would let me go, which he did. RR2 stated there was a staff member in the dining room, but the staff member was assisting other residents with meals, and RR2 did not want to interrupt her. RR2 stated the staff member did not get up, come over to help, or ask what happened. RR2 stated no one talked to her about the incident until the next day. During an interview on 06/16/26 at 3:15 PM, Certified Nurse Aide (CNA) 8 stated that on the date of the incident, she was in the dining room helping another resident with a meal. CNA8 stated R5 and RR2 were at a table behind her, and she could not see them, but she could hear RR2 assisting R5 with his meal and saying things such as, Take a drink, and Here is a bite. CNA8 stated she suddenly heard RR2 yell, Oww! Stop it! You are hurting me! CNA8 stated she turned to look and saw R5 holding RR2's hand/wrist and gripping it hard. CNA8 stated RR2 then reached up with her other hand and slapped R5 across the face. CNA8 stated R5 then let go of RR2 hand/wrist. CNA8 stated she did not get up or go over to the resident or RR2 to intervene. CNA8 acknowledged that a slap across the face was an act of abuse and that the facility policy stated staff should intervene and separate the two individuals involved in the act. CNA8 stated she was confused because RR2 was a family member and R5's caregiver. CNA8 stated she monitored them for the rest of the meal and then reported the incident to the nurse after the meal was over and R5 and RR2 had left the dining room. During an interview on 06/17/26 at 10:15 AM, Licensed Practical Nurse (LPN) 1 stated that on the day of the incident, CNA8 came to her after the dinner meal and reported that R5's RR2 had slapped him across the face in the dining room after he grabbed her wrist. LPN1 stated she went to R5's room to assess him for injury and to determine whether he was upset or in distress. LPN1 stated R5 was not in distress and did not have any marks or redness on his face from the slap. LPN1 stated R5 appeared agitated, but he could present that way in the evening due to his dementia. LPN1 stated RR2 was no longer with the resident and had gone home. LPN1 stated she immediately called the Director of Nursing (DON) and Administrator, reported the incident, and asked CNA8 to write a statement of what happened. During an interview on 06/17/26 at 11:40 AM, the DON stated she was notified of the incident involving RR2 slapping R5 across the face in the dining room on the evening it occurred. The DON stated the investigation started at that point. The DON stated she did not speak to RR2 until the next day to obtain her statement. The DON acknowledged that the slap across the face was a form of abuse but stated she felt it was reactionary and was not intended to hurt R5. The DON also acknowledged that RR2 stated her intention was to startle R5 into letting go of her hand/wrist. The DON stated CNA8 should have gone over to the resident and family member, intervened, asked RR2 to step away for a minute, and had someone else assist R5 with his meal. During an interview on 06/17/26 at 11:50 AM, the Administrator stated her expectation for this incident, in which RR2 slapped R5 across the face, was that the CNA who was in the dining room and observed the altercation should have gotten up and intervened by asking if she could help or by asking RR2 to take a break for a while. The Administrator stated CNA8 should have also notified the nurse immediately so the nurse could intervene. The Administrator stated the slap across the face was abuse.

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 6 of 16 residents (R1, R11, R41, R47, R2, R12) reviewed and for food palatability and 9 supplemental residents (R7, R13, R17, R21, R43, R46, R52, R29, R50).R1, R2, R41, R12, R7, R13, R17, R21, R41, R43, R46, R50, R29, and R52 voiced concerns related to their meals being served at undesirable low temperatures. Resident Representative I indicated R47's hot meal is served cold at times. Surveyors conducted 2 test trays, and the results were not palatable. Evidenced by:Example 1R1 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/17/25 indicate R1's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 12/2/25 at 9:01 AM R1 indicated his hot food is served cold all the time at every meal. R1 stated, They have to know. I tell them every day. Example 2R2 admitted to the facility on [DATE]. R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/28/25 indicates R2's cognition is intact with a BIMS score of 15 out of 15. On 12/2/25 at 10:37 AM, R2 indicated his hot food is always cold, at all meals. R2 indicated the staff know, because he tells everyone.Example 3On 12/3/25 at 11:34 AM, Surveyor observed dietary staff wheel insulated cart into hallway with resident meals on it. On 12/3/25 at 11:35 AM, Surveyor observed nursing staff pass the first resident meal tray. On 12/3/25 at 11:45 AM, Surveyor was served a test tray. Surveyor observed the plate to have a plastic cover and a plastic base, Surveyor took a temperature reading of the tray, noting the following: roast beef 126.7 degrees F, peas 133.3 degrees F, scalloped potatoes 141.4 degrees F, and a grape drink to be 44.8 degrees F. On 12/3/25 at 1:00 PM, Dietary Manager L indicated hot food should be held higher than 135 degrees F or higher and cold food should be held at 41 degrees F or lower. Example 4On 12/2/25 at 1:00 PM, during the resident council task meeting with Surveyors, R46, R7, R13, R11, R29, and R50 indicated their hot meal is often served at a cold and undesirable temperature. Example 5R47 admitted to the facility on [DATE]. On 12/2/25 at 9:42 AM, Resident Representative I indicated R47's hot food is served cold at times, food sits on the table prior to her arriving in the dining room, no one offers to reheat the food when she arrives. Example 6R41 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/17/25 indicates BIMS (Brief interview of mental status) of 4 out of 15. R41's speech is clear, and he usually makes himself understood with difficulty communicating some words or finishing thoughts. R41's MDS also indicates he usually understands others but misses some part/intent of the message. On 12/3/25 at 8:01 AM, R41 indicated he receives his hot food cold at times, especially his morning eggs. Example 7R43 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/26/25 indicates R43's cognition is intact with a BIMS score of 15 out of 15. On 12/3/25 at 7:58 AM R43 indicated he gets cold eggs some days and prefers them to be hot. Example 8R52 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/14/25 indicates BIMS of 9 out of 15 indicating R52's cognition is moderately impaired. On 12/2/2025 at 9:13 AM R52 knocked on the window at Surveyor who was in the conference room. R52 stated, My breakfast was cold again. I rarely get a hot meal here. I eat in the dining room. Example 9R12 was admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/5/25 indicates R12's cognition is intact with a BIMS score of 15 out of 15. On 12/1/25 at 11:27 AM, R12 indicated his hot food is served cold at times. Example 10R17 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/3/25 indicates R17's cognition is intact with a BIMS score of 15 out of 15. On 12/2/2025 at 9:14 AM, R17 stated, We do not get hot meals here. Breakfast was cold again.Example 11R21 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/24/25 indicates BIMS (Brief interview of mental status of 3 out of 15. R21's speech is clear with distinct intelligible words, he is understood by others, and he understands others with clear comprehension. On 12/1/25 at 2:54 PM, R21 indicated he gets served his hot food at a cold, undesirable temperature at times. Example 12R50 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/18/25 indicates R50's cognition is intact with a BIMS score of 13 out of 15. On 12/3/25 at 12:10 PM, Surveyor observed staff place a meal tray on the table where R50 was supposed to sit. R50 was not present. The tray contained a plate covered by a plastic base and cover. The liquids sat on the tray covered. On 12/3/25 at 12:37 PM, Surveyor and Dietary Manager L observed nursing staff serve R50 a meal tray. Surveyor asked R50 how the temperature was of her food. R50 stated, It is halfway warm. Surveyor sked R50 if it was at a desirable temperature. R50 indicated she preferred a hot meal. Surveyor took a temperature reading of the meal at 12:38 PM and recorded the following: roast beef- 102.9 degrees F (Fahrenheit), potatoes 109.6 degrees F, milk-58.1 degrees F. Dietary Manager L indicated these temperatures were not palatable and she would replace the meal with a hot one. During an interview, Dietary Manager L indicated the dietary staff plate the food and set up the trays then the nursing staff serve the residents. DM L indicated there is a problem with nursing department leaving trays sit in hallway carts and at tables for long periods of time causing the food temps to lower before resident is given the meal. On 12/4/25 at 10:14 AM DON B (Director of Nursing), NHA A (Nursing Home Administrator), and ANHA C (Assistant Nursing Home Administrator) indicated residents should be served meals that are at a safe and desirable temperature. NHA A and DON B indicated trays should not be set at tables until the resident is at the table and ready for the meal. NHA A and DON B indicated staff should keep the insulated cart doors shut while passing hallway trays and this could help keep the meals warmer.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 54 residents who reside in the facility. Surveyor observed Mighty shakes to be in the refrigerator without a thaw date. Surveyor observed the facility's stove hood to have hair like dust on it above the food cooking surface. Surveyor observed the facility's mixer and meat slicer to be stored unclean. Surveyor observed staff drying dishes with a towel after cleaning and sanitizing them in the 3-compartment sink. Surveyor observed staff wet stacking dishes while observing the dishwashing process. Surveyor observed [NAME] O serving food without donning a hairnet. Evidenced by: Example Mighty ShakesManufacturer's recommendations for use, includes: store frozen. Thaw at or below 40 degrees Fahrenheit. Use thawed product within 14 days. Keep refrigerated. On 12/1/25 at 9:40 AM during initial tour of the facility's kitchen, Surveyor observed 2 boxes of Mighty Shakes inside of the facility's walk-in refrigerator system. The boxes were labeled with the following dates: 10/28/25 and 11/11/25.Dietary Manager L indicated these are the dates the product was delivered to the facility. Surveyor asked how long the product was good for once it was thawed. Dietary Manager L was not sure. Surveyor and Dietary Manager L reviewed the manufacturer's guidelines for use printed on the side of the carton. Dietary Manager L indicated she would toss the product in the garbage. Example Stove hoodOn 12/1/25 at 9:40 AM during initial tour of the kitchen, Surveyor and Dietary Manager L observed the facility's stove hood's front, inside panel to have hairlike dust on it directly over the food cooking area. Dietary Manager L indicated there is potential for the dust to dislodge into open food.On 12/3/25 at 1:06 PM Dietary Manager L indicated she sent photos to the company who just cleaned their stove hood unit and the person who cleaned the unit told her he missed that area when he was cleaning. Example Hair restraintsUSDA Food Code, 2022, includes, in part: . Hair Restraints. 2-402.11 Effectiveness. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 12/3/25 at 11:14 AM Surveyor observed [NAME] O to have a beard and to be dishing up plates without donning a hair restraint. On 12/3/25 at 1:06 PM Dietary Manager L indicated the facility used to have beard restraints, but she was unable to find them. Dietary Manager L indicated they will order some and she will educated staff again on using them. Example Dirty Meat Slicer and MixerOn 12/1/25 at 9:40 AM during initial tour of the kitchen, Surveyor observed the mixer and meat slicer to be stored with a plastic covering. Surveyor requested that the plastic cover be removed for further observation. Surveyor and Dietary Manager L observed both pieces of equipment to have food debris dried on it. Dietary Manager L indicated staff are to clean equipment before storing it under the plastic. On 12/3/25 at 1:06 PM Dietary Manager L indicated the equipment should be cleaned and dried before storing under plastic. Example not allowing air dry/using towelOn 12/2/25 at 9:29 AM Surveyor observed [NAME] O washing dishes in the three-compartment sink. Surveyor then observed [NAME] O use a towel to dry three items. During an interview [NAME] O indicated he was unaware that he should allow dishes to air dry and not use a towel for drying.On 12/3/25 at 1:06 PM Dietary Manager L indicated staff should allow dishes to air dry completely and should not use a towel to dry. Example wet stackingOn 12/2/25 at 9:31 AM Surveyor observed Dietary Aide P stacking wet cups. Surveyor asked Dietary Aide P to unstack a couple of the cups and turn them over. Surveyor and Dietary Aide P observed water inside of the cups and white film in a straight line at the bottom one third of the cup. Dietary Aide P indicated she was not aware she could not stack wet cups. Dietary Aide P indicated she thinks the white line is from stacking wet cups prior to survey because that white line is right where the cup underneath would line up and trap the chemicals and water. On 12/3/25 at 1:06 PM Dietary Manager L indicated staff should allow dishes to air dry completely before stacking.

Based on observation, interview, and record review the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living for 1 of 16 sampled residents (R28) and 5 of 5 supplemental residents (R16, R25, R26, R49, and R62). Surveyor observed AA J (Activity Assistant) approach R28 from behind in the dining room and pull his wheelchair backwards without warning and move to a different table. Surveyor observed AA J approach R16, R26 and R49 from behind in the dining room and move them to a different spot without talking to the resident and explaining what she was doing. R26, R28, and R49 had a startled look on their face and gripped the chair handles of their wheelchair. Surveyor observed LPN H (Licensed Practical Nurse) approach R25 and R62 from behind in the dining room and move them to a different spot without talking to the resident or explaining what she was doing. The residents looked startled, confused and disoriented. Evidenced by: Facility policy entitled, Resident Rights dated 2/28/2025 states, in part: .4. Respect and dignity. The resident has a right to be treated with respect and dignity. Example 1R28 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, congestive heart failure, and cognitive communication deficit. R28's most recent MDS (Minimum Data Set) states R28 has a BIMS (Brief Interview for Mental Status) score of 12 out of 15, indicating R28's cognition is moderately impaired. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed AA J (Activity Assistant) approach R28 from behind in the dining room and pull his wheelchair backwards about 10 feet without warning and move R28 to a different table. R28 looked startled, confused, and disoriented. R28 was gripping the chair handles of his wheelchair as he was being pulled from behind. AA J did not face R28 from the front and address R28 explaining what she was doing. On 12/3/25 at 11:55 AM, Surveyor interviewed AA J and asked about pulling R28 backwards in his wheelchair and approaching from behind, not addressing R28 and explaining what was happening. Surveyor also informed AA J R28 had a startled look on his face and was gripping the chair handles of his wheelchair as he was being pulled from behind. AA J stated (AA J) should not be doing those things. AA J indicated she will be more aware of how she is approaching residents, transporting residents, and indicated she will approach from the front and explain what she's doing, push residents forward only. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ANHA C (Assistant Nursing Home Administrator). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind. Example 2R26 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, major depressive disorder, vascular dementia, and anxiety disorder. R26's most recent MDS (Minimum Data Set) states R26's BIMS (Brief Interview for Mental Status) staff assessment indicated R26 has a memory problem and severely impaired cognitive skills. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed AA J (Activity Assistant) approach R26 from behind in the dining room and move R26 to a different table without warning. AA J did not face R26 from the front, did not address R26 and explain what she was doing. R26 had a startled look on his face as he was being moved and was gripping the chair handles of his wheelchair. R26 looked confused and disoriented. On 12/3/25 at 11:55 AM, Surveyor interviewed AA J and asked about moving R26 in his wheelchair, approaching from behind, not addressing R26 and explaining what was happening, pushing resident forward without warning. Surveyor also informed AA J R26 had a startled look on his face and was gripping the chair handles of his wheelchair as he was being moved to a different table. AA J stated (AA J) should not be doing those things. AA J indicated she will be more aware of how she is approaching residents, transporting residents, and indicated she will approach from the front and explain what she's doing first. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind. Example 3R49 admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with late onset, dementia, osteoarthritis, and muscle weakness. R49's most recent MDS (Minimum Data Set) states R49 has a BIMS (Brief Interview for Mental Status) score of 4 out of 15, indicating R49's cognition is severely impaired. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed AA J (Activity Assistant) approach R49 from behind in the dining room and move R49 to a different table without warning. AA J did not face R49 from the front, did not address R49 and explain what she was doing. R49 had a startled look on her face as she was being moved and was gripping the chair handles of her wheelchair. R49 looked confused and disoriented. On 12/3/25 at 11:55 AM, Surveyor interviewed AA J and asked about moving R49 in her wheelchair, approaching from behind, not addressing R49 and explaining what was happening, pushing resident forward without warning. Surveyor also informed AA J R49 had a startled look on her face and was gripping the chair handles of her wheelchair as she was being moved to a different table. AA J stated (AA J) should not be doing those things. AA J indicated she will be more aware of how she is approaching residents, transporting residents, and indicated she will approach from the front and explain what she's doing first. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind. Example 4R16 admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, anxiety disorder, unspecified mood affective disorder, and cognitive communication deficit. R16's most recent MDS (Minimum Data Set) states R16 has a BIMS (Brief Interview for Mental Status) score of 9 out of 15, indicating R16's cognition is moderately impaired. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed AA J (Activity Assistant) approach R16 from behind in the dining room and move R16 to a different table without warning. AA J did not face R16 from the front, did not address R16 and explain what she was doing. R16 looked startled, confused and disoriented as she was being moved. On 12/3/25 at 11:55 AM, Surveyor interviewed AA J and asked about moving R16 in her wheelchair, approaching from behind, not addressing R16 and explaining what was happening, pushing resident forward without warning. Surveyor also informed AA J R16 had a confused look on her face as she was being moved to a different table. AA J stated AA J should not be doing those things. AA J indicated she will be more aware of how she is approaching residents, transporting residents, and indicated she will approach from the front and explain what she's doing first. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind. Example 5R25 admitted to the facility on [DATE] with diagnoses including chronic kidney disease, major depressive disorder, unspecified dementia, and Alzheimer's Disease. R25's most recent MDS (Minimum Data Set) states R25 has a BIMS (Brief Interview for Mental Status) score of 4 out of 15, indicating R25's cognition is severely impaired. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed LPN H (Licensed Practical Nurse) approach R25 from behind in the dining room and move R25 to a different table without warning. LPN H did not face R25 from the front, did not address R25 and explain what she was doing. R25 looked confused and disoriented as she was being moved, had a startled look on her face. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind. Example 6R62 admitted to the facility on [DATE] with diagnoses including unspecified dementia, major depressive disorder, cognitive communication deficit, and adjustment disorder with anxiety. R62's most recent MDS (Minimum Data Set) states R62 has a BIMS (Brief Interview for Mental Status) score of 1 out of 15, indicating R62's cognition is severely impaired. On 12/3/25 at 11:50 AM, Surveyor was in the dining room getting ready to observe the lunch meal service. There was a music program in the dining room that had just ended, and staff were transporting residents from where they were seated for the music to a dining table for lunch. Surveyor observed LPN H (Licensed Practical Nurse) approach R62 from behind in the dining room and move R62 to a different table without warning. LPN H did not face R62 from the front, did not address R62 and explain what she was doing. R62 had a startled look on her face and looked confused and disoriented. On 12/4/25 at 10:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing). Surveyor asked what the expectation is for staff approaching residents when transporting them in their wheelchair from one location to another. They all indicated residents should be approached from the front, staff should identify themselves and let them know what is going on and ask if it's ok before doing something. They indicated it is not respectful to pull someone from behind or approach from behind.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 Residents (R2) observed for medication administration, 1 of 1 Residents (R3) observation of wound care, and 1 of 1 observation of equipment disinfection.APNP D (Advance Practice Nurse Practitioner) had breaches in infection control when APNP D did not perform hand hygiene after removal of R3's wound dressings.RN E (Registered Nurse) had a breach in infection control after performing an INR (International Normalized Ratio-a test to determine how long it takes for blood to clot) when RN E did not disinfect the machine prior to bringing the machine out to the nurse's station.LPN F (Licensed Practical Nurse) had breaches in infection control during medication administration when LPN F set clean equipment on R2's bed linens, placed R2's used insulin pen into a clean supply kit, and used bare hands to remove a used needle from R2's insulin pen. Evidenced by:The facility's Infection Prevention and Control Program policy, dated 2/25/25, states, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility. 2. All staff are responsible for following all policies and procedures related to the program.4. Standard Precautions: a. All staff assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices. 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.The facility's Hand Hygiene policy, dated 2/2025, states, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves, and immediately after removing gloves.The facility's Clean Dressing Change policy, dated 2/28/25, states, in part: .9. Loosen the tape and remove the existing dressing. 10. Remove gloves. 11. Wash hands and put on clean gloves. 12. Cleanse the wound. 14. Wash hands and put on clean gloves.Example 1On 12/3/25 at 8:39 AM, Surveyor observed APNP D (Advanced Practice Nurse Practitioner) perform wound care for wounds to R3's coccyx and abdominal fold. APNP D removed the coccyx dressing and removed gloves. APNP D picked up a new pair of gloves and moved the clean dressing supplies. APNP D then set down the gloves and cleansed hands. APNP D removed the abdominal dressing, cleansed the wound, and applied ointment to the wound while wearing the same pair of gloves. APNP D then removed her gloves and cleansed hands. Surveyor asked APNP D when hand hygiene is required with a dressing change. APNP D stated any time you remove gloves. Surveyor asked if hand hygiene is needed after glove removal and prior to touching any additional supplies. APNP D stated yes.Example 2On 12/3/25 at 4:04 PM, Surveyor observed RN E walking down the hall wearing gloves and carrying an INR machine. RN E set the INR machine on multiple surfaces of the nurse's station. Surveyor observed a test strip in the machine. Surveyor asked if a test had been performed. RN E stated yes. Surveyor asked if the used test strip was still in the machine. RN E stated yes, I have to take a photo of the display before I take the strip out of the machine. Surveyor asked if the machine is considered contaminated after exposure to blood for the test. RN E stated yes, I should have disinfected the machine and cleansed my hands before leaving the resident's room.Example 3On 12/3/25 at 4:15 PM, Surveyor observed LPN F during medication administration. LPN F prepared R2's insulin and took the insulin pen along with a supply kit to the resident's bedside. LPN F set the supply kit on the bed next to the resident. After administering the insulin, LPN F placed the used insulin pen into a cup containing a vial of blood glucose test strips in the supply kit. LPN F removed gloves and cleansed hands, then picked up the supply kit and took it to the medication cart at the nurse's station. LPN F set the supply kit onto the medication cart. With bare hands, LPN F took the insulin pen from the kit and removed the used needle from the insulin pen with bare hands. Surveyor asked if the insulin pen is considered contaminated after administering insulin. LPN F stated yes. Surveyor asked if contaminated items should be placed into the supply kit with clean supplies. LPN F stated no. Surveyor asked if a contaminated needle should be removed from the insulin pen with bare hands. LPN F stated no. Surveyor asked if the supply kit should be placed directly onto the resident's bed linens. LPN F stated no, there should be a barrier to prevent cross-contamination.On 12/4/25 at 9:43 AM, Surveyor interviewed RN/IP G (Registered Nurse / Infection Preventionist) and asked about hand hygiene with wound care. RN/IP G stated it is to be done prior to the task, after removal of dressing, after cleaning, and after the dressing application. RN/IP G stated she would expect hand hygiene after removal of gloves prior to touching any supplies. Surveyor asked about infection control with insulin administration. RN/IP G stated the supply kit should not be brought into the resident room, setting it on the bed is a cross-contamination. RN/IP G stated that a used pen should not be placed into the supply kit / touching clean supplies and gloves are to be worn by staff when removing a used needle from an insulin pen. Surveyor asked about infection control following an INR test. RN/IP G stated the machine with a used test strip should not be brought out of a resident's room. It is to be disinfected in the resident's room, at point of service. RN/IP G stated when both the machine and the staff member's hands are clean, the machine is to be brought out of the resident's room and put away.

Based on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent a urinary tract infection (UTI) for 1 of 3 residents (R28) reviewed for catheters.Surveyor observed R28's indwelling urinary catheter bag to be resting in direct contact with the floor.Evidenced by:Facility policy, titled Catheter Care, implemented 2/1/25, includes: privacy bags will be available and catheter drainage bags will be covered at all times while in use. (It is important to note the policy does not give information on whether it is ok for the catheter bag to be in direct contact with the facility floor.)R28 admitted to the facility on [DATE] with diagnoses, including retention of urine and encounter for attention to other artificial openings of urinary tract.R28's Video Visit Note, dated 10/28/25, includes Recurrent complicated E.coli urinary tract infection in the setting of chronic foley indwelling catheter. The patient is seen today by video visit.was seen last 3 months ago on 7/9/25 for his recurrent complicated E.coli urinary tract infection in the setting of chronic indwelling foley catheter.(It is important to note R28 has a history of urinary tract infections.)On 12/2/25 at 9:48 AM, Surveyor observed R28 in the dining room and his catheter bag, including the spout, was in direct contact with the floor.On 12/2/25 at 9:52 AM, Surveyor and ANHA C (Assistant Nursing Home Administrator) observed R28's catheter to have no dignity bag around it and to be in direct contact with the floor. ANHA C indicated catheter bags, should not be in contact with the floor.On 12/4/25 at 9:30 AM, RN/IP G (Registered Nurse/Infection Preventionist) indicated R28 has a history of urinary tract infections with sepsis and his catheter bag or spout should not be in direct contact with the floor.On 12/4/25 at 10:15 AM, DON B (Director of Nursing), NHA A (Nursing Home Administrator), and ANHA C indicated catheter bags should have dignity covers on them and should not be in direct contact with the floor.

Based on observation, interview, and record review the facility did not ensure the resident environment remains as free of accidents/hazards as is possible for 1 of 1 sampled resident (R12) and 1 of 1 supplemental resident (R5) reviewed for accidents/hazards.Surveyor observed R12 sitting in his motorized wheelchair in his room while the chair was plugged into the electrical outlet and charging. The motorized wheelchair has a lithium battery.R12's care plan indicates he can have substances such as beer and cigarettes on the premises and they will be held by nursing staff in a locked area. R12's Nurse Notes indicate R5 entered R12's room and took a beer with him when he exited. While on survey, Surveyor observed R12 to have four 30-packs of beer in his room unsupervised and unattended. Evidenced by:Example 1:R12 admitted to the facility on [DATE] with diagnoses, including alcohol use, alcohol dependence, cocaine use, and nicotine dependence.On 12/3/25 at 4:09 PM, Surveyor observed R12 in his room sitting in his motorized wheelchair while the wheelchair was plugged into the outlet charging. (It is important to note the motorized chair unit contained a lithium battery.)On 12/3/25 at 4:10 PM, CNA M (Certified Nursing Assistant) indicated R12 should not be charging his wheelchair in his room, but that is where it is usually charged. On 12/3/25 at 4:12 PM, LPN F (Licensed Practical Nurse) stated, I do not know for sure where we charge them. I'm not sure if it is ok to charge in his room. We used to charge chairs at the end of the hallway. On 12/3/25 4:17 PM, Surveyor asked CNA M if she would unplug the chair or get someone to unplug the chair due to the risk of the lithium battery exploding. CNA M indicated she would unplug chair and remove the cord. On 12/3/25 at 4:25 PM, DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated motorized wheelchairs should not be charging in residents' rooms with residents present. Example 2:R12 admitted to the facility on [DATE] with diagnoses, including alcohol use, alcohol dependence, cocaine use, and nicotine dependence.R12's Comprehensive Care Plan, includes in part: initiated 10/3/25, revised 11/7/25, target date 12/12/25. R12 has a history of substance abuse. R12 is drinking alcohol products daily and consuming THC gummies occasionally. R12 voluntarily agreed to allow facility to keep alcohol products and THC gummies locked in med room to monitor resident consumption as it relates to administration of narcotics. R12's Nurse Notes, dated 10/27/25, include: R12 reported to writer that R5 had come to his room to ask for a cigarette and then took one of his beers off his bedside table. Writer offered to go close R12's bedroom door, R12 stated No, if we could just keep an eye on R5, if seen walking by or around his room. Incident reported to NHA A (Nursing Home Administrator), R12 agreed to have his case of beer removed from room and locked up but refused to allow writer to remove three cans of beer that was sitting on his bedside table, (NHA A) notified, no further issues.On 12/1/25 at 11:27 AM, Surveyor observed 2 full 30-packs of [NAME] Light in R12's room and another 30-pack with a few cans missing. R12 indicated he drinks the beer every day and he gets it from the gas station. R12 indicated he had trouble with one resident coming in his room and helping himself and had one resident enter his room and take a beer. On 12/2/25 at 3:29 PM, during an interview Activity Therapy Director N indicated R12 keeps his beer in his room, because he will not allow staff to lock it up. Activity Therapy Director N indicated she in not aware of a time when another resident gained access to R12's beer. On 12/3/25 at 4:10 PM, Surveyor observed R12 have another unopened 30 pack of beer in his room on the floor near his bedside table. R12 indicated he just bought the 30 pack of beer today at the gas station and is stocking up for the big snowstorm that is coming. On 12/4/25 at 2:10 PM, DON B (Director of Nursing), ANHA C (Assistant Nursing Home Administrator), and NHA A (Nursing Home Administrator) indicated staff have tried to lock R12's beer up and he gets loud and curses at them. Surveyor asked if the facility has offered to lock it up in R12's room? NHA A indicated they have not, but they could do that as he is in a private room and there is an extra closet.

Based on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 1 of 16 sampled residents (R1). R1 did not receive his ordered nephrocaps (vitamin specific to renal (kidney) support) for several days in November. This is evidenced by: The Facilities Policy and Procedure entitled Medication Administration dated 2/28/25 that does not speak to omitted medications. R1 is a long-term resident of the facility. R1 has the following diagnoses: end stage renal disease, type 1 diabetes mellitus, and dependence on renal dialysis. R1's Physician Orders:Neprhocaps capsule 1 mg (milligram) (B Complex-C-Folic Acid) Give 1 capsule by mouth one time a day for supplement. R1's MAR (Medication Administration Record):Nephrocaps have 10 documented for the following dates- 11/7/25, 11/9/25, 11/10/25, 11/11/25, 11/27/25, and 11/28/25. R1's Nurses Notes:No notes for 11/7/25, 11/10/25, 11/11/25, or 11/27/25. Note on 11/9/25 documents the following- medication unavailable per pharmacy will deliver 11/10/25. Note on 11/28/25 documents the following- medication unavailable per pharmacy will deliver 11/30/25. It is important to note that there is no further documentation following up that the medication is not available. On 12/2/25 at 9:01 AM, Surveyor interviewed R1. Surveyor asked R1 if he receives his medications timely, R1 said he is waiting on a pill he takes after dialysis. Surveyor asked R1 if he knew what the medication was, R1 said my vitamin. Surveyor asked R1 how long he hasn't had it, R1 replied not for a week. On 12/4/25 at 1:17 PM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H what does 10 mean if on MAR, LPN H explained it means there should be a Nurses Note written about the medication. Surveyor asked LPN H if it is marked 10 should there be a nurses note, LPN H stated yes. On 12/4/25 at 2:09 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B would you expect R1 to receive his nephrocaps as ordered, DON B said yes. Surveyor asked DON B would you expect there to be a nurses note if the staff is documenting 10 on MAR, DON B stated absolutely. R1 did not receive his nephrocaps per physician orders.

Based on interview, record review, and facility policy review, the facility failed to ensure antibiotics were administered as ordered by the physician for 1 (Resident #23) of 3 residents reviewed for medication administration.Findings included:A facility policy titled, Medication Administration, implemented 02/01/2025, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.An admission Record revealed the facility admitted Resident #23 on 05/16/2025. According to the admission Record, the resident had a medical history that included diagnoses of acute kidney failure, malignant neoplasm, and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2025, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #23's Order Listing Report, for the timeframe from 05/07/2025 through 07/31/2025, revealed an order started on 05/27/2025 and revised on 05/28/2025 for azithromycin 250 milligram (mg) tablet, two tablets, one time a day on day 1, then one daily for four days for a sinus infection. Resident #23's 05/2025 Medication Administration Record [MAR] revealed staff documented that azithromycin 250 mg, two tablets were administered on 05/28/2025, and one tablet was administered on 05/29/2025, 05/30/2025 and 05/31/2025. Resident #23's 06/2025 Medication Administration Record revealed Licensed Practical Nurse A (LPN) documented 10, which indicated Other/See Progress Notes for the resident's 06/01/2025 dose (final dose) of azithromycin. Resident #23's Progress Notes, dated 06/01/2025, revealed azithromycin was unavailable. During an interview on 07/24/2025 at 3:45 PM, a Pharmacy Representative stated that azithromycin for Resident #23 was delivered to the facility on [DATE] at 1:56 AM. Per the Pharmacy Representative, the pharmacy delivered six tablets, with instructions to take two tablets on day one and one tablet daily thereafter. During an interview on 07/23/2025 at 10:52 AM, Resident #23 revealed they had a sinus infection and there was a mistake during their first round of antibiotic treatment. Resident #23 stated that they currently had no sinus pain or ongoing issues. During an interview on 07/24/2025 at 10:09 AM, LPN A stated that Resident# 23's azithromycin was unavailable (on 06/01/2025). She stated that she contacted the pharmacy, who promised delivery that night. She said the medication did not arrive and was not administered to the resident. LPN A stated that she was off for the next two days and did not leave notes for other nurses or notify the physician that the final dose of the antibiotic was not available. She stated that when she returned to work, the medication had arrived at the facility; however, she did not administer the medication because the resident had started a new round of antibiotics. During an interview on 07/24/2025 at 9:21 AM, the Director of Nursing (DON) stated that after speaking with LPN A, they discovered that the pharmacy had sent only five, instead of six, azithromycin tablets for Resident #23, resulting in a missed final dose. The DON stated the missing pill arrived the following night, but it was too late to administer. Per the DON, HUCU (Patient-Centered Secure Communication Application) was used to communicate with physicians, and a review of the system showed no documentation that the missed dose was reported. During an interview on 07/24/2025 at 2:17 PM, Nurse Practitioner C (NP) stated that regarding Resident #23, antibiotics were prescribed on 05/27/2025. She stated the resident missed a dose on 06/01/2025 but she was not notified. NP C stated it was important to complete an antibiotic course. During an interview on 07/24/2025 at 4:27 PM, the Administrator (ADM) stated when medications were unavailable, nursing staff were expected to contact the pharmacy, notify the physician or nurse practitioner, and provide updates. Per the ADM, staff utilized a messaging application to communicate such requests and updates to providers.

Based on interview and record review the facility did not develop a comprehensive, person-centered care plan for 1 of 6 sampled residents (R3) reviewed for person-centered care plans. R3 does not have a comprehensive care plan that includes triggers and monitoring targetd behaviors. Evidenced by: Facility policy entitled Comprehensive Care Plans, dated 1/25, states, in part; It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care.3. The comprehensive care plan will describe, at a minimum, the following: . f. Resident specific interventions that reflect the resident's needs and preferences . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.8. Qualified staff responsible for carrying out interventions specified in the car plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Example 1 R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance, Anxiety disorder, unspecified, Major Depressive disorder, recurrent, unspecified, and Need for Assistance with personal care. R3s most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview of Mental Status (BIMS) of 12 out of 15, indicating that R3 has mild cognitive impairment. R3's Comprehensive Care Plan states, in part: Focus: The resident demonstrates a pattern of situational and/or coping problems in areas such as: being alone after her spouse leaves. Psychosocial well-being, Mood state and/or behavioral symptoms. Date initiated 10/21/22. Revision on 7/1/24. Goal: The residents mental health and psychosocial well-being will be enhanced: staff encouragement, reminders of how well she is doing. Date initiated 10/21/22. Revision on 9/19/24. Interventions: Encourage the resident to express her thoughts and feelings. Date initiated 10/21/22. Help the resident feel welcome, accepted, acknowledge and well-received. Provide structure and guidance to help the resident feel safe, competent, involved, secure, valued, and appreciated. Work to help the resident develop a role that provides him/her with a sense of purpose and builds esteem/worth. Date initiated 10/21/22. Focus: The resident has an active order for anti-anxiety medication due to Anxiety disorder. Date Initiated 8/19/22. Revision on 8/19/22. Goal: The resident will be free from discomfort or adverse reaction to anti-anxiety therapy through the review date. Date initiated: 8/19/22. Revision on 9/19/24. Interventions: Administer anti-anxiety medications as ordered by physician. Date initiated 8/19/22. Monitor/document/report PRN (as needed) any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated 8/19/22. Provide re-assurance if resident becomes anxious. Allow her to express herself, offer to call her husband. Date initiated 12/10/24 . Focus: The resident has an active order for antidepressant medication for Depression. Date initiated 9/17/24. Revision on 9/17/24. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date: 9/17/24 isolation, suicidal thoughts, withdrawal, decline in ADL (Activities of Daily Living) ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Date initiated 9/17/24. Provide reassurance if resident expresses sadness. Encourage her to think about things she enjoys like her visits with her husband and looking at animals outside her window. Date initiated 12/10/24. R3's Progress Notes, state in part: On 10/1/24 at 2:02 PM, Type: Behavior Note: During shower resident called CNA (Certified Nursing Assistant) a bitch several times and hit CNA in her right arm x2. CNA able to complete shower, no further issues. On 11/24/24 at 8:32 AM, Type: Behavior Note: Resident continues to refuse medications in the morning in an aggressive way. She never just states that she does not want it. She yells, sometimes swears, sometimes demands staff to get out. This is not just on the NOC (nocturnal, overnight) shift but have heard that this is happening on staff on the PM shift as well and she is not getting her important meds. Writer has noticed that she has been getting some of the Parkinson's effects of the tremors while drinking and just lying in bed. When I have brought this to her attention, she always states to me BULLS*** several times. She is also being non-compliant with wanting to be turned for her coccyx/sacrum wound while lying in bed. On 12/3/24 at 11:01 AM, Type: Behavior Note: Resident refuses shower after three attempts by three different people. Resident started to raise her voice and become extremely agitated after final attempt. On 12/21/25 at 1:37 AM, Type: Behavior Note: Resident has been acting out at night. She has been pushing the call light continuous at times stating that she is sinking. All CNA and RN (Registered Nurse) has checked the bed and the alarm on the bed is not going off. Today CNA went into check/change her and she slapped her. She has been getting more and more physical with the staff regarding cares. On 2/21/25 at 5:45 AM, Type: Behavior Note: Resident again, with the nurse helping to provide cares tried to kick the CNA a couple of times while changing her. The CNA asked her not to do that and the resident responded I can if I want to. The RN corrected her and stated NO, you can not. You should not be hitting anyone. On 2/21/22 at 2:22 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) and asked her about R3's behaviors. CNA G stated she has heard of R3 being aggressive with other staff members but never with her. CNA G stated that R3 can become resistive with cares and refuse medications at times. Surveyor asked CNA G what interventions were in place for R3's behaviors. CNA G stated that she will reapproach, not push her, and back off. Surveyor asked CNA G where R3's behaviors and interventions would be listed. CNA G stated they would be in the care plan and CNA Kardex. On 2/21/24 at 2:27 PM, Surveyor interviewed RN D (Registered Nurse) and asked her about R3's behaviors. RN D stated that R3 refuses cares and yells a lot, and that she does attempt to hit and kick with cares. Surveyor asked RN D what interventions were in place for R3's behaviors. RN D indicated that she attempts redirection or distraction, or will step away and let a new face reapproach. RN D indicated that when R3 is agitated, they do cares in pairs, meaning that two staff will go into R3's room together to provide cares. RN D stated that R3 becomes triggered when her husband is not here, that he comes twice a day but when he leaves R3 gets more agitated. Surveyor asked RN D where these behaviors, triggers, and interventions would be listed. RN D stated they would be in R3's care plan. On 2/21/25 at 2:11 PM, Surveyor interviewed CNA H and asked her about R3's behaviors. CNA H stated that R3 will refused cares a lot and get confused. CNA H stated that R3 doesn't like to be touched or messed with too much. CNA H stated that R3 will say no and become real aggressive. CNA H stated that R3 can become agitated and did try to kick her during cares. CNA H stated that R3's husband comes every day, but she becomes more agitated when he leaves. Surveyor asked CNA H what interventions were in place for R3's behaviors. CNA H stated that she offers R3 food, drink, or tries to change the subject to distract her. CNA H states that R3 likes hot chocolate and various snacks, so she will offer her those. Surveyor asked CNA H if these behaviors or interventions were listed on the CNA Kardex. CNA H stated no, behaviors are not on the Kardex. Surveyor asked CNA H if they were written down anywhere for staff to know how to care for R3. CNA H indicated that staff just know what triggers R3 and what can calm her down. On 2/21/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if a resident's behaviors would be listed on the CNA Kardex. DON B stated no, behaviors are not on the Kardex. Surveyor asked DON B if a resident's behaviors should be listed on their care plan. DON B stated yes, behaviors should be listed on the care plan, and also that staff would get information related to resident behaviors in shift-to-shift report. The facility failed to develop and implement a care plan that described the specific aggressive behaviors that R3 was displaying, nor did they outline triggers or interventions to enable staff to provide quality care to R3.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 2 of 6 residents (R) reviewed for abuse (R5 and R6). The facility did not report a resident-to-resident altercation that occurred between R5 and R6. This is evidenced by: The facility policy titled Freedom from Abuse, Neglect, and Exploitation, undated, states in part: It is the policy of this community to take appropriate steps to prevent the occurrence of: Abuse . It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse .are reported immediately to the administrator of the community .such violations are also reported immediately to state agencies in accordance with existing state law. The community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to state agencies and Adult Protective Services as required by state and federal law . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . Resident to Resident Altercations: An incident involving a nursing home resident who willfully inflicts injury upon another resident. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm . Prevention: The administrator and director of nursing services (DON) identify, intervene, and correct in situation in which abuse, neglect, or misappropriation of resident property is more likely to occur . Identification: Incidents of possible abuse or neglect .will be identified through ongoing assessment of resident conditions, incidents, resident interviews, family or resident councils, and verbal or written report of observations . Investigation: .The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative or law enforcement agencies immediately, in accordance with state regulations. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. The investigation can include, but is not limited to i. The name(s) of the resident(s) involved ii. The date and time the incident occurred iii. The circumstances surrounding the incident iv. Where the incident took place v. The names of any witnesses vi. The name of the person(s) alleged with committing the act . Reporting: . The administrator notifies the appropriate state agency immediately in accordance with state law. The results of all investigation are reported to the administrator and to the appropriate state agency . The administrator, or his/her designee, notifies the resident's representative regarding the alleged violation and assessment findings and reassures the resident's representative that an investigation has been initiated and appropriate action will be taken. R5 admitted to the facility on [DATE] with diagnoses including anxiety disorder and depression. R5's Brief Interview for Mental Status (BIMS), dated 2/6/25, has a score of 15, indicating R5 is cognitively intact. R6 admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, anxiety, mood disorder, and cognitive communication deficit. R6's Brief Interview for Mental Status (BIMS), dated 12/30/24, has a score of 10, indicating R6's cognition is moderately impaired. R6's comprehensive care plan printed on 2/21/25, states in part: Focus: The resident has a behavior problem. Interventions: Intervene as necessary to protect the rights and safety of others. On 2/21/25 at 11:09 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) regarding abuse. CNA C indicated a resident-to-resident altercation is abuse. CNA C indicated a resident swearing, name calling, or threatening another resident is abuse. CNA C stated R6 said you're a nosey bitch to R5 while CNA C was in the room. CNA C indicated this happened within the past 2 days. Of note, R5 and R6 share a room. On 2/21/25 at 2:10 PM, Surveyor spoke with NHA A (Nursing Home Administrator) regarding this incident. NHA A stated she was aware of the incident and did not report this incident as abuse to the state agency. NHA A stated she followed Resident-to-Resident Altercation Flowchart and decided to not report this incident. NHA A stated R5 was unbothered by the comment. Of note, the Resident-to-Resident Altercation Flowchart states in part: resident to resident altercation occurs - did resident act willfully? Willful means the individual's act was deliberate- not inadvertent or accidental regardless of whether or not the individual intended to inflict injury or harm. (A resident whose involuntary movements cause him/her to accidentally strike another has not committed a willful act.) if the no option is selected, do not report. Document an immediate assessment and lack of willful intent. Assess-care plan- intervene. Goal: Prevent reoccurrence and keep other residents safe. Also, the flowchart states Use of this flowchart must provide for immediate reporting (see F609) or the facility must clearly document the rationale for not reporting. It should be noted using the reasonable person concept a person would not be expected to be called names or swore at in their own home and may experience fear from such encounter. Surveyor requested R5 and R6's electronic health records documenting this incident including any assessments, nurses' progress notes, updated care plan, etc. Surveyor was not provided any electronic health records documenting the investigation of this incident. Of note there was no evidence the facility documented an immediate assessment and a lack of willful intent. Assessed R5 and R6's-care plan- intervened or implemented interventions to prevent reoccurrence and keep other residents safe.

Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 1 of 2 residents (R2) reviewed for SUDs. R2 has a SUD. The facility failed to create a care plan related to R2's alcohol consumption and failed to implement interventions for behaviors associated with R2's alcohol consumption. This is evidenced by: The facility policy titled Safety for Resident with Substance Use Disorder, dated 1/25, states in part: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder. Definitions: substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home . 1. Residents with a history of SUD will be assessed for risks . Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected .facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for resident and encouraging resident to seek out facility staff to discuss their plan of care .7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with their resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. R2 admitted to the facility on [DATE] with diagnoses including alcohol abuse, repeated falls, unsteadiness on feet. R2's Brief Interview for Mental Status (BIMS) on 11/26/24 has a score of 15, indicating R2 is cognitively intact. R2's Medication administration and Treatment administration records for January 2025 and February 2025 do not include monitoring of behaviors and/or substance use. R2's physician orders dated 2/21/25 does not include an order stating R2 can consume alcoholic beverages. R2's comprehensive care plan dated 2/21/25, states in part: Focus: The resident is functioning at an independent level in his leisure pursuits. Goal: The resident will make one positive statement about his leisure pursuits to staff weekly. Interventions: Encourage the resident to pursue appropriate leisure interest on his/her own. Introduce yourself to the resident to establish a friendly and professional rapport. Offer the resident independent leisure materials for him to pursue. Provide the resident with a copy of the activity calendar on a monthly basis. Of note, R2's comprehensive care plan does not include R2's substance use disorder, nor the triggers related to substance use. R2's comprehensive care plan does not include goals related to R2's substance use disorder. R2's comprehensive care plan does not include person-centered interventions to prevent substance use nor mitigate the risks associated with substance use. R2's comprehensive care plan does not include R2's behaviors associated with R2's substance use. R2's nurses' progress notes state: 12/26/25 8:39 AM Resident appears to be intoxicated, smells of alcohol and slurring words. He was in the dining room arguing with other resident and family . 1/17/25 23:31 (11:31 PM) Nurse was called into the resident room for a fall. When Nurse arrived in room resident was getting up and trying to get into the bed. He had one shoe on and one shoe off with a regular sock on the other foot. This was making his foot slip. The CNA quickly assisted him to prevent a further fall, and the nurse assisted with the other side. Resident sat on the side of the bed and allowed the nurse to do a partial assessment. Resident stated that he did not hit his head. He stated that he was OK and that hisprde [sic] is the only thing that is hurt. Resident's BP (blood pressure) is low due to him being intoxicated all other vital signs are WNL (within normal limits) . 1/19/25 10:59 AM Per administration no resident were to go outside for smoking or store runs due to the freezing temperatures. Message was relayed to resident however resident refused to stay inside stating it's not that cold. Resident made multiple trips outside to smoke and went to Kwik Trip. The facility provided an investigation summary related to R2. The summary states in part: On 1/26/25 around 12:00 PM, R2 had a resident-to-resident altercation with R1. R2 threatened to kill R1. It was noted that R2 had been drinking that morning. Staff have noted on many different occasions, empty bottles of alcohol laying around R2's room along with a smell of alcohol coming off R2. On 2/21/25 at 11:19 AM, Surveyor interviewed RN D (Registered Nurse) regarding R2's behaviors. RN D indicated R2 likes to talk like he's tough and will make sexual comments to the staff. On 2/21/25 at 12:39 PM, Surveyor interviewed SSD E regarding R2's substance use, behaviors and his care plan. SSD E indicated R2's substance use, behaviors and interventions should be on the care plan. SSD E indicated there should be a care plan to monitor and intervene with R2's substance use and associated behaviors and R2 does not have a care plan related to substance use or behaviors. On 2/21/25 at 1:00 PM, Surveyor interviewed DON B regarding R2. DON B indicated R2 should have a care plan for his substance use and associated behaviors but does not.

Based on observation, interview, and record review, the facility did not ensure that self-administering of medications was determined to be clinically appropriate for 1 of 1 resident (R3) reviewed for self-administration of medications out of a total sample of 3 residents. Surveyor observed R3 with a large green pill without staff present. The facility did not complete a self-administration of medication assessment on R3, and R3 did not have a physician order for administering her own medications. Evidenced by: The facility's policy, entitled Self-Administration of Medications and Treatments, undated, includes self-administration of medications and treatment are determined by physician order after determining that a resident is able to self-administer. Medications and treatments for self-administration are kept in a locked drawer in the resident's room . Assessment of the ability to self-administer medications will be done by nursing using the tool assessment for self-administer medications. Resident teaching will be performed by nursing staff. If a treatment is self-administered, the resident must perform a return demonstration of the treatment to be able to do the treatment independently. A care plan (is created) for the resident who self-administer, and documentation should be present in the nursing notes of teaching related to self-administration of medications or treatments. R3 admitted to the facility on [DATE] with diagnoses including cognitive communication deficit and other signs and symptoms involving cognitive function and awareness. On 10/2/24 at 9:47 AM, Surveyor observed a large green capsule lying on R3's bedside table. R3 indicated the nurse dropped off a cup of medications and exited the room. R3 indicated she took the other medications but was waiting on taking this one. R3 indicated the nurse usually sticks around until she has taken her medications, but today she did not. R3 was unsure what the medication was and if the dose was appropriate, but she thought this was a new antibiotic she was prescribed for an infection in her leg. On 10/2/24 at 10:00 AM, LPN C (Licensed Practicing Nurse) indicated R3 does have moments of confusion. LPN C indicated she dropped off R3's medications in her room this morning but did not observe her take them. LPN C indicated she was unaware R3 did not take the large green pill. LPN C indicated R3 does not have a completed assessment demonstrating safe self-administering medications and R3 does not have a physician order for self-administering her medications. On 10/2/24 at 10:15 AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated R3 gets confused at times. DON B and NHA A indicated R3 does not have an order for self-administration of medication or a completed assessment indicating R3 is safe to self-administer her medications. DON B indicated LPN C should not leave medications with R3 unsupervised.

Based on interview and record review, the facility did not develop a comprehensive, person-centered care plan for 1 (R3) of 1 resident reviewed for person-centered care plans. R3's care plan states R3 has an active order for anti-anxiety and anti-depressant medication. R3's care plan does not include person-centered, non-pharmacological interventions for anxiety or depression. Evidenced by The facility policy, Comprehensive Care Plans, dated 9/26/22, states, in part; Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.The care plan will describe interventions .in order to eliminate triggers . The facility policy, Medication Management, dated10/25/14, states, in part; In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescribers, and the consultant pharmacist perform ongoing monitoring for appropriate effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs . R3 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, and cognitive communication deficit. R3's care plan, states, in part; .Focus-the resident has an active order for antidepressant medication for depression. Date initiated 8/27/2024 .Focus-the resident has an active order for anti-anxiety medication for anxiety. On 10/2/24 at 5:47 PM, Surveyor interviewed DON B (Director of Nursing) and asked the facility would expect a comprehensive care plan to be developed for the residents. DON B stated yes. Surveyor asked if facility would expect non-pharmacologic interventions to be performed for a resident if they were having triggered behaviors. DON B stated yes. Surveyor asked if facility would expect that a resident receiving psychotropic medications would have a care plan that reflects a resident's triggered behaviors and the non-pharmacologic interventions to be utilized. DON B stated yes. Surveyor asked if R3 had non-pharmacologic interventions in her care plan. DON B stated no. The facility failed to create a person-centered care plan with interventions that are tailored to the specific individual.

Based on interview and record review, the facility did not ensure written notification of coverage change, the financial liability for continued stay, and appeal rights were provided to a Resident (R) whose Medicare Part A benefits were ending for 2 (R45 and R7) of 3 residents reviewed for Medicare Part A notifications. The facility did not provide R45 and R7 with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form, which includes, notification of change in coverage, financial liability, and appeal rights. Findings include: Per the Centers for Medicare and Medicaid Services (CMS) Form Instructions, the SNFABN provides information to the beneficiary so that he or she can decide whether to get the care that may not be paid for by Medicare and assume financial responsibility. The SNFABN includes information such as the care that may or may not be covered by Medicare, the estimated cost of the corresponding care that may not be covered by Medicare, and appeal options. Surveyor reviewed a sample of residents for Medicare Part A notifications. Surveyor noted two of three sampled residents, R45 and R7, remained at the facility following termination of Medicare Part A coverage. The facility only provided Surveyor with Notice of Medicare Non-Coverage (NOMNC) forms for both R45 and R7. On 08/15/24, at 10:46 AM, Surveyor spoke with Nursing Home Administrator (NHA)- A who indicated R45 and R7 did not receive SNFABN. NHA- A states the previous social worker was responsible for the SNFABN form and did not provide to R45 and R7. NHA- A indicates facility staff have changed and they have since resolved the concern. There is coverage now for these notices.

Based on observation, interview, and record review the Facility did not ensure 1 (R7) of 2 residents were provided privacy during personal cares. *R7 informed Surveyor staff will leave R7's window drapes open when providing personal cares. R7's window is next to a public patio area and R7 would like R7's privacy when personal cares are provided. *Surveyor observed staff leave the window drapes open while providing cares to R7. Findings include: R7 was admitted to the facility on [DATE] with diagnosis that include Type 2 Diabetes, Depression, Muscle weakness, and Lymphedema. R7's Quarterly Minimum Data Set (MDS) dated [DATE], documents R7 is cognitively intact. R7 is frequently incontinent of bowel and bladder and is dependent for toileting. On 08/12/2024, at 10:25 AM, Surveyor interviewed R7. R7 informed Surveyor R7 would prefer that his window curtains be closed when staff change R7's brief. R7 stated R7's window is off a shared, public patio. R7 indicated R7 does not like the fact that people can see in his room when R7 is receiving personal and private cares. On 8/14/2024. at 8:45 AM, Surveyor observed Certified Nursing Assistant (CNA)-F exiting R7's room with a sit to stand lift (EZ stand). Surveyor asked why CNA-F was in R7's room with the EZ stand. CNA-F indicated R7 needed R7's incontinence product changed, and personal cares completed. Surveyor asked CNA-F if the window curtains were closed prior to providing cares to R7. CNA-F stated No. CNA-F stated that CNA-F has asked R7 in the past if R7 wanted the window curtains closed and R7 told CNA-F that R7 did not care. CNA-F stated, I guess I could ask each time, but I didn't. On 8/14/24, at 8:52 AM, Surveyor interviewed R7. Surveyor asked R7 if CNA-F provided personal cares. R7 stated yes. Surveyor asked if the window curtains were closed. R7 stated No. Surveyor asked if R7 wanted the window curtains closed, R7 stated yes but at least there is no one on the patio at this time. On 8/14/2024, at 10:43 AM, Surveyor noted R7's call light was on. Surveyor observed Registered Nurse (RN)-G enter R7's room with the EZ stand. At 10:46 AM, Surveyor observed Director of Nursing (DON)-B enter R7's room. At 10:47 AM, Surveyor knocked on R7's door and observed R7 assisted by RN-G and DON-B in the EZ stand. The window curtain was open. RN-G and DON-B indicated they were doing cares. Surveyor closed the door. At 10:49 AM, Surveyor walked to the public patio located right outside of R7's window. Surveyor noted that R7's window drapes were open and R7's room was visualized from the public patio area. On 8/14/2024, at 10:51 AM, Surveyor interviewed R7. R7 stated staff were just in R7's room to change R7's incontinence product. R7 stated the window curtains were open the whole time. R7 stated staff did not ask if R7 wanted the curtains closed or not. R7 stated again that R7 would prefer the window curtains be closed when providing personal cares and opened when the cares are complete. On 8/14/2024, at 10:54 AM, Surveyor interviewed RN-G. Surveyor asked if RN-G was providing personal cares to R7. RN-G stated yes. Surveyor asked if the window drapes were open the whole time while providing care. RN-G stated yes. On 8/14/2024, at 11:22 AM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A. Surveyor informed DON-B and NHA-A that staff was observed providing personal cares to R7 with R7's window curtains open. Surveyor asked if the window curtains should be closed while providing personal care to a resident. DON-B stated DON-B would expect staff to ask the resident if they wanted the window curtains closed. DON-B stated that a lot of residents do not want them closed. DON-B indicated that DON-B was just in R7's room providing personal care. DON-B stated that DON-B asked R7 if R7 wanted the window drapes closed. DON-B stated that R7 stated R7 didn't care. Surveyor informed DON-B and NHA-A that surveyor's concern regarding R7's privacy remains. Surveyor informed DON-B and NHA-A that R7 expressed a preference the window drapes be closed with any personal cares and opened after the cares are complete due to the room being visible from the public patio area. DON-B stated DON-B will add R7's preference to R7's CNA Kardex. No other information was provided as to why the Facility did not ensure R7 was provided privacy during personal cares.

Based on record review and interview, the facility did not ensure a resident had a neurological assessment after potential head injury and was comprehensively assessed prior to being transferred to the hospital. This was observed with 1 (R104) of 15 residents reviewed. * R104 had 2 unwitnessed falls without consistent completion of a neurological assessment. * R104 family requested R104 to be transferred to a hospital for evaluation on 7/3/24. There is not documentation of R104 clinical status. or physician order, prior to being transferred to the hospital. Findings include: The facility's policy and procedure Neurological Assessment, revision date 9/25/2023, was reviewed by Surveyor. The policy states Residents will have a neurological assessment completed when they experience a head injury, have an unwitnessed fall or a change in condition that deems it necessary or per physician order. The procedures include Observe, assess and document the resident's level of consciousness, speech, pupils, hand grasps and vitals signs. Neuro checks are completed following a schedule using an assessment tool that outlines said schedule. R104 was admitted to the facility on [DATE] with a diagnosis of (TBI) Traumatic Brain Injury with a subarachnoid hemorrhage. R104 has an Guardian for decision making. The Nursing Admission assessment, completed 6/29/24, at 12:50 PM, assesses R104 as a fall-risk. On 6/29/24, at 4:15 PM, R104 has an unwitnessed fall in the hallway. The Fall Incident form documents, Was self ambulating in hallway and unable to state what happened. The Neurological Assessment Flowsheet documents: neurological assessment every 15 minutes x4, then every 30 minutes x4, then every 1 hour x4, then every 4 hours x4, then every 8 hours x3. The assessment includes areas to document vital signs, pupils, motor function, level of consciousness, pain response and other. R104's Neurological Flowsheet does not have an assessment for: 6/29/24, at 6:00 PM and 6:30 PM with a documented reason being, due to on the phone with family, 6/30/24, 7:00 AM and 6/30/24, at 3:00 PM. On 7/3/24, at 12:00 PM, R104 had an unwitnessed fall from their bed. The Fall Incident form documents Resident was looking for their brother and thought they slid out of bed. The Neurological Assessment Flowsheet documents: neurological assessment every 15 minutes x4, then every 30 minutes x4, then every 1 hour x4, then every 4 hours x4, then every 8 hours x 3. R104's Neurological Flowsheet does not have an assessment for: 7/3/24 at 12:45 AM, 1:00 AM, 1:30 AM, 2:00 AM, 2:30 AM, 3:00 AM and 4:00 AM, documented reason being, due to sleeping; 7/3/24, at 5:00 AM, 6:00 AM and 7:00 AM due to R104 refused. The Nurses Notes document on 7/3/24, at 11:56 AM, Resident leaving the facility to be evaluated at the hospital per family request. There is no documentation of a comprehensive clinical assessment of R104's status prior to being transferred. On 8/14/24, at 3:14 PM, Surveyor requested any information regarding R104's neurological assessments, and transfer assessment, from Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B, Consultant-D and Consultant-E. On 8/15/24, at 9:15 AM, NHA-A and Consultant-E spoke with Surveyor. NHA-A stated The nurse was talking to R104's family on 6/29/24 and could not end the conversation to complete the neurological assessments. On 7/3/24 the nurse did not want to wake R104 due to being agitated earlier in the shift. Surveyor noted R104 was admitted to the facility with a diagnosis of TBI with hemorrhage. R104 would be at a high-risk for any neurological changes. NHA-A and Consultant-E agreed. On 8/15/24, at 10:52 AM, DON-B spoke with Surveyor regarding an assessment prior to transfer to the hospital. DON-B stated R104's family wanted a different facility and there was not a change in condition on 7/3/24. DON-B did not provide documentation related to R104's clinical status, or physician order, prior to R104 being transferred to the hospital.

Based on record review and interview, the facility did not complete thorough investigations of resident falls, and identify and implement revisions to the plan of care to prevent future falls. This was observed with 1(R104) of 2 residents reviewed with falls. *R104 had falls on 6/29/24, 7/2/24 and twice on 7/3/24. There was no documentation of a comprehensive assessment to determine causative factors. The Facility does not thoroughly investigate F104's falls to determine the root cause nor implement fall prevention interventions based on the identified root cause to prevent future falls. Findings include: The facility's policy and procedure entitled, Accidents/Fall Prevention Program, dated 1/30/2023, was reviewed by Surveyor. The policy documents: The facility strives to promote safety, dignity and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Any episode of a fall should be documented in risk management. Each fall must be investigated and/or assessed using a root cause analysis process to determine the cause of the fall and prevent any further injury. The individual care plan is to be updated with any changes or new interventions post fall and communicated to staff and implemented. R104 was admitted to the facility on [DATE], at 12:50 PM with a diagnosis of TBI (Traumatic Brain Injury) with subarachnoid hemorrhage. R104 has a Guardian for decision making. The Admission Nursing Assessment conducted on 6/29/24, at 12:50 PM, assesses R104 as a fall risk. Surveyor notes R104 was at the facility from 6/29/24 through 7/3/24 and had 4 falls during this time. R104 discharged prior to the completion of an Admission Minimum Data Set (MDS) assessment. The initial plan of care for Fall Risk dated 6/29/24, with a resolved date of 7/1/2024, with a goal date of 9/27/2024 documents interventions dated 6/29/24: Call light within reach; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Ensure proper footwear; Follow facility fall protocol. The initial plan of care for ADL (activity of daily living) self-care performance deficit due to TBI with weakness, and poor impulse control, which increases risk for complications, such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed. The interventions documented: 7/1/24 provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks; 7/2/24 an intervention of do not leave alone in room. There is a revision date of 7/5/2024 with no changes in interventions. There is a revision date of 7/8/2024 with interventions: bariatric bed with bolsters and extender; call family and allow them to talk as this helps decrease agitation; encourage resident to stay in the common area when awake. The Kardex for staff care printed 8/14/2024, includes under Resident Care: call family and allow them to talk as this helps decrease agitation; encourage resident to stay in the common area when awake. The Kardex does not identify fall risk interventions for safety. FALLS * On 6/29/24, at 4:15 PM, R104 had an unwitnessed fall in the hallway. The fall documentation includes, improper footwear and ambulating without assistance. There is not a comprehensive assessment to determine causative factors to identify what R104 was doing at the time of the fall, when they were last assisted by staff and to support the immediate intervention of R104 to be placed in a wheelchair by the nurses station, then after supper, was transferred to a low bed, in their room. The initial plan of care for fall risk dated 6/29/24, with a resolved date of 7/1/2024, with a goal date of 9/27/2024, documented interventions starting 6/29/24 include to ensure proper footwear. Surveyor notes the fall was not thoroughly investigated to include causative factors leading up to the fall, along with identification of fall prevention interventions related to possible causative factors. On 8/15/24, at 9:15 AM, (Nursing Home Administrator) NHA-A provided additional fall investigation information that is not part of the medical record. The supplemental fall investigation information documented R104 was last toileted at 3:00 PM, had socks on and was not using an assistive device when they fell on [DATE]. The intervention was to keep in a common area. * On 7/2/24, at 3:10 PM, R104 had an unwitnessed fall in their room. The fall incident does not include a comprehensive assessment of causative factors leading up to the fall. The initial plan of care for ADL (activity of daily living) self-care performance deficit due to TBI with weakness and poor impulse control which increases risk for complications such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed; The interventions: 7/1/24, provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks. On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record which documented R104 was in an activity prior to the fall. The activity staff took R104 to their room to use the bathroom. The staff left R104 in their room to get staff to assist with toileting. The staff was re-educated to review Kardex for fall interventions. Surveyor notes R104's Kardex does not identify R104 as a fall risk or provide instructions to not leave R104 alone in their room. The Kardex does not document fall prevention interventions. The ADL plan of care does documents on 7/3/24: do not leave R104 alone in room. * On 7/3/24, at 12:00 PM, R104 had an unwitnessed fall from bed. The fall incident does not document a comprehensive assessment to determine causative factors, along with interventions to prevent further falls. The fall incident report documents R104 was looking for their brother and was put to bed a few minutes prior to the fall. The immediate intervention implemented was 15 minute checks and transferred back to bed. Surveyor notes there is no comprehensive assessment to determine causative factors leading up to the fall to determine appropriate interventions to prevent further falls. On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record. There was no information for possible causative factors leading up to the fall. The interventions were 15 minute checks. Surveyor notes there are no plan of care changes for 7/3/2024 fall and prevention. * On 7/3/24 at 6:40 AM R104 had a fall with staff present. R104 was urinating on the floor as they were walking to the bathroom. The staff was not able to use a gait belt for assistance, R104 legs become weak and they fell to the floor. There is not a documented comprehensive assessment to assess for injury, There was no immediate intervention documented related to this fall. Surveyor notes the fall care plan does not address R104's 4 falls. The initial plan of care for ADL(activity of daily living) self-care performance deficit due to TBI with weakness and poor impulse control which increases risk for complications such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed; The interventions: 7/1/24 provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks. On 7/2/24 an intervention of do not leave alone in room was added. On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record. There was not documentation related to a comprehensive assessment of R104 at the time of the fall. There was no documentation of immediate interventions to prevent further injury. On 7/3/24 at 11:56 AM R104 family requested R104 to be transferred to the hospital. R104 did not return back to the facility. Surveyor informed Nursing Home Administrator-A R104's falls were not comprehensively assessed to identify a root cause analysis, along with appropriate fall prevention interventions identified and R104's care plan revised.

Based on record review and interview, the facility did not ensure a resident's indwelling catheter was medically necessary. This was observed with 1 (R13) of 3 residents reviewed with indwelling catheters. * R13 returned from a hospital stay with an indwelling catheter. There were no medical indications for the use of the catheter and it was not removed for 2 months. Findings include: The facility's policy and procedure Catherization of a Resident or Intermittent Catherization, dated 1/30/2023, was reviewed by Surveyor. The policy documents a resident will only be catherized with a physician's order, and medical justification for use, utilizing proper infection control techniques. R13 was readmitted to the facility from a hospital visit on 6/3/24. The Nurses Note on 6/2/24, at 12: 55 AM, documents Writer called Hospital to check up on resident. Resident was admitted with acute respiratory failure. The Nurses Note on 6/3/24, at 6:54 PM, documents Patient sent to hospital 06/01 for sepsis. At hospital was very combative and given Haldol. Patient's family decided to start comfort care. Hospice coming tomorrow to admit. Patient resting back in bed. Also a catheter was placed. Surveyor notes there is no medical justification documented for the use of an indwelling catheter. The Physician Plan of Care documents an order on 6/4/2, Foley Catheter 16 French and 10 cc (cubic centimeter) balloon to gravity drainage. Every shift Foley Catheter Care. No medical diagnosis was documented. A Bowel and Bladder assessment was completed on 6/4/24. This assessment documents, catheter for [R13] cannot make needs known, as well as in the past, and needs to be checked on regularly. Surveyor notes R13 had an indwelling catheter from 6/10/24 -8/1/24 without medical justification. R13 had no urinary tract infections during the indwelling catheter use. R13 passed away on hospice care 8/13/24. On 8/13/24, at 3:00 PM, Surveyor requested any indwelling catheter justification for R13, during the exit meeting with Nursing Home Administrator (NHA)-A, (Director of Nurses) Director of Nursing (DON)-B, Consultant-D and Consultant-E. On 8/14/24, at 8:51 AM, DON-B spoke with Surveyor. DON-B stated when R13 returned from the hospital, they left it in for comfort, and for Hospice. Then R13, bounced back, and it was removed. Surveyor informed DON-B of the concern R13 had a catheter from 6/10/24-8/1/24 without medical justification.

Based on observation, interviews and record review, the facility did not ensure 1 (R156) of 1 residents reviewed for Dialysis received Dialysis care in accordance with professional standards of practice. *R156 did not have physician's orders for dialysis and there is no evidence staff were assessing and monitoring R156's fistula site on days when R156 did not receive dialysis. Findings include: The facility policy titled, Dialysis Monitoring and Observation dated 5/17/2022, documents, in part: Purpose-To ensure residents receiving hemodialysis are monitored for complications. Monitoring- 1. Listen using a stethoscope for the bruit and thrill of the fistula daily. 2. Document the presence or absence of the bruit and thrill on the [Medication Administration Record (MAR)] or [Treatment Administrations Record (TAR)]. 3. While listening for the bruit and thrill, observe the skin condition for any increased redness or swelling and notify the physician and dialysis center if any present . 10. A care plan will be developed to reflect the need for [Hemodialysis (HD)]. R156 was admitted to the facility on [DATE] with diagnosis that include End Stage Renal Disease (ESRD) with dependence on Renal Dialysis. R156 has an (Arteriovenous Fistula) AV Fistula located in the Left forearm. R156's Admission Minimum Data Set Assessment (MDS) dated [DATE] documents R156 is cognitively intact. R156 requires Dialysis. On 8/14/24, at 1:07 PM, Surveyor observed R156 in bed. Surveyor noted an AV fistula site in R156's left forearm. R156's care plan dated 8/5/2024 documents, Focus: The resident needs dialysis due to ESRD. Goal: The resident will have no [signs/symptoms] of complications from dialysis through the review date. Interventions: Check and change dressing daily at access site. Document (initiated 8/5/2024). Enhanced Barrier precautions (initiated 8/6/2024). Monitor labs and report to doctor as needed (initiated 8/6/2024). Monitor/document/report [as needed] for [signs and symptoms] of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds (initiated 8/6/2024). Surveyor noted the care plan did not address the type of dialysis that R156 receives, did not address R156 has an AV Fistula, and did not address the monitoring of R156's AV Fistula. Surveyor reviewed R156's EMR (Electronic Medical Record) and noted R156 did not have a physician's order for dialysis nor a physician's order to monitor R156's fistula site. Surveyor reviewed R156's MAR and TAR. Surveyor did not locate documentation of R156's AV fistula site being assessed. On 8/14/2024, at 1:21 PM, Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked if R156 needs an order for dialysis. RN-G stated no. Surveyor asked if staff monitor and document R156's AV fistula. RN-G stated that RN-G does check R156's AV fistula every day when she works. Surveyor asked where the assessment is documented. RN-G stated it is in the MAR or TAR. RN-G opened the Electronic Medical Record (EMR). RN-G did not locate any documentation of monitoring of the AV fistula in R156's MAR or TAR. RN-G stated, They should have it in there. On 8/14/2024, at 1:29 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. Surveyor asked if an order for dialysis is needed. ADON-C stated No. Surveyor asked what physician orders are needed for a resident on hemodialysis. ADON-C indicated they would need an order to check the fistula site. On 8/14/2024, at 1:42 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked what physician orders are needed for a resident who needed hemodialysis. DON-B stated there is not an order for dialysis needed, but there should be an order for the type of port/fistula the resident has, where the port/fistula is located and when to document the assessment of the port/fistula. Surveyor asked where the documentation of a fistula assessment would be located. DON-B stated it is in the TAR. Surveyor informed NHA-A and DON-B that R156 did not have an order for dialysis, did not have an order for monitoring of the AV fistula site and that there is no evidence that staff have been assessing R156's AV fistula site on days that R156 did not have dialysis. Surveyor asked how often the AV fistula site should be assessed. DON-B stated it should be assessed every shift. Surveyor noted after the facility was aware of Surveyor's concerns, the following physician orders were added on 8/14/2024: Pre dialysis vitals. Take BP on right arm only one time a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday). Dialysis access type: Fistula located on the Left arm. Site monitored and intact with bruit/thrill without erythema/edema or bleeding unless otherwise documented. For bleeding: hold pressure directly over the site and notify physician. Every shift. Surveyor noted after the facility was aware of Surveyor's concerns, the following care plan intervention was added on 8/14/2024: Do not draw blood or take B/P (blood pressure) in arm with dialysis site. No further information was provided as to why the facility did not ensure R156 received Dialysis care in accordance with professional standards of practice.

Based on observation, interview, medical record review, and facility policy and procedure review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from developing for 1 resident (R1) of 5 residents reviewed for PI. R1 is at risk for PI development. R1 developed an avoidable, facility acquired, unstageable, medical device related PI to his right scrotum from his Foley catheter. The facility did not determine the root cause of R1's PI until 10/20/23. Subsequently, the facility did not take action to remove the source of the pressure to promote healing and prevent additional pressure until 10/20/23. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP) - now known as National Pressure Injury Advisory Panel (NPIAP), an Unstageable pressure injury is defined as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The facility's Pressure Injury and Skin Condition Assessment, dated 5/19/22, states, in part: Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. 2. Residents will have a weekly skin assessment by a licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA (Certified Nursing Assistant). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 5. If the resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock area and groin. 6. Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. 12.If the wound is necrotic and the base of the wound bed is not visible or tunneling, the stage cannot be measured and must be recorded as non-stageable with an undetermined depth. R1 was admitted to the facility 8/24/23 with diagnoses including, but not limited to: diabetes mellitus type 2, paraplegia, fracture of T11-T12 vertebra, pneumonia, chronic kidney disease stage 3b (gradual loss of proper kidney function), benign prostatic hyperplasia (enlarged prostate gland), and morbid obesity. R1 has two (2) skin assessments documented prior to the PI being discovered: On 8/24/23, R1's Admission Skin Assessment indicates Redness to skin folds and buttocks. On 8/26/23, R1's Skin Observation Tool documents the following: Skin Intact: Yes; New Finding: Yes; Resident skin is: Warm/dry; Does the resident have edema: No; Equipment ordered: Low air loss mattress, wheelchair cushion. Of note, from 8/27/23 to 9/7/23 (10 days), the facility has no evidence the staff completed skin observations for R1. Per facility protocol, residents should receive skin observations weekly on shower days. R1's PI was not discovered until it was an unstageable PI. R1's Admission Minimum Data Set (MDS) assessment, on 8/31/23, indicates that R1's Brief Interview of Mental Status (BIMS) is 15, indicating he is cognitively intact. R1 requires extensive assist of 2 staff for bed mobility, hygiene, and toileting. R1 requires total assist of 2+ staff for transfers. Section M notes that R1 is at risk for PI development. R1's Braden Score (Risk factor for PI development) on 10/17/23 = 15 (At Risk). R1's Comprehensive Care Plan, dated 8/24/23, indicates Focus: (Date Initiated: 8/24/24, Revision on: 10/20/23) The resident has an actual impairment to skin integrity due to impaired mobility and paraplegia status: Unstageable pressure ulcer on scrotum. (Date Initiated: 8/24/24, Revision on: 10/20/23) Goal: The resident will develop clean and intact skin by the review date. Interventions: (Date Initiated: 8/24/24) Encourage good nutrition and hydration in order to promote healthier skin. (Date Initiated: 8/24/24) Follow facility protocols or treatment of injury. (Date Initiated: 8/24/24, Revision on: 10/20/23) Provide pressure relieving devices: air mattress, w/c (wheelchair) cushion and heels upon pillows. (Date Initiated: 8/24/24) Turn and position as necessary. R1's Visual/Bedside Kardex Report indicates the following: Bed Mobility: The resident requires 2 assist with bilateral bed enablers and trapeze. Wedges placed bilaterally just above knees when patient is in bed. Dressing: The resident requires 2 staff dressing. Eating: The resident is able to eat independently. Personal Hygiene: The resident is dependent on 2 staff for personal hygiene and oral care. Provide pressure relieving devices: air mattress, w/c (wheelchair) cushion and heels up on pillows. Toilet Use: The resident requires 2 staff for check and change for bowels. 1 assist with Foley care. Transfer: The resident requires 2 assist with full body mechanical lift (Hoyer). R1's skilled daily note dated 9/6/23 at 13:04 (1:04 PM) states in part; see nursing notes for penis area that is infected. Update to the Nurse Practitioner states in part; two small areas on right side of penis that appear pus filled with surrounding edges bright red in color and has brown odorless scant discharge. On 9/8/23 the visiting wound physician assessed and measured R1's right scrotum PI with a progress note that states in part. Right Scrotum 9/8/23 (Initial Wound Evaluation & Management Summary) Wound Size: 1.0 x 4.0 x 0.1 cm (centimeters) Surface Area: 4 cm2 (centimeters squared) Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 1 day Objective: Maintain Healing Phase Peri wound radius: Surrounding DTI (Deep Tissue Injury) (Purple/Maroon) Exudate: Light Serous Slough: 100% Treatment Plan: Zinc ointment apply twice daily for 30 days. **It is important to note, the wound physician identifies this area as an unstageable PI with surrounding DTI. 9/15/23 Wound Size: 1.0 x 3.5 x 0.1 cm (centimeters) Surface Area: 3.5 cm2 Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 8 days Objective: Maintain Healing Phase Exudate: Light Serous Slough: 100% Wound Progress: Improved evidenced by decreased surface area. Treatment Plan: Zinc ointment apply twice daily for 23 days. 9/22/23 Wound Size: 1.0 x 3.5 x 0.1 cm (centimeters) Surface Area: 3.5 cm2 Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 14 days Objective: Maintain Healing Phase Exudate: Light Serous Slough: 80% Granulation tissue: 20% Wound Progress: Improved evidence by decreased slough. Treatment Plan: Zinc ointment apply twice daily for 16 days. 9/29/23 Wound Size: 1.0 x 3.5 x 0.1 cm (centimeters) Surface Area: 3.5 cm2 Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) > (greater than) 21 days Objective: Maintain Healing Phase Exudate: Light Serous Slough: 80% Granulation tissue: 20% Wound progress: At Goal Treatment Plan: Zinc ointment apply twice daily for 9 days. 10/6/23 - Visit rescheduled. 10/13/23 Wound Size: 1.0 x 3.0 x 0.1 cm (centimeters) Surface Area: 3.0 cm2 Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 34 days Objective: Maintain Healing Phase Exudate: Light Serous Slough: 20% Granulation tissue: 80% Treatment Plan: Zinc ointment apply twice daily for 30 days. *Surgical Excisional Debridement Procedure Indication for Procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 10/13/23 to the patient who indicated agreement to proceed with the procedure(s) Procedure Note: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 20 percent 10 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Continue: Zinc ointment Plan of Care Reviewed and Addressed: Goal of treatment is healing evidenced by a 14.3% decrease in surface area and a 75.0% decrease in nonviable tissue within the wound bed. 10/20/23 Wound Size: 3.0 x 6.0 x 0.1 cm (centimeters) Surface Area: 18.00 cm2 Cluster Wound: Open ulceration are of 14.40 cm2. Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 40 days Objective: Healing/Maintain Healing Exudate: Light Serous Thick adherent devitalized necrotic tissue: 30% Slough: 20% Granulation tissue: 30% Skin: 20% *Wound progress: Exacerbated due to Foley positioning Slough: 20% Granulation tissue: 80% Treatment Plan: Zinc ointment apply twice daily for 30 days. 10/27/23 Wound Size: 2.0 x 5.0 x 0.1 cm (centimeters) Surface Area: 10.0 cm2 Cluster Wound: open ulceration area of 8.0 cm2 Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 46 days Objective: Healing/Maintain Healing Exudate: Moderate Serous Thick adherent devitalized necrotic tissue: 10% Slough: 20% Granulation tissue: 50% Skin: 20% Wound progress: Improved evidenced by decreased surface area, decreased slough. Continue: Zinc ointment Plan of care reviewed an addressed: Goal of treatment is healing evidenced by 44.4% decrease in surface area 40.0% decrease in nonviable tissue within the wound bed. 11/3/23 Wound Size: 2.0 x 4.0 x 0.1 cm (centimeters) Surface Area: 8.0 cm2 Cluster Wound open ulceration area of 6.4 cm2. Etiology: Pressure Stage: Unstageable Necrosis Duration: > (greater than) 53 days Objective: Healing/Maintain Healing Exudate: Light Serous Thick adherent devitalized necrotic tissue: 10% Slough: 20% Granulation tissue: 50% Skin: 20% Wound progress: Improved evidenced by decreased surface area. Continue: Zinc ointment apply twice daily for 9 days Expanded Evaluation Performed: The progress of this wound and the context surrounding the progress were considered in greater depth today. Of note, R1 has diagnoses of diabetes mellitus type 2, paraplegia, fracture of T11-T12 vertebra, chronic kidney disease stage 3b, benign prostatic hyperplasia with a Foley catheter, and morbid obesity. These diagnoses place R1 at increased risk for PI development due to impaired healing, impaired mobility, impaired tissue tolerance, and use of a Foley catheter. These diagnoses increase the need for robust skin checks and preventative interventions to prevent PI development. On 11/8/23 at 1:00 PM, Surveyor spoke with R1. Surveyor asked R1, do you have a PI to your scrotum? R1 stated, yes, he has a small PI to his right scrotum. Surveyor asked R1, what caused the PI to your right scrotum. R1 stated, The catheter. Surveyor asked R1, do staff reposition the catheter and tubing? R1 stated, Staff is good about my catheter, they always try. R1 stated, I'm in a chair or bed 24 hours a day. Surveyor observed the trapeze bar above R1's bed. R1 has use of his hands and arms. The trapeze is hooked up on the bar and out of R1's reach which limits his ability to attempt to reposition. On 11/8/23 at 3:34 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when are staff to complete skin checks? DON B stated, weekly on shower days. Surveyor asked DON B, when staff perform pericare and get residents dressed would you expect them to look resident's skin? DON B stated, Yes, and reporting to the nurse. DON B stated, R1 should have weekly skin assessments documented. Surveyor asked DON B, when did you identify the PI on R1's scrotum? DON B stated, we discovered the PI on 9/8/23. Surveyor asked what stage is the PI to R1's right scrotum DON B stated, It's unstageable. Surveyor asked DON B, have you determined the root cause of R1's PI to his right scrotum? DON B stated, We believe it was the catheter. Surveyor asked DON B, what did you put in place to prevent the PI to R1's scrotum from worsening? DON B stated, the wound physician indicated (10/20/23) that the catheter tubing was short due to R1's size and the Statlock (a securement device that prevents pulling on the catheter) was holding it (catheter) down against R1's scrotum (applying pressure). Note, the wound physician's note on 10/20/23 indicates, Wound progress: Exacerbated due to Foley positioning. DON B stated on 10/20/23 she removed the Statlock and educated staff to not use the Statlock. Note, there is no documentation of staff education, and it was not removed from R1's orders as it was bundled (clarified meaning Foley and Statlock together). Note, Surveyor observed the Statlock not in use.

Based on observation, interview, and record review, the facility did not ensure each resident received care consistent with professional standards of practice to prevent pressure injuries (PIs) from developing for 1 Resident (R) (R1) of 3 sampled residents reviewed for PIs. R1 developed an unstageable pressure injury to the right and left heel after admission to the facility. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 did not receive weekly nursing assessment for the left or right heel pressure injury once identified. R1 did not receive weekly skin checks for prevention of skin breakdown. R2 did not receive weekly skin checks for prevention of skin breakdown. R3 did not receive weekly skin checks for prevention of skin breakdown. Findings include: Facility policy named Pressure Injury and Skin Condition assessment dated [DATE] included: .2. Residents identified will have a weekly skin assessment by a licensed nurse. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. 7. At the earliest sign of a pressure injury or other skin problems, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. 10. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. 17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care . 1. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was their own decision maker and on 8/11/22, the Brief Interview for Mental status (BIMS) score was 15/15 which showed no cognitive impairment. On 10/10/22 at 9:25 AM, Surveyor observed R1 sitting up in a wheelchair at the nursing station. R1 had a blue boot on the left foot and a dressing dated 10/9 on the right foot. Right foot did not have a boot on it. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical record included a skin observation tool dated 8/11/22. Listed on the skin observation tool was .other (specify) squishy heels, slightly reddened - air mattress in place . On 8/14/22, a Skin Impairment/Wound form indicated a left heel, Deep Tissue Pressure Injury, measured 1 centimeter (cm) by 1cm. Wound was not open, intervention to elevate heels. On 10/10/22, Surveyor reviewed R1's medical record which showed no evidence of physician notification regarding new left heel pressure injury identified on 8/14/22 or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/10/22, Surveyor reviewed R1's medical record for weekly nursing assessment of pressure injury to left heel and measurement. R1's record showed no evidence of weekly nursing assessment and measurements between the time of 8/14/22 through 10/10/22. On 9/15/22, R1 was seen at (named hospital) Wound Clinic. Wound Clinic notes included: .Left posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss - base of ulcer covered by slough and/or eschar. Length 3cm, Width 2.3cm, Depth 0.1cm, Wound surface area 6.9cm . .Right posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss-base of ulcer covered by slough and/or eschar. Length 0.8cm, Width 0.7cm Depth 0.1cm, Wound surface area 0.56cm . .bilat heels, wound bed: black eschar - some soft some harder unstageable . On 9/15/22, the wound clinic provider orders included: Treatment to both heels and obtain another heel protector for right (rt) foot. On 10/10/22, Surveyor reviewed R1's medical record which showed no evidence of a skin assessment to identify right heel pressure injury prior to wound clinic appointment on 9/15/22. Further reviewed showed no weekly assessments of right heel pressure injury completed by the facility between 9/15/22 through 10/10/22. On 9/22/22, R1 was seen at (named hospital) Wound Clinic. Wound clinic notes included: .Left posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss - base of ulcer covered by slough and/or eschar. Length 3.3cm, Width 2.4cm, Depth 0.1cm, Wound surface area 7.92cm . .Right posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss-base of ulcer covered by slough and/or eschar. Length 0.3cm, Width 0.4cm Depth 0.1cm, Wound surface area 0.12cm . .bilat heels, wound right no infection noted left maybe starting with some infection, wound bed black eschar- soft unstageable, periwound: maceration, [CONDITION(S)] of heel . On 9/22/22, the wound clinic provider orders included: A change in treatment to both heels and start [MEDICATION(S)] for left heel infection .heel protectors - to get one for the right- requested again . On 10/10/22, Surveyor reviewed R1's Treatment Administration Record (TAR) which included the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record indicated on 9/30/22, 10/1/22, and 10/3/22, R1's treatment was not documented as completed. On 10/6/22, R1 was seen at (named hospital) Wound Clinic. Wound clinic notes included: .Left posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss - base of ulcer covered by slough and/or eschar. Length 3.2cm, Width 2.5cm, Depth 0.1cm, Wound surface area 8cm . .Right posterior heel, wound characteristics: black eschar, staging: full thickness tissue loss-base of ulcer covered by slough and/or eschar. Length 0.8cm, Width 0.8cm Depth 0.1cm, Wound surface area 0.64cm . .bilat heels, wound eschar, slight [CONDITION(S)] around heel more on left, wound bed: black eschar- dry unstageable, periwound: [CONDITION(S)], not warm, no drainage noted . On 10/6/22, the wound clinic provider orders included: Heel protectors - Skilled Nursing Facility (SNF) to get one for the right-requested again! . On 10/10/22 at 1:00 PM, Surveyor interviewed Registered Nurse (RN)-D who verified R1 did not have a heel protector/boot on the right foot as ordered. RN-D explained they were waiting for it to be ordered and was unsure if that came from the wound clinic or the facility. On 10/10/22 at 1:09 PM, Surveyor interviewed Advanced Practice Nurse Practitioner (APNP) E from (named facility) wound clinic. APNP-E verified that R1 came to the clinic for the first visit on 9/15/22 and was diagnosed with two unstageable pressure injuries, one to the left heel and one to the right. APNP-E also verified they had been ordering a second heel protector/boot for the right heel which was not on R1 at any visit R1 attended with the APNP-E. APNP-E explained it was important for R1 to be using and wearing the heel protectors/boots to both the right and left heels. On 10/10/22 at 2:25 PM, Surveyor interviewed DON (Director of Nursing)-B who verified the order for heel protector/boots to the right heel was missed on three occasions. The boots are in house and are now placed in R1's room. On 10/10/22, Surveyor reviewed R1's TAR which included orders for weekly skin observations Monday day shift and daily diabetic foot checks. From 8/11/22 through 10/10/22, R1's weekly skin checks were not completed on the following dates: 8/29/22, 9/12/22, and 9/26/22. From 8/11/22 through 10/10/22, R1's daily diabetic foot checks were not completed on the following dates: 8/15/22, 8/16/22, 8/23/22, 8/24/22, 8/25/22, 8/28/22, 8/29/22, 9/6/22, 9/8/22, 9/10/22, 9/11/22, 9/12/22, 9/13/22, 9/20/22, 9/24/22, 9/26/22, 9/29/22, 9/30/22, 10/3/22, and 10/6/22. On 10/10/22 at 10:15 AM, Surveyor interviewed DON-B who explained that the nursing staff should be completing weekly skin observations for each resident to prevention and identify skin concerns. DON-B verified they were not completed on sampled residents. On 10/10/22, Surveyor reviewed R1's nursing care plan for skin which showed no evidence of pressure injuries or interventions. Focus: Resident has potential for impairment to skin integrity due to impaired mobility Date Initiated: 08/12/2022 Revision on: 08/19/2022 Goal: The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 08/12/2022 Revision on: 08/22/2022 Target Date: 11/21/2022 Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 08/12/2022 Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Date Initiated: 08/12/2022 Turn and position as necessary Date Initiated: 08/12/2022 Revision on: 08/12/2022 On 10/10/22 at 11:30 AM, Surveyor interviewed (Nursing Home Administrator) NHA-A and DON B regarding R1's plan of care for pressure injuries. DON-B explained when R1 admitted into the facility, R1 had squishy heel and the facility set up an outside referral to the wound clinic at (named hospital). There was a three week waiting period for R1 to be seen. The facility had a wound nurse, Assistant Director of Nursing (ADON)-C. DON-B verified it was the expectation that R1 wound have been assessed weekly. R1's plan of care was updated to reflect orders and items implemented between 8/14/22 through 10/10/22. DON-B reviewed R1's chart and concluded R1's records did not contain notes from (named hospital) wound clinic and requests were made to obtain documentation of wounds. On 10/10/22 at 2:31 PM, Surveyor interviewed ADON-C regarding R1's pressure injuries. ADON-C explained they were new to the facility and began to follow R1's care at the beginning of September. R1 was waiting to see an outside provider for wound care. ADON-C will review new orders after each provider visit. ADON-C recalled the resident refused to be assessed by ADON-C on a few occasions in September. ADON-C verified there wasn't documentation in R1's medical record regarding assessment refusals. 2. On 10/10/22, Surveyor reviewed R2's TAR which included orders for weekly skin observations, Friday day shift. R2's care plan identified that R2 was at potential risk for skin impairment due to impaired mobility, stroke, and diabetes. From 8/1/22 through 10/10/22, R1's weekly skin checks were not completed on the following dates: 8/19/22, 8/26/22, 9/2/22, 9/9/22, 9/23/22, and 10/7/22. See DON B interview from example 1. 3. On 10/10/22, Surveyor reviewed R3's TAR which included orders for bi-weekly skin observations on Sunday and Wednesday evening shift. R3's care plan identified that R3 was at actual impairment to skin integrity with an identified stage 4 pressure injury. From 8/1/22 through 10/10/22, R1's weekly skin checks were not completed on the following dates: 8/10/22, 10/2/22, and 10/9/22. See DON B interview from example 1.

Based on observation, interview, and record review, the facility did not provide an environment in which residents were free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress). This prevented the resident from reaching his/her highest practicable level of physical, mental, and psychosocial well-being and resulted in psychosocial harm (embarrassment, humiliation, degradation) for 1 of 26 residents sampled (R47). R47 complained one often had to wait for hours for staff to assist with incontinence care. Staff members confirmed R47 had an incontinent BM (bowel movement) while lying in bed and staff did not provide necessary incontinence care until 3 plus hours had passed. R47 expressed fear of defecating and persistent feelings of worthlessness/degradation. Evidenced by: According to the interpretive guidelines to the federal nursing home regulations: Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. Facility policy entitled Abuse Prevention Program, dated 2/7/17, includes, in part: Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain or mental anguish. Neglect is the intentional carelessness, negligence, or disregard of policy or care plan, which causes, or could be reasonably expected to cause pain, injury, or death. R47 was admitted to the facility, on 2/28/19, with [DIAGNOSES REDACTED]. R47's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/7/19, indicates R47 was totally dependent on physical assistance of 2 or more staff members for transfers and required extensive physical assistance of two or more staff members for bed mobility and toileting. R47's MDS also indicated R47 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. R47's most recent MDS, with ARD of 3/14/19, indicates R47 is cognitively intact with a BIMS score of 14 and requires the extensive physical assist of two staff for bed mobility, toileting, and transfers. R47's Comprehensive Care Plan, initiated 3/1/19, includes, in part: Focus: The resident has an ADL (activities of daily living) Self-Care Performance Deficit related to Weakness and Obesity . Goal: The resident will improve current level of function through the review date. Interventions: Bed mobility: The resident requires extensive assistance of two staff to turn and reposition in bed . Toilet use: the resident requires extensive assistance of two staff for toileting . Focus: The resident has limited physical mobility related to weakness . Goal: The resident will demonstrate the appropriate use of adaptive devices to increase mobility through the review date . Interventions: The resident is non-weight bearing . Ambulation: The resident does not ambulate. R47's Social Services Note, dated 3/4/19, includes, in part: Care conference with resident . is getting better movement. Physical Therapist- goal roll side-to-side, right now needs max assist of 2 staff to roll. Occupational therapist- explained . lower body is competing dependent, lower is max (assist), toileting is dependent . and arm strength is 3 out of 5, has range of motion, but needs to improve strength. Oxygen and pain is biggest obstacle. Social Worker- resident goal is to return (to community/previous living arrangements). On 4/15/19 at 8:44 AM, during initial screening, R47 described self as a very accomplished multi-business owner and operator, a top notch man, a person who has done a fair amount of traveling, and one who has a large appreciation for people. R47 indicated that the experience of having to wait for long periods of time for facility staff to assist with cares and being left for long periods of time in stool makes R47 feel like dirt and like other people are more important than me. R47 indicated that it takes 3-4 hours for staff to answer call light and that R47 sat in own feces for 4 hours one time, within the last month. R47 indicated that COTA M (Certified Occupational Therapist Assistant) and PT P (Physical Therapist) came to work with R47 and saw resident full of feces and they went to work with someone else. Several hours later, PT P and COTA M came back in to work with R47 and they saw resident was still lying in feces, so they cleaned R47 up and reassured R47 that they reported the incident. R47 stated, I am afraid to even crap anymore. I let them know I have to poop and they leave. It takes an act of congress to get what I need here. They can't let me go so long that I get pressure injuries or sit in feces. R47 indicated that one's goal is to return to their home in the community and that R47 has recently lost mobility of legs, so is dependent on staff assistance for bed mobility, transferring, and eliminating. R47's PT (Physical Therapy) and OT (Occupational Therapy) Notes were reviewed and include, in part: -3/9/19 Upon arrival, patient reports having had an accident, patient call light put on and staff found to help clean (R47) up (sic). Patient reported feeling unwell again this day and is too tired to do anything. -3/13/19 Upon entering room, patient was covered in BM. Patient reported that (R47) had been soiled since 9:30 AM (entered the room at 1:50 PM). The call light had been on 2 different times throughout the day. Social worker was notified of the neglect. Patient able to roll side-to-side with moderate assist today. -3/13/19 Patient attempted at 10:30 AM; however, patient request for Writer to come back after noon, due to waiting for nursing to clean up and to eat breakfast (sic). Patient approached in afternoon, at 1:50 PM, and reported waiting to be cleaned up. Notified nursing staff, DON B, CSW K. Patient requires total assist for sponge bath . -3/15/19 Patient again has soiled bandages, dated 3/3/19. The bandages fell off during therapy and nursing was notified of this . -4/9/19 . Patient supine in urine saturated sheets, educated patient on utilizing call light to have CNAs change and wash patient .Dressing change required to right posterior thigh, (Unit Nurse) made aware . On 4/16/19 at 10:25 AM, during an interview, PT P indicated that along with COTA M, they went in to assist R47 and R47 had an incontinent BM, so PT P put on R47's call light for resident to get help. PT P knew R47 had an incontinent BM by the odor, visible soiled bedding, and by R47 verbalizing it. PT P and COTA M went back a couple times to try to work with R47 and each time pressed the call light to get R47 cleaned up and after 4-5 hours, COTA M and PT P cleaned resident up themselves. PT P also indicated that on a different occasion, R47 was left in BM for over a half hour after PT P reported that R47 needed assistance due to incontinence. On 4/16/19 at 12:03 PM, during an interview, COTA M indicated that R47 has complained about being left in BM and COTA M witnessed one incident on 3/13/19. COTA M indicated that R47's call light was on and R47 was waiting to be cleaned up at 10:30 AM, when COTA M entered the room, so COTA M excused self, with intentions of returning after R47's needs were met. COTA M was made aware that R47 had an incontinent BM by R47 verbalizations, the visibly soiled bedding, and by the odor in the room. At 1:50 PM, COTA M re-entered R47's room and resident was still lying in BM. COTA M indicated that R47's call light was off the second time and COTA M notified CSW K; COTA M and PT P provided incontinence care. On 4/16/19 at 1:49 PM, during an interview, CNA D indicated that around 9:30 AM, when CNA D went to retrieve R47's meal tray, R47 stated that R47 had a BM. CNA D asked if R47 was on a bedpan which R47 indicated no and did not want CNA D to place one at that moment. CNA D indicated that PT P and COTA M were in R47's room the next time CNA D went in R47's room and they were cleaning resident up. CNA D remembered that day well and CNA D had a horrible day. CNA D recalled self and another staff member both cried at the end of the shift, because they were overwhelmed with the workload. CNA D stated, I did not check back in with (R47) between the morning and 1:50 PM, when R47 was changed, and I should have. CNA D also indicated that a resident should not be left in an incontinent BM for any amount of time. R47's statement, dated 3/19/19, includes, in part: . spoke with resident regarding timeliness of answering call lights. Resident said if one craps self it doesn't take too long, about 1 hour average, to get cleaned up. Occasionally longer, but they are so busy . asked resident what time during the day is resident waiting a long time. Resident said peak time, during the morning it takes the longest . (sic) On 4/16/19 at 12:24 PM, during an interview, when asked if an hour or longer is an appropriate time for someone to wait for assistance after an incontinent BM, CSW K and NHA A stated, No.

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop a PI unless the resident's condition demonstrates that it was unavoidable and a resident with a PI receives necessary treatment and services to promote healing or prevent new injuries from developing for 2 of 5 residents reviewed with PI's of a total of 26 sampled residents (R20 and R51). R20 was at risk for PI development. The facility failed to put interventions in place to prevent R20 from developing a PI. R20 developed a facility acquired Stage 3 PI to right heel, R20's was observed to have heels directly on the mattress. The facility indicated that R51 was readmitted with a PI on 3/11/19. There was no evidence of a wound assessment until 5 days after admission. The facility did not update or develop an individualized Comprehensive Care Plan for R51's PI or for repositioning, according to R51's needs to promote healing of a Stage 3 PI to left buttock. R51 was not accurately assessed for a Stage 3 PI to left buttock. This is evidenced by: The facility's Pressure Ulcer Prevention policy, dated 7/25/16, notes, in part: . A pressure ulcer is considered unavoidable if the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate . -Staging System: . Stage 2 PI: Partial-thickness skin loss with exposed dermis .the wound bed is viable, pink or red, moist . slough and eschar are not present . Stage 3 PI: Full-thickness skin loss . slough and/or eschar may be visible .If slough or eschar obscures the extent of tissue loss this is an Unstageable PI . -Systematic Skin Assessment: An integral part of any skin care program is a systematic skin assessment. It is through these inspections that early skin problems can be detected and interventions started. These inspections start on Admission . Assessment must continue according to an appropriate schedule. Staff should evaluate skin condition and should pay close attention to bony prominence's . -Risk Factors: Primary Risks: Impaired/decreased mobility and decreased functional ability are the primary risk factors for pressure ulcers . -Accurate Documentation: Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors, pressure points, under-nutrition and hydration deficits and moisture and its impact. -Protecting Against External Mechanical Forces: All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours (unless a tissue tolerance test indicated otherwise). This repositioning should also take place when residents are in a chair or wheelchair. Example 1 R20 was admitted to the facility on [DATE]. R20's Comprehensive Care Plan, on 12/20/18, includes, in part: R20 has limited physical mobility related to right knee surgery. Goal: R20 will demonstrate the appropriate use of adaptive devices to increase mobility . R20 was hospitalized and readmitted to the facility, on 1/4/19, with [DIAGNOSES REDACTED]. (It is important to note that there is no documented assessment of R20 having a deep tissue injury (DTI) on readmission on 1/4/19.) On 1/12/19, R20's Progress Notes includes, in part: R20 presented with a DTI to right heel, 100 % eschar, measuring 2.2 CM (Centimeters) x 2.6 CM. Orders received for [MEDICATION NAME] daily to heel. Current treatment and Intervention: heel float, Education: encouraged patient to allow heel float. 1/17/19 care plan indicates: R20 has actual impairment to skin integrity surgical wound, DTI right heel, Goal: R20 will have no complications r/t (related to) surgical incision of the RLE (right lower extremity) or DTI of right heel . Interventions: Float heels when in bed . Provide treatment as prescribed by MD (medical doctor) . Weekly treatment documentation to include measurement of each area of skin breakdown. R20's Weekly Wound Documentation: PI Right heel. On 1/26/19: 1.3 CM x 2 CM, Wound bed 100 % eschar On 2/2/19: 2.5 CM x 2.7 CM, Wound bed 100 % eschar, physician updated about increase in size, new order for [MEDICATION NAME] twice a day, encourage patient to float heels when in bed. 2/6/19 care plan indicates: R20 exhibits the symptom of resisting care r/t cognition/mood/behaviors .Resists therapy, cares and pillows to float heels at times (resident kicks heel lift-pillow out and will get upset when they try to replace). Goal: R20 will comply with care delivery specifically with regard to resists therapy, cares and pillows to float heels at times (resident kicks heel lift-pillow out and will get upset when they try to replace). Interventions: .Emphasize dignity, Emphasize soothing, kind slow and [MEDICATION NAME] speech .Try again later. R20's Kardex Care Plan notes Bed mobility: R20 requires 1 assist by staff to turn and reposition in bed . Float heels. Progress Notes continue: On 2/9/19: 2.1 CM x 2.5 CM, Wound bed 100 % eschar On 2/16/19: 1.5 CM x 1.6 CM, Wound bed 100 % eschar R20's quarterly MDS (Minimum Data Set) assessment, dated 2/18/19, notes a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. Section G notes R20 is extensive assist with bed mobility. Section M notes R20 is at risk for PI and has 1 DTI. Progress Notes continue: On 2/23/19: Measurements: 1.0 CM x 1.6 CM, Wound bed 100 % eschar. Barriers to wound healing: decreased mobility, cardiac Dx. (diagnosis). Non-compliance with heel floats to offload pressure to heel .Pt. (patient) was found at 2 different times today with heels on bed. On 3/2/19: 1.0 CM x 1.4 CM, Wound bed 100 % eschar On 3/9/19: 1.0 CM x 1.1 CM, Wound bed 100 % eschar On 3/16/19: 0.9 CM x 1.1 CM, Wound bed 100 % eschar On 3/23/19: 0.9 CM x 0.8 CM, Wound bed 100 % eschar On 3/30/19: 0.9 CM x 0.8 CM, Wound bed 100 % eschar On 4/6/19: Stage III, Measurements: 1.4 CM x 1.7 CM x 0.7 CM, 25% granulation tissue, 75% slough, Comments: Necrotic tissue off; MD notified. R20's Physician Orders, on 4/11/19, includes, in part: NSW (Normal Saline Wash) to OA (open area) right heel, Pat dry, Skin prep to periwound, Cut Hydrophera Blue (dressing) to size, moisten with saline and apply to wound base. Cover with foam dressing, wrap with Kerlix and tape, change every 3 days and PRN . for Stage 3 PI. On 4/13/19- Stage III, 0.8 x 1.3 CM. x 0.4 CM 25% granulation tissue, 75% slough On 4/16/19 at 9:25 AM, Surveyor observed LPN N (Licensed Practical Nurse) complete R20's treatment to PI on R20's right heel. Surveyor observed R20's right heel PI with an open area approximately 1.0 CM length x 0.5 CM width x 0.2 CM depth. Wound bed was observed to have approximately 60% slough and 40% granulation tissue present. LPN N completed the treatment per order and wrapped R20's right foot in a Kerlix dressing. On 4/16/19 at 2:00 PM, Surveyor observed R20 in bed with right heel in direct contact with the surface of mattress. R51's mattress appeared to be a standard foam mattress. Surveyor asked CNA D to look at R20 in bed, observing that R20's right heel was in direct contact with the mattress. CNA D stated that R20's foot should be on the heel lift pillow and was not. CNA D stated that the nurse must not have placed R20's heel lift pillow under R20's heel after the treatment was completed this morning. CNA D proceeded to place the heel lift pillow to float R20's foot. On 4/22/19, the facility provided requested manufacturer's recommendations for R20's bed mattress. The facility indicated that R20 had a Panacea Original Foam Mattress. According to the manufacturer's recommendations, this mattress provides pressure redistribution and that foam mattresses may be considered up to Stage 3 wounds. R20's foam mattress would not have provided off-loading to R20's Stage 3 PI to heel when in direct contact with the mattress. Example 2 R51 was admitted to the facility on [DATE], was hospitalized and readmitted to the facility, on 3/11/19, with [DIAGNOSES REDACTED]. R51's admission MDS assessment, dated 3/18/19, notes a BIMS score of 15, indicating R51 is cognitively intact. Section G of the MDS notes R51 requires extensive assist of 2 with bed mobility and total assistance with transfers. Section H of the MDS notes R51 is Always incontinent of Bowel. Section M of the MDS notes R51 is at risk for PI. Section M0210 Unhealed Pressure Ulcers/Injuries, Does this resident have one or more unhealed pressure ulcers/injuries. No is indicated. Section M1200 Skin and Ulcer/Injury Treatments, Pressure relieving device for chair and Pressure reducing device for bed are checked. R51's CAA (Care Area Assessment), dated 3/29/19, for PI under Analysis of findings notes, in part: Potential under Problem/need, Nature of problem/condition: Risk factors: Decreased mobility, DM (Diabetes Mellitus), infection, at higher risk for PI. No skin alterations related to pressure present on admission. R51's Comprehensive Care Plan, dated 2/16/19, revision on 3/29/19, includes, in part: R51 has an ADL (Activities of Daily Living) Self-Care Deficit r/t Decreased Mobility and Weakness. Goal: . will improve current level of function through review date, Interventions: . Bed mobility: the resident requires total assist by 2 staff to turn and reposition in bed as necessary . R51 has potential for and actual impairment to skin integrity-groin/peri area redness, Goal: . will maintain or develop clean and intact skin by review date . Interventions: Good nutrition and hydration in order to promote healthier skin, Follow facility protocols for treatment of [REDACTED].e. air mattress, offloader boots, etc. Turn and reposition as necessary. On R51's Braden Score (risk assessment for PI): 3/11/19 was scored, 20 indicating at risk for skin breakdown. 3/18/19 =16 3/25/19= 15 4/1/19 = 19 On 3/11/19, R51's Re-admissions Data Collection Tool under Skin Condition notes: Sacrum . wound-has dressing over it. Hospital states once bandage is removed we can use barrier cream. (Of note, upon request, the facility provided no documentation of this specific order.) R51's Physician order [REDACTED].>2/16/19: (MONTH) use barrier creams PRN (as needed), CNA (Certified Nursing Assistant) may apply. (MONTH) keep at bedside unless contraindicated. 3/29/19: NSW to stage 2 PI on sacrum and buttock. Pat dry, followed by skin prep peri wounds. Apply foam boarder dressing, change q 3 days and PRN (as needed for soiled dressing and every evening shift every 3 days for open area). 4/16/19 at 5:33 PM, Santyl Ointment . Apply to left buttock as needed for soiled dressing and apply to OA (Open Area) left buttock topically every evening shift for OA NSW. Pat dry, f/b (followed by) skin prep periwound. Apply nickel thick layer and cover with island dressing. Review of R51's Wound Documentation sheets PI left buttock include, in part: 3/11/19, Barrier Cream. 3/16/19- Stage II, Length- 4.0 CM x Width-2.2 CM x Depth-0.1 CM, 10 % granulation tissue, 90 % slough . Comments: new area 3/23/19- Stage II, 3.7 CM x 2.0 CM x 0.1 CM, 10 % granulation tissue, 90 % slough. 3/30/19- Stage II, 3.4 CM x 4.1 CM x 0.1 CM, 40% granulation tissue, 60 % slough . Comments Writer saw wound on 3/29/19 in addition, MD updated, new orders received. 4/6/19 - Stage II, 2.4 CM x 1.3 CM x 0.0 CM, 50% granulation tissue, 50% slough. 4/13/19- Stage II, 2.0 CM x 0.9 CM, less than 0.1 CM, 50% granulation tissue, 50% slough. On 4/14/19 at 10:54 AM, Surveyor observed R51 in bed with bariatric air mattress in place and observed a ROHO cushion to wheelchair. Surveyor interviewed R51 about staff helping R51 with repositioning and R51 stated, I have to say, I need to be moved and it doesn't happen regularly here. On 4/15/19 at 2:13 PM, Surveyor interviewed CNA S about how staff repositions R51. CNA S stated that R51 doesn't want to be repositioned sometimes, we respect those wishes, and that R51 would lay in bed all the time, we have to encourage R51 to get up in the wheelchair. On 4/16/19 at 10:00 AM, Surveyor observed LPN N (Licensed Practical Nurse) complete R51's treatment to R51's left buttock. Surveyor observed R51's PI which was an open area measuring approximately 2.0 CM x 1.0 CM, the wound bed was observed to be covered 100% with yellow slough. LPN N was going to update the physician today since the wound was covered in slough. On 4/16/19 at 6:30 PM, Surveyor interviewed DON B (Director of Nursing) about R51's PI. DON B is currently the facility's wound nurse. Surveyor asked DON B when she became aware of R51's PI. DON B stated that R51 was admitted with the PI on 3/11/19. DON B stated the nurse on duty (who is no longer employed and unavailable for interview), reported to DON B, on 3/11/19, that R51 was readmitted with a large dressing to buttocks. Surveyor asked if the wound was assessed on 3/11/19; there was no evidence that it was. DON B stated that she first observed R51's PI on 3/16/19 and documented her findings (as noted above). Surveyor asked if R51 had an open area on sacrum, DON B stated that she observed the open area on R51's left buttock. Surveyor asked if R51's left buttock PI was accurately assessed and staged at admission and since then. DON B stated that she learned today (4/16/19) if a wound has slough in it, it should be staged as a Stage 3 PI and that DON B had staged it incorrectly. Surveyor reviewed R51's Comprehensive Care Plan with DON B asking if R51's Stage 3 PI was addressed on R51's care plan. DON B stated that R51's PI was not addressed on the care plan and should have been. Surveyor asked DON B what does Turn and reposition as necessary mean, DON B stated it means to turn R51 per request. Surveyor asked how often she would expect R51 to be turned and repositioned, DON B stated at least every 2 hours. Surveyor asked if this was being done for R51 and if the facility had documentation of R51's repositioning, DON B stated no. The facility identified R51's PI as an admitted PI and there is no evidence that R51's PI was observed or assessed until 3/16/19, 5 days after admission, and the facility was not staging this PI correctly. R51's PI was not addressed on the care plan. While the facility had some PI prevention interventions in place (air mattress to bed, ROHO cushion to wheelchair), no new interventions were placed for R51's PI until 3/29/19, when a new treatment was ordered. On 4/16/19, Surveyor observed R51's PI had progressed to an Unstageable PI, as the wound bed was completely covered (100%) with slough.

Based on observation, interview, and record review, the facility did not ensure each resident received the necessary respiratory care and services that is in accordance with professional standards of practice and the Residents Choice for 2 of 13 sampled residents (R1 and R4). R1 did not receive 4 doses of her scheduled [MEDICAL CONDITIONS] medication. This medication error was not identified and the physician was not updated. There is no evidence of a Registered Nurse (RN) assessment when R1 had a change of condition. R1 was transported to the hospital and admitted for acute on chronic [MEDICAL CONDITION]. R4 has a history of [MEDICAL CONDITION]. R4 indicated R4 woke gasping for air for the last 2 weeks. There is no evidence of an assessment being completed after R4 reports being short of breath. There is also no evidence that staff is aware how often R4 is self-administering nebulizer treatments for shortness of breath (SOB). This is evidenced by: Example 1: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set Assessment) includes a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating R1 is cognitively intact, required 1 assist with supervision for bed mobility and needed limited assist of 1 for transfers. R1's MDS also indicated R1 has SOB on exertion, at rest and when lying flat and is on oxygen. R1's Hospital Discharge Summary, dated 9/28/18, states, in part, Reason for hospitalization : acute on chronic hypoxic hypercapnic [MEDICAL CONDITION], secondary to acute [MEDICAL CONDITION] exacerbation and possible acute pneumonia with baseline severe [MEDICAL CONDITION] .at baseline patient is oxygen and steroid dependent (10 mg (milligrams) QD (every day) and has severe underlying [MEDICAL CONDITION] R1 has shown significant improvement in respiratory status and was back to baseline on discharge (uses 1.5L ((liter) at rest and 2L with activity) .Chronic systolic [MEDICAL CONDITIONS]. No signs of exacerbation .Start taking these medications: [REDACTED]. Start date: 9/28/18 .[MEDICATION NAME] ([MEDICATION NAME]) 0.5mg/2ml, nebulizer suspension take 2 ml (500 mcg total) via hand-held nebulizer 2 times daily. Start date: 9/28/18 .Continue these medications which have not changed: .[MEDICATION NAME] HFA 108 (90 base) MCG/act inhale 2 puffs 4 times daily PRN .[MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 0.5 -2.5 (3) mg/3ml nebulizer solution take 3 ml via hand-held nebulizer every 4 hours . Per the manufacturer guidelines and important safety information .Use [MEDICATION NAME] exactly as your health care provider tells you to use it. Do not use [MEDICATION NAME] more often than it is prescribed for you or with other LABA (long-acting beta agonist) (a type of [MEDICATION NAME][MEDICATION NAME]) medicines. Do not stop using [MEDICATION NAME] or other medicines to control or treat your [MEDICAL CONDITION] unless told to do so by your health care provider because your symptoms might get worse. These guidelines also state to Store [MEDICATION NAME] Inhalation Solution in the protective foil pouch under refrigeration at 36 degrees - 46 degrees F . Facility policy entitled Oral inhalation administration, dated 10/25/14, states in part: .Nebulizer: .C. Obtain baseline pulse, respiratory rate and lung sounds.T. Obtain post-treatment pulse, respiratory rate and lung sounds and document findings (on the MAR (Medication Administration Record) or in the resident's medical record) . R1's MAR indicated [REDACTED] 9/28/18 at 5:00 PM, R1 received [MEDICATION NAME] 9/29/18 at 9:00 AM, R1 did not receive [MEDICATION NAME] 9/29/18 at 5:00 PM, R1 did not receive [MEDICATION NAME] 9/30/18 at 9:00 AM, R1 did not receive [MEDICATION NAME] 9/30/18 at 5:00 PM, R1 did not receive [MEDICATION NAME]. 10/1/18 at 9:00 AM, R1 received [MEDICATION NAME] 10/1/18 at 5:00 PM, R1 received [MEDICATION NAME] 10/2/18 at 9:00 AM, R1 received [MEDICATION NAME] (Please see 10/16/18 interview with LPN C (Licensed Practical Nurse), it is unknown if R1 actually received [MEDICATION NAME] dose.) 10/2/18 at 5:00 PM, R1 received [MEDICATION NAME] (R1 was transported to the hospital before 7AM on 10/2/18.) (Please note: R1's MAR indicated [REDACTED]. [MEDICATION NAME] inhalers are considered rescue inhalers, as it has a 5 minute onset. 10/2/18 when R1 was having an acute change in respiratory condition, this medication was not utilized. (Please note: None of the Administration Notes or Nurses Notes indicate what R1's baseline pulse, respiratory rate or lung sounds were prior to administration of her PRN (as needed) nebulizers. They also do not indicate what R1's pulse, respiratory rate or lung sounds were post nebulizer treatment for [REDACTED].) 9/28/18 at 11:35 PM: Nurses Note: Resident admitted to rehabilitation (Room #) via ambulance on stretcher. Alert and oriented. On 2L of oxygen. Husband accompanied resident to facility. Resident oriented to facility. Lungs diminished bilaterally. Heart S1 S2 (heart sounds, lub, dub). Pulses regular bilaterally . Requested two [MEDICATION NAME] PRN during shift. 9/29/18 at 3:56 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma per patient request for neb treatment. 9/29/18 at 4:39 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective. 9/29/18 at 10:14 AM: Administration Note: [MEDICATION NAME] Nebulization Solution 15 MCG/2 ML 2 ml inhale orally via nebulizer two times a day for [MEDICAL CONDITION] held due to med is unavailable. (Please note this is the first missed dose of R1's [MEDICATION NAME].) 9/29/18 at 11:01AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma given per request for SOB . 9/29/18 12:01 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective. 9/29/18 6:14 PM: Administration Note: [MEDICATION NAME] Nebulization Solution 15 MCG/2 ML 2 ml inhale orally via nebulizer two times a day for [MEDICAL CONDITION] not available. (Signed by a RN). This is R1's 2nd missed dose of [MEDICATION NAME]. 9/30/18 10:16 AM: Administration Note: [MEDICATION NAME] Nebulization Solution 15 MCG/2 ML 2 ml inhale orally via nebulizer two times a day for [MEDICAL CONDITION]. Held due to med is unavailable. (Signed by a LPN.) This is R1's 3rd missed dose of [MEDICATION NAME]. 9/30/18 12:02 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma given per request for SOB. 9/30/18 1:12 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective. (Signed by an LPN.) 9/30/18 4:19 PM Administration note: [MEDICATION NAME] Nebulization Solution 15 MCG/2 ML 2 ml inhale orally via nebulizer two times a day for [MEDICAL CONDITION]. Held due to med is unavailable. Pharmacy called. (Signed by a LPN.) This is R1's 4th missed dose of [MEDICATION NAME]. 9/30/18 7:03 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma given for complaint of SOB. (Signed by MDS Coordinator.) 9/30/18 7:20 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective, resident states they feel better. (Signed by the MDS Coordinator.) 10/1/18 at 1:49 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma per patient request for NEB treatment (complaint of) SOB. (Signed by Agency LPN.) 10/1/18 at 3:11 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours as needed for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective. (Signed by Agency LPN.) 10/1/18 at 9:50 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma given per res. (resident) request for SOB. (Signed by a LPN.) 10/1/18 at 11:51 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective (Signed by LPN C.) 10/1/18 at 6:51: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma. (Signed by DON B.) 10/1/18 at 10:16 PM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma was: effective no additional complaints of SOB. (Signed by DON B.) 10/2/18 at 3:39 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma. 10/2/18 at 3:47 AM: CNA responded to (R1's) call light at approx. 3:15 AM and found (R1) in bed sitting up on personal cell phone calling 911. RN responded to the room, found (R1) still on the phone. R1 stated they were having difficulty breathing. Resident was 95% heart rate 118, was able to speak in full sentence strings. R1 was denying any chest pain or other pain. R1 informed RN that they called 911 to report difficulty breathing. (R1) was reassured that R1's vital signs are ok and was given a breathing treatment. SPO2 (peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood) improved even more to 98%. EMS (Emergency Medical Service) arrived on scene and assessed (R1) as well. R1 chose to not be transported at this time and was advised by EMS that it would be non-emergent transport. Will continue to monitor resident. DON updated. (Signed by a RN) 10/2/18 at 5:15 AM: Administration Note: [MEDICATION NAME] solution 0.5-2.5 (3) MG/2 ML 2 ml inhale orally every 4 hours PRN for [MEDICAL CONDITION] and Asthma, PRN Administration was: effective, no current complaints of SOB. (Signed by a RN.) 10/2/18 at 6:31 AM: Patient stated they could not breathe, O2 (Oxygen) on 2 liters per min per nc (nasal cannula). O2 sat (saturation) was 91. As patient was receiving nebulizer (neb) treatments. After 1 neb O2 dropped to 85 then 80 then 75. T (temperature) 99.5 (pulse) 134 (respirations) 22 BP (Blood Pressure) 131/92. 911 called and NP (Nurse Practitioner) called for order. (Hospital) called and updated. Patient did put [MEDICAL CONDITION] (Continuous Positive Airway Pressure) on. (Signed by LPN C.) (Nebulizer indicated as being given is not signed out on R1's MAR.) (Please note: There is no indication that an RN was updated or had assessed R1 when she had a change of condition. There is no indication that R1's lung sounds were assessed/evaluated by a RN.) 10/2/18 at 6:36 AM: Patient stated they could not breathe and O2 sat dropped to 75. 911 called NP and family updated. (Signed by LPN C.) 10/2/18 at 6:37 AM: Patient requested to go to (hospital name, location), called and updated. (Hospital) called and updated and patient's husband called and updated. (Signed by LPN C.) On 10/2/18, R1's SBAR (Situation, Background, Assessment and Recommendation), signed by LPN C, indicates, the following: Situation: .This started on (date is blank), since this started it has gotten: Worse. Vital signs: BP 131/92, pulse 134, RR (respiratory rate) 22, Temp. (temperature) 99.5. O2 75% O2 via nasal cannula. 4. Respiratory evaluation: labored or rapid breathing, SOB. Cardiovascular: No changes observed. (Please note R1's pulse is 134 at this time.) Appearance: Patient stated they could not breathe and O2 sat dropped to 75. 911 called. NP and family updated. 10/2/18 at 6:55 AM: Ambulance here and transported patient to (Hospital name). (Signed by LPN C.) 10/2/18 at 6:31AM, (City Name) EMS Patient Care Report, states, in part: 911 dispatched .who was having difficulty breathing. Upon arrival, (city name police department) on scene led crew to (patient's room) where (age) (gender) was sitting, leaning forward in wheelchair holding [MEDICAL CONDITION] mask to face, having obvious difficulty breathing. EMS was called earlier this morning around (2:00AM) for same (patient) for difficulty breathing. EMS was able to coach (patient) with breathing and was able to get (patient) breathing easier and (patient) had decided not to go to hospital at that time. (Patient) has history of [MEDICAL CONDITION] and anxiety. Then at approx. (approximately) (6:00 AM) (patient) had another bout of respiratory distress and was working to breathe, breathing at a rapid rate approx. 36 breaths per minute. Staff on scene told EMS that they got oxygen saturation at 75% on 3.5LPM (liter per minute) oxygen with [MEDICAL CONDITION] ((Patient) is normally on 2LPM). Staff also gave (patient) one a [MEDICATION NAME] treatment as well as [MEDICATION NAME]. (Patient) was assisted to stretcher via stand and pivot. (Patient) vitals obtained in ambulance A&Ox4 (alert and oriented to person, place, time, situation). Lung sounds were clear bilaterally but shallow. No wheezing or rhonchi noted. (Patients) skin was warm and dry. (Patient) blood glucose level was 259. (Patient) started at 88% oxygen sat at 4LPM. EMS increased to 6LPM. (Patient) oxygen sat increased to 96% and crew slowly decreased oxygen down to 2 LPM which (patient) is normally on. (Patient) maintained 93% on 2 LPM for remainder of transport. (Patient) was also coached with breathing and (patient) was able to slow down breathing from initial 36 breaths per minute to 22 breaths per minute. (Patient) heart rate was elevated at 159 beats per minute initially and slowed to 130 beats per minute enroute. As breathing was regulated, (patient) was made comfortable as possible and transport was without incident. Upon arrival to destination, (patient) became anxious and started breathing faster, EMS instructed (patient) to focus on breathing. (Patient) care was transferred and report given to (name of RN) of (hospital name ER room). 10/2/18 at 2:06 PM: (Hospital name) called, patient was admitted for resp. (respiratory) failure into ICU (Intensive Care Unit). (Signed by LPN C.) emergency room Report, dated 10/2/18 at 8:01 AM, states, in part: patient presents with: SOB . (patient) comes to the emergency department by ambulance with a chief complaint of severe SOB. (Patient) just had a prolonged admission here from (MONTH) 9 to the 28th for [MEDICAL CONDITION] exacerbation. (Patient) states that ever since discharged to facility, (patient) has again felt like (patient's) breathing was worsening. (Patient) was on [MEDICAL CONDITION] when EMS picked (patient) up this morning, but they did take (patient) off and placed on nasal cannula for transport. Upon arrival to the emergency department, (patient) is in severe SOB and only able to answer in one or 2 word sentences. It is difficult to get significant history from (patient). Physical exam: .appears in severe respiratory distress. Tachypneic, tripodding, only able to speak one or two word sentences. [MEDICAL CONDITION] around 160. [MEDICAL CONDITION]/chest: severe distress, greatly diminished breath sounds throughout. ED (Emergency Department) Course: patient arrives in severe respiratory distress. (Patient) is saturating in the 70s. We immediately placed on [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) and (patient) is given [MEDICATION NAME] and Solumederol 125 IV (intravenous). Notified (patient's) pulmonologist .and did come over as well.we would consider intubation at this time but patient is refusing that intervention. (patient) was given a 10mg [MEDICATION NAME] Bolus and shortly thereafter did convert to a sinus rhythm with rate of 130. (patient) was given a second [MEDICATION NAME]. Patient did slowly improve on [MEDICAL CONDITION] . Diagnoses: [REDACTED]. Disposition: admit to ICU (Intensive Care Unit). 10/2/18 12:24 PM, discharged on both [MEDICATION NAME] and [MEDICATION NAME] HHN (hand held nebulizer) as well as (patient's) Basal [MEDICATION NAME] of 10mg daily to (facility name). Patient presented today with an acute onset of SOB . states that the facility didn't provide HHNs when patient required them. (Patient) feels (patient) missed doses or went too long in-between doses Reason for hospitalization : acute hypoxic [MEDICAL CONDITION] discharge Diagnoses: [REDACTED]. Hospital course: 1. Acute on chronic [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] exacerbation with pneumonitis (sepsis, septic shock, and pneumonia ruled out) .the patient stated the facility didn't provide breathing treatments when they required them which is what (patient) felt triggered the exacerbation .pulmonology was consulted and (patient) was admitted to the ICU for monitoring. (Please note R1 was discharged to a different facility.) On 10/3/18, a 'Resident Concern Report' was filled out by NHA A regarding R1. This concern report states, in part: (Family member's name) came in on 10/3/18 at 4:15 (PM) concerns was [MEDICATION NAME] was not given every 4 hours. DON explained it's a PRN. (RN's name) had explained that the night of 10/2/18 that it was PRN. Sent to ER (emergency room ) on 10/2 at 6:55 AM. (LPN C) called. Investigation Report, signed 10/5/18, indicates: [MEDICATION NAME] is PRN. See Nursing Progress Notes for times requested and given from 10-1 thru 10-2. 10/4 called spouse, left voice message, no return call (9 AM, 1 PM). 10/5/18 called spouse 10:30AM - spouse even thought explained to him several times that (LPN C) was not on the night shift, but refused to discuss further. Blaming (LPN C) but LPN C did not work night shift. Disposition: Unable to substantiate as spouse would not discuss any issues any further than previously stated. (Please note that R1 informed the ER that R1 had missed dosing of medication, R1's spouse voiced a grievance to the facility about R1 not receiving medications. There is no indication that the facility staff looked at R1's MAR indicated [REDACTED].) On 10/15/18 at 1:03 PM, Surveyor interviewed DON B regarding R1's missed doses of [MEDICATION NAME]. DON B indicated R1's medication was here on the first night in the bottom of the cart, and that it should have been given. On 10/15/18 at 2:25 PM, Surveyor interviewed DON B regarding R1's missed doses of [MEDICATION NAME]. DON B indicated DON B would look for a medication error report. On 10/16/18 at 10:15 AM, Surveyor interviewed LPN C regarding R1's change of condition on 10/2/18. LPN C indicated they were called down to R1's room due to being SOB. R1's O2 was in the 90's, then started to drop, gave a neb (could not specify what neb was given), and oxygen continued to drop. Called 911, then called to update NP on sending R1 out. R1's oxygen (O2) was at 75% on 2L/min via (by) nc and placed R1's [MEDICAL CONDITION] on, once below 80%. LPN C indicated that R1 started to take meds then stopped. LPN C indicated they signed out medications and R1 stopped taking them, and was in a hurry to get R1 out the door. LPN C indicated they don't remember exactly what medications R1 did or didn't take that morning. Surveyor asked if R1 had any respiratory problems throughout the night and LPN C indicated R1 called 911. LPN C indicated to Surveyor that LPN C told RN J. LPN C also indicated they were unsure if RN J went down to assess R1 as they were busy trying to send R1 out. On 10/16/18 at 10:50 AM, Surveyor interviewed RN J regarding R1's change of condition. RN J indicated they do not remember R1. RN J indicated they would go in and do an assessment which would include things like checking lungs sounds and putting the head of the bed up. RN J indicated they were in the building on 10/2, but was not on that Hall. RN J indicated they did not know if they were notified or not. RN J indicated they would have documented their assessment, if they had assessed R1. (Please note there is not note in R1's medical record regarding R1's change of condition from RN J or any other RN.) On 10/16/18 at 12:45 PM, Surveyor interviewed DON B regarding R1's medication and change of condition. DON B stated, Yes, indicating a RN assessment should have been done. DON B indicated she expected the [MEDICATION NAME] to be given. DON B indicated R1's four missed doses as being a medication error, if medication was in facility. DON B indicated pharmacy form indicated medication was delivered on 10/2/18 and that R1's family brought in their own supply. DON B also indicated to Surveyor, at this time, that they gave the [MEDICATION NAME] the first night to R1 and that the medication was in the bottom drawer of the cart. (Please note: This medication is to be refrigerated, and per DON B, the medication was in the bottom drawer of the cart.) On 10/16/18 at 2:10 PM, Surveyor interviewed Physician K, who's listed as being R1's Physician. Physician K indicated that they never saw R1 as they have no records of seeing R1. Physician K stated, I was never updated that it was missed, when asked about missed [MEDICATION NAME] doses. Physician K also indicated [MEDICATION NAME] was not even on R1's medication list. Physician K indicated there is a disconnect in communication, because R1's orders are different than what Physician K has. Physician K stated, potentially could cause a [MEDICAL CONDITION] exacerbation, when asked what could happen if [MEDICATION NAME] was abruptly stopped. Surveyor asked Physician K if missing four doses of [MEDICATION NAME] could have caused R1's acute onset of [MEDICAL CONDITION], Physician K stated, very good possibility. (Please note the manufacturer guidelines states: Appropriate Dosing: Patients should not stop using [MEDICATION NAME] Inhalation Solution unless told to do so by a healthcare provider, because symptoms may get worse. R1 had 4 doses omitted, despite the medication being in the facility. R1 subsequently then had an acute respiratory episode on 10/2/18.) On 10/16/18 at 4:30 PM, DON B brought in a package of [MEDICATION NAME] ([MEDICATION NAME]), which Surveyor observed had R1's name on it. The package stated in part: [MEDICATION NAME] Neb 15 MCG ([MEDICATION NAME] Nebulization Solution 15 MCG/2 ML) Use 1 [MEDICATION NAME] (s) per nebulizer twice daily for [MEDICAL CONDITION]. Disp (dispensed): 9/28/2018. This package had several labels on it, one of which indicated keep in refrigerator, do not freeze. DON B indicated there were 22 individual wrapped vials within the package. (Therefore, this medication was in the building on 9/29 and 9/30 when R1's doses were omitted.) Example 2: R4 was admitted to the facility, on 7/31/18, with [DIAGNOSES REDACTED]. R4's Quarterly MDS, with a target date of 9/19/18, indicates a BIMS summary score of 13, cognitively intact. R4 indicated as being on oxygen. R4's care plan, revision date 9/8/18, for altered respiratory status/difficulty breathing includes interventions of: ~Monitor for signs/symptoms of respiratory distress and report to MD (Medical Doctor) PRN: Increased respirations; decreased pulse oximetry; increased heart rate ([MEDICAL CONDITION]; restlessness; diaphoresis; headaches; lethargy; confusion; hemoptysis; cough; pleuritic pain; accessory muscle usage; skin color changes to blue/grey. ~Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring . R4's medical record contains a MD note, dated 10/9/18, states: 1) History of Present Illness, . states that he has had a cough for the last 2 weeks and has had increased congestion and overall not feeling well . continues with the [MEDICATION NAME], however, this has not made significant improvements with symptoms . 2) Assessment/Plan: [MEDICAL CONDITION] exacerbation: We will check a chest x-ray to rule out pneumonia. We will start R4 on [MEDICATION NAME] and continue with the [MEDICATION NAME] . Review of the Physician order [REDACTED]. 1) [MEDICATION NAME] Solution 0.5-2.5 (3)MG/3ML ([MEDICATION NAME]-[MEDICATION NAME]) 3 ml inhale orally every 4 hours as needed for wheezing/coughing. 2) [MEDICATION NAME] Solution 0.5-2.5 (3)MG/3ML ([MEDICATION NAME]-[MEDICATION NAME]) 3 ml inhale orally three times a day for SOB until 10/13/18. On 10/15/18 at 10:30 AM, Surveyor interviewed R4. R4 stated the following: R4 awoke at 4:00 AM today gasping for air. R4 indicated R4 self-administered a nebulizer treatment when R4 woke, but did not call the nurse as R4 knew she would be coming in with his medications at 5:00 AM. When the nurse came in with his medications, R4 told her he was still short of breath and his stomach hurt from coughing. R4 stated, She didn't do nothing. R4 went on to state R4 has been waking in the night for the last 2 weeks gasping for breath and doesn't feel R4 is getting the help they should. Surveyor asked R4 if the nurse listened to their lungs or checked their vitals when R4 reported to her R4 was still short of breath. R4 stated neither of these things was completed. R4 stated that R4 self-administered a second nebulizer at 7:00AM. R4 does not always tell the nurses R4 has used it and they don't ask. (Please note, R4 has no order or assessment indicating they are able to self-administer medications. Refer to F554.) Surveyor asked R4 if they had spoken to anyone about the concerns and R4 replied they have complained to the nurse about this, but no one else. R4's Nursing Notes were reviewed from 9/28/18 to 10/15/18, no evidence of resident complaints of cough, SOB, or respiratory assessments were present. Surveyor reviewed R4's medical record and noted none of the Medication Administration Notes or Nurse's Notes indicate what R4's baseline pulse, respiratory rate or lung sounds were prior to the self-administration of the PRN nebulizer. They also do not indicate what R4's pulse, respiratory rate or lung sounds were post nebulizer treatment for [REDACTED]. A Medication Administration Note, on 10/15/18 at 9:07 AM, indicated R4 received [MEDICATION NAME] Tablet. Give 400 mg by mouth every 8 hours PRN for Cough and SOB. Despite the documentation indicating R4 was SOB, there was no evidence of an assessment being completed on this date and no evidence that staff were aware R4 self-administered 2 nebulizer treatments in 3 hours. Review of the MAR, for 10/1/18 through 10/15/18, includes documentation that the scheduled [MEDICATION NAME] was administered three times a day on 10/10/18, 10/11/18, 10/12/18, and 10/13/18. There is no documentation of administration of the PRN [MEDICATION NAME] treatments for 10/1/18 through 10/15/18. On 10/15/18 at 2:55 PM, Surveyor asked LPN O what one would do if a resident complained of being SOB. LPN O stated they would assess lungs, vitals, update the physician, check for PRN orders for a nebulizer, and if a nebulizer was given, would check back to see if it helped. Surveyor asked if LPN O would expect to see this information documented in the medical record and LPN O replied, Yes. On 10/15/18 at 4:00 PM, Surveyor interviewed DON B regarding her expectations of staff if a resident complained of being SOB. DON B stated they would expect a set of vitals, an assessment, listen to lungs, an update to the physician, a reassessment in 15 to 30 minutes, if a nebulizer was given, another assessment should be done after the treatment. Surveyor asked DON B if one would expect this to be documented in the medical record and DON B replied, Yes.

Based on interview and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents in 1 of 2 residents (R1) reviewed for transfer concerns when staff attempted to remove a Hoyer sling in a manner contrary to manufacturer's instructions. R1 was transferred with a full body lift by CNA C (Certified Nursing Assistants) and CNA D. When CNA C and CNA D attempted to remove the lift sling from underneath R1 by sitting R1 up, picking her up under her armpits and pulling the sling out from behind her, they heard a pop noise and R1 informed staff she felt pain. Per R1, they again attempted to pull the sling and once again a pop was heard. R1 had increase in her pain and a deformity in her thigh. R1 was transported to the ER (emergency room ) where it was found she had a closed comminuted (definition: break or splinter of the bone into more than two fragments) right femoral shaft fracture that required surgical repair. Because staff did not follow the sling manufacturer's manual on how to remove the sling from under a resident, R1 suffered a fracture that needed surgical repair. In addition, staff attempted a second time to remove the sling, even after R1 complained of pain, resulting in a second pop and even more pain (20 on a scale of 1-10). The facility's failure to properly remove R1's sling from underneath her two times, even after the resident complained of pain following the first attempt, resulted in a finding of Immediate Jeopardy (IJ) beginning on 4/27/18. On 5/3/18 at 12:20 PM, NHA A (Nursing Home Administrator) was informed of the IJ. The IJ was removed on 5/3/18. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: The Invacare Owner's Operator and Maintenance Manual, dated 12/31/13, includes the following: Section 4 - Using Full Body, Comfort and Heavy-Duty One-Piece Style Slings: Positioning the Sling: 4. With an assistant on each side of the bed and up against the mattress, the assistant on the left-hand side of the bed will position his/her right-hand on the elevated knee and his/her left-hand under the patient's right shoulder, slowly push on the knee and assist with a slight lift of the shoulder. The patient will easily roll onto his/her side. 5. With the patient on their side, push the fabrics of the seat and back gently under them. 6. Roll the patient on to his/her back. 7. After the patient has been positioned once again on his/her back, you now need to roll the patient to their right-side (facing the assistant on the left). 8. With an assistant on each side of the bed and up against the mattress, the assistant on the right-hand side of the bed will elevate the left knee and position his/her left-hand on the elevated knee and his/her right-hand under the patient's left shoulder, slowly push on the knee and assist with a light lift of the shoulder and the patient will easily roll onto their side. 9. Pull the fabrics of the seat and back across the mattress until they are smooth. 10. Roll the patient onto their back and they should be approximately centered on the sling. R1's [DIAGNOSES REDACTED]. R1 is her own decision maker. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/16/18 indicates R1 is cognitively intact, needs extensive assistance of 2 people for bed mobility and is totally dependent on 2 people for transfers. R1's Care Plan Focus ADL (Activities of Daily Living) self-care performance deficit r/t (related to) post-polio syndrome - LE (lower extremity) paresis; generalized weakness. Functional limitations in bilateral lower extremities. Revision on: 2/22/18. Interventions include, in part, the following: Transfer: The resident is totally dependent on 2 staff for transferring with mechanical lift. Date Initiated: 12/24/13. Bed Mobility: The resident requires assistance by 1 - 2 staff to turn and reposition in bed; utilizes bilateral enabler bars to increase independence. Date Initiated: 7/26/17. Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 12/24/13. Nursing Restorative: Bed Mobility Program: Resident will assist with bed mobility with use of grab bars and extensive assist of 1 with each interaction. Date Initiated: 5/22/16. R1's Progress Notes include, in part, the following: 4/27/18, 18:40 (6:40 PM): Resident complained of right leg pain 20/10 (20 on a scale of 1-10) after transfer via Hoyer to her bed. Right thigh with deformity. Ice applied to area. MD (Medical Doctor) called and order received to send resident and evaluate in ER. Resident prefers to go to (Hospital). (Emergency Medical Service Company) called to transport resident. Resident given [MEDICATION NAME] 10 mg (milligram) po (orally). (FM F (Family Member)) was notified of the above. DON (Director of Nursing) and administrator notified. Report given to (nurse at hospital). The Emergency Medical Service Company Incident notes, dated 4/27/18, includes, in part, the following: Initial Assessment: Extremities: Contractures in all 4 extremities, right thigh has deformity with a hard protrusion on lateral aspect, severe pain. Narrative . When asked what had happened, LPN (Licensed Practical Nurse) states the aides, Yanked the Hoyer sling out from under her and heard a pop. Pt (patient) is lying, left lateral in bed, legs are contracted at approximately 45 - degree angle. Pt has slight contractions at elbows. Pt is alert, oriented x 4. Crying due to pain in her right thigh while holding her right thigh with her right hand. Pt states aides Jerked the sling out and states she heard and felt a pop, which was followed by intense pain in her right thigh. Pt has a large bulge in lateral right thigh at midline. [MEDICATION NAME] is in place immediately over the bulge area. Pt states she has post-polio syndrome and has used a wheelchair most of her life, which is also the cause of her contractures. Pt appears in obvious pain and rates 20/10. R1's Operative Note, signed 4/30/18, included, in part, the following .She lives in a nursing home and, unfortunately, when they were lifting her with a Hoyer lift last Friday, she suffered a displaced comminuted fracture of her right femoral shaft. She was transferred to (Hospital Name) for definitive management I reviewed the radiographs and clinical exam with the patient and her family. I explained that she had a complex injury and that she had extremely osteoporotic bone, a very unstable fracture which was extremely painful. I would advocate for operative management in the form of cephalomedullary nailing . R1's Discharge Summary, signed 5/2/18, included, in part, the following . Hospital Course: 1. Closed fracture of shaft of right femur; pt (patient) went for ORIF (Open Reduction Internal Fixation, a surgical procedure) and post-op no immediate complication noticed except for blood loss [MEDICAL CONDITION] for which pt. got 2 U (units) of blood. The facility's Misconduct Incident Report includes, in part, the following: Date Occurred: 4/27/18, Time Occurred: PM, Date Discovered: 4/27/18. Briefly describe the incident: (R1) fractured her right femur while staff members (RN E (Registered Nurse) ), (CNA C) and (CNA D) were attempting to remove the sling underneath the resident after completing a Hoyer transfer while the (R1) was in bed. An investigation started immediately. Describe effect: (R1) exhibited s/s (signs and symptoms) of distress related to this incident. Res (Resident) were sent out to the ER and admitted to (Hospital Name). There were two episodes of pop sound. (CNA C) and (CNA D) were present during the first time when res was sitting in bed. (CNA D) told (CNA C) to look for a nurse and resident was not moved. (RN E) came into the room and did with (CNA D) to roll resident's torso in an attempt to remove the sling when second pop sound was heard. (RN E) assessed resident, called MD and got order to send res to the ER. Resident was given pain medication. Family, NHA (Nursing Home Administrator) and DNS (Director of Nursing Services) were contacted. CNA C's Witness Investigation Statement, dated 4/27/18, includes, in part, the following: Another CNA and I used the lift to Hoyer (R1) into bed. Once in bed we both helped lift up her back just a tad. We were gonna lift the sling out from underneath her. When we heard a snapping sound happen on her right thigh area. We laid her down and I went to get the nurse. On 5/2/18 at 4:25 PM, Surveyor interviewed CNA C. CNA C indicated that R1 often yelled out in pain/discomfort and was dramatic. CNA C stated that she and CNA D were transferring R1 from her chair to the bed using a mechanical Hoyer lift with a full body sling. They lowered her onto the bed, unhooked the sling, and then CNA C and CNA D put their arms under R1's armpits. CNA C and CNA D pulled R1 forward so her shoulders were raised off of the bed. CNA C and CNA D used their free hand to pull the sling out from behind R1. CNA C indicated that the sling was supposed to slide out from under R1 towards her pillows, but it did not come out. CNA C indicated that she heard a pop when CNA C and CNA D pulled sling and R1 cried out in pain. CNA C indicated that this was a different kind of pain than R1's baseline pain and that R1 stated aloud, I am in a lot of pain, go get the nurse. CNA C indicated that she left the room to get RN E. CNA C indicated that she left the room a second time to retrieve ice packs and when she returned, RN E and CNA D told her that they had tried to roll her to get sling out and heard a second pop. CNA C also indicated that this method of leaning R1 forward and pulling sling out from behind was a personalized approach that she was trained to use with R1, but that it was not on her care plan or CNA Kardex. CNA D's Witness Investigation Statement, dated 4/27/18, includes, in part, the following: Another CNA and I were putting (R1) to bed. We sat her up an inch or 2 to remove the Hoyer sling. We heard a pop. I sent the other CNA to get the nurse to look at where the pain was coming from. The nurse and I agreed to remove the sling by pulling to try and make her more comfortable. We then heard a second pop and stopped moving her completely. On 5/2/18 at 1:45 PM, Surveyor interviewed CNA D. CNA D stated she and CNA C were pulling R1's sling out by picking her up about an inch and trying to pull it out behind her when we heard a pop. CNA D stated they stopped pulling on the sling and got the nurse. RN E came into the room, we took the sling out by pulling it up her back, heard another pop; R1 stated she was in pain, we stopped then. CNA D stated R1 didn't like to roll. CNA D stated she always removed R1's sling by pulling it out this way. RN E's Witness Investigation, dated 4/27/18, includes, in part, the following: I was called into resident's room by aide. She stated they transported resident via Hoyer to bed + as they were pulling the sling out they heard a pop. Resident was lying in bed, complained of right thigh pain + there was deformity of leg noted. Resident was lying on the sling which was rolled up to the middle of her back. (CNA D) pulled sling out from the left side of resident. Resident agreed she wanted to be seen at hospital. MD called + informed of above. Daughter, DON and Administrator notified of above. Ambulance was called. On 5/2/18 at 1:05 PM, Surveyor interviewed RN F. RN E stated she was called to R1's room because they had heard a pop and R1 was in pain. RN E stated the staff removed the sling while RN E was in the room. RN E stated she heard a pop and R1 was in a lot of pain. The facility's Resident's (R1) Statement (via the telephone), dated 4/28/18, includes, in part, the following: The description was taken on 4/28/18 at 11:45 AM, the hospital RN and daughter were in the room when they had writer on speaker phone talking with resident, resident stated, it was not intentional, it was an accident. They were in a hurry, they were trying to get the sling out from underneath me, they sat me up, they didn't roll me, it happened so quick that I didn't have time to tell them to roll me, it felt like rubber-bands snapping. On 5/2/18 at 2:30 PM, Surveyor interviewed FM F. FM F stated she was in the hospital room when the facility staff called to speak with R1. FM F stated R1 stated she thought the girls were in a hurry, they normally roll her. FM F stated R1 told the girls she needed to roll, but they gave her a good shove, picked her up and tried to pull the sling out up her back, she felt a pop and was in pain. FM F stated R1 said they pushed her further forward to fully pull the sling out and heard another pop. They then got the nurse. On 5/3/18 at 6:45 PM, Surveyor interviewed R1 via phone. R1 stated the CNAs were trying to get the Hoyer sling off of her, they set her up, they were rough, they went really fast, pulled the first time and my leg snapped and I told them I was in pain, but they didn't listen to me, they again tried to pull it to get it out and I told them it hurt but they did it anyway and I heard a second snap and then the pain was the worst pain I have ever had. R1 stated she requested to go to the hospital and to get something for the pain. R1 stated she usually rolls so staff can get the sling out from underneath her. R1 stated she uses the bars on the side of the bed to help roll and if they give me time I can help them to move me, but I am a little slow, because I am weak and have chronic pain. (It is important to know that the following was in CNA C's employee file: Action: Final Written Warning. Date/Location of Incident: 1/5/18/Resident Room. Describe what happened: Employee did not follow resident's request to stop cares, which violated the resident's rights. Employee needs to adhere to resident's rights policy. Any similar actions will result in further disciplinary action up to termination. 1 on 1 training with social worker and policy review is required to remain on staff.) The facility's failure to follow manufacturer's manual on how to remove a sling from under a resident and not listening to the resident voice when she complained of pain created a situation of IJ, which was removed on 5/3/18, when the facility implemented the following action plan: 1. Resident (R1)'s medical record was reviewed for quality assurance purposes. 2. All residents have the potential to be affected by this practice. IDT (Interdisciplinary Team) reviewed resident roster in determining other residents using slings for appropriateness and comfort, including revision of current mechanical lift transfer, sling removal process and rolling best practice. If a resident requires a type of transfer that deviates from the standard of practice then, nursing and/or therapy will conduct a transfer assessment. Care plans and care cards will be updated to reflect any changes on the residents' status, if necessary. 3. (RN E, CNA C and CNA D) were the staff identified during the transfer and will be reeducated on how to remove slings underneath residents, log rolling best practices, abuse/neglect and listening to the voice of the customer. Staff will be asked to perform three (3) return-demos while removing a full-body sling. 4. Facility commenced using enhanced mechanical lift transfer, log rolling, and customer service best practices as well as review facility's abuse, neglect policy on 5/2/18. 5. All facility personnel will be reeducated on abuse, neglect and listening to the voice of the customer. Nursing staff will also be reeducated on mechanical lift transfer, and log rolling best practices before beginning their scheduled shift. Licensed nursing staff will be reeducated on transfer assessments. Nursing staff will be asked to perform three (3) return-demos while removing a full-body for the next three (3) months. DNS or designee will conduct observe at least two (2) nursing staff per week. Staff already working will be in-serviced on a one-on-one basis. Each employee will be required to sign an attendance sheet. New employees will be in-serviced at the time of their orientation. All outsourced employees will be reeducated. Education plan will continue until all personnel have completed this aforementioned in-service. 6. Facility will continue to address residents' mechanical lift transfer needs, abuse and customer service during weekly Quality-of-Care meetings between clinical IDT members, DNS or designee will conduct five (5) random audits per week for the first three (3) weeks and then, weekly audits for the following next three (3) weeks to ensure that full-body sling removal and transfer assessment protocols have been implemented fully. In events but not limited to, during the daily AM/PM clinical meeting. Any negative outcomes will be corrected at the time of discovery and all findings will be presented at the monthly Quality Assurance/Performance Improvement (QAPI) meeting.

Based on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 1 resident (R199) with the potential to affect all 54 residents that reside in the facility. R199, who is alert and oriented and who admitted to being very modest, alleged that CNA L, on the first evening of her admission (1/5/18), ordered her to strip, because she was dirty. After taking off her bra, CNA L told R199 to shake her breasts. CNA L was standing face to face with her and made R199 feel sexually threatened, shamed, violated, humiliated, and defiled. This incident brought up memories for R199 of an earlier time in life when she had been assaulted and she admitted to being unable to sleep, being afraid, and not knowing whom to trust. On 1/6/18 daytime, R199 indicated that she reported to BO E and LPN I. R199 indicated she was told she needed to contact DON B. On 1/8/18, on the evening shift, R199 reported an allegation of abuse against CNA L to CNA F and CNA K. CNA F and CNA K reported this allegation to RN J. NHA A and DON B were not informed immediately, nor was a 24 hour report sent to the state agency. RN J did not report this allegation of abuse to NHA A. CNA L was not suspended to protect R199 or other residents. CNA L worked on 1/8/18. On 1/9/18 at 10:00 AM, Surveyor asked NHA A if there was a self-report for R199. NHA A indicated no. Surveyor reported R199's allegation of abuse to NHA A. The allegations were not immediately reported to the NHA A or sent to the state agency in 24 hours. The failure of the facility to implement the abuse policy and procedure led to the finding of IJ, which started on 1/5/18. The facility was notified of the IJ on 1/10/18 at 3:30 PM. It was determined that the IJ was removed on 1/10/18, but not corrected. The deficiency continues at a scope/severity level F (potential for more than minimum harm that is not IJ / widespread), because the facility has yet to fully implement and to evaluate the effectiveness of its action plan. As evidenced by: 1. The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. R199 was not kept from abuse. R199, who is alert and oriented and who admitted to being very modest, alleged that CNA L, on the first evening of her admission, ordered her to strip, because she was dirty. After taking off her bra, CNA L told R199 to shake her breasts. CNA L was standing face to face with her and made R199 feel sexually threatened, shamed, violated, humiliated, and defiled. This incident brought up memories for R199 of an earlier time in life when she had been assaulted and she admitted to being unable to sleep, being afraid, and not knowing whom to trust. Cross reference F600. 2. The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: The facility is to report these alleged violations to an immediate supervisor who must then report it to the Administrator or Compliance Officer. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not result in serious bodily injury shall be reported within 24 hours. (a) On 1/9/18 at 8:59 AM, Surveyor asked if she told anyone about what had happened on 1/5/18. R199 indicated she did not know who to trust or talk to. R199 indicated she told BO E the next morning; that she had nightmares and could not sleep. R199 indicated she woke up screaming 3 times. R199 indicated BO E told her she had to get a hold of the DON B. On 1/10/18 at 10:50 AM, Surveyor interviewed BO E regarding R199 and the conversation they had on Saturday morning (1/6/18). BO E indicated she was going over admission paperwork with R199 and did recall R199 saying she had a hard time falling asleep. BO E did not recall anything else about R199's sleep issues. (b) On 1/9/18 at 8:59 AM, R199 indicated she talked to LPN I on Saturday (1/6/18). On 1/9/18 at 11:45 AM, Surveyor interviewed LPN I regarding R199 and any concerns she may have brought up. LPN I indicated that R199 did not mention any staff concerns. LPN I indicated that if an allegation of abuse was reported to her, she would tell someone. (c) On 1/9/18 at 1:25 PM, Surveyor interviewed CNA K, who indicated R199 told both CNA K and CNA F on 1/8/18 during an evening shower about the allegation with CNA L. CNA K indicated that she and CNA F went to RN J to report R199's allegation of abuse. CNA K indicated RN J told CNA K and CNA F to give R199 a piece of paper and a pen to write down what happened. On 1/9/18 at 1:00 PM, Surveyor interviewed RN J regarding R199 and any concerns brought to her attention. RN J indicated she spoke with CNA F and CNA K at the same time and indicated to have R199 write a statement. Surveyor asked RN J if she told anyone. RN J indicated no, and it was later on the evening shift and CNA L had left the building. Surveyor asked RN J if she should have reported this. RN J indicated she should have told the DON B. Surveyor asked RN J if she talked to R199. RN J indicated no, as she did not think it was anything serious, as she had a lot of complaints that shift. On 1/9/18 at 10:00 AM, Surveyor asked NHA A if there was a self-report regarding R199's allegation. NHA A indicated no, and he was not aware of the allegation. Cross reference F609. 3. The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: Protection of residents: Employees of this facility, who have been accused of abuse, will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the NHA A and it is determined that any allegation of abuse is unsubstantiated. The facility did not protect R199 and allowed CNA L to continue to work on all 3 of 3 units. CNA L was allowed to work directly with residents until 10:30 PM on 1/8/18. Cross reference F610. 4. The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: Investigation: 1. All incidents will be documented whether or not abuse was alleged or suspected. 2. Any incident or allegation involving abuse will result in an investigation. Reporting: When an allegation of abuse has been made, the NHA A or designee shall complete and submit a DQA (Division of Quality Assurance) form F notifying DQA that an occurrence of potential abuse has been reported to the NHA A and is being investigated. The facility did not investigate the allegation of abuse when it was reported to RN K. The facility did not notify the NHA A when the allegation of abuse occurred and the F form was not completed or sent in. Cross reference F610. 5. The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: Informing Local Law Enforcement (LLE): The facility should also contact local law enforcement authorities in the following situations: When there is reasonable suspicion of a crime. Sexual abuse of a resident by a staff member. The facility did not contact the LLE when an allegation of abuse occurred when R199 indicated she felt like she was sexually threatened. On 1/9/18 at 8:59 AM, Surveyor asked R199 if the local law enforcement agency came to see her. R199 indicated no, the police never came. The failure to implement its policies and procedures to ensure that residents were free from staff-to-resident abuse created a finding of IJ. The facility removed the IJ on 1/10/18 when: 1. Re-education on reporting allegation of abuse immediately to NHA A, following the Elder Justice Act, and steps to following in guaranteeing all residents immediate protection (identified staff will be removed from the floor and escorted to the conference room and suspended pending investigation). The policy on Abuse will be used to educate team members before starting of their shift. New employee's trained on date of hire. 2. Concerns will be reported to NHA A immediately for further follow up and policy compliance, including immediate reporting to the authorities whenever there is a suspicion of a crime being committed (eg. Elder Justice Act). 3. IDT will meet with all residents and screen for any abuse allegations, concerns. 4. Random staff audits will be done daily for 2 weeks, and weekly for an additional 2 weeks to assure that staff understands the policy, psychosocial impact and reporting requirements. Random daily audits will be conducted on residents x 2 weeks for abuse concerns and then weekly for 2 additional weeks. Any deviation will be addressed at time of discovery. Results will be discussed at QAPI. Cross reference F600, and F609.

Based on record review and interview, in 1 of 14 total residents reviewed for abuse (R199), the facility did not ensure that an allegation of abuse was reported immediately to the administrator of the facility. This has the potential to affect all 54 residents. R199 alleged that she was threatened, shamed and humiliated by CNA L, on 1/5/18, when CNA L forced her to strip. R199 reported having nightmares to BO E the next morning (1/6/18) and told LPN I. CNA F and CNA K indicated they were told about the allegation by R199 on 1/8/18 and reported this to RN G who did not report the allegation to NHA A. NHA A was not aware of the allegation when interviewed by Surveyor on 1/9/18. No investigation had been done and CNA L had continued to work. Failure to immediately report an allegation of abuse, which in turn prevented the facility from thoroughly investigating and taking action to prevent further potential abuse, created an IJ that began on 1/6/18. NHA A was informed of this finding on 1/10/18 at 3:30 PM and the IJ was removed on 1/10/18. The deficient practice continues at a scope/severity of F (potential for harm that is not IJ / widespread) as evidenced by the following. This is evidenced by: The facility's policy and procedure for Abuse Prevention last reviewed 2/7/17, includes, in part: The facility is to report these alleged violations to an immediate supervisor who must then report it to the Administrator or compliance officer. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not result in serious bodily injury shall be reported within 24 hours. R199 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R199 is alert and oriented. On 1/9/18 at 8:31AM, Surveyor interviewed R199 about staffing and general care at the facility. R199 indicated that she had a concern with CNA L on 1/5/18 during the evening shift. R199 indicated to Surveyor that CNA L had forced her to take off her clothes and that she felt ashamed, threatened and humiliated. (Cross reference F600.) 1. On 1/9/18 at 8:59 AM, Surveyor asked if she told anyone. R199 indicated she did not know who to trust or talk to. R199 indicated she told BO E the next morning; that she had nightmares and could not sleep. R199 indicated she woke up screaming 3 times. R199 indicated BO E told her she had to get a hold of the DON B. On 1/10/18 at 10:50 AM, Surveyor interviewed BO E regarding R199 and the conversation they had on Saturday morning (1/6/18). BO E indicated she was going over admission paperwork with R199 and did recall R199 saying she had a hard time falling asleep. BO E did not recall anything else about R199's sleep issues. 2. On 1/9/18 at 8:59 AM, R199 indicated she talked to LPN I on Saturday (1/6/18). On 1/9/18 at 11:45 AM, Surveyor interviewed LPN I regarding R199 and any concerns she may have brought up. LPN I indicated that R199 did not mention any staff concerns. LPN I indicated that if an allegation of abuse was reported to her, she would tell someone. 3. On 1/9/18 at 1:25 PM, Surveyor interviewed CNA K regarding any concerns voiced by R199. CNA K indicated that she checked on R199 during the shower that CNA F was assisting R199 with on 1/8/18 evening shift. CNA K indicated R199 told both CNA K and CNA F about the allegation with CNA L on 1/5/18. CNA K indicated that she and CNA F went to RN J to report R199's allegation of abuse. CNA K indicated RN J told CNA K and CNA F to give R199 a piece of paper and a pen to write down what happened. On 1/9/18 at 1:00 PM, Surveyor interviewed RN J regarding R199 and any concerns brought to her attention. RN J indicated that one of the residents did not like CNA L. RN J indicated she spoke with CNA F and CNA K at the same time and indicated to have R199 write a statement. RN J indicated she didn't know it was anything, as she heard R199 did not like CNA L. Surveyor asked RN J if she told anyone. RN J indicated no, and it was later on the evening shift and CNA L had left the building. Surveyor asked RN J if she should have reported this. RN J indicated she should have told the DON B. Surveyor asked RN J if she talked to R199. RN J indicated no, as she did not think it was anything serious, as she had a lot of complaints that shift. Review of R199's hand written statement from the incident, on 1/5/18, includes, in part: Incident Report - Inappropriate behavior, threatening, shamed, violated, humiliating, defiling and sexually threatening as I was told to just strip. Difficult to explain - felt sexually threatened by CNA L. I am very modest and need encouragement, without feeling my privacy was being invaded, or my safety being threatened or sexually harassed or a possible sexual assault occurs. I did a sponge bath and was assisted to the toilet with both CNA L and CNA K; they observed to see how I could do it for safety concerns. Later that night, CNA L came in and said she was going to give me a sponge bath and be clean. R199 asked why, as it was done earlier. CNA L told R199 she was going to do a sponge bath fully and total toilet hygiene. R199 told CNA L she could do all the washing and wiping herself and that angered her. While still in the room, by my bed, CNA L told me to get up and take my clothes off, while she watched. I said for what, again, and this angered her. CNA L responded just do it, undress, strip. I asked what, and she said everything. I still hesitated as it did not seem right, felt scared and didn't know what she was going to do to me. She made me start undressing, I was worried about privacy and wanted to either move to the corner, or close the curtains, or better yet, bathroom. She got angry and told me to just do it - strip everything off. I was scared and started to take my bra off, while questioning it. While removing my bra she said just do it, get them out there and move them around and loosen. I felt defiled, sexually, when I did that, and it was not enough for her and, I was coerced into shaking them more, which she liked. I thought I was done and she wanted me to completely strip down. I refused, especially when she had me in the middle of the room, open to anything. She let me go into the bathroom and wanted me to pull my pants down more and wanted to wash me. I told her I could do that myself. She was still trying to convince me and was very angry, but let me use the toilet and wipe myself. After I went back to bed and she left me alone, I had a very difficult time getting settled down and began to realize it brought out an old depressed memory and nightmares. I told them Saturday morning about the nightmares, still not fully connecting deep fears from past assault. As the weekend progressed, I started realizing who I could trust to confide in and seeking advice. CNA K, double teaming with CNA F, really helped me; they were so awesome and made me feel secure enough to pursue reporting. On 1/9/18 at 10:00 AM, Surveyor asked NHA A if there was a self-report regarding R199's allegation. NHA A indicated no, and he was not aware of the allegation. This allegation was not immediately reported to the NHA A, thus, no measures were taken to prevent further potential abuse as CNA L continued to work with residents. The failure to immediately report, to fully investigate, and to take actions to prevent further potential abuse created a situation of IJ. The facility removed the IJ on 1/10/18 when: 1. Re-education on reporting allegation of abuse immediately to NHA A, following the Elder Justice Act, and steps to following in guaranteeing all residents immediate protection (identified staff will be removed from the floor and escorted to the conference room and suspended pending investigation). The policy on Abuse will be used to educate team members before starting of their shift. New employee's trained on date-of-hire. 2. Concerns will be reported to NHA A immediately for further follow up and policy compliance, including immediate reporting to the authorities whenever there is a suspicion of a crime being. 3. IDT will meet with all residents and screen for any abuse allegations, concerns. 4. Random staff audits will be done daily for 2 weeks, and weekly for an additional 2 weeks to assure that staff understands the policy, psychosocial impact and reporting requirements. Random daily audits will be conducted on residents x 2 weeks for abuse concerns and then weekly for 2 additional weeks. Any deviation will be addressed at time of discovery. Results will be discussed at QAPI. Also cross reference F607.

Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 22 of 54 residents (R3, R38, R41, R199, R20, R16, R13, R45, R10, R43, R148, R149, R1, R32, R22, R152, R153, R198, R155, R156, R26, and R12). Not all licensed nurses working are certified to perform CPR and there were nine shifts between [DATE] and [DATE] when CPR certified staff was not working. This had the potential to affect 22 of 54 residents (R3, R38, R41, R199, R20, R16, R13, R45, R10, R43, R148, R149, R1, R32, R22, R152, R153, R198, R155, R156, R26, and R12) in the facility that chose a Full Code status. The failure to ensure that each shift had at least one staff on duty that is CPR certified resulted in an IJ to the health and safety of those 22 residents (R3, R38, R41, R199, R20, R16, R13, R45, R10, R43, R148, R1, R32, R22, R149, R152, R198, R153, R155, R156, R26, and R12) that chose a Full Code status. The IJ began on [DATE]. NHA A was notified of the IJ on [DATE] at 4:25 PM. The IJ was removed on [DATE]. The non-compliance of F726 remains at severity and scope level of E (potential for more than minimal harm that is not IJ / pattern) as the facility continues to work through their removal plan. As evidenced by: Review of the Order Listing Report for advanced directives shows there were 22 Full Code (desire for CPR to be initiated) residents (R3, R38, R41, R199, R20, R16, R13, R45, R10, R43, R148, R149, R1, R32, R22, R152, R153, R198, R155, R156, R26, and R12) in the facility. The facility has 3 separate hallways. Each hallway has residents on it that have chosen Full Code status. [DATE] at 8:41 AM, Surveyor interviewed DON B. Surveyor asked who in facility was required to have CPR certification; DON B stated the nurses are required to be CPR certified. Review of staff list and CPR certification credentials showed there were 2 nursing staff that were not CPR certified, DON B and LPN AA. On [DATE] at 11:31 AM, Surveyor interviewed EA LL. Surveyor asked EA LL if she completed the nursing schedules. EA LL stated she does the CNA schedule and DON does the nurses schedule. [DATE] at 11:40 AM, Surveyor interviewed DON B. Surveyor asked DON B if she was in charge of completing the nurses' schedule, and DON B stated yes. Surveyor asked DON B if she was aware of any nurses that were not CPR certified. DON B said, Besides myself, I am not aware of anyone else. Surveyor asked DON B if she has a list of staff that is CPR certified to ensure that there is at least one nurse working each shift that is CPR certified. DON B stated no, she does not have a list. [DATE] at 11:46 AM, Surveyor interviewed NHA A. Surveyor asked if NHA A was aware that there were nursing staff working that are not currently CPR certified. NHA A stated he is aware that some staff aren't certified, but they only need one in the building. Review of staff schedules, from [DATE] through [DATE], show there were a total of 9 N(NAME) (10 PM-6 AM) shifts that the only nurse on duty was not certified to perform CPR ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]). The facility did not ensure that each shift had at least one licensed nurse on duty that is CPR certified, which has the potential to affect 22 residents (R3, R38, R41, R199, R20, R16, R13, R45, R10, R43, R148, R1, R32, R22, R152, R198, R155, R156, R26, and R12) who have chosen a Full Code status on 9 shifts from [DATE] through [DATE]. The failure to ensure that each shift had at least one licensed nurse on duty that is CPR certified created a finding of IJ. The IJ was removed on [DATE], after the facility completed the plan to include: 1) NHA obtained all current licensed staff CPR credential and retained in employee file and communicate to IDT, completed on [DATE]. 2) Human Resources is to document expiration dates for all CPR certified staff to maintain an updated files and current certification, completed [DATE]. 3) NHA/DON/Human Resources is to have all new licensed staff provide proof of CPR training on hire and a copy will be kept in the personnel file, in progress. 4) NHA/DON ensure each shift has a CPR certified nurse that understands and has been educated on the policy on advanced directives and procedure for initiating CPR, completed [DATE]. 5) NHA/DON are to provide CPR education/certification to licensed nursing staff now and yearly, in progress. 6) Nurse Consultant is to revise the CPR policy to include the current stand of practice C-A-B, in progress. 7) NHA/DON/Admissions are to ensure each resident's advance directive is immediately added to the EMR and Face Sheet Binder upon admission, in progress. 8) Nurse Consultant re-educated IDT members of their compliance requirements specifically on CPR requirements, completed [DATE]. 9) NHA is to commence weekly IDT Systems Review and Risk Management meetings to ensure systems regulatory compliance, in progress. 10) NHA/Nurse Consultant are to review current standards of practice in all services provided, in progress. 11) NHA commenced revised daily AM/PM clinical meetings, completed [DATE]. 12) NHA/IDT reviewed daily staff huddle meetings' agenda to ensure communication of any systems review and implementation, completed [DATE]. 13) NHA/IDT are to re-educate all staff on systems administration within a SNF setting and regulatory compliance requirements, in progress. 14) NHA commences immediately all licensed and unlicensed staff competency evaluations to ensure all staff is competent in their respective field, in progress. 15) NHA/Nurse Consultant will meet weekly in reviewing systems implementation and root-cause-analysis interventions, in progress. 16) NHA/IDT is to conduct daily audits on systems for 2 weeks and then weekly audits for an additional 2 weeks to ensure follow-up with any systems revisions and risk management root cause analysis, in progress. 17) NHA/IDT is to conduct random daily audits on residents for 2 weeks on grievances and concerns and weekly audits for an additional 2 weeks. Any deviation will be addressed at time of discovery. Results will be discussed at ad-hoc and monthly QAPI committee meetings.

Based on interview and record review, the facility did not ensure the resident's right to request, refuse and/or discontinue treatment and to formulate an advanced directive (i.e. code status) in 4 of 54 residents reviewed (R248, R149, R153, R6) as their charts did not accurately identify their wish for code status. Code status is either resuscitation, which includes the desire to have CPR (Cardiopulmonary Resuscitation)/Full Code and/or external defibrillation (use of an AED (Automated External Defibrillator)), or no resuscitation (DNR (do not resuscitate), No Code), which means no CPR or external defibrillation will be done. The failure to accurately identify R248, R149, R153 and R6's code status resulted in an Immediate Jeopardy (IJ) to their health and safety. R248, R149, R153 and R6, who did not have their code status choice readily accessible, had the potential to not have their code status choice followed or delayed initiation of life-sustaining measures. The IJ began on [DATE]. NHA A was notified of the IJ on [DATE] at 4:25 PM. The IJ was removed on [DATE]. The non-compliance of F578 remains at severity and scope level of E (potential for more than minimal harm that is not IJ / Isolated) as the facility continues to work through their removal plan. As evidenced by: According to a decision by the Division of Appeals Board, It is crucially important that nursing homes have in place, policies and procedures designed to ensure that the wishes of their residents, both for DNR and CPR, are accurately recorded, made accessible and implemented as desired by the residents. Per facility's CPR policy, undated, it states, in part: All residents will have a CPR consent form signed on admission or as soon as the resident or resident representative is able to give consent . Per facility's CPR - Basic Life Support (BLS) procedure, with an effective date of [DATE] and most recent revision date of [DATE], states, in part: .6 b. Use the one-way valve mask on the individual according to manufacturer's instructions. Mask to face .7. Initiate CPR . This procedure follows the old sequence of steps A-B-C (Airway, Breathing, Chest compressions). The 2010 American Heart Association (AHA) guidelines for CPR recommend a change in the BLS sequence of steps from A-B-C to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants. On [DATE] at 8:21 AM, Surveyor interviewed LPN H. Surveyor asked LPN H where to find a resident's code status. LPN H replied she would first look at her Medication Administration Record [REDACTED]. LPN H stated that the SW BB kept binder up-to-date, until she left ([DATE]), and she thought BO E and DON B were doing it now. Surveyor asked LPN H where the code status should be located for each resident; LPN H stated in the computer so we know what it is. On [DATE] at 11:13 AM, Surveyor interviewed LPN D. Surveyor asked LPN D where to find a resident's code status; LPN D replied in the MAR. Surveyor asked LPN D if the code status was not there, what next? LPN D stated then the resident would be considered Full Code until it is seen in writing what their code status is. On [DATE] at 11:35 AM, Surveyor interviewed RN J. Surveyor asked RN J where one would find a resident's code status. RN J said in EMR in the documents section, or in the MAR indicated [REDACTED]. RN J stated she would call the physician office or ask the resident or their Power of Attorney (POA) or check with Medical Records. On [DATE] at 2:40 PM, Surveyor interviewed LPN X. Surveyor asked LPN X where to find a resident's code status. LPN X stated in the MAR indicated [REDACTED]. LPN X stated she would look in the drawer for hard copies in the nurse's station, if it wasn't in the computer. On [DATE] at 3:35 PM, Surveyor interviewed DON B. Surveyor asked DON B where to find a resident's code status. DON B replied on the home screen, Physician order [REDACTED]. Surveyor asked DON B if the code status was not in the computer how would she know what it was. DON B stated she would look in folder in drawer and/or in binder for DNR residents at the nurse's station. Surveyor asked DON B what her expectation would be if a resident was pulseless and non-breathing and the staff was unable to find their code status; DON B replied the resident would be a Full Code until you see in writing no code. On [DATE] at 2:37 PM, Surveyor interviewed LPN W. Surveyor asked LPN W if he could show where R248's code status was. LPN W went into the computer, looked on the home screen, Physician order [REDACTED]. LPN W then stated there is a binder with DNR bracelets in it; if a resident is a full code they would be going out anyway. LPN W then looked in a filing drawer at the nurse's station and located DNR paperwork for R248. Surveyor asked LPN W if R248's code status should be in computer; LPN W replied yes and it will be now. Surveyor asked LPN W if all staff would know where to look for code status if it was not in the computer; LPN W stated, In a perfect world, yes. (It is important to note that R248 admitted to facility [DATE] and did not have her code status choice in the EMR for 19 days.) Surveyor reviewed binder that LPN W referred to and noted that the binder was in alphabetical order, divided by letter tabs, followed by sheet protectors with DNR sheets, with DNR bracelets inside, as well as Full Code sheets for individual residents. Surveyor cross referenced Order Listing Report for advanced directives and Resident List Report to ensure that all residents in the facility, on [DATE], had a code status in the computer and found that 3 more residents, R149, R153 and R6, did not have their code status in EMR. Surveyor discovered R6's code status was DNR and was located in the binder at the nurse's station. R6's code status was signed [DATE] on a previous admission. (It is important to note that R6's most recent re-admitted was [DATE] and did not have her code status choice in EMR for 22 days.) R149 and R153 had no evidence of having a code status completed. R149 admitted to the facility [DATE]; on [DATE] it was determined that R149 did not have a code status completed on admission. R149's code status was completed [DATE] indicating Full Code. R149 was in facility for 8 days without a code status being determined. R153 admitted to the facility [DATE]; on [DATE] it was determined that R153 did not have a code status completed on admission. R153's code status was completed [DATE] indicating Full Code. R153 was in facility for 7 days without a code status being determined. On [DATE] at 5:50 PM, Surveyor interviewed NHA A regarding the facility's Advanced Directive/Code Status policy. Surveyor asked NHA A who was responsible for adding a resident's advanced directive/code status into the resident's EMR. NHA A stated management is responsible to enter the information immediately upon admission or just prior to admission based on resident intake. Surveyor asked NHA A if a particular discipline was responsible; NHA A stated any management may enter the code status. Surveyor asked NHA A who is responsible to ensure the code status is entered into the EMR. NHA A stated management, including Social Services (SS) and nursing, are responsible to ensure the residents code status is immediately placed in the EMR. Surveyor asked NHA A if they have a system for ensuring the code status is entered. NHA A stated it should be entered upon admission and the document is then scanned into the EMR within 24 - 48 hours after admission. Surveyor asked NHA A if he was aware 4 residents did not have their code status listed in the EMR and 2 residents with no declaration of code status on file. NHA A stated he was not aware of this information. Surveyor asked NHA A what the facility policy is if a resident does not have a code status listed in their EMR. NHA A stated the staff should look in the EMR, under Face Sheet, or look in the uploaded document section of the EMR. If there is no code status listed, management should be notified to complete the necessary paperwork. Surveyor asked NHA A how staff should proceed if there is no code status on file and staff found a resident pulseless and non-breathing. NHA A stated the staff should begin CPR for any resident with an unknown/undeclared code status. Surveyor asked NHA A who is able to change a code status in the EMR if a resident changes their preference. NHA A stated nursing is able to change the code status anytime a resident changes their preference. On [DATE] at 7:50 AM, Surveyor interviewed BO E regarding the facility's Advanced Directive/Code Status policy. Surveyor asked BO E whom was responsible for adding a resident's advanced directive/code status into the resident's EMR. BO E stated SS or nursing is responsible to enter the resident's code status into the EMR immediately upon admission. Surveyor asked BO E who is responsible to ensure the code status is entered into the EMR. BO E stated nursing or SS are responsible to ensure the residents code status is immediately placed in the EMR. Surveyor asked BO E as management if she was responsible to enter a resident's code status. BO E stated she does not input resident's medical information - nursing enters a resident's medical information including code status into the EMR. BO E stated the floor nurses or the DON would be responsible for entering medical information such as a resident's code status into the EMR. On [DATE] at 8:41 AM, Surveyor interviewed DON B. Surveyor asked DON B how often and who is in charge of reviewing code status with the residents. DON B stated nursing completes on admission and social services reviews in care conference, either quarterly or annually, she wasn't sure which. The facility did not ensure R248, R149, R153 and R6's code statuses were accurately documented in their record in the place 6 of 6 nursing staff (5 floor nurses and DON) interviewed would look for such information during an emergency. The failure to ensure that residents' advanced directives are accurately documented created a finding of IJ. The IJ was removed on [DATE], after the facility completed the plan to include: 1) LPN W updated R248's code status in the EMR on [DATE] upon discovery of signed paperwork from her admission [DATE]. 2) R6's code status was updated in the EMR on [DATE] upon discovery of signed paperwork from her previous admission [DATE]. 3) R149 and R153's code status choices were completed on [DATE] upon discovery that they had not been completed on admission. R149 and R153's code statuses were updated in the EMR on [DATE]. 4) NHA/DON educated nurses on [DATE] on the policy on advanced directives and procedure for initiating CPR. 5) NHA/DON are to provide CPR education/certification to licensed nursing staff now and yearly, in progress. 6) Nurse Consultant is to revise the CPR policy to include the current stand of practice C-A-B, in progress. 7) NHA/DON/Admissions are to ensure each resident's advance directive is immediately added to the EMR and Face Sheet Binder upon admission, in progress. 8) Nurse Consultant re-educated IDT members of their compliance requirements, specifically on CPR requirements, completed [DATE]. 9) NHA is to commence weekly IDT Systems Review and Risk Management meetings to ensure systems regulatory compliance, in progress. 10) NHA/Nurse Consultant are to review current standards of practice in all services provided, in progress. 11) NHA commenced revised daily AM/PM clinical meetings, completed [DATE]. 12) NHA/IDT reviewed daily staff huddle meetings' agenda to ensure communication of any systems review and implementation, completed [DATE]. 13) NHA/IDT are to re-educate all staff on systems administration within a Skilled Nursing Facility (SNF) setting and regulatory compliance requirements, in progress.

Based on record review and interview, the facility did not ensure that each resident was free from mental abuse for 1 of 14 sampled residents (R199). R199, who is alert and oriented and who admitted to being very modest, alleged that CNA L, on the first evening of her admission, ordered her to strip, because she was dirty. After taking off her bra, CNA L told R199 to shake her breasts. CNA L was standing face to face with her and made R199 feel sexually threatened, shamed, violated, humiliated, and defiled. This incident brought up memories for R199 of an earlier time in life when she had been assaulted and she admitted to being unable to sleep, being afraid, and not knowing whom to trust. This is evidenced by: The facility's policy and procedure for Abuse Prevention, last reviewed 2/7/17, includes, in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. This will be done by: * Conducting pre-employment screening of employees and pre-admission screening of residents. * Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, misappropriation of property. * Establish an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. * Identifying occurrences and patterns of potential mistreatment. * Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property. * Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property, mistreatment, and making the necessary changes to prevent future occurrences . R199 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R199 is alert and oriented. On 1/9/18 at 8:31 AM, Surveyor interviewed R199 regarding staffing and general care at the facility. R199 indicated that she had a concern with a CNA on the evening shift of her admission. Surveyor asked R199 if she would to tell the Surveyor about it. R199 indicated to Surveyor that she was admitted later in the afternoon on Friday. R199 indicated that a couple of CNA staff assisted her with cares and getting cleaned up (CNA K and CNA L). R199 indicated that later in the evening, CNA L came back into R199's room and stood face to face with R199 and indicated you need to be clean and we are going to do this now. R199 indicated to CNA L that she had pajamas on. R199 indicated that CNA L told her to undress. R199 indicated she was already washed up. R199 asked what do you want me to take off. CNA L told R199 take everything off and show me how you do everything, do it and do it now. R199 indicated she felt threatened. CNA L told R199 to take bra off. R199 indicated that CNA L gestured by pointing to her shoulders and moving them down. R199 indicated, as she was taking her bra off, CNA L told R199 to flip them out there (indicating her breasts). R199 indicated that CNA L wanted me to strip off the lower part of her body. R199 indicated that CNA L wanted to do her sponge bath. R199 indicated she was afraid to tell CNA L to leave. R199 indicated that CNA L asked her what she would do if she needed to use the restroom. R199 indicated she could make it to the bathroom. R199 indicated she told CNA L she was not going to strip down. R199 indicated that CNA L told R199 to show her what she will do in the bathroom. R199 indicated she would sit on the toilet and could wipe herself. R199 indicated that CNA L wanted her to take everything off, before she went into the bathroom, as CNA wanted to clean me off. R199 indicated she could do it and would ask for help if she needed it. R199 indicated she was humiliated by taking her pants down in front of CNA L and finally gave in and took her pants down. R199 indicated she reached for the toilet paper and CNA L got angry with her. R199 indicated she wiped herself and CNA L was pissed at her. R199 indicated that CNA L asked R199 what are you going to do if you soil yourself. R199 indicated she called her husband and he was angry and wanted to come and get her. Surveyor asked if she knew the CNA L's name and R199 indicated she was a bigger blonde young woman. 1/9/18 at 8:59 AM, R199 indicated she felt it was threatening and had nightmares that someone was going to do something to her. R199 indicated afterwards she would jump up, was very frightened, and hardly slept. R199 indicated that one of the agency girls told me to write this up. I was afraid to be here, I don't know who to trust or who to talk to. Surveyor asked R199 if she documented what occurred on 1/5/18. R199 indicated she wrote down that she was threatened, and felt that CNA L was going to be abusive with her, humiliated, and felt defiled. R199 indicated she had a dream that someone was raping her. R199 indicated CNA L was working in the building, but did not come in her room. R199 indicated that she wouldn't want CNA L taking care of anyone. R199 indicated that she will never forget this. Surveyor asked R199 if the local law enforcement agency came to see her. R199 indicated no, the police never came. On 1/9/18 at 1:45 PM, R199 indicated that she woke up screaming three times that night and indicated what happened to her on Friday night triggered something from her past, when she was assaulted. R199 indicated that incident terrified her and made her relive it all over again. R199 indicated she was afraid. On 1/10/18 at 11:30 AM, Surveyor asked R199 how she was doing today. R199 indicated that she finally slept last night and hated to report this incident, as she did not want to get anyone in trouble, but she felt terrified and had to tell someone. Review of R199's hand written statement from the incident, on 1/5/18, includes, in part: Incident report - Inappropriate behavior, threatening, shamed, violated, humiliating, defiling and sexually threatening as I was told to just strip. Difficult to explain - felt sexually threatened by CNA L. I am very modest and need encouragement, without feeling my privacy was being invaded, or my safety being threatened or sexually harassed or a possible sexual assault occurs. I did a sponge bath and was assisted to the toilet with both CNA L and CNA K; they observed to see how I could do it for safety concerns. Later that night, CNA L came in and said she was going to give me a sponge bath and be clean. R199 asked why, as it was done earlier. CNA L told R199 she was going to do a sponge bath fully and total toilet hygiene. R199 told CNA L she could do all the washing and wiping herself and that angered her. While still in the room, by my bed, CNA L told me to get up and take my clothes off, while she watched. I said for what, again, and this angered her. CNA L responded just do it, undress, strip. I asked what, and she said everything. I still hesitated as it did not seem right, felt scared and didn't know what she was going to do to me. She made me start undressing, I was worried about privacy and wanted to either move to the corner, or close the curtains or better yet, bathroom. She got angry and told me to just do it - strip everything off. I was scared and started to take my bra off, while questioning it. While removing my bra she said just do it, get them out there and move them around and loosen. I felt defiled, sexually, when I did that, and it was not enough for her and, I was coerced into shaking them more, which she liked. I thought I was done and she wanted me to completely strip down. I refused, especially when she had me in the middle of the room, open to anything. She let me go into the bathroom and wanted me to pull my pants down more and wanted to wash me. I told her I could do that myself. She was still trying to convince me and was very angry, but let me use the toilet and wipe myself. After I went back to bed and she left me alone, I had a very difficult time getting settled down and began to realize it brought out an old depressed memory and nightmares. I told them Saturday morning about the nightmares, still not fully connecting deep fears from past assault. As the weekend progressed, I started realizing who I could trust to confide in and seeking advice. CNA K, double teaming with CNA F, really helped me; they were so awesome and made me feel secure enough to pursue reporting. (It is important to know, both CNA K and CNA F are agency staff, and CNA L is employed by the facility.) On 1/10/18 at 10:40 AM, Surveyor interviewed FM II regarding R199 and any concerns she may have brought to his attention. FM II indicated R199 called him and reported what happened to her on Friday night with CNA L. FM II indicated he was ready to come and get his wife and take her home. FM II indicated that CNA L set R199 off and this gave her nightmares. FM II indicated R199 had been assaulted in the past and this incident trigged the memory of it. FM II indicated it really freaked her out. FM II told R199 she had to tell someone. FM II indicated R199 told him that CNA L demanded that R199 strip, as she didn't like dirty people. FM II indicated R199 will not undress in front of him, as she is very modest. FM II indicated R199 was scared as CNA L was a big girl and R199 just had her knee replaced and moved slow. On 1/10/18 at 10:05 AM, CNA L returned Surveyor's phone call. Surveyor asked CNA L if she could recall any concerns regarding R199 on Friday night. CNA L indicated that she worked with R199 Friday on the evening shift. Surveyor asked CNA L if she provided any care for R199. CNA L indicated that she assisted R199 to pull up her pants. Surveyor asked CNA L if she provided peri care for R199. CNA L indicated R199 could do it herself. Surveyor asked CNA L if she ever asked R199 to strip. CNA L indicated no. Surveyor asked CNA L if she stayed on the Deer Path unit on 1/8/17. CNA L indicated no, as she helps answer call lights on all three units (Meadow View, Deer Path, and Wood Side). CNA L indicated she did assist with toileting on Meadow View. (To be noted, R199 lives on the Meadow View unit.) Review of DON B's investigation of 3 staff interviews via phone, includes, in part; 1. On 1/9/18, without a time, RN G indicated that R199 told her there was an issue, since admission, but was very aloof about it. RN G indicated that R199 and FM II were very upset, but were over it, stated it's not good, but not going to report it. R199 would not give specifics, acted like it had already been handled. 2. On 1/9/18, without a time, CNA F indicated that R199 wanted a shower on Monday PM, but is self-conscious and didn't want assistance. CNA F cleared it with the nurse to stand outside the shower, behind the curtain. R199 was thankful and wished others felt the same way. R199 went on to say that Friday, when she was admitted , she had already washed up and got on her pajamas for night when CNA L came in and told her to take everything off, to check to see if she did it right. R199 indicated FM II was very upset about it and wanted to take her home. R199 indicated she did not want CNA L taking care of her again, as she felt very disrespected. CNA F went to RN J, the PM supervisor, who directed her to have R199 write out her statement and will get it to the DON in the morning. 3. On 1/9/18, without a time, CNA K indicated that R199 was assisted with a shower by CNA F, knocked on the door to see if they needed assistance. CNA F relayed the information from R199 to CNA K. R199 told CNA K and CNA F that she felt demeaned, privacy was taken away, felt like she was about to be raped, loss of dignity. R199 indicated she had nightmares. CNA K indicated she and CNA F reported this to the PM supervisor, RN J, who told both CNA's to give R199 paper and pen to write it down. CNA K indicated she took a pen and paper to R199. Surveyor asked NHA A to see his investigation into R199's allegation at this time. No further information was provided. This allegation was not immediately reported to the NHA A, thus the investigation was not thorough and complete and no measures taken to prevent further potential abuse, as CNA L continued to work with residents. Cross reference F607 and F609

Based on interview and record review, the facility did not consult with the resident's physician when there was a change in the resident's physical condition or a need to alter treatment for 1 resident (R23) reviewed out of a sample of 12. R23 was on Hospice services when she experienced severe pain, gasping for air to breathe, and actively dying when the facility received a stat (immediate) order for [MEDICATION NAME] and [MEDICATION NAME]. The facility knew their pharmacy would take up to 4 hours to deliver the stat medication and did not notify a physician of the delay in medication arrival or request a different form of treatment. Prompt notification to the MD (Medical Doctor) to alter the course of treatment could have lessened R23's pain and air hunger at the end of life. This is evidenced by: The facility's policy Notification of Change in Resident Health Status, undated, includes, in part: the facility will consult the resident's physician, nurse practitioner or medical director and when indicated notify the resident's legal representative or an interested family member when there is: B. Acute illness or significant change in the residents' physical, mental or psychosocial status. Criteria: Life threatening conditions such as a [MEDICAL CONDITION] or respiratory distress. C. A need to alter treatment. Criteria: need to stop a form of treatment or commence a new form of treatment to address a problem. Nursing judgement is an integral part of the skilled care provided in this facility; therefore, such judgement must be applied on a case by case basis in keeping with acceptable nursing practices. The facility policy Provider Pharmacy Requirements, dated 10/27/14, includes, in part: 6. a. Emergency or stat medications are available for administration no more than 4 hours after the valid order is received by the pharmacy. R23's recent admission to the facility was on 1/15/17, with [DIAGNOSES REDACTED]. R23's POA is activated. Nursing Notes, dated 1/20/18 at 9:30 AM, include, in part: R23 is febrile, resp (respirations) labored, usage of accessory muscles for respirations. Audible secretions to the back of R23's throat and restless. Hospice notified of significant change of condition. FM QQ notified of change of condition and is here. Hospice ordered [MEDICATION NAME] and [MEDICATION NAME] stat at 10:55 AM. Approximately 20 minutes later they (pharmacy) called to clarify allergy to [MEDICATION NAME] (narcotic like pain reliever). FM QQ indicates he is the POA and he wants the [MEDICATION NAME], since he is not aware of any major reactions to the [MEDICATION NAME]/[MEDICATION NAME]. On 1/25/18 at 2:18 PM, Surveyor interviewed RN J regarding R23 and medication needs. RN J indicated that R23 was actively dying and had the death rattle. RN J indicated R23 was using her accessory muscles as she had air hunger (deep, rapid, and labored breathing). RN J indicated R23 was gasping for air as she had terminal restlessness. Surveyor asked RN J if R23 had medication available to manage R23 while she was actively dying. RN J indicated there was an issue with the medication at first as the facility uses a pharmacy in Illinois. RN J indicated that a stat order for [MEDICATION NAME] and [MEDICATION NAME] was faxed to the pharmacy on 1/20/18 at 11:00 AM and did not arrive in the facility until 4:30 PM RN J indicated that R23's FM QQ was very upset, while at bedside observing his mother with air hunger. RN J indicated she told FM QQ about medications and what they could do to help her. RN J indicated FM QQ kept asking, Are they here yet? RN J told FM QQ that Hospice ordered the medication at 10:55 AM and it would take 4 hours for stat orders to be delivered. RN J indicated she told FM QQ it is harder on the family than it is on R23. RN J indicated R23 had an order for [REDACTED]. Surveyor asked RN J if she called Hospice or R23's physician to notify the delay in the stat ordered [MEDICATION NAME] and [MEDICATION NAME]. RN J indicated no. RN J indicated it was very difficult for R23 to swallow, so she gave her Tylenol, which is not signed out on 1/20/18. RN J indicated that R23 was in [MEDICAL CONDITIONS]. Surveyor asked what symptoms R23 was experiencing with [MEDICAL CONDITION]. RN J indicated R23 could not breathe. RN J indicated she gave R23 [MEDICATION NAME] on 1/20/18 at 4:15 PM. Surveyor asked where RN J obtained the [MEDICATION NAME] if it had not arrived from the pharmacy yet. RN J indicated she borrowed someone else's [MEDICATION NAME]. RN J indicated she gave R23 [MEDICATION NAME] at 4:15 PM from the contingency box. Surveyor asked RN J why she borrowed the [MEDICATION NAME] and did not wait for R23's prescription to arrive. RN J indicated that R23 was in distress and she needed it. Nursing Notes, dated 1/20/18 at 4:15 PM, includes, in part: R23 is given [MEDICATION NAME] and [MEDICATION NAME] for terminal restlessness and air hunger. Oxygen per Cannula at 3 LPM (liters per minute), family at bedside. There is no documentation to indicate the symptoms R23 was experiencing and what the facility did prior to the arrival of the [MEDICATION NAME] and [MEDICATION NAME]. (It is important to know the pharmacy documentation indicates the [MEDICATION NAME] and [MEDICATION NAME] was signed as received at 6:15 PM.) The facility failed to notify R23's primary MD or contact Hospice MD to inform them of the delay in the arrival of the [MEDICATION NAME] and [MEDICATION NAME] that R23 needed, while she was experiencing pain and air hunger during the dying process of her life. Prompt notification to the MD to alter the course of treatment could have lessened R23's pain and air hunger at the end of life. Cross reference F697, F684, F585, and F849.

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop a PI for 1 of 2 residents (R18) reviewed for PI's. R18 was admitted to the facility without a PI and was identified to be at risk for PI development. R18 developed an avoidable, unstageable PI while in the facility and was observed with the incorrect dressing on his PI and his care plan was not updated to reflect the PI. This is evidenced by the following: The facility's Pressure Ulcer Prevention Policy, revision date 7/25/17, includes, in part: the facility follows the National Pressure Ulcer Advisory Panel (NPUAP). Risk assessment should identify which factors can be removed or modified. Staff should evaluate skin condition and pay attention to bony prominences. R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R18's quarterly MDS, dated [DATE], with a BIMS score of 5, indicates severe cognitive impairment. Section G0110: bed mobility and transfer status indicates R18 requires extensive assistance with two person physical assist. Section M0150 indicates R18 is at risk for PI development. Section M0210 indicates R18 does not have a PI. R18's Braden (skin breakdown risk) scores: 12/28/15 - 13 this equals moderate risk for skin breakdown. 1/10/18 - 12 this equals high risk for skin breakdown. R18's Comprehensive Care Plan: R18 has impaired skin impairment r/t fragile skin, R18 self-propelling at times, and tremors from [MEDICAL CONDITION], with a revision date of 1/8/18, includes, in part; Goal - compromised skin integrity to the R 2nd and 3rd toe will be healed by review date. Interventions include: provide padding to the R 2nd and 3rd toes, and red areas to R foot anterior toes. (It is important to know R18's care plan does not address his shoes or slippers.) Review of R18's Physician Orders, dated 11/17/17, include in part: cleanse R 2nd toe abrasion with normal saline (NS) F/B (followed by) triple ATB (antibiotic) cover with band. Change twice daily. Notify MD if symptoms worsen. (It is important to know that this treatment was not documented as completed on the Treatment Administration Record (TAR) on 12/8 PM, 12/13 PM, 12/24 PM, and 12/29 PM.) On 12/23/17 at 9:28 PM, R18's Wound Documentation per RN M includes, in part: Wound type: Pressure Ulcer. Site: Right foot second digit. Stage/ tissue depth: Stage 3. Length: 0.5 cm. Width: 0.7 cm Depth: unknown. Wound tissue bed: 95% slough. Comments: area is noted to be slightly moist with no drainage. On 1/4/18 at 5:14 PM, R18's Wound Documentation per RN M includes, in part: Wound type: Pressure Ulcer. Site: R anterior toe. Stage/ tissue depth: unstageable. Length: 0.4 cm Width: 0.9 cm Depth: 0 Wound tissue bed: 100% eschar. Comments: hard cap noted to the toe. On 1/4/18 at 5:33 PM, R18's Wound Documentation per RN M includes, in part: Wound type: Pressure Ulcer. Site: anterior R 3rd toe. Stage/ tissue depth: Stage 1. Length: 0.2 cm Width: 0.4 cm Depth: 0 Wound tissue bed: 100% Non-blanchable [DIAGNOSES REDACTED]. Comments: R18 noted to have only socks on today. 1/8/18 at 3:17 PM, Surveyor observed R18 lying on an air bed set at 180 LA (low air loss). 01/09/18 at 8:16 AM, Surveyor observed R18's R foot as CNA O removed two socks from R18's R leg/foot. R18 indicated he had a deep sore on his toe. R18 indicated it hurt. Surveyor asked how the wound developed. R18 indicated he used to wear shoes. Surveyor observed a band aid on R18's 2 R second toe. DON B came in R18's room and removed the band aid. DON B described R18's 2nd toe as having a scab on it. DON B replaced the same band aid. Surveyor asked DON B how the PI occurred. DON B indicated possibly by his shoes. Surveyor asked to see the wound treatment tomorrow morning when it is due to be completed. On 1/9/18 at 8:05 AM, Surveyor asked LPN D to observe R18's wound care. LPN D indicated he already did it and was not informed the Surveyor requested to view the wound care. On 1/10/18 at 11:00 AM, Surveyor observed LPN D remove R18's R gripper sock and observed a foam dressing covering R18's 2nd R toe. LPN D removed the foam dressing and indicated the black cap had come off. Surveyor noted the R 2nd toe wound to have slough in the center. Surveyor asked LPN D to describe the wound. LPN D indicated the wound has a yellow center and replaced the same foam dressing. (To be noted, there was not a dressing covering R18's R 3rd toe.) On 1/11/18 at 10:15 AM, Surveyor observed R18's wound treatment with RN M. RN M removed the dressing from R18's R 2nd toe. Surveyor asked RN M to describe the wound. RN M indicated the wound has slough and she is unable to determine the depth. RN M placed a Derma Dressing over the 2nd and 3rd toes. (It is important to know the 3rd toe did not have a dressing on it prior to RN M changing the dressing.) Review of R18's Physician Orders, dated 12/23/17, include, in part: cleanse area and cover with foam dressing until resolved. Review of R18's Physician Orders, dated 1/4/18, include, in part: cleanse area to 2nd and 3rd toes and cover with foam dressing until resolved. Review of R18's Physician Orders, dated 1/5/18, include, in part: cleanse area to 2nd and 3rd toes and cover with foam dressing until resolved at bedtime. Review of R18's Physician Orders, dated 1/8/18, include, in part: cleanse area to 2nd and 3rd toes and cover with foam dressing until resolved at bedtime. (To be noted, there was no nursing documentation regarding the new PI or an update to the care plan.) Review of R18's Physician Orders, dated 1/9/18, include, in part: cover R second toe with foam every AM and PM. Monitor for changes at bedtime for dressing change and in the morning for dressing change. R18's Nursing Notes, dated 1/11/18 at 10:24 AM, per RN M, includes, in part: dressing to R foot 2nd and 3rd digits was changed. Noted: 2nd toe had slough in the center, surrounding tissue is red, blanchable, R18 has discomfort with palpation and at times without, current treatment is to cover the areas with a foam dressing bid (twice daily). Plan to ask MD if we can have an order to apply a Hydrogel to the wound bed of the second toe and cover both toes with [MEDICATION NAME] dressing daily. May we also have an order for [REDACTED]. R18's Nursing Notes, dated 1/11/18 at 2:41 PM, per RN M, includes, in part: NP N (Nurse Practitioner) gave the following orders: Hydrogel to R 2nd toe open area, cover with foam dressing daily until resolved. Have ABI (Ankle Brachial Index, a test for blood flow and to determine peripheral artery disease), culture the wound bed, may proceed with ordering specialized shoes, and make sure to leave shoes and slippers off at this time. The facility failed to update the care plan when the PI developed and did not follow Physician order [REDACTED]. R18 developed an avoidable unstageable PI to his R 2nd toe when at moderate risk for PI development.

Based on interviews and record reviews, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 1 residents' reviewed for pain (R23). R23's was observed in pain and gasping to breathe. Hospice was called and faxed a stat order for [MEDICATION NAME] to the facility pharmacy. The pharmacy has a 4 hour delivery time. The facility did not update Hospice nor R23's doctor to make them aware of the extended delivery time to get R23 pain medications so that alternate pain managment medication could be acquired. This is evidenced by the following: R23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23's BIMS, dated 1/10/18, score of 7, indicates R23 has significant cognitive impairment R23 was admitted to Hospice services on 12/29/17. Hospice orders faxed to the facility pharmacy includes, in part: [MEDICATION NAME] 20 mg / ml (milliliters) given 10 mg (0.5 ml) PO/SL (by mouth or under tongue) every one hour prn for pain, fever, restlessness / anxiety. (Please note this order was not sent to the facility.) Nursing Notes, dated 1/20/18 at 9:30 AM, per RN J includes, in part: R23 is lethargic. Resp labored, usage of accessory muscles for respirations. Audible secretions to back of throat, restless. Hospice notified of significant change in condition. Son notified of change of condition and is here. Hospice ordered [MEDICATION NAME] and [MEDICATION NAME] stat at 10:55 AM. Approx 20 min later they called to clarify allergy to [MEDICATION NAME]. Son states he is POA and he wants the [MEDICATION NAME], since he is not aware of any major reactions to [MEDICATION NAME]/ [MEDICATION NAME]. (sic) Social Service Note, dated 1/20/18 at 11:00 AM, includes, in part: R23 appeared SOB (Shortness of Breath). Collaborated with Hospice. (sic) Hospice verification of visit on 1/20/18, without a time, includes, in part: change of condition visit. FM QQ present during visit. R23 very restless, hallucinating, reaching for things in the air. R23 denied pain, but appears to be in pain by facial grimaces. Documented on this sheet without a signature or time stamp, temp 99.5 at 2:30. [MEDICATION NAME] at 2:00 and [MEDICATION NAME] 3:10. (sic) (To be noted, these medications were not signed out on the MAR indicated [REDACTED] Nursing Notes, dated 1/20/18 at 4:15 PM, includes, in part: R23 not able to take anything by mouth. [MEDICATION NAME] and [MEDICATION NAME] given for terminal restlessness and air hunger. Oxygen per n/c (nasal cannula) at 3 LPM. Family at bedside. On 1/25/18 at 2:18 PM, Surveyor interviewed RN J regarding R23 and medication needs. RN J indicated that R23 was actively dying and had the death rattle. RN J indicated R23 was using her accessory muscles as she had air hunger. RN J indicated R23 was gasping for air as she had terminal restlessness. Surveyor asked RN J if R23 had medication available to manage R23, while she was actively dying. RN J indicated there was an issue with the medication at first as the facility uses a pharmacy in Illinois. RN J indicated that a stat order for [MEDICATION NAME] and [MEDICATION NAME] was faxed to the pharmacy on 1/20/18 at 11:00 AM and did not arrive in the facility until 4:30 PM. (To be noted: the Narcotic Sheet - [MEDICATION NAME] is documented as 1/20/18 at 6:15 PM. Surveyor reviewed the list of contingency medications and noted [MEDICATION NAME] was not on the list, but [MEDICATION NAME] was.) (It is very important to know that R23 received [MEDICATION NAME] 1/20/18 at 4:15 PM, per RN J when RN J just indicated the [MEDICATION NAME] arrived at 4:30 PM, but it is documented to have arrived at 6:15 PM.) RN J indicated that R23's FM QQ was very upset, while at bedside observing his mother with air hunger. RN J indicated she told FM QQ about medications and what they could do to help her. RN J indicated FM QQ kept asking, Are they here yet? RN J told FM QQ that Hospice ordered the medication at 10:55 AM and it would take 4 hours for stat orders to be delivered. RN J indicated she told FM QQ it is harder on the family than it is on R23. RN J indicated R23 had an order for [REDACTED]. Surveyor asked RN J if she called Hospice or R23's physician to notify the delay in the stat ordered [MEDICATION NAME] and [MEDICATION NAME]. RN J indicated no. (To be noted - the facility contingency box did contain [MEDICATION NAME].) RN J indicated it was very difficult for R23 to swallow, so she gave her Tylenol, which is not signed out on 1/20/18. RN J indicated that R23 was in [MEDICAL CONDITION]. Surveyor asked what symptoms R23 was experiencing with [MEDICAL CONDITION]. RN J indicated R23 could not breathe. RN J indicated she gave R23 [MEDICATION NAME] on 1/20/18 at 4:15 PM. Surveyor asked where RN J obtained the [MEDICATION NAME] if it had not arrived from the pharmacy yet. RN J indicated she borrowed someone else's [MEDICATION NAME]. RN J indicated she gave R23 [MEDICATION NAME] at 4:15 PM from the contingency box. Surveyor asked RN J why she borrowed the [MEDICATION NAME] and did not wait for R23's prescription to arrive. RN J indicated that R23 was in distress and she needed it. RN J indicated the facility pharmacy said they had to deliver it. RN J indicated to Surveyor, not all pharmacies have liquid [MEDICATION NAME]. Surveyor asked where it is documented that RN J called the pharmacy. RN J indicated that she did not document this. RN J indicated FM QQ was at bedside observing his mother with respiratory distress, air hunger, and agonal breathing. RN J indicated R23's respiratory rate was 24 and her heart rate was going up. RN J indicated that R23's lips were blue. RN J indicated FM QQ was extremely upset that it was taking so long to get R23's medications. Surveyor asked RN J if it is the facility standard of practice to borrow another resident's medication, especially [MEDICATION NAME]. RN J indicated no, and said, I did what I thought I had to do as a nurse. RN J indicated she used her nursing judgement. RN J indicated R23 was so bad, she needed the [MEDICATION NAME]. RN J indicated R23 respiratory issues would make it more difficult to watch and we are trying everything that we can. RN J indicated she was the Nurse Manager. 2nd Hospice verification of visit on 1/20/18, without a time, includes, in part: change of condition - decline. Restless labored breathing. Nursing Notes, dated 1/21/18 at 12:22 PM, include, in part: R23 denies pain, but FM QQ indicates R23 is having pain. R23 is having issues with swallowing small amount of fluid on toothette. Nursing Notes, dated 1/21/18 at 3:38 PM, includes, in part: at end of shift, R23 began with terminal restlessness, and air hunger. [MEDICATION NAME] and [MEDICATION NAME] given. Nursing Notes, dated 1/22/18 at 12:46 AM, includes, in part: R23 was given [MEDICATION NAME] at midnight to stay comfortable. R23 oxygen saturation was 97% on 4.5 liters. Pulse118. (sic) Nursing Notes, dated 1/22/18 at 2:16 AM, includes, in part: R23 was given [MEDICATION NAME]. Heart rate elevated to 126 and breathing was harsh and labored. (sic) Hospice verification of visit, on 1/22/18, without a time, includes, in part: change of condition visit. FM QQ is upset about the weekend situation regarding [MEDICATION NAME]. FM QQ requested order for scheduled [MEDICATION NAME] to ensure R23 is comfortable. R23 showed signs of discomfort- grimaces and twitching. 2nd Hospice verification of visit, on 1/22/18, without a time, includes, in part: change of condition visit. R23 has a rattle when she breathes. Nursing Notes, dated 1/23/18 at 2:38 AM, includes, in part: LPN MM indicated a new order was going to be faxed over for R23's [MEDICATION NAME] and [MEDICATION NAME] to be scheduled every 3 hours. LPN MM waited until 2:00 AM, and still had not received the fax with new orders. LPN MM called Hospice back who indicated the new prescription won't be ready until tomorrow. Continue to use the prn order for now. LPN MM indicated he would tell the day shift. Hospice verification of visit, on 1/23/18, without a time, includes, in part: change of condition visit. R23 appears restless as she was grimacing at times. On 1/29/18 at 11:35 AM, Surveyor interviewed CNA EE who worked with R23 on 1/20/18. Surveyor asked CNA EE if R23 appeared to be having any pain on Saturday. CNA EE indicated R23's FM QQ was at bedside and was complaining that the facility did not have R23's pain pills. CNA EE indicated you could tell R23 was in pain by her facial grimaces. CNA EE indicated that R23 would grimace with repositioning, too. On 1/25/18 at 12:55 PM, Surveyor interviewed LPN MM regarding R23's pain and dyspnea. LPN MM indicated that R23 was on Hospice and did have an order for [REDACTED]. LPN MM indicated that he gave R23 [MEDICATION NAME] every hour as she was declining rapidly. On 1/25/18 at 3:50 PM, Surveyor interviewed DON B regarding the process if there is an order for [REDACTED]. DON B indicated that Hospice gave the original order for every hour and FM QQ requested that the [MEDICATION NAME] be given every three hours, so the facility obtained an order for [REDACTED]. DON B indicated that the facility should have contacted Hospice to let them know. Surveyor asked DON B if the physician should have been contacted regarding R23 and not having the ordered [MEDICATION NAME] on hand. DON B indicated that Hospice and the physician should have been notified that the facility did not have the [MEDICATION NAME] available. Surveyor asked DON B who is responsible in the facility for coordination with Hospice. DON B indicated that the social worker will make contact with Hospice services and when Hospice comes in the facility they will check in with staff for care. DON B indicated that the floor nurse should have let the Hospice know what medication the facility has on hand. The facility failed to ensure that R23 had her stat pain relieving medication available when she was experiencing pain, while actively dying.

Based on interview and record review, the facility did not ensure that the drug regimen of 1 of 6 residents reviewed (R157) was free from unnecessary drugs out of a total sample of 14. An unnecessary drug is any drug when used without adequate monitoring or in the presence of adverse consequences, which indicate the dose should be reduced or discontinued. R157 has a [DIAGNOSES REDACTED]. R157 did not have an order to check INRs (International Normalized Ratio - monitors the clotting ability of the blood). The facility administered R157's [MEDICATION NAME] daily and did not note their lack of INR orders. On 1/8/18, 10 days after admission, R157 developed shortness of breath, nausea, and a nose bleed and was sent to the emergency room (ER). R157's hospital admission labs indicate her INR level at >14.0 (a supratherapeutic and critical level), her PIV (peripheral intravenous) sites were oozing, and she was bleeding through pressure dressings. The hospital held [MEDICATION NAME], administered 1 mg IV (intravenous) Vitamin K, and started trending her INRs. Findings as follows: The facility policy, undated, states it is the policy of this facility that residents on anticoagulation therapy will be monitored to ensure the maintenance of safe laboratory parameters as established by the attending physician. The protocol for managing anticoagulant therapy will assist in reducing the risk of negative effects from the use of anticoagulation medications. Procedure: 1. Residents receiving anticoagulation therapy require regular monitoring and will have anticoagulation PT/INR tracking information placed on the [MEDICATION NAME] tracking log. 2. To initiate anticoagulation PT/INR tracking, review the resident's medical record to ensure anticoagulation therapy orders include a supportive diagnosis, appropriate dosage, desired INR range, and the parameters for physician notification of abnormal laboratory results. 3. The MAR indicated [REDACTED]. The results of the most recent laboratory draw, c. Current medication and dose orders, d. Date of the next scheduled laboratory draw, and e. Parameters for abnormal results and physician notification. 4. With each medication administration opportunity, the nurse or med tech (technician) will review the MAR indicated [REDACTED]. 5. Do not administer the medication if laboratory results are not clearly identified on the MAR indicated [REDACTED]. Always have results of the most current laboratory tests prior to administering anticoagulants. 6. Licensed staff receiving laboratory results shall be required to update the MAR, notify the physician of results, and adjust dosage orders as necessary. 7. Tracking of PT/INR values will be maintained until the drug regime has been discontinued by Physician Orders. 8. Changes in dosage requires the entire medication order to be discontinued and a new order be written. Highlight the discontinued order on the MAR, indicate the date of discontinuation and write the new orders in a separate space to prevent confusion. 9. All anticoagulation therapy requires close monitoring and it is critical that the resident is continuously assessed for adverse drug reactions (ADR) such as bruising, bleeding gums, rectal bleeding (melena), bloody urine (hematuria), change in mental status, etc. All adverse reactions must be reported to the attending physician immediately and documented in the medical record. Standing Orders (provided to the facility on [DATE]), undated, for MD DD, NP CC - For all patients admitted under MD DD, the following standing admission orders [REDACTED]. (Note, while R157 was hospitalized prior to her admission on 12/29/17, her most recent INRs at the hospital are as follows: 12/29/17 - 3.2, 12/28/17 - 3.0; 12/27/17 - 3.4. A normal range for an INR is 2.0 - 3.0 to prevent [MEDICAL CONDITION] ([MEDICAL CONDITION] or blood clot), PE (pulmonary embolism) and [MEDICAL CONDITION] (an irregular heartbeat that can lead to stroke/death). This indicates that R157 was supratherapeutic prior to admit at the facility, which makes monitoring INRs of critical importance.) R157 was admitted to the facility on [DATE] following a motor vehicle accident, in which she sustained multiple fractures: R femur, multiple rib fractures, R tibial plateau, R fibular neck and other injuries, R hepatic lobe hematoma, R hemothorax, scapular body fracture. Her hospital stay was complicated with R lower extremity ischemia and R157 underwent a right [MEDICAL CONDITION] on 12/11/17. R157 has Diagnoses: [REDACTED]. R157's Admitting Orders, from the hospital, include the following medications, in part: [MEDICATION NAME] ([MEDICATION NAME]) 3 mg tab - Take 4.5 mg (1 and 1/2 tablets) on Monday and Thursday and 3.0 mg (1 tablet) on all other days (Sunday, Tuesday, Wednesday, Friday, Saturday) of the week and [MEDICATION NAME] 75 mg ([MEDICATION NAME]) - Take 1 tablet (75 mg total) by mouth daily. The MAR indicated [REDACTED]. On 1/8/18 at 1:00 PM, LPN D documented the following Nurses Note (NN): Patient had blood coming from her nose. O2 (Oxygen) removed. NP called and she ordered a CBC and INR Stat. Also [MEDICATION NAME] spray BID x 3 days. Patient updated. Lab called and Stat lab orders requested. On 1/8/18 at 2:00 PM, LPN D documented the following NN: No further bloody noses, patient was put back to bed and labs were drawn. On 1/8/18 at 2:15 PM, the first INR was collected from R157. On 1/8/18 at 4:00 PM, RN Z documented the following NN: Res reports not feeling well. Res had nosebleed earlier. Res vitals are stable at this time. No Fever. Res shaking in bed, blood sugar was 141. Pt has labs which are abnormal. NP called and updated on labs and condition by LPN. (Note, R157's INR was >12.0 (a supratherapeutic and critical level.)) LPN received orders from NP to send to ER. Res is being transported to ER. Ambulance called at 4:43 PM and family updated, who is present, along with res at 4:40 PM. Res wanted son, who was in the room, to be updated. Res is on oxygen and lungs are diminished, but clear with coughing. Res states her pain 6/10 and general pain. Res has refused to get out of bed for last several days. Res will be transported via ambulance and family is following. 1/8/18 at 4:58 PM, LPN D documented the following NN: NP called with results of CBC and NP ordered patient to go to ER. This was explained to patient and son who was in room. Ambulance called and ordered. R157's Hospital Admission Labs indicate her INR level at >14.0 (a supratherapeutic and critical level), her PIV sites were oozing, and she was bleeding through pressure dressings. The hospital held [MEDICATION NAME], administered 1 mg IV Vitamin K, and started trending her INRs. On 1/10/18 at 1:15 PM, Surveyor spoke with LPN H. Surveyor asked LPN H what is the process when a resident is admitted to the facility on [MEDICATION NAME]. LPN H stated the process has changed as of today. LPN H stated that NP CC told them with any new admissions we're going to need an INR the next day. If a resident comes in on [MEDICATION NAME] and there's no order I would call the on-call physician. I would tell them we have a new admit with no dosing, tell them the last INR, and request a dosing schedule. I would look at their dosing schedule, last INR, what was it (really high or really low) and follow protocol. We would also watch for bleeding or bruising. Surveyor asked LPN H should there be a care plan to watch for bleeding for bruising. LPN H stated, I think there should be a care plan, too. On 1/10/18 at 1:22 PM, Surveyor spoke with LPN D. Surveyor asked LPN D what is the process when a resident is admitted to the facility on [MEDICATION NAME]. LPN D stated their process changed as of today. LPN D stated that all new residents admitted on [MEDICATION NAME] are to get an INR drawn by the next day. When we send the information to AMS, we fill out the sheet with the INR, NP CC signs off, the information is sent to AMS and AMS follows the resident. All INRs go to AMS and they do the dosing (for the Medical Director's residents that NP CC follows). Surveyor asked LPN D what was the process prior to being changed today. LPN D stated we call NP CC, call the hospital or call the doctor on call; sometimes the doctor will say check with the primary tomorrow. LPN D stated that R157 did not have orders for an INR when she was admitted . LPN D stated he did not see her until 12/31/17. Surveyor asked LPN D if you are doing an admission for a resident coming in the facility on [MEDICATION NAME] what do you do. LPN D stated I check for INR orders. If there's no orders, I call the doctor to see when they want an INR. LPN D stated 99% of the time orders are in the residents discharge instructions from the hospital. LPN D stated on 1/8/18 when he was working with R157, it happened quickly, where she didn't look right, didn't feel right, and had a bloody nose and that's when I contacted NP CC. On 1/10/18 at 4:40 PM and 1/11/18 at 10:50 AM, Surveyor spoke with DON B. Surveyor asked DON B what is the process when a resident comes into the facility on [MEDICATION NAME]. DON B stated the order is entered and we are supposed to make sure we have the next INR order. DON B stated one nurse enters the order and another nurse is to do the second check. DON B stated that within 24-48 hours a third nurse is to check the order for accuracy. Surveyor asked DON B if R157 has any order to have her INR checked since she was admitted on [DATE]. DON B stated, No. Surveyor asked DON B if the facility should have noted her lack of INR orders upon admit. DON B stated, Yes, we should have. Surveyor asked DON B if the facility had an INR results from R157's hospital stay prior to admit. DON B stated, no. DON B stated our NP that works with our Medical Director implemented a new policy that anybody admitted to the facility on [MEDICATION NAME] has an INR drawn the next day. This will be a new standing order for all residents on [MEDICATION NAME]. DON B stated the NP wrote us the order today (1/11/18). Surveyor asked DON B why is it important to monitor INR levels when a resident is on [MEDICATION NAME]. DON B stated, It's important to monitor [MEDICATION NAME] because it can be life threatening. It's a very sensitive .sensitive medication. On 1/11/18 at 11:30 AM, Surveyor spoke with NP CC. NP CC has been working with facility for six months. NP CC stated that every resident who is admitted on [MEDICATION NAME] is supposed to have an Admission Order for INR checks. NP CC stated that AMS follows all residents on [MEDICATION NAME] and their INR levels. Surveyor stated that R157 did not have any orders to have an INR levels monitored. NP CC stated, I saw that. Surveyor asked NP CC if the facility contacted her to request INR orders. NP CC stated nobody has requested INR orders from her. NP CC stated it is her expectation that the facility call her for INR orders when a resident is admitted on [MEDICATION NAME] and does not have an order in place to have INRs monitored. Surveyor asked NP CC if this is a new policy she put in place. NP CC stated, no, this has always been her policy to follow this procedure. NP CC stated she is unsure if facility had this in writing prior to yesterday, but this has always been her policy, process, and expectation. NP CC agreed that R157 should have had orders in place to have INRs monitored upon admit and if the orders did not come from the hospital, the facility should have called NP CC to request an INR order.

Based on observation, interview, and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being for 1 of 1 resident (R2) reviewed for wound care. The facility did not clarify wound care orders with a physician upon admission, follow Physician Orders, or ensure monitoring and accurate documentation of wound assessments/treatments resulting in an infection in a wound that required [MEDICATION NAME] and negative pressure wound therapy (Wound V.A.C). This is evidenced by: Facility Wound Management Program Policy, dated 10/16/15, states .E. Surgical Wounds .Open surgical wounds . will require more aggressive local wound care as well as proper management of general systemic function to promote healing. KCI's V.A.C. Instill System (Wound V.A.C.) Recommended Guidelines state, .Infected Wounds . If wound is chosen for V.A.C. Therapy and is infected .change dressing every 12-24 hours . It also states, . Adjusting Settings on V.A.C. Instill System .3. Select Intensity Level. Use the arrow keys to choose rate of pressure change at the wound .This should be adjusted in accordance with varying wound conditions, patient's pain tolerance, and at direction of a physician . On 10/16/17, during initial tour, R2 asked Surveyor to look into her wound care. R2 stated that she had been having a hard time getting the staff to change her dressing and now it is infected. Surveyor observed R2's Wound V.A.C. setting at 125 mm/Hg (mm of mercury). R2 is [AGE] years old, admitted to facility, on 9/28/17, after a coronary artery bypass graft. Her [DIAGNOSES REDACTED]. Admission Nursing Assessment, dated 9/28/17, states: Skin Condition . chest surgical incision with sutures, right inner leg harvest site with sutures. No [MEDICAL CONDITION] noted. R2's Hospital Discharge Plan, dated 9/28/17, states: R2's incision is to be washed daily with soap and water (Note: this order does not indicate which incision that they are referring too). Patient should wear TED hose daily for 6 weeks. Wrap lower extremities daily with ACE. Change dressings daily and apply [MEDICATION NAME]. R2's Minimum Data Set (MDS) assessment, dated 10/5/17, indicates that R2's Brief Interview for Mental Status (BIMS) score is 13, which indicates R2 is cognitively intact and R2 requires extensive assistance with transferring, dressing, bathing, and toileting. R2's care plan, dated 10/7/17, states, The resident has potential/actual impairment to skin integrity of the chest right inner leg related to CABG, surgical incisions. Interventions include: Keep skin clean and dry. Use lotion on dry skin . Treatment/dressing as ordered. Wound V.A.C. as ordered, date initiated 10/16/17. (It is important to note that the Wound V.A.C. was ordered on [DATE].) A Nursing Note, on 9/28/17, at 1:51 PM, states, .Incision on chest intact and no signs or symptoms of infection. (It is important to note the right leg incision assessment is not documented.) A Nursing Note, on 10/1/17, at 11:13 AM, states, Dressings changed to right leg, thigh wrapped with Coban, [MEDICATION NAME] on right lower leg. (Note: there is no Physician's Order for this dressing and this dressing does not match the Physician's Discharge Summary Order.) A Nursing Note, on 10/4/17, at 9:17 AM, states, Surgical incisions covered. A Nursing Note, on 10/6/17, at 1:55 PM states, .right lower leg copious amounts of serosanguinous drainage-seeping, some Steri Strips applied - dry dressing applied - legs elevated - leg remains with [MEDICAL CONDITION] - call placed to (MD E - Medical Doctor) - awaiting return call. A Nursing Note, on 10/7/17, at 11:20 AM, states, Received a call from (MD E) office because family called again about her leg incision. MD E said keep doing the dressing as we are and monitor for signs and symptoms of infection. (It is important to note that the surveyor was told that the family had been doing dressing changes due to increased drainage and calling the physician about the wound.) The facility had no follow up as to why they were doing the dressing changes or what the concern was as to why they were calling the MD. A Nursing Note, dated 10/11/17, states, .while nurse changed dressing; she noted the dressing to be soaked with yellowish-tan foul smelling drainage and yellowish-tan creamy drainage coming from wound. Wound edges appeared reddened and swollen-resident did indicate some slight discomfort to the area. Wound cleansed and dressing applied. Prior to this date, wound did not appear to have any signs of infection. Resident will see surgeon tomorrow, will await any new orders. A Physician Order, dated 10/11/17, indicates to change dressing to right thigh wound every PM shift and PRN soiled/not intact (as needed). Cleanse wound to right thigh, apply ABD pad followed by Kerlix wrap and wrapped with Coban (elastic dressing material to hold bandages in place) to keep in place. Ensure that entire dressing is covered. MD E's Consultation Report, dated 10/12/17, states, .Wound V.A.C. to right thigh, change every 48 hours .right leg saphenous vein harvest site was debrided. Keflex 500 MG (milligram) by mouth every 6 hours to treat right thigh wound infection. The Treatment Administration Record (TAR), for October 2017, states: Wound V.A.C. therapy dressing change to be every Monday, Wednesday, and Friday on AM shift. (It is important to note that the TAR schedule does not match the Consultation Report order.) A Physicians Order, on 10/13/17, states, Keflex, give one 500MG capsule by mouth four times a day for infection in right thigh until 10/23/17. Negative Pressure Wound Therapy at (left blank, not completed) mmhg (continuous/intermittent-indicated to choose one but neither was chosen) suction to (specific location-left blank) wound. Connect to Wound V.A.C. and every 4 hours verify Wound V.A.C. functioning and order settings. (It is important to note that there is no specific setting ordered for the wound vac.) On 10/16/17, at 2:45 PM, SW D (Social Worker) stated that R2's family consists of two nurses and they took it upon themselves to do dressing changes. She stated that this is not a standard of practice for family members to perform dressing changes on residents. She stated in a care conference, on 10/11/17, which a member from the nursing department told the family to report changes in color and amount of fluid in dressing to nurse. On 10/16/17, at 3:00 PM, LPN C (Licensed Practical Nurse) stated, I never called the doctor to tell them it (her thigh wound) was weeping, because I work PM's (second shift). I just dressed wound the way I thought was best from being a nurse so long. LPN C also stated that, on 10/11/17, she reported to DON B (Director of Nursing) that the family was changing the wound dressing unsupervised. LPN C informed writer that there were no risks and benefits information given to family regarding doing the dressing changes when facility was made aware of family performing wound care on their own. She also agreed that the October TAR (Treatment Administration Record) should match Physician's Orders of every 48 hour dressing changes and not Monday, Wednesday, and Friday. On 10/16/17, between 3:15 PM and 5:00 PM, Surveyor interviewed DON B. DON B stated, The admission orders [REDACTED]. DON B was unable to recall if LPN C reported that R2's family had been changing dressings on their own and stated that family members changing dressings is not a standard of practice and they would have no way of monitoring if family was changing dressing. She also stated, We only do wound rounds for pressure ulcers and skin tears. The Wound V.A.C. orders should have been clarified and documented. (It is important to note there was no evidence of wound measurement or wound assessment documentation.) The facility failed to complete weekly wound assessments to determine if the wound was changing, did not provide the accurate Physician's Orders and the nurse placed a dressing without an order and did not follow up on family's concerns about the wound and why they were changing the dressings to her lower legs. R2's wound deteriorated and became infected needed [MEDICATION NAME] and antibiotic and a Wound V.A.C.

Based on interview and record review the facility failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 resident out of 6 reviewed (Resident 6) for pain. Resident 6 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident 6 did not have a care plan developed to address his pain and the facility decreased his long term pain management medication. The facility failed to realize the dose reduction that was taking place when the Nurse Practitioner changed Resident 6's long term pain management medication. As evidenced by: Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Of note: Resident 6 has a history of a tumor that wraps around his spine. Resident 6's admission Minimum Data Set ((MDS) dated [DATE] section C0500: Brief Interview for Mental Status (BIMS) scored an 11 which indicates that Resident 6 has moderate cognitive impairment. Section J400: Pain Frequency - Scored Constant, J0600: Pain Intensity- Scored Severe. The Care Area Assessment (CAA) indicates: Resident 6's verbal description of pain was severe and it was frequent. Resident 6 was asked how much pain he was experiencing over the past 5 days. Resident 6 responded with almost constantly. Thus, the CAA was triggered for Pain and a Care Plan was to be developed. The facility's Pain Screening Form dated 6/28/16, scored a 6 which indicates a comprehensive assessment needs to be completed. The facility's Pain - Comprehensive Evaluation dated 7/20/16, states in part, the location of the pain: Left leg tingles at all times, bilateral shoulders, chronic, states cartilage is worn out, chronic back pain, constant. Pain level 7, Vocal complaints of pain, Medication makes it better, Acceptable level of pain- 4, What makes the pain worse- exercise, worst pain -10, Effects of pain- sleep and rest, social activities, appetite, physical activity and mobility, emotions. Resident 6 answered yes, to all the above factors that are affected by the pain he is experiencing. On 7/28/16 at 1:00 PM, Surveyor reviewed Resident 6's record which did not contain a comprehensive care plan to address Resident 6's pain. Resident 6's signed MD (Medical Doctor) orders dated 6/28/16 includes: * [MEDICATION NAME] capsule extended release 24 hour 60mg (Milligram). Give 60mg by mouth two times a day for pain. It is important to know that Resident 6 was prescribed and had been receiving a total dose of 120 mg daily of the [MEDICATION NAME]. [MEDICATION NAME] is a [MEDICATION NAME]-sulfate extended release medication. * [MEDICATION NAME] Imm Rel (Immediate Release) Tablet 5mg. Give one tablet by mouth every 6 hours as needed for pain. * [MEDICATION NAME] tablet 50mg. Give 50mg by mouth two times a day for pain. (Of note: Resident 6's signed consent for the [MEDICATION NAME] use was listed as [MEDICAL CONDITION] not pain.) May substitute generic/formulary equivalent unless otherwise specified. Nursing note on 6/28/16 at 12:57 PM, states in part, Completed pain screening form. Score = 6 which puts Resident 6 at high risk for pain. Nursing note on 6/28/16 at 6:08 PM includes, in part: [MEDICATION NAME] Capsule extended release 24 hour 60mg by mouth two times a day for pain not in yet, pharmacy to stat (Immediate) order. The following nurse's notes document Resident 6's pain entries (in part): On 7/2/16 at 6:42 AM Resident 6 is pain free or receiving successful pain management on current regime. At 8:03 AM [MEDICATION NAME] Tablet 5mg given for low back and bilateral leg pain. On 7/3/16 at 11:23 PM Pain 6/10 (scored 6 out of 10) before pain med (Medication). On 7/4/16 at 3:27 PM [MEDICATION NAME] Tablet 5mg given for pain. Nursing note on 7/4/16 at 9:29 PM includes, in part: Earlier this afternoon Resident 6 was c/o (complaned of) pain rating 8/10. Registered Nurse (RN) X asked whether or not Resident 6 wanted his PRN (When needed) [MEDICATION NAME] along with his scheduled [MEDICATION NAME] ([MEDICATION NAME]) and Resident 6 replied, 'Of course I do'. RN X explained that the question was asked because he hasn't received one since the end of June and Resident 6 became upset. RN X asked Resident 6 why he was upset and Resident 6 replied that he thought he'd been receiving the [MEDICATION NAME] all along and 'No wonder my pain is so damn bad.' Nursing note on 7/5/16 at 1:00 AM includes: [MEDICATION NAME] Tablet 5mg PRN was effective. On 7/5/16 at 7:14 AM includes: [MEDICATION NAME] Tablet 5mg every 6 hours as requesting with [MEDICATION NAME]. On 7/5/16 at 8:34 AM includes: [MEDICATION NAME] Tablet 5mg PRN was effective. Follow up pain scale was 5. Nursing note on 7/5/16 at 1:34 PM includes, in part: [MEDICATION NAME] Tablet 5mg 1 tablet by mouth every 6 hours as needed for pain. Resident 6 c/o pain, requesting [MEDICATION NAME] every 6 hours. Rated pain 8/10 on a 0-10 pain scale. On 7/5/16 at 4:19 PM includes, [MEDICATION NAME] Tablet 5mg PRN administration was ineffective. Nursing note on 7/5/16 at 5:41 PM includes, in part, Participated in PT (Physical Therapy), propels self-wheel chair, but only when going to and from therapy. Asked for pain med at 5:00 PM, was reminded that he was now getting scheduled 60 mg [MEDICATION NAME], had an oxy ([MEDICATION NAME]) at 1:30 PM, must wait 6 hours before repeat dose. Pain rated 7/10 in shoulder and low back. Nursing note on 7/5/16 at 8:20 PM includes, in part: [MEDICATION NAME] Tablet 5mg 1 tablet by mouth every 6 hours as needed for pain lbp (Lower back pain), would like every 6 hours, explained it to be used for every 6 hours for breakthrough pain, not scheduled per Licensed Practical Nurse (LPN) F. Nursing note on 7/7/16 at 5:42 PM includes, in part: Spoke with Resident 6 for MDS interview. Resident 6 stating constant pain that is severe. Discussed medications. States he takes PRN [MEDICATION NAME] with his scheduled [MEDICATION NAME] usually at home. Spoke with nurse regarding pain. Educated on ability to give PRN with scheduled med if he is due for it. Monitor. This note is per Registered Nurse (RN) R. Nursing note on 7/7/16 at 9:37 PM includes, in part: Alert and oriented X (Times) 3. Pain is rated at 7/10 at 3:30 PM, and 6:00 PM 6/10 low back. On 7/8/16 at 1:33 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for back pain. On 7/8/16 at 11:31 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Nursing note on 7/10/16 at 10:57 AM includes, in part: Resident 6 has not c/o breakthrough pain on the day shift past 2 days, receives [MEDICATION NAME] every morning. When he does c/o pain it is in his right shoulder. On 7/11/16 without a time stamp, Surveyor reviewed a fax order written by Nurse Practitioner (NP) G which states, D/C (Discontinue) [MEDICATION NAME]. Start MS ([MEDICATION NAME]) Contin. Change made due to formulary change. The prescription reads as follows: [MEDICATION NAME] 15mg 12 hour CR (Controlled Release) tablet. 1 tablet PO (Oral) BID (Twice Daily). Hold for lethargy/ decrease RR (Respiratory Rate). With this change, the dosage of [MEDICATION NAME] sulfate was reduced from 120 mg/day (60 mg x 2) to 30 mg. (15 mg. x 2). Nursing note on 7/11/16 at 11:53 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain level 7. Nursing note on 7/11/16 at 6:01 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain 8/10. Nursing note on 7/11/16 at 9:53 PM includes, in part, Alert and oriented X 3. Pain 8/10 before scheduled pain med. PRN at lunch and 6:00 PM. Became upset when trying to explain new pain med order. Resident 6 stated that he desires the pain clinic regime back. Needs to be reiterated when in a calm state. This note is per LPN F. Nursing note on 7/12/16 at 10:47 AM includes, in part: Resident 6 c/o pain before he received his scheduled pain med this AM. Of note: There is no description of the pain level noted. Nursing note on 7/12/16 at 1:54 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain in hips. Nursing note on 7/12/16 at 3:52 PM includes, in part, Resident 6 asked what the blue pill was and where his [MEDICATION NAME] was. I told him that his dose had been changed. Resident 6 swore at me and became upset, said that he didn't even see the doctor and that he has been getting meds from the pain clinic for 6 years and that no one believes him when he says he is in pain. This entry was by LPN E. Nursing note on 7/13/16 at 4:35 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Nursing note on 7/14/16 at 9:04 AM includes, in part, Resident 6 c/o pain since med decrease. Stating pain in left arm and left leg that was within tolerable limits now is not tolerable. States his normal pain has now increased. Resident stated he did not sleep at all last night and was uncomfortable. Stated transfers have become very difficult and does not want to get out of bed. RN updated and will address with MD. Nursing note on 7/14/16 at 9:13 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Review of Nursing Fax dated 7/14/16 without a time stamp includes, in part: Resident 6 was on [MEDICATION NAME] 60 mg 24 hr (Hour) capsule. Was decreased to MS 15 mg BID. Resident 6 is noticeably in more pain. Difficulty with transfers. C/O left sided pain. Resident 6 has not complained about this prior to the decrease. Does not want to get out of bed. Resident 6 has not been eating well. Stated pain has made his stomach upset. Please address today. On the bottom of the fax sheet new orders as follows: 1. Increase [MEDICATION NAME] to 30 mg 1 every 24 hours. 2. Continue MS 15 BID 3. Ok - MS 15mg 3 (45mg) po tonight. Nursing note on 7/14/16 at 7:19 PM includes, in part, [MEDICATION NAME] Extended Release 15mg give 1 tablet by mouth two times a day for pain. 1 tab (tablet) po bid, hold for lethargy or decreased respirations. Additional 2 tabs given 1 time only this HS (Bedtime) d/t (due to) increased pain from decreasing medication. MD (Medical Doctor) here and aware. New orders received and will monitor. Nursing note on 7/15/16 at 4:19 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. At 6:05 AM includes, in part: Awake on and off through the night. C/O general pain. PRN Oxy given X 1 effective. Nursing note on 7/15/16 at 9:44 AM includes, in part: Resident 6 verbalizes anger when asked about the effectiveness of his pain medication. Resident 6 states 'he's pissed off they changed my meds without even asking me.' Resident 6 requesting PRN [MEDICATION NAME] but too early at this time let Resident 6 know he can have one at 10:15 AM, if he still needs it. Nursing note on 7/15/16 at 12:58 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for c/o low back and leg pain. At 10:16 PM includes, in part: Alert and oriented X 3, pain rated 7/10, not defined in location or what provokes. Complaint pain meds not the same as pain management clinic routine. Review of nursing fax to MD T/ NP G on 7/16/16 without a time stamp includes, in part: Resident 6 noted to have increased pain. Difficulty transferring and c/o pain throughout. Medical Director here add [MEDICATION NAME] 60 mg with MS 15mg BID ordered throughout weekend. Resident 6 called family c/o his medications being taken away and pain uncontrollable. Resident 6 did appear to be in pain. Grimacing/ not getting up, not using extremities. C/O left arm and leg pain. He does not normally c/o these areas. Please address ASAP. (As soon as possible). Nursing note on 7/16/16 at 12:02 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for c/o pain right arm pain post shower. On 7/17/16 at 6:45 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for c/o pain low back break through pain. On 7/17/16 at 7:45 AM includes, in part: PRN administration was Effective resting f/u (Follow up) pain scale was: 5. At 2:00 PM includes, in part: [MEDICATION NAME] Tablet 5mg 1 tablet by mouth every 6 hours as needed for pain c/o right arm pain. Pain bilateral shoulders. At 5:10 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for c/o low back break through pain. Of note: The PRN order for [MEDICATION NAME] is for every 6 hours and the [MEDICATION NAME] was administered within a 3 hour 10 minute time frame. Nursing note on 7/17/16 at 8:03 PM includes, in part: PRN administration was Ineffective neck and shoulder pain 8/10. Review of returned nursing fax that was sent on 7/16/16 without a time stamp dated 7/18/16 by NP G states, Nobody here to get faxes addressed on weekends. Did this get addressed by on call? Review of fax dated 7/18/16 without a time stamp from Nursing Home Administrator (NHA) A to MD T includes, in part: Resident 6 c/o pain. Recently had [MEDICATION NAME] changed from 60mg BID to 30 mg daily. Resulting in decreased participation in therapy. Pain MD U phone number listed. Of note: Resident 6's pain had been managed on 120mg of [MEDICATION NAME] daily and this was decreased to 30mg daily on 7/11/16. Nursing note on 7/18/16 at 9:43 PM includes, in part: Stated can't get through the day on 15 mg of MS. Fax sent to MD earlier today regarding pain control. Facility nursing note on 7/18/16 at 10:06 PM includes, in part: Oxy at 10:00 PM for pain 8/10. On 7/19/16 at 12:15 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain per resident request. At 6:00 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain per resident request. Review of nursing faxed note to MD U dated 7/19/16 without a time stamp includes, in part: Please be advised that Resident 6 now lives here. On 7/11/16 MD T's NP G changed Resident 6's pain management - D/C [MEDICATION NAME], start [MEDICATION NAME] 12 hour CR - d/t formulary. Since that time Resident 6 c/o pain has increased with MS not being effective for him. - Please review current med list. Was on [MEDICATION NAME] 60mg 24 hour capsule, then it dropped to 15mg BID - on 7/14 MD S prescribed [MEDICATION NAME] 30 mg daily and to continue MS 15 mg BID. Resident 6 has notable change in appetite stating pain makes his stomach upset. Resident 6 and family accusing staff/facility of not giving meds. I understand you have not seen this Resident 6 since April- Looking to you for advice. (Of note: The [MEDICATION NAME] 60 mg 24 hour capsule was ordered BID (120 mg./day). The above fax lists it as once daily.) Nursing note on 7/19/16 at 9:38 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Last Oxy given at 2:15 PM. To be noted: The [MEDICATION NAME] given at 2:15 PM was not documented in the nursing notes or the Medication Administration Record [REDACTED] Nursing note on 7/20/16 at 3:46 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Nursing note on 7/20/16 at 11:09 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain in his spine. Facility Social Worker (SW) V's note on 7/20/16 at 11:09 AM includes, in part: Spoke with Resident 6 today about IDT (Inter Disciplinary Team) meeting tomorrow. He was preoccupied and difficult to redirect in conversation r/t (Related to) pain medication changes. Explained that the staff was actively trying to get medicine changed back to prior dose. To be noted: The pain medication was changed on 7/11/16. Nursing note on 7/20/16 at 1:02 PM includes, in part: Resident 6 lying in bed most of this shift, Resident 6 continues to c/o break thorough pain and was given an Oxy at 11:11 AM. Nursing note on 7/20/16 at 1:52 PM includes, in part: Writer spoke to MD U's NP W r/t Resident 6's c/o pain. NP U gave new orders to d/c [MEDICATION NAME], and to increase [MEDICATION NAME] ER (Extended Release) to 30 mg TID (Three times daily). NP U states this is all she is willing to prescribe at this time, as we still have PRN [MEDICATION NAME] 5mg for breakthrough pain. Nursing note on 7/20/16 at 4:57 PM includes, in part: Contacted pharmacy for auth (Authorization) number to give new order for [MEDICATION NAME] sulf ER 30 mg TID. Resident 6 and family at nurses station requesting pain med administration. Pharmacy needs signed document from physician, faxed MD T for written order pending response. Nursing note on 7/20/16 at 22:44 PM includes, in part: Resident 6 did participate in Occupational Therapy (OT). Pain rated 9/10. Nursing note on 7/21/16 at 5:40 AM includes, in part: [MEDICATION NAME] ER Tablet Extended Release 30 mg give 1 tablet by mouth three times a day for chronic pain. Resident 6 reports pain in shoulders 8/10. Nursing note on 7/21/16 at 11:22 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain level 7. Nursing note on 7/21/16 at 6:26 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for 8/10 pain in shoulders. Nursing note on 7/21/16 at 7:52 PM includes, in part: PRN Administration was ineffective states pain 7/10. Nursing note on 7/21/16 at 10:51 PM includes, in part: Resident 6 would like something for pain, last prn oxy at 6:30 PM, and scheduled morph ([MEDICATION NAME] sulfate) at 8:00 PM. Resident 6 unhappy needs to wait one hour for pain med. Nursing note on 7/21/16 at 11:04 PM includes, in part: Had pain med at 2:00 PM, at 2:45 PM states pain 7/10. At 4:00 PM requested pain med, explained next PRN can't be given until 6:20 PM. Shoulder pain is severe 9/10. At 6:30 PM PRN pain medication given for pain 8/10. At 8:00PM scheduled [MEDICATION NAME] 30 mg given. Nursing note on 7/22/16 at 1:32 AM includes, in part: Resident 6 c/o pain med scheduled and PRN are not effective for severe shoulder pain. Nursing notes document [MEDICATION NAME] 5mg was given on the following dates and times for pain: 7/22/16 at 4:37 PM 7/23/16 at 12:02 AM 7/23/16 at 2:52 AM 7/23/16 at 9:45 AM 7/23/16 at 5:55 PM 7/24/16 at 12:13 AM 7/24/16 at 7:18 AM - given for right shoulder pain. Nursing note on 7/24/16 at 10:00 AM includes, in part: Resident 6 has been complaining a lot of right shoulder pain and is requesting and receiving PRN Oxy per his request along with his scheduled [MEDICATION NAME]. Nursing note on 7/24/16 at 6:14 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for shoulder pain. Nursing note on 7/25/16 at 3:42 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for shoulder pain. Nursing note on 7/25/16 at 9:51 PM includes, in part: Pain 8/10 in shoulders, Oxy PRN X 1 given this shift pain still 8/10 at 8:00 PM. Nursing note on 7/26/16 at 12:10 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain. Nursing note on 7/26/16 at 7:22 AM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain level of 9. Nursing note on 7/26/16 at 4:55 PM includes, in part: [MEDICATION NAME] Tablet 5mg given for pain level of 8/10 in shoulders. Nursing note on 7/26/16 at 8:03 PM includes, in part: PRN Administration was Ineffective 8/10. Nursing note on 7/26/16 at 8:44 PM includes, in part: Pain consistently rated at 8/10 before, and after pain meds, states it's the same pain in shoulders. Fully aware of discharge tomorrow and aware of home care. On 7/23/16 at 1:40 PM, Surveyor interviewed via phone NP G regarding Resident 6 and the d/c of the [MEDICATION NAME]. NP G indicated that the [MEDICATION NAME] was not covered by Resident 6's insurance. NP G indicated that she changed Resident 6 to [MEDICATION NAME] hour tablet BID. Surveyor asked NP G if the dose of 15mg bid of [MEDICATION NAME] equal to the [MEDICATION NAME] 60mg 24 hour BID. NP G stated, The order should have been for 30 mg CR (Controlled Release). Surveyor asked NP G if Resident 6's increased pain could be related to the dose of [MEDICATION NAME] at 15 mg BID. NP G indicated she would assume that is why he is having the pain. NP G stated, I feel terrible if I made that mistake. I am so sorry. NP G indicated that her documentation shows she ordered [MEDICATION NAME] mg BID. Surveyor read off the prescription that NP G wrote for 15 mg [MEDICATION NAME]. On 7/28/16 at 1:45 PM, Surveyor interviewed Pharmacist (Pharm) H regarding the Resident 6's medication. Surveyor asked Pharm H if the [MEDICATION NAME] 60 mg 24 hour BID was equivalent to [MEDICATION NAME] mg BID. Pharm H indicated that she did not believe it was. Pharm H stated, The mg was not equivalent. That was a dose reduction. On 7/28/16 at 2:15 PM, NP G called Surveyor back at the facility. NP G stated, I gave the incorrect order. I documented 30 mg on our chart. I'm so sorry. NP G then stated, I don't know why this wasn't caught. There are others that are accountable too. I'm glad you are looking into this. On 7/28/16 at 2:00 PM, Surveyor interviewed Family Member (FM) I via telephone regarding Resident 6's pain management. FM I indicated that MD T and NP G cut his medication without talking to him. Resident 6 had been on that pain medication for many years. He has a tumor on his spine. No one told me about the medication change. FM I indicated you could see the pain on Resident 6's face by the grimacing and contorting expressions he makes. FM I stated, It took more than a week and many phone calls to get the medication changed and they never got him back to the same level. FM I indicated that during the IDT (Interdisciplinary team) group meeting, Resident 6 was in pain, contorting his face and had to leave the meeting. FM I indicated that on 7/20/16 she was at the facility and Resident 6 was asking for pain medication at 2:00 PM and did not receive any until 4:00 PM. On 7/28/16 at 2:30 PM, Surveyor interviewed Resident 6 via telephone. Resident 6 indicated that he sees the pain doctor in Oconomowoc. Resident 6 indicated while at the facility his chronic pain medication was [MEDICATION NAME] 60 mg BID and they decreased it to 15 mg BID. Resident 6 indicated he was at the facility for strengthening as he had fallen at home. Resident 6 indicated that he needs to have his right shoulder replaced as he is in awful pain. Resident 6 indicated he is usually an 8/10. Resident 6 indicated that he has a lot of pain in his lower back. Resident 6 stated, always in pain. Resident 6 indicated that upon admission he had to go a half of a day without pain medication. Resident 6 stated, My shoulder was so (swear word) painful. Resident 6 indicated that he had to wait for pain medication. Resident 6 indicated even at rest he was in pain. On 7/28/16 at 5:30 PM, NHA A showed Surveyor a fax that she sent to MD T on 7/18/16 and another fax she sent to MD U on 7/19/16. Of note: Resident 6's medication was reduced on 7/11/16. Surveyor asked NHA A and Director or Nursing (DON) B if the facility ever calls the physician versus using the fax machine. DON B stated, A lot of the doctors will only communicate via fax. The facility failed to meet the pain management needs for Resident 6 by not creating a comprehensive care plan, nor alerting the MD when Resident 6 continued to have increased pain, and not questioning the pain medication dose when it was decreased from 120 mg daily to 30 mg daily.

Based on interview and record review the facility failed to immediately consult with a physician when 1 of 10 sampled residents experienced a significant change of condition (Resident 1). *Resident 1 had a significant change of condition that occurred on 5/7/12. Resident 1 began complaining of increased pain localized to her right side which made it difficult to breathe. *The facility did not assess or do any vital signs and did not promptly consult with a physician concerning Resident 1's increased pain and complaints of dyspnea. *Resident 1 had requested to be sent to the hospital to be evaluated for her increased pain and dyspnea and the RN told Resident 1 and her son that she did not need to go. The family had to insist that Resident 1 be sent to the hospital for evaluation where she was diagnosed with [REDACTED]. The facility failure to consult with the physician in regards to Resident 1's significant change of condition throughout the day a resulted in a finding of Immediate Jeopardy which began 5/7/12. The NHA was notified of the finding of Immediate Jeopardy on 5/24/12. The immediate Jeopardy was removed on 5/24/12; however, the deficient practice continues at a severity level of D (potential for harm that is not immediate jeopardy/isolated) as the facility has to fully implement and evaluate the effectiveness of its action plan. Findings as follows: The facility uses the AMDA (American Medical Directors Association) guidelines: Protocols for Physician Notification. A Guide for Nurses on Effective Communication with Physicians. The following are standards for calling the physician in each case: *Dyspnea (difficulty breathing) - the physician should be notified immediately if acute onset or change from usual pattern or with chest pain, labored respirations, or unstable vital signs. *Medical complaint by family or resident-Demand to speak with a physician or medical treatment without delay. *Shortness of breath- abrupt onset with SOB (shortness of breath) with pain, fever, or respiratory distress. A medical record review of Resident 1 revealed the following information: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set ((MDS) dated [DATE] indicates that Resident 1 scored 15 out of 15 on her BIMS (Brief Interview of Mental Status) indicating she is cognitively intact. Resident 1 is her own legal decision maker. Resident 1 is a full code status. Resident 1's Physician order [REDACTED]. Resident 1's MAR indicates that she has taken PRN Tylenol on 5/3/12 at 8:40 PM, and at 7:30 AM and 2:00 PM on 5/5/12. Resident 1 Received [MEDICATION NAME] 1 tablet on 5/6/12 at 7:30 AM for pain "all over" and at 8:00 AM with [MEDICATION NAME] for general pain. Two [MEDICATION NAME] tablets were given at 4:30 PM on 5/7/12. A nursing note on 5/4/12 at 8:30 AM indicates Resident 1 has complaints of pain at back of neck going into head causing a head ache-Tylenol given and [MEDICATION NAME] applied per resident request. Resident states very helpful effective 1 1/2 hour later. (Please note that the [MEDICATION NAME] is not signed out on the MAR as given on 5/4/12 at 8:30 AM). A nursing note on 5/5/12 at 8:00 AM states, "Res again c/o pain at back of neck causing headache. Tylenol 325-2 tablets given, neck rub given. Resident states helpful Res is awake and A&Ox3 able to voice concerns with clear speech." A nursing note on 5/6/12 at 9:00 AM states, "Resident is awake, A&Ox3 able to voice concerns...res offers no complaints this AM remains polite and friendly." Resident 1's MAR reveals that at 7:30 AM on 5/6/12 Resident 1 had a pain rating of 6/10 for pain all over and received [MEDICATION NAME] 1 tablet. Please note that the nursing note does not reflect accurate information related to Resident 1's complaints of pain. A nursing note on 5/7/12 at 8:30 AM states, "Res is awake, A&Ox3, voices concerns with clear speech...Resident does request [MEDICATION NAME] on right shoulder for arthritis stiffness and [MEDICATION NAME] for general aches this AM given at 8:00 with good effect noted at 9:00 AM resident continues to attend OT/PT as scheduled, does not voice any other concerns remains polite and congenial." At 1:00 PM a note states, "Res c/o muscle spasm on lower right quad going up back and across right shoulder, Res states it catches when she breathes. [MEDICATION NAME] given at 11:30 AM (Please note that this medication is scheduled to be given at 10:00 AM) Res on bed resting, [MEDICATION NAME] given for spasm and increased anxiety (this is not documented on the MAR as being given), Res states 'If I could just calm down'. Res (Resident 1) also calls son (Family member G) canceling this PM appt stating she does not want to sit in car or go that far (No reason documented as to why)." At 1:00 PM Resident 1 still had pain even though she had her scheduled [MEDICATION NAME] late at 11:30 AM; no further pain interventions were attempted even though Resident 1 could have received PRN [MEDICATION NAME]. A physician was not called to report Resident 1's unrelieved pain or the significant increase in pain in the past 24 hours. No assessment of Resident 1's pain was conducted to find the possible causes of her pain. The next nursing note dated 5/7/12 at 4:30 PM, indicates a set of vital signs 97.2, 110/64, 80, 20, 96% RA, resident c/o unrelieved pain. See SBAR (Situation, Background, Assessment, Request). Documented by RN F. The SBAR dated 5/7/12 at 4:30 PM states the following information: Resident 1 had unrelieved body aches upon awakening this AM. The symptoms have gotten worse with movement of upper trunk and physical therapy. No current treatment is effective. Resident 1 is experiencing increased discomfort and anxiety. Vital signs: 97.2, 110/64, 80, 20, 96% on RA Lung sounds bilateral present equal and clear. Pain level/location status-general, but more severe on right side (upper trunk and neck). The assessment section of the SBAR indicates that RN F thinks it may be an acute exacerbation of her [MEDICAL CONDITION] Arthritis pain. RN F's Progress note attached to the SBAR is as follows: 5/7/12 at 4:30 PM, Resident reported C/O a "kink" in her back this AM upon awakening. PRN and scheduled pain medications were ineffective on relief as well as body repositioning multiple times and again PRN pain meds administered at 2:30 PM and ice pack applied to right should/ back region. Resident considered this discomfort to be similar to other bad exacerbations of her [MEDICAL CONDITION] arthritis. Resident attended PT and reported no significant pain to therapy staff per therapy report and per therapy report that a mild "kink" in her back was reported but easily relieved with therapy interventions without further concerns/complications. Assessments currently find pt skin pink/warm & dry & very anxious re: unrelieved pain with excessive fidgeting of upper and lower extremities increased from baseline, due to history of muscle spasm, pain generalized all over but more significant to right upper trunk/shoulder and neck, no changes in skin color to these regions or deformities through palpation of these regions Increased pain. Pain rated '8/10' at 2:30 PM and still currently 8/10 and feeling worse. Family adamant of resident being transferred to (hospital name). MD contacted and orders received to transfer to ED due to family request. Resident 1's ambulance run sheet (non-911) dated 5/7/12 at indicates that they were called at 4:27 PM and arrived at the facility at 4:58 PM. The signs and symptoms listed on the form were: Left (should be right) sided pain from neck down to waist, makes it difficult to breathe. Vital signs: BP 130/59, Pulse 104, 20 respirations and SPO2 92%. Normal respiratory effort and alert and oriented x3. Resident 1's pain was a 10/10. Chief complaint was right sided pain starting in her right jaw and then down her right back. Denies chest pain and shortness of breath...Primary MD believes pain is related to rehab she has been getting. Pain is unrelieved by scheduled or PRN medications. Resident 1's transfer form dated 5/7/12 filled out by RN F states the reason for transfer is "Resident awoke with discomfort believed to be related to history of [MEDICAL CONDITION] arthritis that was unrelieved by scheduled pain meds and prn pain med. Attended therapy session and pain increased and family requested ED eval". Resident 1's emergency department notes dated 5/7/12 states, "...She states that today she woke up at 6:30 AM with right sided pain and it has just gotten worse throughout the day. The patient does have a history of [MEDICAL CONDITION] arthritis. Initially she thought with was consistent with pain that she has had with [MEDICAL CONDITION] arthritis however her pain is much more than she usually experienced. The patient states that she had not experienced pain like this in her last [AGE] years of dealing with her [MEDICAL CONDITION] arthritis. Pain is primarily on right side, extends down under back and down to her buttocks. Breathing makes pain worse movement makes pain worse. She feels short of breath. She also notes the pill shave made her constipated and she is passing some blood with bowel movements...Temp 99.7, pulse 102...Lung sounds are diminished at the bases. Otherwise no rales no wheezes noted...She does have tenderness to palpation over the posterior chest wall...The patient was critical through her stay and generalized weakness and appeared overtly ill...At this point presentation is most consistent with pneumonia and started her on pneumonia protocol. Clinical Impression: Pneumonia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident 1's history and physical dated 5/7/12 indicates that Resident 1 presents with right sided pain and it is pleuritic in nature. It just started this morning. Apparently there has been pneumonia in the facility where she is currently residing...She denies cough or fever however just states that she is feeling terrible. She has had pains before from her arthritis but none as severe as this one. Surveyor interviewed Resident 1 on 5/23/12 during an on site investigation. The interview took place in Resident 1's room at 9:45 AM. Surveyor introduced self and Resident 1 stated that she knew why surveyor was there due to the concerns that she and her family had with the care she received on 5/7/12 while at the facility. The following information was received from the interview: Surveyor requested Resident 1 to explain what occurred that day in her own words. Resident 1 stated, "I woke up with pain in my back and couldn't get air well. I had pain in my back before but not like this, couldn't get air. I went to therapy thinking that might help. (Therapist name) knew I wasn't doing well. He had to give me extra breaks and took a long time to do therapy. He did rub my back/neck area and it helped but it didn't go away. (Day RN name) did give me extra pain pills, but did not do vital signs or listen to my lungs; I'm not sure why - I kept saying that it hurt to breathe. (RN D) stated that it was just my arthritis. I called my son to cancel my appt as I knew I couldn't tolerate the sitting and the ride in the car. (RN D) did cancel my appt for me and she knew I was in pain. I told my son that I couldn't catch my breath and I thought I should be seen and he told me to tell the nurses that I should be seen. I told (RN F) that I wanted to go to the hospital to be checked out as I couldn't catch my breath. Around shift change (RN F) told me "no" I didn't need to go to the emergency room it was just my arthritis acting up. He did come and give me 2 more pain pills and an ice pack. He did not do any vital signs on me or listen to my lungs. He didn't listen to my complaints either." Resident 1 continued on, "My son came to see me and said that I looked terrible and should be seen by a doctor, then he called my other son and they agreed it was best to do. (RN F) came back into the room and we told him that I wanted to be seen again. (RN F) told my son and me that I didn't need to go it was only my arthritis and the physician agrees with (RN F) that I didn't need to go. (RN F) stated that we would need an order from the MD and he didn't have one. My son told him that I was going with or without a DR order and (RN F) left the room. Around 4:30 PM (RN F) came back into the room and told us that we had an order to be seen on request of the family." Resident 1 continued to state, "On my way out of the building while I was on the cart, (RN F) came to my side and bent down to me and stated 'Now just how foolish are you gonna be when they look at you and send you right back because it is just your arthritis and nobody dies from arthritis. This ride is going to be bumpy and painful in the ambulance and they are just going to turn around and bring you back won't you look silly.'" Surveyor interviewed the following as it relates to the allegations that Resident 1 voiced: On 5/23/12 at 10:30 AM Surveyor interviewed PTA I regarding working with Resident 1 on 5/7/12. PTA I stated that he remembers that day and stated, "The wing was still under quarantine so I did therapy down at the end of the hall. She was not good that day didn't feel good, her back hurt. I thought she maybe slept wrong and when palpated it felt like a muscle spasm on the right. She stated that it was hard to breathe, but the rubbing helped her breathe better. She was short of breath so it took longer than normal to due PT due to shortness of breath. I talked to the nurse and told her that (Resident 1) was short of breath and had muscle spasms shortly after breakfast." PTA I stated that Resident 1 "seemed very fatigued." Surveyor asked PTA I if anyone had talked to him about Resident 1 before today and he stated, "No." On 5/23/12 at 12:15 PM Surveyor interviewed Family Member G (FM) via phone. FM G stated on 5/7/12 at around 1:00 PM Resident 1 called him and stated that she couldn't breathe; he told her that she should go to the ER and get checked out and to tell the nurse you want to go. FM G stated he received a call from FM H that Resident 1 couldn't breathe and the 2 family members felt that she should be seen and FM H was going to insist. Around 3:30 or 4:00 PM FM G stated that he came to the facility and RN F stated to Resident 1 that she didn't need to go to the hospital. FM G stated that they told RN F that Resident 1 will be going to the ER with or without an MD order. On 5/23/12 at 1:00 PM Surveyor interviewed FM H regarding Resident 1 on 5/7/12. FM H stated that Resident 1 had an appointment and she called to cancel it, but he went to the facility anyway to see her as he felt it was unusual for Resident 1 to cancel an appointment. FM H stated that when he saw her he knew something was wrong with her. Resident 1 was in severe pain, trouble breathing saw her take deep breaths and her whole body would shake with pain. A male nurse walked in (RN F) and stated he talked to the MD and the nurse convinced the MD it was due to her arthritis. The nurse (RN F) stated that he felt that she shouldn't go as it was arthritis RN F stated to Resident 1 and FM H that "You're going to be wasting time going in and coming back with the same orders and a new pain medication." FM H told RN F that he didn't care if Resident 1 had an order and that he was to call the transport and send her to ER or he would. FM H stated that he was upset due to the staff not taking her complaints and obvious signs of difficulty breathing seriously; and the fact that RN F told Resident 1 and the family that she should not go into the ER it would be a waste. FM H stated that the hospital took a large amount of fluid off her lungs so she did have legitimate complaints and it wasn't her arthritis. On 5/23/12 at 1:30 PM interviewed RN D regarding the events of 5/7/12 with Resident 1. RN D stated that Resident 1 was very nice and polite and had a good rapport with her. RN D stated that Resident 1 had been pretty normal all AM. At around 12 noon asked for a pain pill due to muscle spasms and right flank pain. RN D stated at around 12:30 or 1:00 PM Resident 1 called her son as she had a glitch in her side every once in a while and didn't want to ride in the car. At around that time I gave Resident 1 [MEDICATION NAME] for muscle spasms (this medication is not signed out on Resident 1's MAR). Surveyor asked RN D if this was a change from her normal and RN D stated that it was, she had more pain than usual but RN D focused on her arthritis pain. Surveyor asked RN D if she at any time did any assessment or vital signs during the day for Resident 1's change. RN D stated that she did not. RN D stated upon return from the hospital Resident 1 talked to RN D and RN D stated that she was devastated to learn that she had pneumonia. RN D states that now she will listen to what the resident has to say, monitor pain, and other symptoms and always do vital signs and now every assessment gets lung sounds. On 4/23/12 at 2:15 PM, Surveyor interviewed RN F with NHA A in the room. Surveyor asked RN F about Resident 1's care on 5/7/12, and he stated that he remembered. RN F stated that he received report from the day nurse (shift starts 2:00 PM) and day nurse stated that Resident 1 had awakened with pain and received a PRN in the AM. That was not unusual, but in the afternoon she requested more pain medication and that was unusual because she usually had good pain relief with her scheduled pain med at 10:00 AM. After report RN F stated that he went to check on Resident 1 and found her in severe pain, which Resident 1 talked about it being similar to a bad day of arthritis. She had multiple surgeries but this was different. RN F stated that he assessed her comfort level and she seemed to have spasm exacerbation, she was writhing around a lot and complained of pain on whole right side from neck to lower mid back. RN F stated that he palpated along where she did have pain and it provoked pain response, but there was no discoloration, when he raised up her shirt. RN F stated at that point he gave Resident 1 two [MEDICATION NAME] tablets and went on to other residents. RN F stated that 30 to 45 minutes later he re-assressed her pain level and she was still uncomfortable. Resident 1 said that she wanted to go to the hospital. RN F indicated he went to call the MD; I had to find where he was and see if he can address this. RN F stated that he reported that Resident 1 was in significant amount of pain not controlled by her usual pain med regime. RN F stated that he was told to fax all meds to office. RN F stated that by the time he was able to do that the sons came in and stated that she should go to the hospital. RN F stated that he would have to call the MD back and get an order. Surveyor asked RN F what the family member said when he requested a hospital transfer. RN F stated, "My mom has a high tolerance for pain so if she says she hurts it's bad. When on the phone the first time with mom I asked her what was going on and she stated that she reported waking up ungodly uncomfortable she went to PT and felt worse. Then I came in and saw her grimacing and stating it hurt to breathe." Surveyor asked RN F if any kind of assessment was done to her lungs or vital signs taken. RN F stated that he tried to listen to her lungs, but nothing significant found but couldn't really hear due to her breathing and writhing around. Surveyor asked how RN F listened to her lungs and RN F responded that he thought he put the stethoscope on her by her axilla (underarm). Surveyor asked RN F if he took any vital signs. RN F responded that he used the vital signs from the ambulance crew. RN F stated that he went to the ambulance and got the vital signs from them. Surveyor asked why he charted the vital signs if he did not take them and why this was not done before he called the MD, also why he documented lung sounds to be 'bilaterally clear' when he "couldn't really hear them." RN F stated that he should have taken the vital signs, and done a complete lung assessment before calling the physician. (RN F did not respond as to why he documented them when he didn't do them.) RN F stated that he was focused on her arthritis and didn't feel at the time it was anything else. Surveyor asked if any assessments were done to rule out anything else besides arthritis and RN F stated "No." Surveyor asked RN F if there was anything that was said to Resident 1 that he felt that was in appropriate. RN F stated, "Yes, I told her that she shouldn't go the hospital because it was only arthritis. I should not have said that to her or her family." On 5/23/12 at 6:00 PM Surveyor interviewed CNA C regarding Resident 1 on 5/7/12. CNA C stated that she remembered it well, she is usually the day aide down there (on the hallway with Resident 1) but not that day, but took over on PM shift. CNA C stated, "The day shift CNA (CNA K) came to me and said that she (Resident 1) is not herself. CNA K said look at her she is in a lot of pain from her right shoulder and radiating down. The nurse said it was just her arthritis. I went to (RN F) and told him that she (Resident 1) was very pale in color and has increased pain and she is not better. I also told him that she said that she doesn't feel she can make it through the night like this. (RN F) said the same thing as the day shift, that nothing is wrong with her it is just her arthritis. She (Resident 1) said that she felt something was wrong with her and wanted to get it checked out and the RN said no. I went up to the desk and told (RN F) what Resident 1 said and the family said they wanted her transported to the ER. (RN F) said at that time 'I'm not bothering an MD for nothing; this is pointless it is just her arthritis.' "RN F" then came to room with son and resident and stated that 'an emergency room visit is for a life threatening issues not for something that is not life threatening.' "Resident 1's" son stated that he is insisting that he get an order for [REDACTED]." On 5/24/12 at 1:00 PM Surveyor interviewed EMT J regarding the transport of Resident 1 on 5/7/12. EMT J stated that he remembered the transport. EMT J stated that the family was there 2 sons and a nurse. The nurse (RN F) came out and told us that her symptoms were part of her [MEDICAL CONDITION] arthritis and the MD did not want her to go (to the ER), it was the family that insisted. Surveyor asked if RN F received any vital signs from the EMT's. EMT J stated he was not aware of (RN F) coming and getting any vital signs from them, as they took them in the ambulance. Surveyor asked EMT J if at any time was RN F talking to Resident 1 when she was on the gurney. EMT J stated that RN F was in the hallway talking to Resident 1 when she was on the cart he bent down to her, but was unable to hear what was being said, then he handed him more papers. On 5/30/12 at 3:46 PM Surveyor interviewed CNA K regarding Resident 1 on 5/7/12. CNA K stated that she remembered the day. CNA K stated, "I told the nurse she (Resident 1) was still having more pain than before and I went up and told the nurse (this was after lunch). I went back to check on her in 15 minutes and she was still in pain. (Resident 1) called her son (I had to hold the phone so I heard all the conversation). She (Resident 1) told her son that she was having trouble breathing, and the son said that she should go to the hospital. She also cancelled her appt. I went then and told the nurse (RN D) about the conversation that she complained of trouble breathing and wanting to go to the hospital. (RN D) stated that it was just arthritis, and I don't know if she went back in the room or not." Surveyor asked CNA K to describe Resident 1 appearance. CNA K stated, "Normally she is not in that much pain. She was groaning and making faces. She was groaning and said it hurt to breathe which made it harder to breathe rather than struggling to breathe as in short of breath." CNA K added that she brought it to the attention of the RN more than once but felt that it was not checked out like it should have been. On 6/4/12 at 1:55 PM, Surveyor interviewed MD L (medical doctor) regarding Resident 1 on 5/7/12. MD L stated that he only recalled getting a report that pt appeared in respiratory distress or shortness of breath and they told me she is having problems with her pain I told them to send her to the hospital. MD L states that he only remembers talking to the facility on ce about Resident 1. The facility's failure to promptly consult with a physician when Resident 1 first had a change of condition created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 5/24/12 when: Inservices were held on the following information for all licensed nurses who are currently on duty and each nurse prior to next shift worked. 1. The education includes: -Change of condition policy and procedure -Conducting a full head to toe assessment -Taking vitals as part of an assessment -Documenting findings accurately -Documentation of what you observed -Call the MD timely and provide accurate full assessment -Take what the resident states as their work and relay it to MD -Remember the resident has a right to participate in their own care 2. The change of conditions will be reviewed by DON/designee at daily triage meeting and daily clinical review meeting. Change of condition will be reviewed at QPI. 3. RN's involved in case will be suspended until a full investigation is conducted. A full investigation will be conducted. 4. Social Services is conducting resident interviews regarding nursing services handling of their care, and their comfort level in reporting concerns to nurse. 5. Administrative RN is conducting CNA interviews in regards to resident care and follow through with what they brought forth.

Based on interview and record review the facility failed to ensure that residents have the right to choose health care consistent with his or her interests, assessments and plans of care, and to make choices about aspects of his or her life in the facility that are significant to the resident for 1 resident out of 10 reviewed (Resident 1). resuscitation. On 5/7/12, Resident 1 was complaining of increased pain and difficulty breathing beginning in the morning. Resident 1 continued to complain of increased pain in the afternoon. No licensed staff assessed her condition change, nor called a physician to report the change. Resident 1 requested to go the emergency room to be evaluated, and the licensed staff told her no that she did not need to go as the pain was "just due to arthritis." Resident 1's family came in to see her and noted the condition change also and insisted that she be sent to the emergency room . The licensed staff told the family that Resident 1 did not need to go as the pain was just a worsening of her arthritis. At the family's continued insistence, Resident 1 was subsequently sent to the hospital and was diagnosed with [REDACTED]. According to Resident 1, "My sons were deathly scared they thought I was a gonner. I was in ICU (intensive care unit). The doctor said I was lucky I came when I did. I was terrified as I didn't know what was happening to me and nobody would listen to me. I was angry for what the nurse said to me it was uncalled for made me feel stupid and ashamed as if I was not really sick." The facility's failure to honor Resident 1's wishes to be seen by a physician created a situation of Immediate Jeopardy. Immediate Jeopardy began on 5/7/12. The NHA was notified of Immediate Jeopardy on 5/24/12. The Immediate Jeopardy was removed on 5/24/12; however, the deficient practice continues at a severity/scope level D (potential for harm that is not Immediate Jeopardy/isolated) as the facility has to fully implement and evaluate the effectiveness of its action plan. Findings as follows: A medical record review of Resident 1 revealed the following information: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set ((MDS) dated [DATE] indicates that Resident 1 scored 15 out of 15 on her BIMS (Brief Interview of Mental Status) indicating she is cognitively intact. Resident 1 is her own legal decision maker. Resident 1 is a full code status. Surveyor interviewed Resident 1 on 5/23/12 during an on site investigation. The interview took place in Resident 1's room at 9:45 AM. Surveyor introduced self and Resident 1 stated that she knew why surveyor was there due to the concerns that she and her family had with the care she received on 5/7/12 while at the facility. The following information was received from the interview: Surveyor requested Resident 1 to explain what occurred that day (5/7/12) in her own words. Resident 1 stated, "I woke up with pain in my back and couldn't get air well. I had pain in my back before but not like this, couldn't get air. I went to therapy thinking that might help. (Therapist name) knew I wasn't doing well. He had to give me extra breaks and took a long time to do therapy. He did rub my back/neck area and it helped but it didn't go away. (Day RN name) did give me extra pain pills, but did not do vital signs or listen to my lungs; I'm not sure why - I kept saying that it hurt to breathe. (RN D) stated that it was just my arthritis. I called my son to cancel my appt as I knew I couldn't tolerate the sitting and the ride in the car. (RN D) did cancel my appt for me and she knew I was in pain. I told my son that I couldn't catch my breath and I thought I should be seen and he told me to tell the nurses that I should be seen. I told (RN F) that I wanted to go to the hospital to be checked out as I couldn't catch my breath. Around shift change (RN F) told me "no" I didn't need to go to the emergency room it was just my arthritis acting up. He did come and give me 2 more pain pills and an ice pack. He did not do any vital signs on me or listen to my lungs. He didn't listen to my complaints either." Resident 1 continued on, "My son came to see me and said that I looked terrible and should be seen by a doctor, then he called my other son and they agreed it was best to do. (RN F) came back into the room and we told him that I wanted to be seen again. (RN F) told my son and me that I didn't need to go it was only my arthritis and the physician agrees with (RN F) that I didn't need to go. (RN F) stated that we would need an order from the MD and he didn't have one. My son told him that I was going with or without a DR order and (RN F) left the room. Around 4:30 PM (RN F) came back into the room and told us that we had an order to be seen on request of the family." Resident 1 continued to state, "On my way out of the building while I was on the cart, (RN F) came to my side and bent down to me and stated 'Now just how foolish are you gonna be when they look at you and send you right back because it is just your arthritis and nobody dies from arthritis. This ride is going to be bumpy and painful in the ambulance and they are just going to turn around and bring you back won't you look silly.'" On 5/24/12 at 3:50 PM Surveyor interviewed Resident 1 for follow up. Resident 1 reiterated, "I had such a pain in by back and chest. I told them that I couldn't catch my breath. I wanted to go to the hospital and they said "no" it was only my arthritis. They (RN's D and F) focused on my arthritis if only they would have listened to my lungs and checked my temp they would have known more. My sons were deathly scared they thought I was a gonner. I was in ICU (intensive care unit). The doctor said I was lucky I came when I did. I was terrified as I didn't know what was happening to me and nobody would listen to me. I was angry for what the nurse said to me it was uncalled for made me feel stupid and ashamed as if I was not really sick. Since this happened I had to let it all go as I was so upset, but I knew I wouldn't get better if I dwelled on it, but it still makes me angry that I had to go through all of that and put my family through it also." Surveyor interviewed the following as it relates to the allegations that Resident 1 voiced: On 5/23/12 at 10:30 AM Surveyor interviewed PTA I regarding working with Resident 1 on 5/7/12. PTA I stated that he remembers that day and stated, "The wing was still under quarantine so I did therapy down at the end of the hall. She was not good that day didn't feel good, her back hurt. I thought she maybe slept wrong and when palpated it felt like a muscle spasm on the right. She stated that it was hard to breathe, but the rubbing helped her breathe better. She was short of breath so it took longer than normal to due PT due to shortness of breath. I talked to the nurse and told her that (Resident 1) was short of breath and had muscle spasms shortly after breakfast." PTA I stated that Resident 1 "seemed very fatigued." On 5/23/12 at 12:15 PM Surveyor interviewed Family Member G (FM) via phone. FM G stated on 5/7/12 at around 1:00 PM Resident 1 called him and stated that she couldn't breathe; he told her that she should go to the ER and get checked out and to tell the nurse you want to go. FM G stated he received a call from FM H that Resident 1 couldn't breathe and the 2 family members felt that she should be seen and FM H was going to insist. Around 3:30 or 4:00 PM FM G stated that he came to the facility and RN F stated to Resident 1 that she didn't need to go to the hospital. FM G stated that they told RN F that Resident 1 will be going to the ER with or without an MD order. On 5/23/12 at 1:00 PM Surveyor interviewed FM H regarding Resident 1 on 5/7/12. FM H stated that Resident 1 had an appointment and she called to cancel it, but he went to the facility anyway to see her as he felt it was unusual for Resident 1 to cancel an appointment. FM H stated that when he saw her he knew something was wrong with her. Resident 1 was in severe pain, trouble breathing saw her take deep breaths and her whole body would shake with pain. A male nurse walked in (RN F) and stated he talked to the MD and the nurse convinced the MD it was due to her arthritis. The nurse (RN F) stated that he felt that she shouldn't go as it was arthritis RN F stated to Resident 1 and FM H that "You're going to be wasting time going in and coming back with the same orders and a new pain medication." FM H told RN F that he didn't care if Resident 1 had an order and that he was to call the transport and send her to ER or he would. FM H stated that he was upset due to the staff not taking her complaints and obvious signs of difficulty breathing seriously; and the fact that RN F told Resident 1 and the family that she should not go into the ER it would be a waste. FM H stated that the hospital took a large amount of fluid off her lungs so she did have legitimate complaints and it wasn't her arthritis. On 5/23/12 at 6:00 PM Surveyor interviewed CNA C regarding Resident 1 on 5/7/12. CNA C stated that she remembered it well, she is usually the day aide down there (on the hallway with Resident 1) but not that day, but took over on PM shift. CNA C stated, "The day shift CNA (CNA K) came to me and said that she (Resident 1) is not herself. CNA K said look at her she is in a lot of pain from her right shoulder and radiating down. The nurse said it was just her arthritis. I went to (RN F) and told him that she (Resident 1) was very pale in color and has increased pain and she is not better. I also told him that she said that she doesn't feel she can make it through the night like this. (RN F) said the same thing as the day shift, that nothing is wrong with her it is just her arthritis. She (Resident 1) said that she felt something was wrong with her and wanted to get it checked out and the RN said no. I went up to the desk and told (RN F) what Resident 1 said and the family said they wanted her transported to the ER. (RN F) said at that time 'I'm not bothering an MD for nothing; this is pointless it is just her arthritis.' "RN F" then came to room with son and resident and stated that 'an emergency room visit is for a life threatening issues not for something that is not life threatening.' "Resident 1's" son stated that he is insisting that he get an order for [REDACTED]. On 5/30/12 at 3:46 PM Surveyor interviewed CNA K regarding Resident 1 on 5/7/12. CNA K stated that she remembered the day. CNA K stated, "I told the nurse she (Resident 1) was still having more pain than before and I went up and told the nurse (this was after lunch). I went back to check on her in 15 minutes and she was still in pain. (Resident 1) called her son (I had to hold the phone so I heard all the conversation). She (Resident 1) told her son that she was having trouble breathing, and the son said that she should go to the hospital. She also cancelled her appt. I went then and told the nurse (RN D) about the conversation that she complained of trouble breathing and wanting to go to the hospital. (RN D) stated that it was just arthritis, and I don't know if she went back in the room or not." Surveyor asked CNA K to describe Resident 1 appearance. CNA K stated, "Normally she is not in that much pain. She was groaning and making faces. She was groaning and said it hurt to breathe which made it harder to breathe rather than struggling to breathe as in short of breath." CNA K added that she brought it to the attention of the RN more than once but felt that it was not checked out like it should have been. On 4/23/12 at 2:15 PM, Surveyor interviewed RN F with NHA A in the room. Surveyor asked RN F about Resident 1's care on 5/7/12, and he stated that he remembered. RN F stated that he received report from the day nurse (shift starts 2:00 PM) and day nurse stated that Resident 1 had awoken with pain and received a PRN in the AM. That was not unusual, but in the afternoon she requested more pain medication and that was unusual because she usually had good pain relief with her scheduled pain med at 10:00 AM. After report RN F stated that he went to check on Resident 1 and found her in severe pain, which Resident 1 talked about it being similar to a bad day of arthritis. She had multiple surgeries but this was different. RN F stated that he assessed her comfort level and she seemed to have spasm exacerbation, she was writhing around a lot and complained of pain on whole right side from neck to lower mid back. RN F stated that he palpated along where she did have pain and it provoked pain response, but there was no discoloration, when he raised up her shirt. RN F stated at that point he gave Resident 1 two [MEDICATION NAME] tablets and went on to other residents. RN F stated that 30 to 45 minutes later he re-assressed her pain level and she was still uncomfortable. Resident 1 said that she wanted to go to the hospital. RN F indicated he went to call the MD; I had to find where he was and see if he can address this. RN F stated that he reported that Resident 1 was in significant amount of pain not controlled by her usual pain med regime. RN F stated that he was told to fax all meds to office. RN F stated that by the time he was able to do that the sons came in and stated that she should go to the hospital. RN F stated that he would have to call the MD back and get an order. Surveyor asked RN F what the family member said when he requested a hospital transfer. RN F stated, "My mom has a high tolerance for pain so if she says she hurts it's bad. When on the phone the first time with mom I asked her what was going on and she stated that she reported waking up ungodly uncomfortable she went to PT and felt worse. Then I came in and saw her grimacing and stating it hurt to breathe." Surveyor asked RN F if any kind of assessment was done to her lungs or vital signs taken. RN F stated that he tried to listen to her lungs, but nothing significant found but couldn't really hear due to her breathing and writhing around. Surveyor asked how RN F listened to her lungs and RN F responded that he thought he put the stethoscope on her by her axilla (underarm). Surveyor asked RN F if he took any vital signs. RN F responded that he used the vital signs from the ambulance crew. RN F stated that he went to the ambulance and got the vital signs from them. Surveyor asked why he charted the vital signs if he did not take them and why this was not done before he called the MD, also why he documented lung sounds to be 'bilaterally clear' when he "couldn't really hear them." RN F stated that he should have taken the vital signs, and done a complete lung assessment before calling the physician. (RN F did not respond as to why he documented them when he didn't do them.) RN F stated that he was focused on her arthritis and didn't feel at the time it was anything else. Surveyor asked if any assessments were done to rule out anything else besides arthritis and RN F stated "No." Surveyor asked RN F if there was anything that was said to Resident 1 that he felt that was in appropriate. RN F stated, "Yes, I told her that she shouldn't go the hospital because it was only arthritis. I should not have said that to her or her family." On 6/4/12 at 1:55 PM, Surveyor interviewed MD L (medical doctor) regarding Resident 1 on 5/7/12. MD L stated that he only recalled getting a report that pt appeared in respiratory distress or shortness of breath and they told me she is having problems with her pain I told them to send her to the hospital. MD L states that he only remembers talking to the facility on ce about Resident 1. Resident 1's transfer form dated 5/7/12 filled out by RN F states the reason for transfer is "Resident awoke with discomfort believed to be related to history of [MEDICAL CONDITION] arthritis that was unrelieved by scheduled pain meds and prn pain med. Attended therapy session and pain increased and family requested ED eval". On 5/24/12 at 1:00 PM Surveyor interviewed EMT J regarding the transport of Resident 1 on 5/7/12. EMT J stated that he remembered the transport. EMT J stated that the family was there 2 sons and a nurse. The nurse (RN F) came out and told us that her symptoms were part of her [MEDICAL CONDITION] arthritis and the MD did not want her to go (to the ER), it was the family that insisted. Surveyor asked if RN F received any vital signs from the EMT's. EMT J stated he was not aware of (RN F) coming and getting any vital signs from them, as they took them in the ambulance. Surveyor asked EMT J if at any time was RN F talking to Resident 1 when she was on the gurney. EMT J stated that RN F was in the hallway talking to Resident 1 when she was on the cart he bent down to her, but was unable to hear what was being said, then he handed him more papers. Resident 1's ambulance run sheet (non-911) dated 5/7/12 at indicates that they were called at 4:27 PM and arrived at the facility at 4:58 PM. The signs and symptoms listed on the form were: Left (should be right) sided pain from neck down to waist, makes it difficult to breathe. Vital signs: BP 130/59, Pulse 104, 20 respirations and SPO2 92%. Normal respiratory effort and alert and oriented x3. Resident 1's pain was a 10/10. Chief complaint was right sided pain starting in her right jaw and then down her right back. Denies chest pain and shortness of breath...Primary MD believes pain is related to rehab she has been getting. Pain is unrelieved by scheduled or PRN medications. Resident 1's emergency department notes dated 5/7/12 states, "...She states that today she woke up at 6:30 AM with right sided pain and it has just gotten worse throughout the day. The patient does have a history of [MEDICAL CONDITION] arthritis. Initially she thought with was consistent with pain that she has had with [MEDICAL CONDITION] arthritis however her pain is much more than she usually experienced. The patient states that she had not experienced pain like this in her last [AGE] years of dealing with her [MEDICAL CONDITION] arthritis. Pain is primarily on right side, extends down under back and down to her buttocks. Breathing makes pain worse movement makes pain worse. She feels short of breath. She also notes the pill shave made her constipated and she is passing some blood with bowel movements...Temp 99.7, pulse 102...Lung sounds are diminished at the bases. Otherwise no rales no wheezes noted...She does have tenderness to palpation over the posterior chest wall...The patient was critical through her stay and generalized weakness and appeared overtly ill...At this point presentation is most consistent with pneumonia and started her on pneumonia protocol. Clinical Impression: Pneumonia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility's failure to honor Resident 1 wishes to immediately be seen by a physician created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 5/24/12 when: Inservices were held on the following information for all licensed nurses who are currently on duty and each nurse prior to next shift worked. 1. The education includes: -Change of condition policy and procedure -Conducting a full head to toe assessment -Taking vitals as part of an assessment -Documenting findings accurately -Documentation of what you observed -Call the MD timely and provide accurate full assessment -Take what the resident states as their work and relay it to MD -Remember the resident has a right to participate in their own care 2. The change of conditions will be reviewed by DON/designee at daily triage meeting and daily clinical review meeting. Change of condition will be reviewed at QPI. 3. RN's involved in case will be suspended until a full investigation is conducted. A full investigation will be conducted. 4. Social Services is conducting resident interviews regarding nursing services handling of their care, and their comfort level in reporting concerns to nurse. 5. Administrative RN is conducting CNA interviews in regards to resident care and follow through with what they brought forth. Cross reference F309.

Based on interview and record review the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 residents out of 10 reviewed (Residents 1 and 10). Example 1 Resident 1 had a significant change of condition that was not identified by 2 RN staff on 5/7/12. Resident 1 had complained of increased pain, was moaning and writhing, requesting to go the hospital and voiced concerns of difficulty breathing and that she was unable to catch her breath. Resident 1 told ER staff that she had not experienced pain like this in her last [AGE] years of dealing with her [MEDICAL CONDITION] arthritis The 2 RN nursing staff did not complete an assessment or take vital signs to complete a proper assessment and did not immediately honor her request to be taken to the emergency room . At the family's continued insistence, Resident 1 was subsequently sent to the hospital and was diagnosed with [REDACTED]. The facility's failure to assess Resident 1 and to honor Resident 1's wishes to be seen immediately by a physician or to contact a physician when she had a change of condition created a situation of Immediate Jeopardy. Immediate Jeopardy began on 5/7/12. The NHA was notified of Immediate Jeopardy on 5/24/12. The Immediate Jeopardy was removed on 5/24/12; however, the deficient practice continues at a severity/scope level D (potential for harm that is not Immediate Jeopardy/isolated), as evidenced by: Example 2 Facility staff signed out treatments as being completed on Resident 10 when these treatments had not been done. . Findings as follows: Example 1 The facility uses the AMDA (American Medical Directors Association) guidelines: The AMDA guidelines state that the standard for Assessing Patients and Collecting Data on Nursing Facility patients states that in assessing the patient always ask how the patient is feeling, Always take vital signs, Always assess the patient's overall condition, level of consciousness and function., Always review and report current medications, and Always consider possible causes (acute and chronic) to help determine which body systems to evaluate (acute and chronic symptoms can co-exist and symptoms such as pain or swelling may be "referred" from other areas of the body. The AMDA guideline for collecting physical data for assessment for Dyspnea and Shortness of Breath are as follows: Vital signs including changes such as increased/decreased pulse rate and rhythm, blood pressure and respiratory rate and rhythm. Heart and lung exam including rales, wheezes, rhonchi, and labored breathing. Abdominal assessment for [MEDICAL CONDITION] tenderness. Pain assessment including quality (tightness or heaviness, pressure or vague discomfort). Onset and duration of the pain and precipitating factors...Whether individual is struggling to breathe and or using accessories muscles to breathe. A medical record review of Resident 1 revealed the following information: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set ((MDS) dated [DATE] indicates that Resident 1 scored 15 out of 15 on her BIMS (Brief Interview of Mental Status) indicating she is cognitively intact. Resident 1 is her own legal decision maker. Resident 1 is a full code status. Resident 1's Physician order [REDACTED]. Resident 1's MAR indicates that she has taken PRN Tylenol on 5/3/12 at 8:40 PM, and at 7:30 AM and 2:00 PM on 5/5/12. Resident 1 Received [MEDICATION NAME] 1 tablet on 5/6/12 at 7:30 AM for pain "all over" and at 8:00 AM with [MEDICATION NAME] for general pain. Two [MEDICATION NAME] tablets were given at 4:30 PM on 5/7/12. A nursing note on 5/4/12 at 8:30 AM indicates Resident 1 has complaints of pain at back of neck going into head causing a head ache-Tylenol given and [MEDICATION NAME] applied per resident request. Resident states very helpful effective 1 1/2 hour later. (Please note that the [MEDICATION NAME] is not signed out on the MAR as given on 5/4/12 at 8:30 AM). A nursing note on 5/5/12 at 8:00 AM states, "Res again c/o pain at back of neck causing headache. Tylenol 325-2 tablets given, neck rub given. Resident states helpful Res is awake and A&Ox3 able to voice concerns with clear speech." A nursing note on 5/6/12 at 9:00 AM states, "Resident is awake, A&Ox3 able to voice concerns...res offers no complaints this AM remains polite and friendly." Resident 1's MAR reveals that at 7:30 AM on 5/6/12 Resident 1 had a pain rating of 6/10 for pain all over and received [MEDICATION NAME] 1 tablet. Please note that the nursing note does not reflect accurate information related to Resident 1's complaints of pain. A nursing note on 5/7/12 at 8:30 AM states, "Res is awake, A&Ox3, voices concerns with clear speech...Resident does request [MEDICATION NAME] on right shoulder for arthritis stiffness and [MEDICATION NAME] for general aches this AM given at 8:00 with good effect noted at 9:00 AM resident continues to attend OT/PT as scheduled, does not voice any other concerns remains polite and congenial." At 1:00 PM a note states, "Res c/o muscle spasm on lower right quad going up back and across right shoulder, Res states it catches when she breathes. [MEDICATION NAME] given at 11:30 AM (Please note that this medication is scheduled to be given at 10:00 AM) Res on bed resting, [MEDICATION NAME] given for spasm and increased anxiety (this is not documented on the MAR as being given), Res states 'If I could just calm down'. Res (Resident 1) also calls son (Family member G) canceling this PM appt stating she does not want to sit in car or go that far (No reason documented as to why)." At 1:00 PM Resident 1 still had pain even though she had her scheduled [MEDICATION NAME] late at 11:30 AM; no further pain interventions were attempted even though Resident 1 could have received PRN [MEDICATION NAME]. A physician was not called to report Resident 1's unrelieved pain or the significant increase in pain in the past 24 hours. No assessment of Resident 1's pain was conducted to find the possible causes of her pain. The next nursing note dated 5/7/12 at 4:30 PM, indicates a set of vital signs 97.2, 110/64, 80, 20, 96% RA, resident c/o unrelieved pain. See SBAR (Situation, Background, Assessment, Request). Documented by RN F. The SBAR dated 5/7/12 at 4:30 PM states the following information: Resident 1 had unrelieved body aches upon awakening this AM. The symptoms have gotten worse with movement of upper trunk and physical therapy. No current treatment is effective. Resident 1 is experiencing increased discomfort and anxiety. Vital signs: 97.2, 110/64, 80, 20, 96% on RA Lung sounds bilateral present equal and clear. Pain level/location status-general, but more severe on right side (upper trunk and neck). The assessment section of the SBAR indicates that RN F thinks it may be an acute exacerbation of her [MEDICAL CONDITION] Arthritis pain. RN F's Progress note attached to the SBAR is as follows: 5/7/12 at 4:30 PM, Resident reported C/O a "kink" in her back this AM upon awakening. PRN and scheduled pain medications were ineffective on relief as well as body repositioning multiple times and again PRN pain meds administered at 2:30 PM and ice pack applied to right should/ back region. Resident considered this discomfort to be similar to other bad exacerbations of her [MEDICAL CONDITION] arthritis. Resident attended PT and reported no significant pain to therapy staff per therapy report and per therapy report that a mild "kink" in her back was reported but easily relieved with therapy interventions without further concerns/complications. Assessments currently find pt skin pink/warm & dry & very anxious re: unrelieved pain with excessive fidgeting of upper and lower extremities increased from baseline, due to history of muscle spasm, pain generalized all over but more significant to right upper trunk/shoulder and neck, no changes in skin color to these regions or deformities through palpation of these regions Increased pain. Pain rated '8/10' at 2:30 PM and still currently 8/10 and feeling worse. Family adamant of resident being transferred to (hospital name). MD contacted and orders received to transfer to ED due to family request. Resident 1's ambulance run sheet (non-911) dated 5/7/12 at indicates that they were called at 4:27 PM and arrived at the facility at 4:58 PM. The signs and symptoms listed on the form were: Left (should be right) sided pain from neck down to waist, makes it difficult to breathe. Vital signs: BP 130/59, Pulse 104, 20 respirations and SPO2 92%. Normal respiratory effort and alert and oriented x3. Resident 1's pain was a 10/10. Chief complaint was right sided pain starting in her right jaw and then down her right back. Denies chest pain and shortness of breath...Primary MD believes pain is related to rehab she has been getting. Pain is unrelieved by scheduled or PRN medications. Resident 1's transfer form dated 5/7/12 filled out by RN F states the reason for transfer is "Resident awoke with discomfort believed to be related to history of [MEDICAL CONDITION] arthritis that was unrelieved by scheduled pain meds and prn pain med. Attended therapy session and pain increased and family requested ED eval". Resident 1's emergency department notes dated 5/7/12 states, "...She states that today she woke up at 6:30 AM with right sided pain and it has just gotten worse throughout the day. The patient does have a history of [MEDICAL CONDITION] arthritis. Initially she thought with was consistent with pain that she has had with [MEDICAL CONDITION] arthritis however her pain is much more than she usually experienced. The patient states that she had not experienced pain like this in her last [AGE] years of dealing with her [MEDICAL CONDITION] arthritis. Pain is primarily on right side, extends down under back and down to her buttocks. Breathing makes pain worse movement makes pain worse. She feels short of breath. She also notes the pill shave made her constipated and she is passing some blood with bowel movements...Temp 99.7, pulse 102...Lung sounds are diminished at the bases. Otherwise no rales no wheezes noted...She does have tenderness to palpation over the posterior chest wall...The patient was critical through her stay and generalized weakness and appeared overtly ill...At this point presentation is most consistent with pneumonia and started her on pneumonia protocol. Clinical Impression: Pneumonia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident 1's history and physical dated 5/7/12 indicates that Resident 1 presents with right sided pain and it is pleuritic in nature. It just started this morning. Apparently there has been pneumonia in the facility where she is currently residing...She denies cough or fever however just states that she is feeling terrible. She has had pains before from her arthritis but none as severe as this one. Surveyor interviewed Resident 1 on 5/23/12 during an on site investigation. The interview took place in Resident 1's room at 9:45 AM. Surveyor introduced self and Resident 1 stated that she knew why surveyor was there due to the concerns that she and her family had with the care she received on 5/7/12 while at the facility. The following information was received from the interview: Surveyor requested Resident 1 to explain what occurred that day in her own words. Resident 1 stated, "I woke up with pain in my back and couldn't get air well. I had pain in my back before but not like this, couldn't get air. I went to therapy thinking that might help. (Therapist name) knew I wasn't doing well. He had to give me extra breaks and took a long time to do therapy. He did rub my back/neck area and it helped but it didn't go away. (Day RN name) did give me extra pain pills, but did not do vital signs or listen to my lungs; I'm not sure why - I kept saying that it hurt to breathe. (RN D) stated that it was just my arthritis. I called my son to cancel my appt as I knew I couldn't tolerate the sitting and the ride in the car. (RN D) did cancel my appt for me and she knew I was in pain. I told my son that I couldn't catch my breath and I thought I should be seen and he told me to tell the nurses that I should be seen. I told (RN F) that I wanted to go to the hospital to be checked out as I couldn't catch my breath. Around shift change (RN F) told me "no" I didn't need to go to the emergency room it was just my arthritis acting up. He did come and give me 2 more pain pills and an ice pack. He did not do any vital signs on me or listen to my lungs. He didn't listen to my complaints either." Resident 1 continued on, "My son came to see me and said that I looked terrible and should be seen by a doctor, then he called my other son and they agreed it was best to do. (RN F) came back into the room and we told him that I wanted to be seen again. (RN F) told my son and me that I didn't need to go it was only my arthritis and the physician agrees with (RN F) that I didn't need to go. (RN F) stated that we would need an order from the MD and he didn't have one. My son told him that I was going with or without a DR order and (RN F) left the room. Around 4:30 PM (RN F) came back into the room and told us that we had an order to be seen on request of the family." Resident 1 continued to state, "On my way out of the building while I was on the cart, (RN F) came to my side and bent down to me and stated 'Now just how foolish are you gonna be when they look at you and send you right back because it is just your arthritis and nobody dies from arthritis. This ride is going to be bumpy and painful in the ambulance and they are just going to turn around and bring you back won't you look silly.'" Surveyor interviewed the following staff as it relates to the allegations that Resident 1 voiced: On 5/23/12 at 10:30 AM Surveyor interviewed PTA I regarding working with Resident 1 on 5/7/12. PTA I stated that he remembers that day and stated, "The wing was still under quarantine so I did therapy down at the end of the hall. She was not good that day didn't feel good, her back hurt. I thought she maybe slept wrong and when palpated it felt like a muscle spasm on the right. She stated that it was hard to breathe, but the rubbing helped her breathe better. She was short of breath so it took longer than normal to due PT due to shortness of breath. I talked to the nurse and told her that (Resident 1) was short of breath and had muscle spasms shortly after breakfast." PTA I stated that Resident 1 "seemed very fatigued." Surveyor asked PTA I if anyone had talked to him about Resident 1 before today and he stated, "No." On 5/23/12 at 12:15 PM Surveyor interviewed Family Member G (FM) via phone. FM G stated on 5/7/12 at around 1:00 PM Resident 1 called him and stated that she couldn't breathe; he told her that she should go to the ER and get checked out and to tell the nurse you want to go. FM G stated he received a call from FM H that Resident 1 couldn't breathe and the 2 family members felt that she should be seen and FM H was going to insist. Around 3:30 or 4:00 PM FM G stated that he came to the facility and RN F stated to Resident 1 that she didn't need to go to the hospital. FM G stated that they told RN F that Resident 1 will be going to the ER with or without an MD order. On 5/23/12 at 1:00 PM Surveyor interviewed FM H regarding Resident 1 on 5/7/12. FM H stated that Resident 1 had an appointment and she called to cancel it, but he went to the facility anyway to see her as he felt it was unusual for Resident 1 to cancel an appointment. FM H stated that when he saw her he knew something was wrong with her. Resident 1 was in severe pain, trouble breathing saw her take deep breaths and her whole body would shake with pain. A male nurse walked in (RN F) and stated he talked to the MD and the nurse convinced the MD it was due to her arthritis. The nurse (RN F) stated that he felt that she shouldn't go as it was arthritis RN F stated to Resident 1 and FM H that "You're going to be wasting time going in and coming back with the same orders and a new pain medication." FM H told RN F that he didn't care if Resident 1 had an order and that he was to call the transport and send her to ER or he would. FM H stated that he was upset due to the staff not taking her complaints and obvious signs of difficulty breathing seriously; and the fact that RN F told Resident 1 and the family that she should not go into the ER it would be a waste. FM H stated that the hospital took a large amount of fluid off her lungs so she did have legitimate complaints and it wasn't her arthritis. On 5/23/12 at 1:30 PM interviewed RN D regarding the events of 5/7/12 with Resident 1. RN D stated that Resident 1 was very nice and polite and had a good rapport with her. RN D stated that Resident 1 had been pretty normal all AM. At around 12 noon asked for a pain pill due to muscle spasms and right flank pain. RN D stated at around 12:30 or 1:00 PM Resident 1 called her son as she had a glitch in her side every once in a while and didn't want to ride in the car. At around that time I gave Resident 1 [MEDICATION NAME] for muscle spasms (this medication is not signed out on Resident 1's MAR). Surveyor asked RN D if this was a change from her normal and RN D stated that it was, she had more pain than usual but RN D focused on her arthritis pain. Surveyor asked RN D if she at any time did any assessment or vital signs during the day for Resident 1's change. RN D stated that she did not. RN D stated upon return from the hospital Resident 1 talked to RN D and RN D stated that she was devastated to learn that she had pneumonia. RN D states that now she will listen to what the resident has to say, monitor pain, and other symptoms and always do vital signs and now every assessment gets lung sounds. On 4/23/12 at 2:15 PM, Surveyor interviewed RN F with NHA A in the room. Surveyor asked RN F about Resident 1's care on 5/7/12, and he stated that he remembered. RN F stated that he received report from the day nurse (shift starts 2:00 PM) and day nurse stated that Resident 1 had awoken with pain and received a PRN in the AM. That was not unusual, but in the afternoon she requested more pain medication and that was unusual because she usually had good pain relief with her scheduled pain med at 10:00 AM. After report RN F stated that he went to check on Resident 1 and found her in severe pain, which Resident 1 talked about it being similar to a bad day of arthritis. She had multiple surgeries but this was different. RN F stated that he assessed her comfort level and she seemed to have spasm exacerbation, she was writhing around a lot and complained of pain on whole right side from neck to lower mid back. RN F stated that he palpated along where she did have pain and it provoked pain response, but there was no discoloration, when he raised up her shirt. RN F stated at that point he gave Resident 1 two [MEDICATION NAME] tablets and went on to other residents. RN F stated that 30 to 45 minutes later he re-assressed her pain level and she was still uncomfortable. Resident 1 said that she wanted to go to the hospital. RN F indicated he went to call the MD; I had to find where he was and see if he can address this. RN F stated that he reported that Resident 1 was in significant amount of pain not controlled by her usual pain med regime. RN F stated that he was told to fax all meds to office. RN F stated that by the time he was able to do that the sons came in and stated that she should go to the hospital. RN F stated that he would have to call the MD back and get an order. Surveyor asked RN F what the family member said when he requested a hospital transfer. RN F stated, "My mom has a high tolerance for pain so if she says she hurts it's bad. When on the phone the first time with mom I asked her what was going on and she stated that she reported waking up ungodly uncomfortable she went to PT and felt worse. Then I came in and saw her grimacing and stating it hurt to breathe." Surveyor asked RN F if any kind of assessment was done to her lungs or vital signs taken. RN F stated that he tried to listen to her lungs, but nothing significant found but couldn't really hear due to her breathing and writhing around. Surveyor asked how RN F listened to her lungs and RN F responded that he thought he put the stethoscope on her by her axilla (underarm). Surveyor asked RN F if he took any vital signs. RN F responded that he used the vital signs from the ambulance crew. RN F stated that he went to the ambulance and got the vital signs from them. Surveyor asked why he charted the vital signs if he did not take them and why this was not done before he called the MD, also why he documented lung sounds to be 'bilaterally clear' when he "couldn't really hear them." RN F stated that he should have taken the vital signs, and done a complete lung assessment before calling the physician. (RN F did not respond as to why he documented them when he didn't do them.) RN F stated that he was focused on her arthritis and didn't feel at the time it was anything else. Surveyor asked if any assessments were done to rule out anything else besides arthritis and RN F stated "No." Surveyor asked RN F if there was anything that was said to Resident 1 that he felt that was in appropriate. RN F stated, "Yes, I told her that she shouldn't go the hospital because it was only arthritis. I should not have said that to her or her family." On 5/23/12 at 6:00 PM Surveyor interviewed CNA C regarding Resident 1 on 5/7/12. CNA C stated that she remembered it well, she is usually the day aide down there (on the hallway with Resident 1) but not that day, but took over on PM shift. CNA C stated, "The day shift CNA (CNA K) came to me and said that she (Resident 1) is not herself. CNA K said look at her she is in a lot of pain from her right shoulder and radiating down. The nurse said it was just her arthritis. I went to (RN F) and told him that she (Resident 1) was very pale in color and has increased pain and she is not better. I also told him that she said that she doesn't feel she can make it through the night like this. (RN F) said the same thing as the day shift, that nothing is wrong with her it is just her arthritis. She (Resident 1) said that she felt something was wrong with her and wanted to get it checked out and the RN said no. I went up to the desk and told (RN F) what Resident 1 said and the family said they wanted her transported to the ER. (RN F) said at that time 'I'm not bothering an MD for nothing; this is pointless it is just her arthritis.' "RN F" then came to room with son and resident and stated that 'an emergency room visit is for a life threatening issues not for something that is not life threatening.' "Resident 1's" son stated that he is insisting that he get an order for [REDACTED]." On 5/24/12 at 1:00 PM Surveyor interviewed EMT J regarding the transport of Resident 1 on 5/7/12. EMT J stated that he remembered the transport. EMT J stated that the family was there 2 sons and a nurse. The nurse (RN F) came out and told us that her symptoms were part of her [MEDICAL CONDITION] arthritis and the MD did not want her to go (to the ER), it was the family that insisted. Surveyor asked if RN F received any vital signs from the EMT's. EMT J stated he was not aware of (RN F) coming and getting any vital signs from them, as they took them in the ambulance. Surveyor asked EMT J if at any time was RN F talking to Resident 1 when she was on the gurney. EMT J stated that RN F was in the hallway talking to Resident 1 when she was on the cart he bent down to her, but was unable to hear what was being said, then he handed him more papers. On 5/30/12 at 3:46 PM Surveyor interviewed CNA K regarding Resident 1 on 5/7/12. CNA K stated that she remembered the day. CNA K stated, "I told the nurse she (Resident 1) was still having more pain than before and I went up and told the nurse (this was after lunch). I went back to check on her in 15 minutes and she was still in pain. (Resident 1) called her son (I had to hold the phone so I heard all the conversation). She (Resident 1) told her son that she was having trouble breathing, and the son said that she should go to the hospital. She also cancelled her appt. I went then and told the nurse (RN D) about the conversation that she complained of trouble breathing and wanting to go to the hospital. (RN D) stated that it was just arthritis, and I don't know if she went back in the room or not." Surveyor asked CNA K to describe Resident 1 appearance. CNA K stated, "Normally she is not in that much pain. She was groaning and making faces. She was groaning and said it hurt to breathe which made it harder to breathe rather than struggling to breathe as in short of breath." CNA K added that she brought it to the attention of the RN more than once but felt that it was not checked out like it should have been. On 6/4/12 at 1:55 PM, Surveyor interviewed MD L (medical doctor) regarding Resident 1 on 5/7/12. MD L stated that he only recalled getting a report that pt appeared in respiratory distress or shortness of breath and they told me she is having problems with her pain I told them to send her to the hospital. MD L states that he only remembers talking to the facility on ce about Resident 1. The facility's failure to assess Resident 1's complaints of pain, to respond and provide needed services in response to her pain, which included a failure to honor Resident 1's wishes to be seen by a physician, created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 5/24/12 when: Inservices were held on the following information for all licensed nurses who are currently on duty and each nurse prior to next shift worked. 1. The education includes: -Change of condition policy and procedure -Conducting a full head to toe assessment -Taking vitals as part of an assessment -Documenting findings accurately -Documentation of what you observed -Call the MD timely and provide accurate full assessment -Take what the resident states as their work and relay it to MD -Remember the resident has a right to participate in their own care 2. The change of conditions will be reviewed by DON/designee at daily triage meeting and daily clinical review meeting. Change of condition will be reviewed at QPI. 3. RN's involved in case will be suspended until a full investigation is conducted. A full investigation will be conducted. 4. Social Services is conducting resident interviews regarding nursing services handling of their care, and their comfort level in reporting concerns to nurse. 5. Administrative RN is conducting CNA interviews in regards to resident care and follow through with what they brought forth. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by: Example 2 Resident 10 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. State Surveyors received a complaint that facility staff were not treating Resident 10's hip wound as ordered. Resident 10's physician's orders [REDACTED]. Resident 10's POF from 5/16/12 shows an order which states: "Clean wound daily and apply new dressing until healed R (right) hip with island [MEDICATION NAME] dressing". Resident 10's TAR (Treatment Administration Record) for 5/2012 shows an entry which states: "R hip - Clean wound daily and apply new dressing until healed - island dressing". This treatment has been signed out as having been completed (as evidenced by facility staff initials) each day 5/17/12 through 5/22/12. On 5/24/12 at 10:00 AM Surveyor spoke with RN E regarding Resident 10 and his hip treatment. RN E stated that she was made aware the dressing changes had not been done it was reported her by CNA. RN E stated that she wrote up a disciplinary action form but did not give it to her yet. RN E stated that she put the forms on the DON desk. RN E stated that the dressings should be changed every day as the order states. State Surveyors were provided the "Disciplinary Action Report" for RN (Registered Nurse) D dated 5/21/12. This report documents the "Specific work rule, policy, standard etc., violated - not following MD orders." The report goes on to state that "Dressing dated 5/18 found on Resident 5/21/12. Was a scheduled daily am dressing change. Was checked and changed 5/18/12 when Res (resident) had PM shower." This report does not address the issue of RN D signing out a treatment as being completed when it had not been done. This report also is not signed by the employee, does not give the name of the facility staff completing the report, and does not indicate what disciplinary action was taken.

Based on interview and observation the facility did not ensure that residents are free of any significant medication errors for 1 resident out of 8 reviewed (Resident 1). Resident 1 received medications of another resident. The medications that she ingested were hypotensive drugs, antipsychotic drugs and several had a black box warning on the drugs. The facility felt that Resident 1 was having an anxiety attack after they told her of the medication error. The symptoms of severe anxiety, nervousness, confusion and continuous movements were not relieved. Resident 1 requested to go to the hospital and was sent. The assessment from the ER stated that the patient appeared to be experiencing side effects from the medications she had been given. She was subsequently transferred to a different hospital because of the higher level of care that was needed. The facility did not monitor vital signs closely after Resident 1 took the wrong medications. The nurses did not research the side effects of each medication that was given erroneously so that they could monitor specifically for those symptoms. The facility stated that the error occurred due to nurse distractions during medication pass. The facility did inservice nurses regarding the 6 rights of medication pass but there is no evidence that the facility determined the root cause of the distractions and what the facility is going to do about correcting the distraction problem and did not inservice on what the staff should do to monitor residents after they had a medication error. Findings as follows: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is a full code status for Resuscitation. Resident 1's 4/5/12 MDS (Minimum data set) states that Resident 1 scored a 15 on her BIMS (Brief interview of mental status). A score of 15 indicates that Resident 1 has no cognitive deficits. On 4/23/12 Resident 1's physician ordered medications included: [MEDICATION NAME] 0.5 mg every evening for anxiety, [MEDICATION NAME] CD 180 mg by mouth daily for heart, [MEDICATION NAME] 75 mg 1 patch every 3 days. [MEDICATION NAME] 2.5 mg give 7 tablets each week for [MEDICAL CONDITION] arthritis and [MEDICATION NAME] 25 mg daily for hypertension. On 4/23/12, Resident 1 received the following medications in error: Tylenol 1000 mg, Naltrexone 50 mg, [MEDICATION NAME] 800 mg, [MEDICATION NAME] 1 mg, Calcium 600 mg plus vitaimin D, Fluoxitine 40 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 5 mg, Multivitmins with minerals, [MEDICATION NAME] DR 20 mg, and Vitamin E 400 IU. A nursing note dated 4/23/12 at 10:10 AM states, "When it was identified that resident received the wrong medication, resident was told and she became very anxious. Resident taken to her room and laid down. BP taken 180/100 P 96 and R 22. Unable to reach (primary physician) and (on call physician) was called and reviewed one by one which medication she had inadvertently received. He stated check her vital (signs) in an hour and update (primary physician) in 2 hours. Resident continued to be very anxious and unit manager sat with resident for 1:1 calming. Primary physician was called and the list of meds she had gotten was faxed to him. Resident continued to be very anxious and wanted to be seen my MD. (Ambulance transport name) called and daughter was called and she came to the facility to accompany her (Resident 1) to the ER. Resident 1 was taken a local hospital." This note was written by LPN E. Resident 1's transfer form dated 4/23/12 indicates the reason for transfer is, "Having an anxiety related to receiving wrong medications." BP 184/100, R 22. This form was documented by LPN E. Surveyor used the facility's Nursing Drug Reference 2012 book to look up the medications listed above: Naltrexone included the following information: Do not use with drugs that contain opioids (Resident 1 was on [MEDICATION NAME] an opioid). Side effects are anxiety and Nervousness. [MEDICATION NAME]: side effects include Confusion, memory impairment, nervousness, depression, [MEDICAL CONDITION] extrapyramidal reaction. Surveyor used an official FDA information website to look up [MEDICATION NAME] and its effects. [MEDICATION NAME] information has a warning and states as follows: "Because [MEDICATION NAME] can cause marked elevation of supine blood pressure , it should be used in patients whose lives are considerably impaired despite standard clinical care. Adverse reactions that can occur when taking this drug are Hypertension, confusion/thinking abnormality, nervousness and anxiety." A fax dated 4/23/12 sent to Resident 1's primary MD states that the drugs that Resident 1 received were: Naltrexone 50 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME], and [MEDICATION NAME] 5 mg, at 8:30 and indicated that Resident 1 exhibited very high anxiety. B/P at this time 184/110 the fax indicated that none of Resident 1's meds were given. At 10:05 AM the facility received a response from the MD stating: The other stuff should wear off in 1-2 days and no way to reverse it, give blood pressure meds. Resident 1's blood pressure medications are [MEDICATION NAME] CD 100 mg, [MEDICATION NAME] 25 mg, however it is important to note that Resident 1 did not receive her blood pressure medications as ordered before she left the facility for the hospital. The ambulance run sheet dated 4/23/12 indicates that they were enroute at 9:54 AM and arrived at the facility at 10:18 AM and left the facility at 10:34 AM. The ambulance got to the Hospital at 11:10 AM. The report states that Resident 1 was found in her room in a wheelchair. RN staff gave 5 different antipsych meds that were not hers. Pt is very anxious and is kicking her legs and failing her arms and can't sit still. An IV was started with 500 cc [MEDICATION NAME]; lungs were clear after [MEDICATION NAME] states her legs and hands feel busy. Pt is alert and oriented x 3... Heart monitor shows sinus tach with ectopy, pt given a total of 2 mg of [MEDICATION NAME] which reduced anxiety but pt still very restless. Resident 1's ER report dated 4/23/12 at 11:15 AM indicates that Resident 1 appears distressed, well groomed, behavior is agitated, anxious, restless, uncooperative. Level of consciousness is confused. Resident is in [MEDICAL CONDITION] with rapid ventricular response. BP at 11:30 is 205/104 pulse 122 and respirations 30. The emergency room report documents that Resident 1 was transferred to a different hospital due to a higher level of care needed. Resident 1 had elevated troponin levels, fever, [MEDICAL CONDITIONS] with rapid ventricular response, and Hypertension. Resident 1's troponin level was 0.24 (normal range is 0-0.05). Resident 1's history and physical from where she was transferred to states that when she was admitted , was squirming in bed and combative with shortness of breath. The assessment from the ER states that the patient appears to be experiencing side effects from the medications she was given this AM. The three medications whose side effects profile correlate with the patients presenting symptoms are [MEDICATION NAME], and [MEDICATION NAME]. Pt with repetitive movements of mouth and extremities: could be from TD (Tardive Dyskensia) from antipsychotic [MEDICATION NAME], but odd to occur after just one dose; this could have been exacerbated by the [MEDICATION NAME] she received. Resident 1 has [MEDICAL CONDITION] side effect from [MEDICATION NAME] and [MEDICATION NAME]. Hypertension likely side effect from [MEDICATION NAME]. Troponin on the rise from 0.24 to 0.68 to 2.2 here; most likely secondary 2 demand from [MEDICAL CONDITION] hypertension induced my medications. A cardiology consult states that the Resident 1 had elevated troponin peaked at 4.59 most likely secondary to demand MI ([MEDICAL CONDITION] infarction) in the setting of [MEDICAL CONDITION] hypertension. On 4/30/12 at 9:55 AM Surveyor interviewed RN F (Registered Nurse) regarding the medication error that occurred with Resident 1 on 4/23/12. RN F stated that she was at the desk when LPN E came up to the desk and reported that LPN E had made a medication error by giving Resident 1 Resident 3's medications. RN F stated that LPN E went to call the MD and received orders for vitals in an hour and call primary in 2 hours. LPN E stated that Resident 1 was "freaking out" about getting the wrong medication. RN F stated that she went to Resident 1's room to calm her and Resident 1 had an incontinent episode of BM which is unusual for her and Resident 1 was breathing hard and rolling back and forth in bed, and side to side. RN F stated she told Resident 1 to calm down and Resident 1 stated that she "couldn't." Resident 1 had another incontinent episode. RN F stated that LPN E said LPN E was going to get a hold of Resident 1's primary MD now. Resident 1 "couldn't be still" and wanted to get into her bed and then in her chair and that her arms and legs were constantly moving. Resident 1 told RN F she wanted to be seen by an MD. LPN E called an ambulance service (non-emergency). Surveyor asked RN F why 911 was not called and RN F stated that Resident 1's "anxiety attack" is not emergent, and "that (anxiety attack) is what she was having." RN F stated that Resident 1 had this happen once before. However, it should be noted there is no documentation in Resident 1's medical record of this behavior previously. Surveyor asked RN F what assessments were being on Resident 1 regarding the medication error. RN F stated that RN F determined that Resident 1 was having an "anxiety attack and they were trying to calm her." RN F indicated that RN F did not look up the medications that Resident 1 ingested to check for side effects and reactions. RN F stated that she remembers that she took another BP and respiratory rate but couldn't get a pulse as she couldn't keep the pulse ox on Resident 1 long enough to complete it due to Resident 1's thrashing. Surveyor asked RN F to provide her documentation of the incident in the medical record and RN F agreed that there is no documentation of the events that occurred in the medical record from RN F. On 4/30/12 at 9:45 AM Surveyor interviewed LPN E regarding the medication error of Resident 1. LPN E stated that she gave Resident 1 medications and then continued on passing medications. When LPN E was preparing to give Resident 3 (who has the same first name) her medications she realized that the medications were already punched out and knew at that moment that LPN E had made a mistake. LPN E stated that she took Resident 1 to her room and told her that she had made a medication error and took Resident 1's vital signs. LPN E stated that Resident 1 became upset and had jumpy legs. LPN E stated that then LPN E went and reported the incident to RN F. RN F went down to check Resident 1 out and LPN E stated that she called the MD. LPN E stated that Resident 1 said that she "didn't feel good, but she had a history of [REDACTED]." LPN E stated that Resident 1 was "not getting better and was still very restless" and that is why she "didn't wait 2 hours to call primary." During this time Resident 1 stated that she wanted to go to a hospital. LPN E stated that RN F was with Resident 1 and that LPN E had gone back to passing medications. LPN E does not know if any more vital signs were taken. LPN E stated that she looked up some of the medications but could not recall which ones or what she was to monitor for. On 4/30/12 at 9:55 AM Surveyor interviewed CNA G regarding Resident 1's incident on 4/23/12. CNA G stated that Resident 1 had her breakfast and was okay. Then after we found out she had the wrong meds given to her she was abnormal. Resident 1 had 3 incontinent liquid BM's which is very unusual for her Resident 1 couldn't control her arms and legs and her voice was very high pitched as it gets when you suck helium. CNA G stated that Resident 1 was short of breath and was constantly kicking her legs. Resident 1 was also talking about her husband like he was alive although he has been dead for awhile. Resident 1's daughter came in and was angry. She asked the DON (Director of Nursing) for a list of meds that Resident 1 took and was angry that the facility told her they felt Resident 1 was having an anxiety attack. Resident 1's daughter was angry and wanted 911 called as they were not here yet. It is important to note that the facility called an ambulance transport from a nearby town not 911. On 4/30/12 at 10:35 AM Surveyor interviewed DON B regarding the medication error that occurred with Resident 1 on 4/23/12. DON B stated that after LPN E made the error she was horrified and she called the MD. Resident 1 was never left alone after the error. We educated LPN E right away and talked to all the nurses after that and went over the 6 rights and preventing medication errors. The MD felt that is was not going to present a problem but she could be sleepy and he gave orders for her blood pressure meds. Resident 1 became so agitated and a "panic attack ensued." Resident 1 was "very agitated and frightened." After the ordeal we called the pharmacy and DON B went through the medications and any interactions and we felt comfortable that they would primarily cause drowsiness. We did audit and make sure that all MARs have pictures in them. The nurse did not call 911 as the police come then and it was not written that there was an emergent life threatening problem. Surveyor asked DON B what her expectation for monitoring and assessing a resident after a significant medication error is made. DON B stated that her expectation is that vitals signs are taken every 15 minutes and to monitor for what the side effects of the medication that were given in error. On 4/30/12 at 3/20 PM Surveyor and Surveyor interviewed DON B regarding medication errors. Surveyor asked what the root causes of medication error distractions was. The facility had inserviced the nurses to make sure to double checking after a distraction and to take time to be certain of a task, but the root cause and plan of lessening distractions during med pass is unclear. DON B stated that they certainly tighten that area up. DON B also stated that they did med pass audits with the inservice nurse. It should be noted that the med pass audits were started before this medication error and were not a direct result of this error as a plan of correction and that LPN E although may have been distracted had given the medication to the wrong resident and had staff had not immediately reviewed the potential side effects and put a plan in place to monitor for those effects. . The facility did not ensure that medication errors do not occur and did not completely determine the root cause of why the medication errors were occurring in addition what the facility intends to do to alleviate the distractions and did not address what staff are to do if a medication error occurs to closely monitor the resident. Therefore this medication error has not been corrected to prevent re-occurrence. Cross reference F425.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 5 residents out of 10 residents with pressure ulcers (Residents 8, 15, 9, 14, and 12). Resident 8 was admitted to the facility with no pressure ulcers. Resident 8 subsequently developed unstageable ulcers on her coccyx. The facility failed to correctly identify, document, and evaluate the wounds and did not timely consult with the physician or family concerning appropriate treatments or possible treatment changes when the wounds deteriorated. The coccyx wound progressed to a stage 4 and became infected. The failure to provide Resident 8 with the care necessary to prevent the development of an infected stage 4 pressure ulcer created a finding of immediate jeopardy. The facility administrator was notified on [DATE] at 3:14 PM, of the finding of immediate jeopardy beginning [DATE]. The immediate jeopardy was removed on [DATE], when a Plan for Improved Compliance was initiated; the deficient practice continues at a scope/severity level of G (actual harm that is not immediate jeopardy/isolated), as evidenced by the following examples. Resident 15 was at moderate risk for developing pressure ulcers. When three new open areas appeared on [DATE], the facility did not implement new treatment measures until three days later. On [DATE], the facility did not implement the use of an air mattress as directed on the plan of care. Resident 12's right heel was noted to be a purple color on [DATE]. The facility did not have evidence that an assessment of the skin on the heel was completed for 12 days after the initial discovery of the heel ulcer. After the fourteenth day, the facility identified that the ulcer had increased in width. The facility did not have evidence that treatments were provided as ordered to Resident 12's right heel. Documentation in Resident 12's medical record refers to ulceration of the left heel. The facility did not have documentation related to assessment or progression of the left heel ulcer. Resident 9 was admitted to the facility without pressure ulcers. Resident 9 was assessed to be at low risk for the development of pressure ulcers. Resident 9 developed pressure ulcers to right heel, left heel, left inner buttock, right inner buttock and coccyx. The facility did not immediately revise the care plan or implement new interventions when these pressure ulcers developed or worsened. Resident 14 was admitted to the facility on [DATE] without pressure ulcers, after sustaining a left [MEDICAL CONDITION]. [MEDICATION NAME] was low, but dietary did not address this or its implications for skin integrity. Despite the resident ' s risk factors, there was no evidence that aggressive off loading interventions were instituted on admission to prevent the subsequent development of the right and left heel pressure ulcer. There was no evidence that staff had identified problems with the resident ' s heels until the right heel was unstageable; a weekly skin check on [DATE] noted no skin issues yet on [DATE], one heel was unstageable (1.6 x 1.6 cm) and the other heel had a stage 2 pressure ulcer that was 0.2 x 0.2 cm. Findings as follows: 1. Resident 8 Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 was not her own legal decision maker. Resident 8's MDS dated [DATE] with an assessment reference date of [DATE] indicates that Resident 8 is usually understood and understands. Resident 8 did not reject any cares. Resident 8 required extensive assistance of 2 persons with bed mobility, transfer and toilet use. Resident 8 could walk in room with extensive assistance of 1 person and a walker. Resident 8 was frequently incontinent and only occasionally incontinent of bowels. Resident 8's MDS also indicates that she is at risk for pressure ulcers but has no current pressure ulcers with a turning and repositioning program and pressure relieving devices for the bed and chair. Resident 8's care plan for skin integrity initiated on [DATE] indicates that Resident 8 had a pressure ulcer to her left heel. The interventions that were checked or added to Resident 8's care plan include the following: monitor wound weekly and prn, see skin grid, provide treatment per MD order, update MD within 2 weeks if no evidence of healing, EZ Boot to left heel when in recliner (no date as to when added), prefers to sleep in recliner (added [DATE]) air mattress to bed (added [DATE]), do not lift or slide resident, use assistive devices to reduce friction and facilitate resident movement such as turning sheets overbed trapeze and resident lift, keep head of bed at or below 30 degrees, protect elbows and heels as needed, lotion frequently, encourage motility and ambulation and yellow dot program (which means to be turned and repositioned every 2 hours). This pressure ulcer healed on [DATE]. Resident 8 was assessed for pressure ulcers on [DATE] via the Braden Risk Assessment Scale. This assessment indicates that Resident 8 scored a 20, which represents no risk for pressure ulcers. Resident 8's nursing note dated [DATE] at 9:00 PM state, "CNA noted open area coccyx. This nurse examined area has 3 x 3 ulcer (stage 2) and slit down coccyx. Cleansed applied gauze place on side in bed." A nursing note on [DATE] at 10:00 PM states, "Area of breakdown noted in coccyx approx 3 x 3 cm (centimeters) physician notified for treatment orders." (A fax was sent to MD office at 10:00 PM.) On [DATE] a Skin Grid-Pressure /[MEDICAL CONDITION] Ulcer/Other form was filled out indicating a 3 x 3 cm open area stage 2 with a small amount of bloody drainage, which was not present on admission and caused by friction. The MD was notified by fax. On [DATE] (no time noted), a nursing note stated that resident turned side to side to keep off of butt coccyx area. [DATE] a skin grid entry was added indicating that the open area on Resident 8's coccyx was a stage 2 measuring 3 cm x 1 cm and red. The comment added states, "Area on coccyx looks like a slit. Not pressure related. No drainage. Requesting Happy Butt. New order received for Happy Butt cream." (Happy Butt cream is Diaper Rash ointment Zinc Oxide and [MEDICATION NAME] 5% mixed together to form a cream the therapeutic activity is for protectant and local anesthetic, and for external use only. This information was faxed from the facility pharmacy on [DATE].) This treatment is not consistent with the facility policy for Wound Prevention and Management (effective [DATE], revised ,[DATE] and ,[DATE]), which states, "Best Practice Guidelines for a stage 2 ulcer treatment objective is to protect and manage exudate. To consider for none to light drainage absorptive/foam thin dressing, [MEDICATION NAME] dressing, and hydro gel. For moderate to heavy drainage absorptive/foam thin dressing, absorptive foam adhesive dressing, absorptive foam non-adhesive dressing and hydro gel." On [DATE] a skin grid entry states, "Stage 2 open area 3 cm x 1 cm with only redness." The comment states, "No drainage, reddened area looks like a crack in the skin. Happy Butt applied." On [DATE] at 10:00 PM a nursing note states positioned in bed with head of bed elevated on fluctuating air mattress, repositioned every 2 hours to relieve pressure on coccyx. There were no further nursing notes regarding Resident 8's pressure area on her coccyx after [DATE]. There is no weekly skin grid entry for [DATE]. A skin grid entry on [DATE] states, "Stage 2 open area 3 cm x 1 cm with redness." A comment added states, "DON assessed area. Change to pressure, requested nurse to contact Dr for new treatment orders." There is no documentation in the medical record that the physician was contacted and consulted with to get a new treatment order. A skin grid entry on [DATE] indicates that a stage 2 open area measuring 5 cm by 3 cm with red and black tissue color. There is no documentation that a physician or wound nurse or RN was informed that Resident 8's wound had almost doubled in size and was turning black. There was no change in treatment. Resident 8's Braden Risk Assessment scale was updated on [DATE] and indicates that his skin risk is a 16 which represents minimal risk. Resident 8's nursing notes on [DATE] indicate that she was having respiratory distress with respirations at 35 and was transported to the hospital emergency room . Resident 8's hospital History and Physical dated [DATE] indicates that her skin exam found a large inner gluteal decubitus lesion with some well demarcated surrounding [DIAGNOSES REDACTED]. Resident 8 was diagnosed with [REDACTED]. A wound consult was ordered. Resident 8's wound consult dated [DATE] states that she has a decubitus ulcer over the sacrum with a black eschar in place. The ulcer measures 5.5 x 3.5 cm and the depth cannot be ascertained because of the eschar, so it is an unstageable ulcer with the potential for deeper tissue injury. She does have some exudate around the edges of the ulcer that was swabbed and sent for aerobic culture. This is an unstageable sacral ulcer. The impression and plan was to recommend offloading, using a stage 3 mattress and standard nursing care with rolling the patient from side to side every couple of hours and keeping her perineal area clean and dry and to avoid shear forces. Resident 8's hospital Discharge Summary dated [DATE] lists the following discharge orders related to the pressure ulcers: Heel protectors, Stage 3 mattress, Roll patient side to side every 3 hours. Apply [MEDICATION NAME] Silver to ulcer and then cover this with Allevyn dressing and change this every 5 days and more frequently if moist. Make arrangements for follow up wound care. A review of Resident 8's treatment sheets for readmission on [DATE] indicate the above orders for wound care on readmission are written on the treatment sheet except for turning resident side to side every 3 hours. This was a physician's orders [REDACTED]. A readmission nursing note dated [DATE] at 8:00 PM states Skin assessment done. Dressing to open area on buttocks changed. Odor from wound noted. A skin grid entry on [DATE] indicates that the pressure ulcer measurements were "upon hospital return" no stage indicated, but measures 7 cm by 3 cm no depth noted with red and black tissue. Resident 8's Braden scale was updated to reflect a score of 16 which is minimal risk. A skin grid entry on [DATE] indicates that the pressure area is a stage 2 measuring 6 x 3 cm with dashes in the color of drainage and wound color section. The comment added states Black necrotic skin in middle of open area. On [DATE] a nursing notes at 2:10 states open area of coccyx has black necrotic area as it was on readmission... A wound consult note dated [DATE] states that she is being seen regarding a decubitus ulcer over her sacrum and also the right heel. The wound measures 6.5 x 3.8 cm and is level with the surface of the skin with a large area of eschar about 30 % of the ulcer and the center of the ulcer is eschar. The wound was excisionally debrided the eschar down to healthier looking tissue. No bone was exposed and no purulent discharge. To further debride the ulcer Santyl with a gauze dressing daily, and peri skin to be washed with soap and water and apply Vaseline to the peri ulcer skin so it does not macerate from the drainage. The ulcer, after debridement, appears to be a stage 2 ulcer. She needs to have an alternating pressure that is rated a stage 3 or better and also continue with the Roho in the wheelchair. The patient also had a ulcer located over the left heel that measures 1.3 x 1.0 with eschar in place. The eschar was removed and a new layer of tissue was exposed underneath the eschar. Again offloading is very important to suspend the heels when she in bed so that there are not pressure problems on the heels by placing pillows behind the legs. The total surface area debrided was 20 cm2. Recommend to recheck in one month. A nursing note on [DATE] at 1:05 PM states that IDT team met to review recent wound clinic appt. Resident received new treatment orders and area on coccyx is improving. A nutritional note dated [DATE] states readmit status [REDACTED]. Plan recommend 30 cc Pro stat BID, continue nectar thick juice 206 TID with meals continue supermilk TID, change vitamin to vitamin with minerals daily, 500 mg vit C BID for healing. This dietary note was written due to a readmission from the hospital. No dietary assessment was completed when Resident 8 developed a pressure area on [DATE] until [DATE]. A review of Resident 8's [DATE] treatment sheet shows the Vitamin C that was ordered [DATE] for wound healing was only administered one time a day for 13 days instead of 2 times a day as ordered. The facility did find this issue and fill out a medication error report for this. Resident 8 did not receive the Vitamin C as ordered to promote additional wound healing. A skin grid entry on [DATE] indicates a stage 2 open area that measures 7 cm by 3 cm x 2 cm deep with serosanguineous drainage with the wound being red and black with a foul odor. The comment added states, "Black necrotic/slough skin within middle of OA. Foul odor noted with outer edges reddened. Facility Policy 1.19.1 Wound Prevention and Management effective [DATE], revised ,[DATE] and ,[DATE]) states, "TREATMENT PROTOCOL" Infected wound signs and symptoms of infection may include, but are not limited to: swelling Induration or [DIAGNOSES REDACTED], increased pain/tenderness at site, purulent exudate, significant inflammation, periwound warmth, delayed wound healing, friable granulation, increased exudate, odor (increased or abnormal) absent or abnormal granulation tissue. "PROCEDURE" includes 1. Assess and evaluate the wound for signs and symptoms of infection. 2. Initiate/revise the skin grid -pressure ulcer [MEDICAL CONDITION] ulcer other for documentation which may include: Length, width, depth. odor, drainage, exudate, periwound condition, tunneling/undermining, wound edges, location, pain, s/s of infection wound base. 8. Identify and /or revise prevention interventions. 9. Contact the physician for potential orders which may include culture and sensitivity and pharmacological interventions. 10. Obtain a physician's orders [REDACTED]. The facility did not consult with a physician and made no treatment changes despite the presence of an odor, which could indicate a developing infection. On [DATE] Resident 8's primary physician came to the facility to assess her breathing difficulties that were occurring. Under the skin section of the assessment it states, "There is no acute rash, no bruising or petechiae. She does have a sacral decubitus wound but this was not examined as it would have been very difficult to move the patient. Resident 1 had her [MEDICATION NAME] increased and put on an antibiotic for [MEDICAL CONDITION]. The MD has asked the nursing staff to make sure that she gets to see the wound care specialists for follow up of [MEDICAL CONDITION]. A skin grid entry on [DATE] states that the ulcer is now a stage 3 which measures 7 x 6 x 4 cm deep with serosanguineous drainage with necrotic and black tissue with a foul odor with questionable tunneling. The comment added states "Visualized area called wound clinic to expedite next visit." The next appointment was to be around [DATE]. On [DATE] a stat 4 air mattress was delivered to the facility and placed on Resident 8's bed. A nursing note on [DATE] at 11:00 PM states that a Foley catheter was placed and resident was positioned on left side. A skin grid entry on [DATE] states that the ulcer is now unstageable; it measures 6 cm x 6 cm x 3.2 cm deep with purulent drainage and necrotic and black tissue with foul odor. The comment states, "area reassessed and measured by DON/UM-education provided to all nurses via corp on [DATE] and [DATE]. " There is no documentation regarding a phone call to the wound clinic, or primary physician to report Resident 8's worsening pressure ulcer now with purulent drainage, foul odor and significantly larger. On [DATE] a nursing note at 3:30 PM states that the IDT team met to review skin. Physician returned mitigating factors form. Resident was on a stat 2000 mattress. Resident on a stat 4000 air mattress. Therapy looking for a new cushion for w/c. The Mitigating Factors for the Development of Pressure Ulcers form, dated [DATE] and faxed back to the facility on [DATE] and signed by the MD, indicates that Resident 8 has received all routine preventative care for pressure ulcers. This includes but is not limited to turning and proper positioning, application of pressure reduction or relief devices, providing good skin care, adequate nutrition, and hydration. Clinical condition this resident exhibits which make the likelihood of this pressure ulcer unavoidable include but are not limited to resident immobility and Diabetes, Severe [MEDICAL CONDITION], Chronic Bowel incontinence, Head of bed elevated the majority of the day related to medical necessity, non compliance with care interventions of turning and repositioning and pressure relieving devices. Please note that the form did not get filled out until Resident 8's pressure ulcer had progressed to a stage 3 or unstageable ulcer with purulent drainage. In addition no where in Resident 8's medical record does it state that Resident 8 was non-complaint with any pressure ulcer prevention interventions. There were at least 2 different times that the physician should have been called to report the condition of the wound and did not. Weekly monitoring was not done consistently. There is no documentation to back up that this pressure ulcer was unavoidable. On [DATE] a physician wound care progress note states, "...The patient still has a small hospital bed, standard size at the nursing home....Her respiratory status has been deteriorating and spends most of time in bed or wheelchair...The sacral ulcer now measures 6 cm x 5 cm x 3 cm. It has gotten considerably deeper since last visit, and she has 90% eschar with purulent drainage. Aerobic cultures of the sacral ulcer were obtained. Because of the eschar this is an unstageable ulcer. The last time I saw her she was a stage 2 but it looks like it has increased in depth an is infected now. Suspect deeper tissues are involved and this would be classified as a stage 4 ulcer. Assessment and plan: as far as long term management of the sacral ulcer, recommend app mattress pad for her bed at the nursing home and a bariatric bed. Talked with primary MD and send to ER for worsening respiratory status. The orders from the wound care physician on [DATE] were to loosely pack sacral ulcer with ,[DATE] strength Dakins solution moistened Kerlix with ABD pad for drainage, change daily and prn. Sensicare #3 barrier cream or zinc oxide 20% to periulcer sacral skin to protect from maceration. DX: stage 4 pressure ulcer.. Bariatric hospital bed with air mattress to off load sacral ulcer and prevent further decubital pressure ulcers. Resident needs frequent repositioning for comfort and prevention of ulcers. Roll from side to side every 2 hours. A review of Resident 8's treatment sheet for [DATE] indicates that Roll side to side every 2 hours was entered on the treatment sheet but not signed out from the 28th to the 30th as being done. A nursing note on [DATE] at 3:00 PM states that Resident 8 was seen in ER for breathing problems and was given IV [MEDICATION NAME] and MS to facilitate breathing and extended her antibiotic that was given for pneumonia ([MEDICATION NAME]). The MD spoke with guardian regarding open area and overall condition mentioning hospice to her. No further information documented regarding her condition status and what the plan was to be. A nursing note on [DATE] states that Resident 8 had hematuria in her urine and the MD was called. Received orders to collect a urinalysis for culture and sensitivity. MD ordered to change antibiotic for pneumonia to [MEDICATION NAME] 500 mg for 7 days. A skin grid entry on [DATE] states that the ulcer is unstageable measuring 7 cm x 6 cm x 3 cm deep with serosanguineous drainage with necrotic/black tissue with a foul odor. On [DATE] a HD mattress (Bariatric) was delivered and placed on Resident 8's bed. A nursing note on [DATE] at 4:05 PM states that the MD was called with the culture results from [DATE] urine sensitivity and he changed the antibiotic to [MEDICATION NAME] 100 mg every day, Resident 8 had VRE (vanco resistant [MEDICATION NAME]) in her urine. A nursing note on [DATE] (no time noted) states that Resident 8 had moderate amount of dark drainage with some blood in it on old dressing and odor to dressing. A skin grid entry on [DATE] states that open area is a stage 4 that measures 9.1 cm x 8.0 cm by about 3 cm deep with purulent drainage with necrotic black tissue with a foul odor. The comment added states call was placed to MD at wound clinic for consultation and his long term plan awaiting return call written by DON B. A wound care certified nurse from the corporation assessed the wound on [DATE] and it states, "Resident with a stage 4 wound to sacral area measurements 9.1 x 8.0 x 3 cm depth. Measurement are approximate due to site of ulcer and manipulation of tissue.. Foul odor noted. Drainage purulent in nature. Wound bed necrotic in nature with spongy feel. Would expect size of ulcer to increase quite a bit as necrosis is removed. Resident without pain unless area palpated. Has Roho cushion in wheelchair and air mattress to bariatric bed. Nutritional supplements include prostat BID, multivitamin with mineral and vit c BID. Would recommend review wound cultures obtained at wound clinic. Speak with MD regarding enzymatic debridement or sharps debride ulcer. Recommend frequent checks of roho cushion and air mattress to ensure optimal pressure relief and have therapy screen for repositioning. There is no documentation in Resident 8's medical record of any conversation with the wound care physician or that any physician that was called and consulted with on significant changes to Resident 8's pressure ulcer on ,[DATE] and ,[DATE]. On [DATE] Resident 8 had a wound clinic visit. The notes state since he saw her last the facility obtained a bariatric bed so that the patient can be accommodated better and rolled more often to prevent further breakdown of the sacral ulcer...The patient ' s sacral ulcer has increased in size to 8.0 x 8.5 x 1.5 cm she has foul smelling anaerobic drainage from the ulcer cite. Resident was locally anesthetized and excisional debridement of the necrotic tissue. The extent of the debridement was all the way down to the coccyx and sacrum and the necrotic tissue extended all the way down to the bony cortex...She has localized anaerobic infection also with gram-negative organisms. In addition to [MEDICATION NAME] would recommend adding [MEDICATION NAME] 875 mg BID for 14 days. A review of Resident 8's medical record does not indicate that Resident 8 was started on the [MEDICATION NAME] antibiotic that was ordered on [DATE]. On [DATE] DON B stated that they filled out a medication error form for the missed antibiotic from [DATE]. A nursing note on [DATE] at 10:30 AM states, "Nursing assessment-VS ,[DATE], R36, 103 pulse POX 86% 3 L/M NC T-99.3 No c/o pain. Abdomen soft and nontender. BS all active. Resident alert oriented to self. Blood sugar was 439. Resident resting in bed now will be sending out to ER...Spoke with MD regarding critical labs and received orders to send to ER. Critical labs-glucose of 480, and abnormal labs of sodium of 158, potassium of 3.1, BUN of 40, Creatinine of 1.15, and [MEDICATION NAME] 2.4. Resident 8's hospital History and Physical dated [DATE] states that she was transported to the ER due to her elevated sodium. In addition her blood sugar was around 500. Resident 8 is currently on antibiotics for pneumonia, UTI and sacral decubitus ulcer that is down to the bone, she is morbidly obese and has numerous chronic medical problems. The MD talked to family and due to very guarded condition suggested hospice. Resident 8 expired at the hospital on [DATE]. Resident 8's final [DIAGNOSES REDACTED]. On [DATE] at 1:10 PM Surveyor interviewed DON B and RCDS (Regional Clinical Director of Services) C regarding pressure ulcers for Resident 8. DON B stated that a skin assessment should have been done on [DATE] and she did review Resident 8's pressure ulcer on [DATE] and told the nurse to call the physician and get a new treatment and the wound did worsen on [DATE] stating that the MD should have been called then also. RCDS C stated that in April the facility had a "Mock Survey" done and found areas that needed improvement with pressure ulcers. RCDS C stated that they had identified in April that skin assessments were incomplete or delayed, skin grid and treatment documentation and physician contact for wound changes needed improvement along with not staging wounds correctly. The facility put a correction plan in place beginning on [DATE]. The plan was to re-inservice all nurses and direct care staff on Clinical Program Training: skin. A skin sweep was done, DON B was to conduct all wound measurements for consistency, medical record review of all resident with pressure ulcers. In addition all applicable residents with pressure ulcers will be brought to daily clinical meeting every Tuesday for 4 weeks. The failure to assure that Resident 8's wounds were assessed, staged, and treated according to pressure ulcer guidelines and facility policy, and failure to consult with the doctor and family when significant changes occurred created an immediate jeopardy situation. The immediate jeopardy was removed on [DATE] when the facility completed the following: -A medical record review was done of resident 8's record for educational and process improvement. -Skin sweep was completed on [DATE] with no new pressure ulcers identified. -A skin packet check list will be formulated to assist the licensed nurses in the immediate steps of action to take when a new wound is discovered. The packet will be formulated [DATE]. -Licensed staff will be re-educated on the Skin Management program which includes: daily skin checks, prevention measures, reporting process when skin changes occur, and repositioning methods. The education was initiated on [DATE]. -medical record reviews of all residents with identified pressure ulcers to ensure all components of wound management in place which includes review of skin grid, treatment orders, and documentation. -Implemented [DATE], at least 2 RNs will make wound rounds with a wound certified nurse at minimum of 2 times a month. -The IDT team will bring all applicable residents with pressure ulcers to the daily clinical meeting to ensure all skin grids, treatments, physician orders, resident plan of care wound clinic/consultation visit reports have been addressed and completed in accordance with the directives. The deficient practice continues at a scope/severity level G (actual harm/isolated) as evidenced by: 2. Resident 15 Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was his own legal decision maker. Resident 15's admission MDS, dated [DATE], indicates that his short term memory is impaired and his long term memory is intact but has moderately impaired decision making skills. Resident 15 has been assessed to need the extensive assistance of 2 people for bed mobility, transfers, and toilet use. Additionally the MDS states that Resident 15 is at risk for pressure ulcers, but does not have any current pressure ulcers. Resident 1 has a pressure reducing device for his chair and bed; however, he is not on a turning and repositioning program. Resident 15's Braden Risk Assessment Scale score dated [DATE] indicates that he is at a moderate risk for acquiring a pressure ulcer. Resident 15's care plan for skin integrity dated [DATE] indicates a turning Schedule, use foam wedges for 30 degree lateral positioning and manage moisture, nutrition, friction and shear. One goal listed is to remain free of pressure areas. Interventions included on the care plan state to use a commercial moisture barrier, use absorbent pads offer bedpan/urinal and a glass of water at scheduled turning, elevate HOB not to exceed 30 degrees, and use lift sheet to move resident, protect elbows and heels, and a stat 2000 alternating air mattress. A nursing note on [DATE] no time noted stated that writer got an order from MD for [MEDICATION NAME] to coccyx every 3 days and prn for preventive measures. On [DATE] a SBAR (physician communication progress note was filled out for Resident 15 at 8:30 AM and faxed to the physician. The SBAR states CNA reports new OA to coccyx- areas appear to be friction upper left buttock, lower left buttock, and 1 on right buttock. no drg, no odor, noted resident denies pain/discomfort to area or otherwise. Happy butt cream applied, MD notified-waiting new orders..." A fax sent on [DATE] with the "same day request" indicated states, "Res has several (3) new open areas to buttocks, appears to be from friction-we currently tx coccyx with [MEDICATION NAME] every 3 days and prn [MEDICATION NAME]-may we also tx OA with [MEDICATION NAME] every 3 days and PRN. The physician indicates an agreement to the order: this order, however, is dated [DATE], 3 days after the discovery of the new open areas, during which time the resident went without physician evaluation and potential new interventions. On [DATE] a nursing note, no time noted, states that MD was aware of OA on buttocks and to continue with treatment of [REDACTED]. Resident 15's MD was not notified of his new open areas until 3 days later. Facility policy for wound management and prevention (effective [DATE] and revised ,[DATE] and ,[DATE]) indicates with the therapeutic support surfaces algorithm that if Multiple stage 2 pressure ulcers are present additional pressure relief is needed such as a stat 2 alternating air overlay. Resident 15 had a history of [REDACTED]. A nursing note on [DATE] at 5:30 PM states, "IDT team met to review preventative pressure relief for bed and wheelchair. stat 2, therapy screen and assessment of w/c cushion. Dietitian review of the chart completed. Juice 206 and 2 eggs at breakfast." On [DATE], at 7:50 AM Surveyor observed Resident 15 in bed on his back on a regular standard prevention mattress. On [DATE] at 9:00 AM, Surveyor observed Resident 15 in his bed on his back and in the corner of his room is an air mattress overlay. (Please note that this stat 2 air mattress was on Resident 15's care plan and was supposed to be an intervention that was already in place.) On [DATE] at 10:00 AM, Surveyor interviewed DON B regarding Resident 15's open areas. DON B stated that the mattress was put on his (Resident 15) when he got up to go to [MEDICAL TREATMENT] later that day. DON B also stated that the physician should have been called and consulted with on [DATE] when he did not respond to the fax on [DATE]. The facility did not obtain potential new treatment measures when new open areas were discovered on [DATE] and did not implement the use of an air mattress as direct

Based on interview and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 16 Residents reviewed (Resident 9). Resident 9 experienced a darkened area under his great toenail and the great toenail became loose. The facility did not complete a thorough assessment of the area that would determine the cause, did not implement measures to prevent the area from worsening, and did not monitor the healing process. This is evidenced by: Resident 9 was admitted to the facility on [DATE] with the following diagnoses; Parkinson ' s disease, Diabetes Mellitus, and Urinary tract infection. Resident 9's Admission Minimum Data Set (MDS), dated [DATE], indicates the following; Resident 9's cognitive status is severely impaired. Resident 9's speech is unclear and his ability to make concrete request is limited. Resident 9's Admission MDS, dated [DATE], also indicates Resident 9 does not have any unhealed pressure ulcers at stage 1 or higher. In addition, the admission MDS indicates Resident 9 is at risk for developing pressure ulcers. Resident 9 was seen by a podiatrist on 5/26/11. The report of this visit indicated the following: 1. Dorsal Pedis pulses are absent in the right and left foot. 2. Posterior tibial pulses are absent in the right and the left foot. 3. [MEDICAL CONDITION] is 2 plus pitting in the right and the left foot. 4. Hair Growth is absent in the right and left foot. 5. Increased distal cooling is present in the right and the left foot. Podiatry [DIAGNOSES REDACTED]. Resident 9's nursing notes, dated 6/13/11, at 8:50 AM indicates Resident 9's physician was updated regarding Resident 9's left great toenail is loose and close to falling off the nail bed. Resident 9's physician gave new orders to secure the toenail with a Band-Aid and change the Band-Aid daily. Resident 9's accident/incident report, dated 6/13/11, at 6:00 AM indicates the following; 1. Resident 9's left great toenail is loose and the left great toenail appears that is will fall off soon. 2. Resident 9's type of injury left great toenail loose. 3. Does Resident 9 know what caused the injury? The answer is "no". 4. Activity when incident occurred? The answer is "unknown". On 6/29/11 at 4:20 PM Surveyor requested Skin grid sheets from DON B for Resident 9's left great toe. DON B provided Surveyor with resident 9's skin grid sheet, dated 6/22/11. DON B also indicated there was not a skin grid sheet completed on 6/13/11 when the left great toe area first occurred. DON B stated there should have been a skin grid sheet filled out on Resident 9's left great toenail on 6/13/11. In addition, DON B indicated any break or change in any skin integrity or discoloration of skin must have a skin grid form completed. Facility staff did not start a skin grid sheet until 6/22/11. Resident 9's "SBAR Physician/NP (Nurse Practitioner)/PA (Physician assistant) Communication and progress note" form, dated 6/15/11 at 6:00 PM indicates the following; Situation: 1. Resident 9 is having symptoms of increased temperature of 101.3 degrees Fahrenheit and swelling of the right hand. 2. Resident 9's symptoms started on 6/15/11 and have gotten worse ... Order received to send Resident 9 out to the hospital emergency room for evaluation and treatment. A physician was at the facility to see Resident 9 prior to transfer to the hospital emergency room . There is no evidence of an assessment, consultation or documentation of Resident 9's left great toenail on the Physician communication form or to the physician during the physician visit to see Resident 9. Surveyor spoke Director of Nursing (DON) B regarding Resident 9's unknown cause of the injury to the left great toenail on 6/29/11 at 4:20 PM. DON B stated she believed the toenail was from the visit form the podiatrist cutting Resident 9's toenails. DON B also indicated she did not remember the date when the podiatrist cut Resident 9's toenails and DON B has not contacted the Podiatrist since the toenail began to fall off. DON B indicated she did not do an investigation regarding the loose toenail or how the injury to the toenail occurred. DON B stated she seen Resident 9's great toe on 6/14/11 when the nurse first noticed the toe nail coming off. DON B also stated the entire great toenail was dark red/black in color looked like dried old blood on 6/14/11. DON B also indicated she believed the toe nail coming off was a result of the podiatry visit prior to 6/14/11. DON B stated she has not seen the podiatry report from the previous visit and was unaware of what was done at the time of the last podiatry visit. Resident 9's nursing note, dated 6/17/11, at 3:05 PM indicates... Resident 9's left great toe was necrotic, black in color on nail bed. Resident 9's on-call physician was notified and updated about the nail bed. Resident 9's on-call physician gave orders to clean the toe with soap and water and monitor for surrounding necrosis on skin on the left great toe... (It is important to note there is no assessment or narrative descriptive documentation of Resident 9's left great toe since 6/13/11 at 8:50 AM and none on 6/18/11. Resident 9's "SBAR, Physician/NP/PA Communication and Progress note, dated 6/18/11, at 2:15 PM indicates the following; Situation: Resident 9 temperature is 100.9 degrees Fahrenheit, and pulse is 120. Resident 9's symptoms started at 1:00 PM and are worse. Resident 9's problem which occurred with this symptom is "shaky." Background: Resident 9 has a [DIAGNOSES REDACTED]. Assessment: (For (Registered Nurses) RNs) the documentation for assessment is blank in this section. (For LPNs) Resident 9 the documentation for assessment is blank in this section. Resident 9's Nursing progress note, dated 6/18/11, at 3:00 PM indicates, Resident 9 is visibly shaky and non verbal. Resident 9 is currently taking an antibiotic (Bactrim DS) and [MEDICATION NAME]. RN assessment related to increased temperature and pulse rate. Resident 9's physician was contacted and order received to send to hospital emergency room for evaluation and treatment. The nursing note was completed by a LPN. (There is no assessment or narrative documentation of the great toe and no evidence the physician was consulted on Resident 9's condition of his great toe.) Resident 9's nursing notes, dated 6/18/11, at 3:15 PM indicates, Resident 9 temperature 100.8 degrees Fahrenheit, pulse 118, respirations 30, oxygen saturation 89% on room air. Resident 9's nursing note also indicates Resident 9 is visibly shaking, non verbal, lung sounds diminished, abdomen soft and non tender, and no [MEDICAL CONDITION]. Sent to the hospital emergency room . The nursing note was completed by a RN. (There is no assessment or narrative documentation of the great toe and no evidence the physician was consulted on Resident 9's condition of his great toe.) Resident 9's Resident Transfer form, dated 6/18/11, indicates the following: Reason for transfer: This section of the transfer form is blank. List of Diagnosis: [REDACTED]. At risk alerts: Falls, and pressure ulcers There is no evidence the transfer form indicated Resident 9's left great toe is necrotic and black. Resident 9's nursing note, dated 6/18/11, at 7:30 PM indicates, The facility LPN received a call from the hospital and Resident 9 was admitted to the hospital for possible amputation of the left great toe, blood poisoning to the knee on the left side, a hard lump under the left buttock pressure ulcer, white blood count at 17.4 (elevated above normal level) and [MEDICAL CONDITION]. Resident 9's recent hospitalization History and Physical, dated 6/18/11, indicates the following; Resident 9's was seen in the emergency and finding included a fever of 102 and a blood pressure of 76/39. Resident 9 developed a black big toe about a week ago, which has been getting progressively worse and today the black area of the tip of the big toe also surrounded by [DIAGNOSES REDACTED] and red streaking up to the knee. Resident 9 received a dose intravenously (IV) of [MEDICATION NAME], and [MEDICATION NAME] in the hospital emergency room . Assessment and plan: 1. Urinary tract infection ... 2. Ischemic big toe with [MEDICAL CONDITION] ... will consult surgery. 3.[MEDICAL CONDITION] with [MEDICAL CONDITION], elevated white blood count, bandemia, and fevers... 5. Acute [MEDICAL CONDITION] due [MEDICAL CONDITION]. Resident 9's hospital discharge summary, dated 6/21/11, indicates the following; Principal [DIAGNOSES REDACTED]. Hospital course: Resident 9 was admitted with several problems, the first of which being a ischemic big toe with surrounding [MEDICAL CONDITION] Resident 9 was also diagnosed with [REDACTED]. Resident 9's Health care power of attorney activated (HCPOA) and Resident 9's surgeon to discuss amputation of the big toe and decided to discuss the amputation at a later date... Physical examination: Extremities Big toe is blackened and gangrenous appearing. The surrounding [DIAGNOSES REDACTED] of the big toe in the lateral foot seems to be dissipating. A royal blue permanent maker was used to demarcate the area of inflammation with dots... Facility staff began a skin grid sheet for Resident 9 following his return to the facility. This sheet notes: 1. On 6/22/11 Resident 9's whole left great is necrotic. The left great toe originally started as a toenail coming off and returned from the hospital with a necrotic left great toe. The left great toe [DIAGNOSES REDACTED]. 2. On 6/28/11 Resident 9's left great toe is unstageable and has dry gangrene. His left great toe "measuring over the toe from the closest to base at top of foot 3 centimeters (cm) to top of great toe. 2.6 (cm) from top of great toe to back of toe to posterior foot width of necrosis area 1.6 (cm) X (by) 0.8 (cm)". It is important to note there are no measurements on 6/22/11 to assess the changes from 6/22/11 to 6/28/11 of the left great toe. On 6/28/11 at 10:15 AM, Surveyor with DON B and LPN N Observed Resident 9's necrotic great toe. Resident 9's pressure ulcer observation indicated, resident 9's great toe was dark black in color and dry. The area surrounding the great toe was pink with blue permanent marker dots. DON B measured the necrotic are to measure 3 cm by 2.6 cm by 3.2 cm. During the observation LPN N questioned DON B regarding the blue dots on Resident 9's foot and why the dots were present. DON B indicated she had not seen the blue dots before and no further information was provided. On 6/29/11 at 4:20 PM surveyor spoke with DON B regarding Resident 9's necrotic great toe and change of condition. DON B indicated a RN is to do an assessment on all residents who have a change of condition and write an assessment in the nursing notes. DON B indicated yes a RN should have done an assessment on 6/17/11 when the physician was called and an order for [REDACTED].

Based on record review and interview, for 5 of 16 sampled residents (Residents 8, 15, 9, 14, and 13) the facility did not immediately inform the resident, consult with the resident's physician, or notify the resident's legal representative or an interested family member when there was a significant change in the resident's physical status or a need to alter treatment. Resident 8 had a facility acquired pressure ulcer that had deteriorated. The physician was not called when appropriate to consult with him regarding appropriate treatment plan and interventions. Resident 8 presented with hematuria (bloody urine) on 4/26/11 and a nurse's note states the MD's nurse was informed. There is no indication that the facility consulted with the physician or received orders for assessing or treating the hematuria. On 4/30/11 resident again had hematuria; a culture with sensitivity was ordered with the resulting finding of a VRE infection in her urine. Resident 15 had new open areas on his buttocks that were found on 6/24/11. The facility faxed a physician and did not get a response until 6/27/11. Resident 9 had an abnormal urine culture, and was receiving an antibiotic to which the bacteria were resistant. The physician was not notified regarding Resident 9 taking an antibiotic to which the urine culture noted the bacteria were resistant. Resident 9 was admitted to the hospital. Resident 14 had changes in skin integrity. The facility did not promptly consult with the resident's physician when changes were noted to Resident 14's skin. Resident 14 was noted to have a necrotic area to the left outer heel. The facility did not consult with Resident 14's physician until 2 days after the area on the heel was discovered. Resident 13 was experiencing significant [MEDICAL CONDITION] to the lower extremities. A physician was notified and a new treatment was initiated along with instructions to update the physician on 5/31/11. Resident 13's condition did not improve. A physician was not consulted until 6/2/11 when new orders were received. This is evidence by: The facility policy titled "Notification of Resident change in condition", dated 2/2011 indicates the following: Policy: (Company Name) clinicians will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status... If the change in the resident's condition is not crucial or significant (does not meet AMDA criteria) the resident's Physician and family or legal representative will be notified at the earliest convenient time during regular business hours. Procedure: 1. Notify the Physician and family or legal representative at the earliest possible time, during waking hours, if there is a non-critical change in condition. 2. Notify the Physician and family or legal representative immediately if there is a significant change in condition, regardless of time... b. Contact the Medical Director if unable to contact attending Physician or on-call Physician... 3. Document in the Nurses notes the time notification was made and the names of the person to whom the nurse spoke... The AMDA (American Medical Directors Association), "Protocols for Physician Notification," state the following related to assessment and data collection to be described to a physician concerning pressure ulcers: "Purpose: This manual is for the use of assisting nursing staff with necessary assessments and data collection prior to notifying the physician of clinical problems in facility residents. This allows the physician to get more complete information about the patient and his or her problem, to facilitate decision making...Pressure Sores; Physical data: 1. Vital signs. 2. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. 3. Pain assessment; Medical History: 1. Patient's age and sex. 2. Patient's mobility status. 3. Current treatments, including support surfaces. 4. All active diagnoses, especially [MEDICAL CONDITIONS], diabetes, [MEDICAL CONDITIONS], incontinence, weight loss. 5. Current medications, especially steroids, chemo." Facility Policy 1.19.1 Wound Prevention and Management effective November 1998, revised 4/09 and 10/2010) states, "TREATMENT PROTOCOL" Infected wound signs and symptoms of infection may include, but are not limited to: swelling Induration or [DIAGNOSES REDACTED], increased pain/tenderness at site, purulent exudate, significant inflammation, periwound warmth, delayed wound healing, friable granulation, increased exudate, odor (increased or abnormal) absent or abnormal granulation tissue. "PROCEDURE" includes 1. Assess and evaluate the wound for signs and symptoms of infection. 2. Initiate/revise the skin grid -pressure ulcer [MEDICAL CONDITION] ulcer other for documentation which may include: Length, width, depth. odor, drainage, exudate, periwound condition, tunneling/undermining, wound edges, location, pain, s/s of infection wound base. 8. Identify and /or revise prevention interventions. 9. Contact the physician for potential orders which may include culture and sensitivity and pharmacological interventions. 10. Obtain a physician's orders [REDACTED]. Example 1 Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 was not her own legal decision maker. Resident 8's nursing note dated 3/3/11 at 9:00 PM state, "CNA noted open area coccyx. This nurse examined area has 3 x 3 ulcer (stage 2) and slit down coccyx. Cleansed applied gauze place on side in bed." A nursing note on 3/3/11 at 10:00 PM, states, "Area of breakdown noted in coccyx approx 3 x 3 cm (centimeters) physician notified for treatment orders." (A fax was sent to MD office at 10:00 PM.) Please note that the clinic office is not open at 10:00 PM. On 3/3/11 a Skin Grid-Pressure /[MEDICAL CONDITION] Ulcer/Other form was filled out indicating a 3 x 3 cm open area stage 2 with a small amount of bloody drainage, which was not present on admission and caused by friction. The MD was notified by fax. On 3/4/11 a skin grid entry was added indicating that the open area on Resident 8's coccyx was a stage 2 measuring 3 cm x 1 cm and red. The comment added states, "Area on coccyx looks like a slit. Not pressure related. No drainage. Requesting Happy Butt. New order received for Happy Butt cream." A skin grid entry on 3/21/11 states, "Stage 2 open area 3 cm x 1 cm with redness." A comment added states, "DON assessed area. Change to pressure, requested nurse to contact Dr for new treatment orders." There is no documentation in the medical record that the physician was contacted and consulted with to get a new treatment order. A skin grid entry on 3/28/11 indicates that a stage 2 open area measuring 5 cm by 3 cm with red and black tissue color. There is no documentation that a physician or wound nurse or RN was informed that Resident 8's wound had almost doubled in size and was turning black. There was no change in treatment. A skin grid entry on 4/18/11 indicates a stage 2 open area that measures 7 cm by 3 cm x 2 cm deep with serosanguineous drainage with the wound being red and black with a foul odor. The comment added states, "Black necrotic/slough skin within middle of OA. Foul odor noted with outer edges reddened. The facility did not consult with a physician and made no treatment changes despite the presence of an odor, which could indicate a developing infection. On 4/24/11 Resident 8's primary physician came to the facility to assess her breathing difficulties that were occurring. Under the skin section of the assessment it states, "There is no acute rash, no bruising or petechiae. She does have a sacral decubitus wound but this was not examined as it would have been very difficult to move the patient. Resident 1 had her [MEDICATION NAME] increased and put on an antibiotic for [MEDICAL CONDITION]. The MD has asked the nursing staff to make sure that she gets to see the wound care specialists for follow up of [MEDICAL CONDITION]. A skin grid entry on 4/25/11 states that the ulcer is now a stage 3 which measures 7 x 6 x 4 cm deep with serosanguineous drainage with necrotic and black tissue with a foul odor with questionable tunneling. The comment added states "Visualized area called wound clinic to expedite next visit." The next appointment was to be around 5/13/11. A skin grid entry on 4/26/11 states that the ulcer is now unstageable; it measures 6 cm x 6 cm x 3.2 cm deep with purulent drainage and necrotic and black tissue with foul odor. The comment states, "area reassessed and measured by DON/UM-education provided to all nurses via corp on 4/25/11 and 4/26/11." There is no documentation regarding a phone call to the wound clinic, or primary physician to report Resident 8's worsening pressure ulcer now with purulent drainage, foul odor and significantly larger. A nursing note on 4/26/11 at 10:30 AM states, "400 CC output, hematuria. Dr (MD name) nurse and DR updated on blood in urine. There is no evidence in Resident 8's medical record that the MD was consulted with regarding Resident 8's hematuria, that the physician received the message, or that a plan of care for the hematuria was developed. A nursing note on 4/30/11 states that Resident 8 had hematuria in her urine and the MD was called. Received orders to collect a urinalysis for culture and sensitivity. MD ordered to change antibiotic (that was being given for pneumonia) to [MEDICATION NAME] 500 mg for 7 days. A nursing note on 5/4/11 at 4:05 PM states that the MD was called with the culture results from 5/3/11 urine sensitivity and he changed the antibiotic to [MEDICATION NAME] 100 mg every day, Resident 8 had VRE (vanco resistant [MEDICATION NAME]) in her urine. A skin grid entry on 5/10/11 states that open area is a stage 4 that measures 9.1 cm x 8.0 cm by about 3 cm deep with purulent drainage with necrotic black tissue with a foul odor. The comment added states call was placed to MD at wound clinic for consultation and his long term plan awaiting return call written by DON B. A wound care certified nurse from the corporation assessed the wound on 5/10/11 and it states, "Resident with a stage 4 wound to sacral area measurements 9.1 x 8.0 x 3 cm depth. Measurement are approximate due to site of ulcer and manipulation of tissue.. Foul odor noted. Drainage purulent in nature. Wound bed necrotic in nature with spongy feel. Would expect size of ulcer to increase quite a bit as necrosis is removed. Resident without pain unless area palpated. Has Roho cushion in wheelchair and air mattress to bariatric bed. Nutritional supplements include prostat BID, multivitamin with mineral and vit c BID. Would recommend review wound cultures obtained at wound clinic. Speak with MD regarding enzymatic debridement or sharps debride ulcer. Recommend frequent checks of roho cushion and air mattress to ensure optimal pressure relief and have therapy screen for repositioning." There is no documentation in Resident 8's medical record of any conversation with the wound care physician or that any physician that was called and consulted with on significant changes to Resident 8's pressure ulcer on 5/10 and 5/11. On 5/12/11 Resident 8 had a wound clinic visit. The notes state since he saw her last the facility obtained a bariatric bed so that the patient can be accommodated better and rolled more often to prevent further breakdown of the sacral ulcer...The patient ' s sacral ulcer has increased in size to 8.0 x 8.5 x 1.5 cm she has foul smelling anaerobic drainage from the ulcer cite. Resident was locally anesthetized and excisional debridement of the necrotic tissue. The extent of the debridement was all the way down to the coccyx and sacrum and the necrotic tissue extended all the way down to the bony cortex...She has localized anaerobic infection also with gram-negative organisms. In addition to [MEDICATION NAME] would recommend adding [MEDICATION NAME] 875 mg BID for 14 days. On 6/29/11 at 1:10 PM Surveyor interviewed DON B and RCDS (Regional Clinical Director of Services) C regarding pressure ulcers for Resident 8. DON B stated that a skin assessment should have been done on 3/14/11 and she did review Resident 8's pressure ulcer on 3/21/11 and told the nurse to call the physician and get a new treatment and the wound did worsen on 3/28/11 stating that the MD should have been called then also. The facility did not promptly consult with resident 8's physician when significant changes of condition occurred to Resident 8. Example 2 Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was his own legal decision maker. On 6/24/11 a SBAR (physician communication progress note) was filled out for Resident 15 at 8:30 AM and faxed to the physician. The SBAR states CNA reports new OA to coccyx- areas appear to be friction upper left buttock, lower left buttock, and 1 on right buttock. no drg, no odor, noted resident denies pain/discomfort to area or otherwise. Happy butt cream applied MD notified-waiting new orders..." A fax sent on 6/24/11 with the "same day request" indicated states, "Res has several (3) new open areas to buttocks, appears to be from friction-we currently tx coccyx with [MEDICATION NAME] every 3 days and prn [MEDICATION NAME]-may we also tx OA with [MEDICATION NAME] every 3 days and PRN. The physician did not respond to this fax until three days later, 6/27/11. The physician indicates an agreement to the order: this order. The three day delay means the resident went without physician evaluation and potential new interventions and created an opportunity for the wound to worsen. On 6/29/11 at 10:00 AM, Surveyor interviewed DON B regarding Resident 15's open areas. DON B stated that the physician should have been called and consulted with on 6/24/11 when he did not respond to the fax on 6/24/11. Example 3 Resident 9 was admitted to the facility on [DATE]. Resident 9's Physician order [REDACTED]. Physician order [REDACTED]." Resident 9's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 9's Urine Culture results, dated 6/17/11 indicate that the bacteria were resistant to Bactrim. Facility nurses did not notify the physician of this finding. Resident 9's physician communication and progress note, dated 6/18/11, at 2:15 PM indicates under the progress note section Resident 9's Temperature is 100.9 degrees Fahrenheit, Pulse 120, Respiration 22, and Resident 9 is visibly shaking. The Physician communication and progress note also indicates Resident 9 is already on Bactrim DS and [MEDICATION NAME]. Resident 9 to be sent to the emergency room for an evaluation. Resident 9's History and Physical (H&P), dated 6/18/11 indicates the following; Resident 9 was brought into the emergency roiagnom on [DATE] with a temperature of 102 degrees Fahrenheit, blood pressure in the emergency room was 76/39. The H&P also indicated Resident 9 was seen in the emergency roiagnom on [DATE], for fevers, and diagnosed with [REDACTED]. Resident 9 continued to have a fever and was brought back to the emergency roiagnom on [DATE]. Resident 9 Urine culture from 6/15/11 grew Staphylococcus epidermidis sensitive to [MEDICATION NAME] and resistant to Bactrim. The facility received this information on 6/17/11 at noon and did not update the physician so an alternate antibiotic could be ordered... Assessment and Plan : 1. Urinary Tract infection with Staphylococcus epidermidis.... Resident 9 to be started on [MEDICATION NAME] Intravenously (IV) ... 2. Right lower lobe pneumonia... 3. Right ischemic big toe surrounded by [MEDICAL CONDITION] 4.[MEDICAL CONDITION] with [MEDICAL CONDITION], elevated white blood counts, bandemia, and fevers. Will treat underlying course and give patient aggressive hydration of IV fluids... 5. Acute [MEDICAL CONDITION] due [MEDICAL CONDITION] On 6/29/11 at 4:20 PM Surveyor spoke with Director of Nursing (DON) B regarding the urine culture for Resident 9. DON B indicated yes the culture results should have been called to the physician on 6/17/11 due to the Bactrim was resistant to the growth found. Example 4 Resident 14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 14's nursing notes, dated 6/14/11, at 11:00 AM indicates the following; Resident 14 noted to have bilateral heel breakdown. Already receives skin prep on heels. Stryker boots were applied. MD (Medical Doctor) sent a fax to update. A message was left for Resident 14's wife. Resident 14's Fax, dated 6/14/11, (no time indicated) indicates the following, Resident 14 has an area on the right heel that has a hard cap on the heel. Currently Resident 14 is receiving skin prep to Resident 14 heels BID (twice a day). Resident 14 also has an area on the left heel that is dry, but starting to break down... signed by Licensed Practical Nurse (LPN) D. There is no indication the facility described the size of the breakdown (pressure ulcer). Facility staff did not consult with the physician and did not attempt to reach a physician when there was no reply to the fax. Resident 14's nursing note, dated 6/15/11, at 10:30 PM indicates... The MD noted the use of the boots at all times and agrees with this. Resident 14's Skin grid form, dated 6/14/11 indicates Resident 14's right heel was unstageable, with a color description as necrotic, and measured 1.6 centimeters (cm) by 1.6 cm. Resident 14's Skin grid form, dated 6/14/11 indicates Resident 14's left heel was a stage 2, with a color description as pink, and measured 0.2 centimeters (cm) by 0.2 cm. On 6/29/11 at 4:20 PM Surveyor spoke with Director of Nursing (DON) B regarding physician notification and the facility nurses sending a fax to the physician. DON B indicated it was her expectation a fax for pressure ulcer is to be returned the same day as the nurse sent the information to the physician. DON B also indicated a completed description of all pressure ulcer is to be given to the physician when notifying the physician of any pressure ulcer. In addition the DON B indicated a fax is not a consultation with the Physician, the nurses should follow up with a call to the physician. Example 5 Resident 13's [DIAGNOSES REDACTED]. Resident 13's record contains the following documentation: Physician / NP (Nurse Practitioner) / PA (Physician Assistant) Communication and Progress 5/26/11: 11:20 - "... Resident has [MEDICAL CONDITION] bilaterally to R (right) & L (left) leg... R leg has +1 [MEDICAL CONDITION] from knee to ankle. Ankle to +2 (sic) and top of foot + 4. Resident currently wears [MEDICATION NAME]. Resident at this time had feet elevated...Currently taking 80 mg (milligrams) [MEDICATION NAME] No [MEDICAL CONDITION] noted to hands..." 5:15 pm - "Called RN (Registered Nurse) @ 1115 (11:15 am) for an assessment of resident L (left) LE (lower extremity) when resident c/o (complained of) pain, discomfort. +4 [MEDICAL CONDITION] noted on top of foot, from knee to ankle +2 [MEDICAL CONDITION] noted. Resident had no [MEDICAL CONDITION] noted on hands... Called (Physician's) office at 1130 (11:30 am) and left message with RN for MD. She stated she would rely (sic) message to MD and call back with results. Writer called 2x after to check if MD received messages. Was told he will return call before leaving the office. Waiting for MD to call." 6:30 pm - "Called MD office again. Spoke to (Physician) about Resident's [MEDICAL CONDITION]. He ordered another diuretic for 2 days and call to update on Tuesday of results" 5/26/11 Telephone order - "[MEDICATION NAME] 2.5 mg (milligrams) q (every) am x 2 days. Call MD on Tues (Tuesday) with results." 5/27/11 Nurses Note 10:00 am - "... Resident continues (with) 4+ [MEDICAL CONDITION] to top of foot. +1 [MEDICAL CONDITION] from knee to ankle... Legs elevated while sitting in recliner. Will continue (with) [MEDICATION NAME] per MD order. Will monitor." 5/28/11 Nurses Note 5:00 pm - "... L (left) LE (lower extremity) continues to have +3 [MEDICAL CONDITION] on top of foot, +1 knee to ankle. Denies discomfort r/t (related to) foot. Will update MD." 5/29/11 Nurses Note - 3:30 am - "[MEDICAL CONDITION] continues L foot. Legs (up) in bed @ noc (night). (No) c/o pain or nausea this noc." 5/30/11 Nurses Note - 4:00 pm - "...L foot has 4 - 5 + [MEDICAL CONDITION] on top of foot. (Physician) to be updated regarding L foot [MEDICAL CONDITION] on 5/31/11. Legs elevated while resting in recliner." 5/31/11 (Tuesday) Nurse Notes 5:20 pm - "...(Physician's) office called to update about continued + 3 - 4 [MEDICAL CONDITION] top of L foot. Waiting for MD to call back. Sent fax with update as well." 5/31/11 Fax 5:20 pm - "FYI (For your information) F/U (follow up) Resident's L top foot continues to have + 3 - 4 [MEDICAL CONDITION] and around ankle. + 1 pitting from knee to ankle. Finished taking 2 day dose of metolazon 2.5 mg. Any new orders? Please update. Also resident continues to wear [MEDICATION NAME] Bilat (bilaterally) LE." This fax indicates the facility is requesting a response on this same day (5/31/11). There is no evidence Resident 13's physician responded to this fax on 5/31/11, no evidence Resident 13's physician was consulted (spoken to) regarding Resident 13's continued [MEDICAL CONDITION] on 5/31/11, and no evidence the facility attempted to contact the on call physician regarding Resident 13's continued [MEDICAL CONDITION] on 5/31/11. 6/1/11 Nurses Notes 2:20 pm - "L top foot +4 [MEDICAL CONDITION] continues to be noted. No c/o of pain r/t [MEDICAL CONDITION]." There is no evidence Resident 13's physician responded to the fax sent 5/31/11 regarding Resident 13's continued [MEDICAL CONDITION] on 6/1/11, no evidence Resident 13's physician was consulted (spoken to) regarding Resident 13's continued [MEDICAL CONDITION] on 6/1/11, and no evidence the facility attempted to contact the on call physician regarding Resident 13's continued [MEDICAL CONDITION] on 6/1/11. 6/2/11 Nurses Note 10:22 pm - "... New order received R/T [MEDICAL CONDITION] & to update MD in about 10 days." 6/2/11 returned fax with order - "Add the metolozone 2.5 mg po on three days per week 1/2 hour before furosimide. Update in (about) 10 days." On 6/29/11 at 4:00 pm Surveyor spoke with Unit Manger LPN (Licensed Practical Nurse) D regarding several topics including Resident 13 and his [MEDICAL CONDITION]. LPN D stated that if staff did not get a timely response from the physician she would expect the on call physician to be notified.

Based on interview and record review, the facility failed to immediately consult with the physician when 1 of 8 sampled residents experienced a significant change in condition. *Resident 1 had a significant change of condition that was identified in the nursing notes at 7:00 AM on [DATE]. The AM nurse and DON (Director of Nursing) were informed but no assessment, evaluation and implementation of interventions were taken. The change of condition worsened during the day and into the PM shift. No thorough assessment was done, no condition change was reported to a Registered Nurse (RN) or a physician as Resident 1 became worse. When staff found Resident 1 pulseless and non-breathing on [DATE] at approximately 11:00 PM, CPR was not initiated, even though the resident had expressed a desire to be full code and had physician's orders [REDACTED]." The nurse that was caring for Resident 1 did not know he was a full code at that time and did not know that CPR should be initiated with an unwitnessed arrest. The failure to consult with the physician in regard to Resident 1's significant change of condition throughout the day and evening of [DATE] resulted in a finding of Immediate Jeopardy which began on [DATE]. The facility was notified of Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope severity level of D (potential for harm that is not immediate jeopardy/isolated) because the facility has to fully implement and evaluate the effectiveness of its action plan. Findings as follows: The facility uses the AMDA (American Medical Directors Association) guidelines: Protocols for Physician Notification. A Guide for Nurses on Effective Communication with Physicians. The following are standards for calling the physician in each case: *Cardiopulmonary Arrest- The physician should be called immediately when an unexpected arrest in someone who is a full code. *Dyspnea (difficulty breathing)- the physician should be notified immediately if acute onset or change from usual pattern or with chest pain, labored respirations, or unstable vital signs. *[MEDICAL CONDITION]-Abrupt onset unilateral leg [MEDICAL CONDITION] with tenderness and redness should be notified immediately *Respiratory Rate-abrupt increase in rate with dyspnea, pain, fever, or respiratory distress should be called to the MD immediately. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is his own legal decision maker. Resident 1's Nursing Comprehensive Admission Data Collection and Assessment form, dated [DATE], done by a Licensed Practical Nurse (LPN), and was cosigned by the DON on [DATE] states that Resident 1 is alert and oriented to person place and time. Resident 1 also has 1 + [MEDICAL CONDITION] (swelling) to his ankles and feet (this means that when the area is depressed with a finger it leaves a slight indent and the indent disappears rapidly). The form also states that Resident 1 is not short of breath but the form indicates that Resident 1 becomes short of breath "a little on exertion." Crackles and wheezes were heard in Resident 1's lungs. Resident 1 also has a Foley catheter. Resident 1's admission orders [REDACTED]. Instructions for taking [MEDICATION NAME] are handwritten on the entry indicating "decrease extra fluid." The order does not indicate parameters as to how often and when to give it for "extra fluid." Resident 1 signed the facility's (CPR) Cardiopulmonary Resuscitation Consent form, dated [DATE], indicating, "It is my desire that: (a check mark was placed by Resuscitation) Resuscitation-I am expressing a desire to have CPR and /or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personal will be called." Resident 1's Physicians orders, signed by a physician on [DATE], indicate, "Full Code." Resident 1 experienced a significant change of condition on [DATE]. Following is a chronological summary of the events of [DATE] based on entries in the nursing notes, statements taken during the facility ' s internal investigation, and surveyor interviews of staff. On [DATE] at 7:00 AM a nursing note states, "Many and varied C/O (complaints) during the NOC. Uses call light to get staff assist. First C/O of not being able to sleep. Call placed to (MD name) (MD Name) on call and returned call. Order given for Tylenol PM 1 to 2 tabs at NOC, prn (as needed) to promote sleep. 1 tab given to trial how resident would respond. Minimal effect noted. Several hours after C/O SOB (shortness of breath). O2 (oxygen) on at 2 liters per nc (nasal cannula) BP ,[DATE], P 104, R 29, and PO 93%. No cyanosis noted, capillary refill good to finger tips. Also C/O itching to torso. Worked with resident on focusing on how he breathes. Inhaling through nose and exhaling slowly through mouth. Was effective. Also massage gently with lotion over back and torso. Resident indicated this helped. Then after a short period CNA (certified nursing assistants) reports that resident C/O feet hurt ,[DATE] + [MEDICAL CONDITION] noted to feet. Encouraged to elevate. Reported to AM nurse and (Name) DON." This entry was documented by a LPN. The facility staff did not have an RN assessment completed for the significant changes in Resident 1's condition including his complaints of shortness of breath and complaints of [MEDICAL CONDITION] painful feet. Then nurse did not immediately consult with the physician, even though facility policies indicate that staff should immediately consult with a physician when a resident has difficulty breathing and an abrupt onset of leg [MEDICAL CONDITION] (went from 1+ to ,[DATE]). Statement from the NOC LPN Q dated [DATE] taken during the facility ' s internal investigation: LPN Q documented in her statement at about 3:00 AM Resident 1 had been complaining of SOB and vital signs along with lung sounds were done. Resident 1 did not take very deep inspirations even with encouragement, but LPN Q indicated she did not hear anything abnormal. At about ,[DATE] AM Resident 1 complained to the CNA's that his feet hurt and then it was noted by LPN Q that Resident 1 had ,[DATE] + [MEDICAL CONDITION]. LPN Q documented that it was "close to the end of her shift" so she reported what had occurred to the AM nurse to follow up. LPN Q did not call the MD that AM as it was close to end of shift and felt that it would be more likely that AM nurse would be able to contact primary care physician as opposed to physician on call who would not know resident as well. A statement from LPN E dated [DATE] taken during the facility ' s internal investigation stated that LPN E went to give Resident 1 his AM medications and Resident 1 asked LPN E to look at his calves and feet. LPN E noted that he had 2+ [MEDICAL CONDITION] bilaterally. The note continues to indicate that LPN E then asked RN F what Resident 1's normal was for the [MEDICAL CONDITION] to his legs. LPN E gave prn [MEDICATION NAME] per RN F direction for the [MEDICAL CONDITION]. LPN E gave report to RN F and left at around 10:30 AM. On [DATE] at 1:15 PM Surveyor interviewed LPN E regarding Resident 1. LPN E stated, "I worked that day from 6 AM to 10:00 AM. I gave him his meds and he was very anxious. He was anxious the night before. Noted that he had 2 + [MEDICAL CONDITION] in lower legs, I wanted his feet elevated due to the swelling but he wouldn't do it. I went and asked the RN about the PRN [MEDICATION NAME] order and she said to give it. The RN stated that he was always anxious, that was normal. Resident 1 was so anxious he could not sit still." A nursing note dated [DATE] "late entry for [DATE]" no time noted, states, "Resident was noted to have 2+ [MEDICAL CONDITION] to bilateral lower extremities, calf to toes. RN notified of [MEDICAL CONDITION] and prn [MEDICATION NAME] given. Lung sounds were clear and resident encouraged to elevate legs on bed but insisted on sitting up with legs to side of bed. No further complaints." This note was written by an LPN. There is no RN documentation that an assessment was done for giving the PRN [MEDICATION NAME] or what parameters were used or why the physician was not contacted. A statement from CNA C dated [DATE] taken during the facility ' s internal investigation stated that Resident 1 was on his call light repeatedly from about 6:00 PM on. CNA C indicated Resident 1 kept complaining he couldn't breathe and he kept saying he felt like he was going to die. CNA C indicated notifying the nurse to what Resident 1 was saying and the nurse said she knew it. CNA C stated that she did turn up Resident 1's oxygen and notified the nurse right after doing that. On [DATE] at 2:20 PM Surveyor interviewed CNA C regarding Resident 1 on [DATE]. CNA C stated, "He had been on the call light a lot that night, especially after 6:00 PM it was like every ,[DATE] minutes. He kept telling me that he couldn't breathe, needed his MD and that he was gonna die. He was sitting on the side of the bed moving back and forth, uncomfortable, breathing heavily. I reported this to the nurse at least 5 times and she stated that she knew that and he had anxiety issues. He wanted an MD and I turned up the oxygen to 5 liters, I didn't know what else to do. I told the LPN that I turned it up and she said I couldn't do that. I offered to go and turn it down and she refused. I noticed that his legs were swollen not sure if they were before or not. I left at shift change." On [DATE] at 12:45 PM, Surveyor interviewed LPN G regarding the events of the PM shift on [DATE] regarding Resident 1. LPN G stated, " ...(CNA C) came and told me that he complained that he couldn't breathe and needed an MD. (CNA C) stated that she turned up his oxygen because he couldn't breathe. I think (CNA C) told me a couple of times. I went and turned the O2 back down and explained that you cannot turn up oxygen on certain residents as it could be detrimental to their health. This aide thinks we do not respond quick enough to her concerns and we don't know how to do our job." LPN G continued on to state, "(Resident 1) was very anxious, he was beyond anxious he couldn't sit still. (Resident 1) told me that he was going to die tonight and if he dies that it will be on my conscience for the rest of my life. When he said that I asked him what he wanted me to do. (Resident 1) said, 'I don't know, you gotta do something look at my legs and feet how swollen they are.' I tried to elevate his legs on pillows, but he couldn't/wouldn't lay down. I did vital signs and they were starting to go up and his pulse ox was in the 80's and 70's but would bounce back up when I tried to calm him down. He kept asking for oxygen and I told him that he is already on it. I do not remember reporting this to the RN and I should have. I tried to get his legs up." Surveyor asked LPN G what actions were taken for Resident 1. LPN G stated that she gave a prn [MEDICATION NAME] also and a prn Tylenol PM. LPN G did not notify the PM RN of Resident 1's significant change of condition and did not notify the resident ' s physician. Surveyor asked LPN G how she monitored output of Resident 1 after the PRN [MEDICATION NAME]. LPN G stated the CNA staff tells her of the output and she records it. LPN G stated that she did not notice any increase in Resident 1's output on [DATE]. There is no documentation of Resident 1's output on [DATE] on day or PM shift to monitor the prn [MEDICATION NAME], in fact, there is no mention of any output in the nursing notes or the Caretracker. Surveyor asked LPN G if Resident 1 asked that his physician be called. LPN G responded that he (Resident 1) "didn't tell me that, only the aide, I guess." Surveyor asked LPN G what is the procedure for a change of condition of a resident. LPN G responded that when a change of condition occurs, vital signs and data should be collected, and then report the information to the charge nurse, and or call the physician. Document the information on the 24 hour board and document what was done and ordered in the medical record. " A late entry nursing note for 9:45 PM by LPN G states, "Res. C/O (arrow pointing up) increased swelling to BLE (Bilateral lower extremities). Upon assessment res. (arrow pointing up) anxiety ,[DATE]+ [MEDICAL CONDITION] PRN [MEDICATION NAME] 20 mg given. Requested pillow to elevate feet which was done although resident didn't elevate BLE's when pillows brought to room. Kept asking for O2 which O2 was on at 2 lm per nc T96.8, P76, R 20, BP ,[DATE], POX 93% with O2 on." This entry is signed by a LPN. No RN assessment was completed with this significant change of condition. Resident 1's physician was not called with his continued complaints of shortness of breath, [MEDICAL CONDITION] legs and restlessness. " On [DATE] at 4:00 PM Surveyor interviewed LPN D regarding Resident 1 on [DATE]. LPN D stated, "I worked another hall on PM shift and then I worked the NOC shift on his hallway. At about 10:00 PM, the PM LPN (LPN G) and I had report and then went out for a smoke break as I thought it would be the only one we got that night as I thought I would be alone in the building. (LPN G) stated to me that (Resident 1) told her that he was gonna die tonight and his death would be on her conscience for the rest of her life. I told (LPN G) that I would be mad if he died tonight because he said that. (LPN G) stated that she did a set of vital signs and they were fine, and he had all the PRNs that he could have. He was very restless and anxious and had C/O of his legs swelling but he wouldn't put them up. This occurred was around 10:00 PM when I came in from outside I had to do some staffing calls. The NOC aide came to me around 11:00 PM and stated that she thought (Resident 1) was dead. I went down to his room and he was sitting on the edge of the bed and leaning over almost folded in half. We placed him on his bed and I went to call everyone. The DON walked in (as she was working a NOC shift) and I told her what happened and she stated to follow the procedure for a death in the manual. I was collecting the paperwork and noted that he was a full code. I reported this to the DON. We know now that all full codes, regardless of witnessed or not should have CPR initiated. We have had inservice training on change of condition, assessments, using PRN's that have parameters, CPR, and staff not turning up O2. I thought that only witnessed codes get CPR." This interview indicates that LPN D was aware that Resident 1 told LPN G that he felt he was going to die and LPN D and LPN G went outside the facility to have a smoke break and did not go immediately to see what Resident 1's condition was prior to leaving the unit. LPN did not consult with an RN or ensure that the physician was immediately contacted. A nursing note dated [DATE] at 11:30 PM states, "Called to resident's room by CNA's on unit. Resident found by staff slumped over in bed and unresponsive. Upon entering room Resident bilat LE's mottled and cold, lips blue. No heart rate/pulse, no O2 level, no BP. DON in house and notified. Family notified and on their way in. DR on call paged and awaiting ret (return) phone call." The facility failed to initiate CPR as Resident 1 had requested a full code. The facility failed on multiple occasions to call Resident 1's physician to report significant changes of condition. Surveyor requested a copy of the urinary outputs for Resident 1 to find out the urinary output for [DATE] after Resident 1 received prn [MEDICATION NAME]. A review of Resident 1's Caretracker documentation intake and output record (ran at 5:03 PM on [DATE]) reveals that Resident 1 did not have any output recorded on [DATE]. Resident 1's average fluid intake from [DATE] to [DATE] (7 days) is 1770 cc a day total fluid intake and an average of the 7 days of urine output is 307 cc this is a fluid variance of 1440 cc a day greater intake than output. No nursing personal reviewed, analyzed and acted upon Resident 1's outputs that were exceeding his intakes by over 1000cc a day. No one notified the physician that Resident 1 appeared to be retaining fluids. On [DATE], at 12:50 PM, Surveyor interviewed DON B regarding Resident 1. DON B stated, "I was not made aware of anything but Resident 1 getting the Tylenol PM. I was not made aware that he was short of breath. We did review the incident and we did several corrective actions and several inservices for areas for improvement that we found. The physician should have been called in the morning when he was short of breath and his feet swelled, the physician should have been called when the PRN [MEDICATION NAME] was given and in the evening when he still had shortness of breath... The facility's failure to immediately consult with the physician when Resident 1 experienced a significant change in condition and as his condition worsened throughout the day created a situation of Immediate Jeopardy. The facilty removed the Immediate Jeopardy on [DATE] when: 1. A medical record review was conducted on Resident 1 2. LPN G and LPN E, and RN F were re-educated and counseled on change of condition, AMDA guidelines for physician notification, RN assessment and changes in condition, LPN to RN dialog, RN/LPN standards of practice, and [MEDICAL CONDITION] care path. plus all other licensed staff re-educated 3. A review of all other residents with [MEDICAL CONDITION] to make sure all monitoring devices were in place. 4. Licensed staff re-educated on CPR policy and procedure. 5. LPN D was counseled on not initiating CPR when Resident 1 was a full code. Cross Reference F281, F242, and F309.

Based on interview and record review, the facility failed to implement policies and procedures to prevent neglect and facility staff did not provide the necessary care for 1 of 8 sampled residents requesting Full Code services (Resident 1) and for assessing, evaluating, and implementing interventions for a significant change of condition. Resident 1 had a significant change of condition that was identified in the nursing notes at 7:00 AM on [DATE]. The night nurse did not take action to call the physician or fully brief the oncoming nurse; the 6 - 10 AM nurse did not take action to call the physician and also did not brief the 10 - 2 PM nurse on Resident 1's significant anxiety and [MEDICAL CONDITION]. The DON (Director of Nursing) was informed but no assessment, evaluation and implementation of interventions were taken. The evening nurse did not assess the resident, seek a Registered Nurse (RN) to do a full assessment of the worsening condition and did not monitor for output after giving the resident a second diuretic to lessen the [MEDICAL CONDITION]. When Resident 1 indicated that he was going to die, the PM LPN told the night LPN that Resident 1 had indicated that that his death would be on her conscience; the 2 staff exited the building for a smoke break without the night nurse doing an immediate observation of Resident 1. Upon the night LPN's return to the building Resident 1 expired and finally, the night LPN, DON and the night Certified Nursing Assistants (CNA's) did not initiate CPR per Resident 1's advanced directives. There was a systemic neglect of Resident 1's condition from 7:00 AM through his death at approximately 11:00 PM. The systemic lack of response to Resident 1's significant change of condition throughout the day shift, lack of RN assessment, not calling the physician to update the physician on Resident 1's status, and lack of response to initiate CPR, thus denying this resident his only chance at survival, resulted in a finding of Immediate Jeopardy which began on [DATE]. The facility was notified of Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope severity level of D (potential for harm that is not immediate jeopardy/isolated) because the facility has to fully implement and evaluate the effectiveness of its action plan. Findings as follows: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is his own legal decision maker. Resident 1's Nursing Comprehensive Admission Data Collection and Assessment form, dated [DATE], done by a Licensed Practical Nurse (LPN), and was cosigned by the DON on [DATE] states that Resident 1 is alert and oriented to person place and time. Resident 1 also has 1 + [MEDICAL CONDITION] (swelling) to his ankles and feet (this means that when the area is depressed with a finger it leaves a slight indent and the indent disappears rapidly). The form also states that Resident 1 is not short of breath but the form indicates that Resident 1 becomes short of breath "a little on exertion." Crackles and wheezes were heard in Resident 1's lungs. Resident 1 also has a Foley catheter. Resident 1 signed the facility's (CPR) Cardiopulmonary Resuscitation Consent form, dated [DATE], indicating, "It is my desire that: (a check mark was placed by Resuscitation) Resuscitation-I am expressing a desire to have CPR and /or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personal will be called." Resident 1's physician's orders [REDACTED]." Resident 1's nursing notes, dated [DATE] at 2:30 PM, indicate that he refused to have his vital signs taken. But it is documented that his pulse is 80 and regular and his breathing pattern normal and steady at 28 (abnormal). Resident 1 complained of being dizzy when lying in bed and did not want to take his medications. Resident 1 was talked into taking his medications. No follow up charting was documented regarding his elevated respirations or his complaints of dizziness. No RN assessment was completed for the changes in Resident 1 status. Resident 1 experienced a significant change in condition on [DATE]. Following is a chronological summary of the events of that day based on entries in the nursing notes, statements taken during the facility's internal investigation, and surveyor interviews of staff. On [DATE] at 7:00 AM a nursing note states, "Many and varied C/O (complaints) during the NOC. Uses call light to get staff assist. First C/O of not being able to sleep. Call placed to (MD name) (MD Name) on call and returned call. Order given for Tylenol PM 1 to 2 tabs at NOC, prn (as needed) to promote sleep. 1 tab given to trial how resident would respond. Minimal effect noted. Several hours after C/O SOB (shortness of breath). O2 (oxygen) on at 2 liters per nc (nasal cannula) BP ,[DATE], P 104, R 29, and PO 93%. No cyanosis noted, capillary refill good to finger tips. Also C/O itching to torso. Worked with resident on focusing on how he breathes. Inhaling through nose and exhaling slowly through mouth. Was effective. Also massage gently with lotion over back and torso. Resident indicated this helped. Then after a short period CNA (certified nursing assistants) reports that resident C/O feet hurt ,[DATE] + [MEDICAL CONDITION] noted to feet. Encouraged to elevate. Reported to AM nurse and (Name) DON." This entry was documented by a LPN. The facility staff did not have an RN assessment completed for the significant changes in Resident 1's condition including his complaints of shortness of breath and complaints of [MEDICAL CONDITION] painful feet. Statement from the NOC LPN Q dated [DATE] taken during the facility's internal investigation: LPN Q documented in her statement at about 3:00 AM Resident 1 had been complaining of SOB and vital signs along with lung sounds were done. Resident 1 did not take very deep inspirations even with encouragement, but LPN Q indicated she did not hear anything abnormal. At about ,[DATE] AM Resident 1 complained to the CNA's that his feet hurt and then it was noted by LPN Q that Resident 1 had ,[DATE] + [MEDICAL CONDITION]. LPN Q documented that it was "close to the end of her shift" so she reported what had occurred to the AM nurse to follow up. LPN Q did not call the MD that AM as it was close to end of shift and felt that it would be more likely that AM nurse would be able to contact primary care physician as opposed to physician on call who would not know resident as well. This note/interview indicates that the LPN was aware of Resident 1 having shortness of breath, 2 - 3 plus [MEDICAL CONDITION] and not being able to take deep inspirations even with encouragement; this staff person did not seek immediate RN assessment and did not consult with Resident 1's physician. Also, LPN Q did not put Resident 1 on the 24 hour report so that he would be monitored by nursing management. A statement from LPN E dated [DATE] taken during the facility's internal investigation stated that LPN E went to give Resident 1 his AM medications and Resident 1 asked LPN E to look at his calves and feet. LPN E noted that he had 2+ [MEDICAL CONDITION] bilaterally. The note continues to indicate that LPN E then asked RN F what Resident 1's normal was for the [MEDICAL CONDITION] to his legs. LPN E gave prn [MEDICATION NAME] per RN F direction for the [MEDICAL CONDITION]. LPN E gave report to RN F and left at around 10:30 AM. On [DATE] at 1:15 PM Surveyor interviewed LPN E regarding Resident 1. LPN E stated, "I worked that day from 6 AM to 10:00 AM. I gave him his meds and he was very anxious. He was anxious the night before. Noted that he had 2+ [MEDICAL CONDITION] in lower legs, I wanted his feet elevated due to the swelling but he wouldn't do it. I went and asked the RN about the PRN [MEDICATION NAME] order and she said to give it. The RN stated that he was always anxious, that was normal. Resident 1 was so anxious he could not sit still." Surveyor asked LPN E how a change of condition was communicated between staff. LPN E stated that when a change occurs it gets written on the 24 hour board and is documented until it is resolved." This note/interview indicates that LPN E knew that Resident 1 was very anxious and had been through the night, had 2 plus [MEDICAL CONDITION], would not elevate the lower extremities and had given Resident 1 a diuretic. However, LPN E did not ensure that RN assessment was completed and did not consult with Resident 1's physician for his continuing concerns. Also, LPN E did not put Resident 1 on the 24 hour report so that he would be monitored by nursing management. An entry on a separate nursing note, not documented as a late entry, or dated/timed as to when actually documented in the record (Cross Reference F514), dated [DATE] at 1:00 PM states, Writer entered resident's room at lunch time with noon pill. Asked resident if he needed anything at that time. Resident took noon pill and was sitting up at bedside his norm, waved writer out of room towards door. Resident denied pain or discomfort." This entry was written by an RN; however, there is no RN assessment of Resident 1 to follow up on his significant change of condition that was documented at 7:00 AM on [DATE]. On [DATE] at 1:30 PM Surveyor interviewed RN Unit Manager F regarding Resident 1. RN F stated, "I was just the nurse on the floor from 10:00 AM until around 2 PM. I was told in report that he had been given prn [MEDICATION NAME]. I have dealt with him (Resident 1); he is rude and pushy eats lunch in his room and I went in to give him his meds. I asked him if he needed anything else and he waved me toward the door. The LPN told me she gave the PRN [MEDICATION NAME]. I didn't go into the room until around 12 noon for pills. He did not offer anything further. I eyeballed him he was in a t-shirt and boxers. I did not note any [MEDICAL CONDITION] or shortness of breath, nothing out of the ordinary." Surveyor asked RN F how changes of condition are communicated. RN F stated that when she is acting as the unit manager the 24 hour boards are collected and taken to the DON and then they review them. After the meeting we are assigned to follow up. Then we get back together and the DON reports off on what was done. There is no documentation on the 24 hour board regarding Resident 1 and any new medications, complaints or prns given. This note/interview notes that RN F indicates that RN F felt that Resident 1 was "rude and pushy" and thus, did not ensure that a full assessment was done when the LPN communicated that Resident 1 had continued shortness of breath and 2 plus [MEDICAL CONDITION]. Although she gave the LPN direction to give an as needed [MEDICATION NAME] she did not do a full assessment of Resident 1 and consult with his physician on the ongoing change in his condition. Also, RN F did not put Resident 1 on the 24 hour report so that he would be monitored by nursing management. A statement from CNA C dated [DATE] taken during the facility's internal investigation stated that Resident 1 was on his call light repeatedly from about 6:00 PM on. CNA C indicated Resident 1 kept complaining he couldn't breathe and he kept saying he felt like he was going to die. CNA C indicated notifying the nurse to what Resident 1 was saying and the nurse said she knew it. CNA C stated that she did turn up Resident 1's oxygen and notified the nurse right after doing that. On [DATE] at 2:20 PM Surveyor interviewed CNA C regarding Resident 1 on [DATE]. CNA C stated, "He had been on the call light a lot that night, especially after 6:00 PM it was like every ,[DATE] minutes. He kept telling me that he couldn't breathe, needed his MD and that he was gonna die. He was sitting on the side of the bed moving back and forth, uncomfortable, breathing heavily. I reported this to the nurse at least 5 times and she stated that she knew that and he had anxiety issues. He wanted an MD and I turned up the oxygen to 5 liters, I didn't know what else to do. I told the LPN that I turned it up and she said I couldn't do that. I offered to go and turn it down and she refused. I noticed that his legs were swollen not sure if they were before or not. I left at shift change. I know now that if I have an issue I can go to another nurse or call the DON." This note/interview indicates that CNA C knew that Resident 1 was significantly short of breath, stating that he was going to die and that CNA made repeated attempts to convey these concerns to LPN G. However, CNA C did not attempt to get the RN that was also in the building to intervene or to contact the DON with the ongoing concerns. On [DATE] at 12:45 PM, Surveyor interviewed LPN G regarding the events of the PM shift on [DATE] regarding Resident 1. LPN G stated, "I got from day shift report that he was given prn [MEDICATION NAME] for his swollen legs. I do not recall his urine output. He lay down in bed all day and slept. After supper he was sitting at the foot of the bed and looked out the doorway. He did this every single night this was nothing new. (CNA C) came and told me that he complained that he couldn't breathe and needed an MD. (CNA C) stated that she turned up his oxygen because he couldn't breathe. I think (CNA C) told me a couple of times. I went and turned the O2 back down and explained that you cannot turn up oxygen on certain residents as it could be detrimental to their health. This aide thinks we do not respond quickly enough to her concerns and we don't know how to do our job." LPN G continued on to state, "(Resident 1) was very anxious, he was beyond anxious he couldn't sit still. (Resident 1) told me that he was going to die tonight and if he dies that it will be on my conscience for the rest of my life. When he said that I asked him what he wanted me to do. (Resident 1) said, 'I don't know, you gotta do something look at my legs and feet how swollen they are.' I tried to elevate his legs on pillows, but he couldn't/wouldn't lay down. I did vital signs and they were starting to go up and his pulse ox was in the 80's and 70's but would bounce back up when I tried to calm him down. He kept asking for oxygen and I told him that he is already on it. I do not remember reporting this to the RN and I should have. I tried to get his legs up." Surveyor asked LPN G what actions were taken for Resident 1. LPN G stated that she gave a prn [MEDICATION NAME] also and a prn Tylenol PM. LPN G did not notify the PM RN of Resident 1's significant change of condition. Surveyor asked LPN G how she monitored output of Resident 1 after the PRN [MEDICATION NAME]. LPN G stated the CNA staff tells her of the output and she records it. LPN G stated that she did not notice any increase in Resident 1's output on [DATE]. There is no documentation of Resident 1's output on [DATE] on day or PM shift to monitor the prn [MEDICATION NAME], in fact, there is no mention of any output in the nursing notes or the Caretracker. Surveyor asked LPN G if Resident 1 asked that his physician be called. LPN G responded that he (Resident 1) "didn't tell me that, only the aide, I guess." Per the interview LPN G was aware that Resident 1 was "beyond anxious" and that Resident 1 stated "he was going to die tonight and if he dies that it will be on my (LPN G's) conscience for the rest of her life." LPN G gave prn [MEDICATION NAME] without monitoring the effectiveness and did not seek RN assessment and did not consult with the physician on the ongoing changes in Resident 1's condition. A late entry nursing note for 9:45 PM by LPN G states, "Res. C/O (arrow pointing up) increased swelling to BLE (Bilateral lower extremities). Upon assessment res. (arrow pointing up) anxiety ,[DATE]+ [MEDICAL CONDITION] PRN [MEDICATION NAME] 20 mg given. Requested pillow to elevate feet which was done although resident didn't elevate BLE's when pillows brought to room. Kept asking for O2 which O2 was on at 2 lm per nc T96.8, P76, R 20, BP ,[DATE], POX 93% with O2 on." This entry is signed by a LPN. No RN assessment was completed with this significant change of condition. Resident 1's physician was not called with his continued complaints of shortness of breath, [MEDICAL CONDITION] legs and restlessness. " LPN G did not document Resident 1's condition accurately and the documentation was not completed until after Resident 1 had expired. On [DATE] at 4:00 PM Surveyor interviewed LPN D regarding Resident 1 on [DATE]. LPN D stated, "I worked another hall on PM shift and then I worked the NOC shift on his hallway. At about 10:00 PM, the PM LPN (LPN G) and I had report and then went out for a smoke break as I thought it would be the only one we got that night as I thought I would be alone in the building. (LPN G) stated to me that (Resident 1) told her that he was gonna die tonight and his death would be on her conscious for the rest of her life. I told (LPN G) that I would be mad if he died tonight because he said that. (LPN G) stated that she did a set of vital signs and they were fine, and he had all the PRNs that he could have. He was very restless and anxious and had C/O of his legs swelling but he wouldn't put them up. This occurred was around 10:00 PM when I came in from outside I had to do some staffing calls. The NOC aide came to me around 11:00 PM and stated that she thought (Resident 1) was dead. I went down to his room and he was sitting on the edge of the bed and leaning over almost folded in half. We placed him on his bed and I went to call everyone. The DON walked in (as she was working a NOC shift) and I told her what happened and she stated to follow the procedure for a death in the manual. I was collecting the paperwork and noted that he was a full code. I reported this to the DON. We know now that all full codes, regardless of witnessed or not should have CPR initiated. We have had inservice training on change of condition, assessments, using PRN's that have parameters, CPR, and staff not turning up O2. I thought that only witnessed codes get CPR." This interview indicates that LPN D was aware that Resident 1 told LPN G that he felt he was going to die and LPN D and LPN G went outside the facility to have a smoke break and did not go immediately to see what Resident 1's condition was prior to leaving the unit. Additionally, LPN D, DON B and the night CNA's were not aware of the code policy and that Resident 1 wanted to be a full code. A nursing note dated [DATE] at 11:30 PM states, "Called to resident's room by CNA's on unit. Resident found by staff slumped over in bed and unresponsive. Upon entering room Resident bilat LE's mottled and cold, lips blue. No heart rate/pulse, no O2 level, no BP. DON in house and notified. Family notified and on their way in. DR on call paged and awaiting ret (return) phone call." There is no entry by the DON when informed that Resident 1 expired. The facility failed to initiate CPR as Resident 1 had requested a full code. The facility failed on multiple occasions to call Resident 1's physician to report significant changes of condition. On [DATE], at 12:50 PM, Surveyor interviewed DON B regarding Resident 1. DON B stated, "I was not made aware of anything but Resident 1 getting the Tylenol PM. I was not made aware that he was short of breath. We did review the incident and we did several corrective actions and several inservices for areas for improvement that we found. The physician should have been called in the morning when he was short of breath and his feet swelled, the physician should have been called when the PRN [MEDICATION NAME] was given and in the evening when he still had shortness of breath...The procedure is to initiate CPR when a resident is a full code witnessed or unwitnessed. The NOC nurse should have initiated CPR but thought that it was only when it was witnessed arrest. The staff are to look at the chart if there is an arrest/or event. We have tried other stickers or bands but things change too often to make it an effective system. The staff is to go to the chart or send someone and find out from the original form if they are a code or no code." Surveyor asked DON B how staff is to follow up on a change of condition of any Resident. DON B stated, "We have a process called the Daily Clinical Review. That is where the 24 hour boards are collected and we review in the morning and expect follow up by the IDT (interdisciplinary team) in the afternoon to make sure that residents were followed up and documented on." It should be noted, there is no entry on the 24 hour board for Resident 1 on [DATE], but there should have been as he had a change in condition and then would have received follow up. The facility systemically failed to provide Resident 1 the care and treatment that he needed. Resident 1 had 7 staff caring for him for over 16 hours that did not fully assess his concerns of shortness of breath, anxiety and significant [MEDICAL CONDITION] and when he was found pulseless and breathless staff did not initiate CPR as he had wished. The facility's failure to appropriately respond to Resident #1's significant change in condition and its failure to provide appropriate life saving CPR per the resident's wishes created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on [DATE] when: 1. A medical record review was conducted on Resident 1 2. LPN G and LPN E, and RN F were re-educated and counseled on change of condition, AMDA guidelines for physician notification, RN assessment and changes in condition, LPN to RN dialog, RN/LPN standards of practice, and [MEDICAL CONDITION] care path. plus all other licensed staff re-educated 3. A review of all other residents with [MEDICAL CONDITION] to make sure all monitoring devices were in place. 4. Licensed staff re-educated on CPR policy and procedure. 5. LPN D was counseled on not initiating CPR when Resident 1 was a full code.

Based on interview and record review, the facility failed to ensure that residents have the right to choose health care consistent with his or her interests, assessments and plans of care, and to make choices about aspects of his or her life in the facility that are significant to the resident for 1 resident out of 8 reviewed (Resident 1) and 26 supplemental residents. Resident 1 was his own legal decision maker and signed his own admission paperwork. Resident 1 had signed, on [DATE], that he chose to have resuscitation efforts initiated in the event of observed or unobserved cardiac event. On [DATE], Resident 1 was anxious, having difficulty breathing and requested to be seen by a physician. Staff did not honor the resident's wishes and did not consult with a physician. When Resident 1 was found slumped over on [DATE] without a pulse or blood pressure and cessation of breathing, the nurse did not perform CPR as directed on Resident 1's signed CPR form, physician's orders [REDACTED]. The facility's failure to honor Resident 1's wishes to be seen by a physician and the failure to honor his wishes with respect to end-of-life care for resuscitative efforts, which denied this resident his only chance at survival, created a situation of Immediate Jeopardy. This began on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope severity level of E (not immediate jeopardy/patterned). The facility still needs to address how each resident will be identified as a Full Code. This has the potential to affect the 26 additional residents who were identified as wishing Full Code status (Residents 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34). Findings as follows: The facility's policy and procedure, last revised [DATE], states that the facility will be staffed with at least one person that is certified to administer CPR, 24 hours a day/7 days a week. The policy states that unless a decision not to initiate CPR has previously been made by the resident and state guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center. The procedure states that the staff is to determine if an arrest has occurred and call for assistance. All CPR certified persons are to report to the area of arrest, or suspected arrest. Determine if a code status has been established and documented using the CPR consent form. The form is to be filed under the Advanced Directives section of the residents' medical record. Initiate CPR and continue to do so until EMS (emergency medical services) arrives and takes over. Resident 1 signed the facility's (CPR) Cardiopulmonary Resuscitation Consent form, dated [DATE], indicating, "It is my desire that: (a check mark was placed by Resuscitation) Resuscitation-I am expressing a desire to have CPR and /or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personal will be called." Resident 1's Physicians orders, signed by a physician on [DATE], indicate, "Full Code." Resident 1 experienced a significant change of condition on [DATE]. Resident 1 was anxious, having difficulty breathing, and believed he was dying. Facility staff failed to honor Resident 1's request to be seen by his physician and for staff to do something, as evidenced by the following interviews. On [DATE] at 2:20 PM CNA C told Surveyor that Resident 1 "had been on the call light a lot that night, especially after 6:00 PM it was like every ,[DATE] minutes. He kept telling me that he couldn't breathe, needed his MD and that he was gonna die. He was sitting on the side of the bed moving back and forth, uncomfortable, breathing heavily. I reported this to the nurse at least 5 times and she stated that she knew that and he had anxiety issues. He wanted an MD and I turned up the oxygen to 5 liters, I didn't know what else to do. I told the LPN that I turned it up and she said I couldn't do that. I offered to go and turn it down and she refused. I noticed that his legs were swollen not sure if they were before or not. I left at shift change." On [DATE] at 12:45 PM, Surveyor interviewed LPN G regarding the events of the PM shift on [DATE] regarding Resident 1. LPN G stated, "...(CNA C) came and told me that he complained that he couldn't breathe and needed an MD. (CNA C) stated that she turned up his oxygen because he couldn't breathe. I think (CNA C) told me a couple of times. I went and turned the O2 back down and explained that you cannot turn up oxygen on certain residents as it could be detrimental to their health. This aide thinks we do not respond quick enough to her concerns and we don't know how to do our job." LPN G continued on to state, "(Resident 1) was very anxious, he was beyond anxious he couldn't sit still. (Resident 1) told me that he was going to die tonight and if he dies that it will be on my conscience for the rest of my life. When he said that I asked him what he wanted me to do. (Resident 1) said, 'I don't know, you gotta do something look at my legs and feet how swollen they are.' I tried to elevate his legs on pillows, but he couldn't/wouldn't lay down. I did vital signs and they were starting to go up and his pulse ox was in the 80's and 70's but would bounce back up when I tried to calm him down. He kept asking for oxygen and I told him that he is already on it. I do not remember reporting this to the RN and I should have. I tried to get his legs up." A nursing note on [DATE] at 11:30 PM states, "Called to resident's room by CNA's on unit. Resident found by staff slumped over in bed and unresponsive. Upon entering room Resident bilat LE's mottled and cold, lips blue. No heart rate/pulse, no O2 level, no BP. DON in house and notified. Family notified and on their way in. DR on call paged and awaiting ret. phone call." Resident 1 had indicated he wished to be a full code and CPR was not initiated at the time the nurse found him slumped over. On [DATE] at 4:00 PM Surveyor interviewed LPN D regarding Resident 1 on [DATE]. LPN D stated, "I worked another hall on PM shift and then I worked the NOC shift on his hallway...The NOC aide came to me around 11:00 PM and stated that she thought (Resident 1) was dead. I went down to his room and he was sitting on the edge of the bed and leaning over almost folded in half. We placed him on his bed and I went to call everyone. The DON walked in (as she was working a NOC shift) and I told her what happened and she stated to follow the procedure for a death in the manual. I was collecting the paperwork and noted that he was a full code. I reported this to the DON. We know now that all full codes, regardless of witnessed or not should have CPR initiated. We have had inservice training on change of condition, assessments, using PRN's that have parameters, CPR, and staff not turning up O2. I thought that only witnessed codes get CPR." On [DATE], at 12:50 PM, Surveyor interviewed DON B regarding Resident 1. DON B stated that the procedure is to initiate CPR when a resident is a full code witnessed or unwitnessed. The NOC nurse should have initiated CPR but thought that it was only when it was witnessed arrest. The staff are to look at the chart if there is an arrest/or event. We have tried other stickers or bands but things change too often to make it an effective system. The staff is to go to the chart or send someone and find out from the original form if they are a code or no code. We inserviced the whole staff on CPR status and if Full code to initiate CPR witnessed or unwitnessed." The facility's failure to honor Resident 1's wishes to be seen by a physician and the failure to honor his wishes with respect to end-of-life care for resuscitative efforts, which denied this resident his only chance at survival, created a situation of Immediate Jeopardy. The facility removed the immediate Jeopardy on [DATE] when: 1. A medical record review was conducted on Resident 1's record. 2. All licensed staff were re-educated including LPN G and LPN E, and RN F who were re-educated and counseled on change of condition, AMDA guidelines for physician notification, RN assessment and changes in condition, LPN to RN dialog, RN/LPN standards of practice, and [MEDICAL CONDITION] care path. plus all other licensed staff were re-educated 3. A review of all other residents with [MEDICAL CONDITION] to make sure all monitoring devices were in place. 4. Licensed staff re-educated on CPR policy and procedure. 5. LPN D was consulted on not initiating CPR when Resident 1 was a full code.

Based on interview and record review and review of professional standards of practice, the facility failed to ensure that the services provided by nursing personal met the professional standards of quality for 1 of 8 residents reviewed (Resident 1) Resident 1 had a significant change of condition that was identified in the nursing notes at 7:00 AM on [DATE]. The AM nurse and Director of Nursing (DON) were informed but no assessment, evaluation and implementation of interventions were taken. The change of condition worsened during the day and into the PM shift. No thorough assessment was done. LPNs did not report the resident's deteriorating condition to a Registered Nurse (RN) or a physician. As his condition worsened, Resident 1 stated that he was "going to die" to staff and staff did not intervene immediately to ensure that Resident 1 was assessed and that the physician was immediately called. As a result, tfacility nurses failed to comply with Wisconsin Administrative Code, Board of Nursing, N6, Standards of Practice for Registered Nurses and Licensed Practical Nurses, which outlines the responsibilities of RN's and LPN's. Resident 1 was found on [DATE] at approximately 11:00 PM without a pulse or blood pressure and CPR was not initiated, even though the resident, on admission had signed for a full code, which states that Cardiopulmonary Resuscitation (CPR) will be initiated in a witnessed or unwitnessed arrest. The nurse that was caring for Resident 1 did not know he was a full code at that time, did not check his status, and did not know that CPR should be initiated with an unwitnessed arrest. Staff did not comply with N6.03(1)(c) and implement the plan of care, which called for resuscitation. Given the seriousness of the significant changes in condition that were occurring, staff failure to follow professional standards of practice created a finding of Immediate Jeopardy, which began on [DATE]. The facility was notified of Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope severity level of D (potential for harm that is not immediate jeopardy/isolated) because the facility has yet to fully implement and evaluate the effectiveness of its plan and training. Findings as follows: Wisconsin Administrative Code, Board of Nursing, N6, Standards of Practice for Registered Nurses and Licensed Practical Nurses, at N 6.04(1) states, "In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a physician, podiatrist, dentist or optometrist: (a) Accept only patient care assignments which the LPN is competent to perform; (b) Provide basic nursing care; ("Basic nursing care" is defined at N 6.02(1) as "care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.") (c) Record nursing care given and report to the appropriate person changes in the condition of a patient." N 6.03(1) also requires RNs to " utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N. ' s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient ' s progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The Protocols for Physician Notification: Assessing Patients and Collecting Data on Nursing Home Facility Patients, A guide for Nurses on Effective Communication with Physicians, by the American Medical Directors Association copyright 2000 notes that the standard of practice for physician notification relating to a "Complaint, medical, by family or patient (Always demand to speak to physician or have a medical assessment without delay)." The physical data to assess states, "1. Vital signs. 2. Physical assessment in relation to nature of complaint. (Use the companion to decide what to assess. For example, if family member reports that the patient has back pain, see section on back pain). " The Acute Changes in Condition in the Long-Term Care Setting, a clinical practice guideline, written by the American Medical Directors Association, copyright 2003, reveals that a physician should be notified immediately if the resident has sudden onset of acute changes in [MEDICAL CONDITION], and normal breathing pattern. The rate of weight gain or loss may be a more important indicator than the amount of gain or loss. . Evaluate signs and symptoms that may suggest fluid imbalance (e.g. [MEDICAL CONDITION] or change in [MEDICAL CONDITION]). Acute rapid weight gain may indicate an acute change in condition that is accompanied by fluid accumulation (e.g. acute [MEDICAL CONDITION]) These standards were not met in the care of Resident 1, as follows: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is his own legal decision maker. Resident 1's Nursing Comprehensive Admission Data Collection and Assessment form, dated [DATE], done by a Licensed Practical Nurse (LPN), and was cosigned by the DON on [DATE] states that Resident 1 is alert and oriented to person place and time. Resident 1 also has 1 + [MEDICAL CONDITION] (swelling) to his ankles and feet (this means that when the area is depressed with a finger it leaves a slight indent and the indent disappears rapidly). The form also states that Resident 1 is not short of breath but the form indicates that Resident 1 becomes short of breath "a little on exertion" in parentheses. Crackles and wheezes were heard in Resident 1's lungs. Resident 1 also has a Foley catheter. Resident 1's admission orders [REDACTED]. Instructions for taking [MEDICATION NAME] are handwritten on the entry indicating "decrease extra fluid." Resident 1 signed the facility's (CPR) Cardiopulmonary Resuscitation Consent form, dated [DATE], indicating, "It is my desire that: (a check mark was placed by Resuscitation) Resuscitation-I am expressing a desire to have CPR and /or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personal will be called." Resident 1's Physicians orders, signed by a physician on [DATE], indicate, "Full Code." Resident 1 experienced a significant change in condition on [DATE]. Following is a chronological summary of the events of that day based on entries in the nursing notes, statements taken during the facility ' s internal investigation, and surveyor interviews of staff. On [DATE] at 7:00 AM a nursing note states, "Many and varied C/O (complaints) during the NOC. Uses call light to get staff assist. First C/O of not being able to sleep. Call placed to (MD name) (MD Name) on call and returned call. Order given for Tylenol PM 1 to 2 tabs at NOC, prn (as needed) to promote sleep. 1 tab given to trial how resident would respond. Minimal effect noted. Several hours after C/O SOB (shortness of breath). O2 (oxygen) on at 2 liters per nc (nasal cannula) BP ,[DATE], P 104, R 29, and PO 93%. No cyanosis noted, capillary refill good to finger tips. Also C/O itching to torso. Worked with resident on focusing on how he breathes. Inhaling through nose and exhaling slowly through mouth. Was effective. Also massage gently with lotion over back and torso. Resident indicated this helped. Then after a short period CNA (certified nursing assistants) reports that resident C/O feet hurt ,[DATE] + [MEDICAL CONDITION] noted to feet. Encouraged to elevate. Reported to AM nurse and (Name) DON." This entry was documented by a LPN. The facility staff did not have an RN assessment completed for the significant changes in Resident 1's condition including his complaints of shortness of breath and complaints of [MEDICAL CONDITION] painful feet. Statement from the NOC LPN Q dated [DATE] taken during the facility's internal investigation: LPN Q documented in her statement at about 3:00 AM Resident 1 had been complaining of SOB and vital signs along with lung sounds were done. Resident 1 did not take very deep inspirations even with encouragement, but LPN Q indicated she did not hear anything abnormal. At about ,[DATE] AM Resident 1 complained to the CNA's that his feet hurt and then it was noted by LPN Q that Resident 1 had ,[DATE] + [MEDICAL CONDITION]. LPN Q documented that it was "close to the end of her shift" so she reported what had occurred to the AM nurse to follow up. LPN Q did not call the MD that AM as it was close to end of shift and felt that it would be more likely that AM nurse would be able to contact primary care physician as opposed to physician on call who would not know resident as well. Resident 1's MAR (medication administration assessment) record for [DATE]th states that his admit weight was 140 pounds, [DATE]th was blank, [DATE] has an (R) in it, to represents that Resident 1 refused to be weighed. There is no weight in Resident 1's medical record other than his admission weight on [DATE]. An assessment to determine if Resident 1 had gained weight would have been essential for determining if his [MEDICAL CONDITION] in his feet and legs was significant, and if the PRN [MEDICATION NAME] was effective or not. A statement from LPN E dated [DATE] taken during the facility's internal investigation stated that LPN E went to give Resident 1 his AM medications and Resident 1 asked LPN E to look at his calves and feet. LPN E noted that he had 2+ [MEDICAL CONDITION] bilaterally. The note continues to indicate that LPN E then asked RN F what Resident 1's normal was for the [MEDICAL CONDITION] to his legs. LPN E gave prn [MEDICATION NAME] per RN F direction for the [MEDICAL CONDITION]. LPN E gave report to RN F and left at around 10:30 AM. On [DATE] at 1:15 PM Surveyor interviewed LPN E regarding Resident 1. LPN E stated, "I worked that day from 6 AM to 10:00 AM. I gave him his meds and he was very anxious. He was anxious the night before. Noted that he had 2 + [MEDICAL CONDITION] in lower legs, I wanted his feet elevated due to the swelling but he wouldn't do it. I went and asked the RN about the PRN [MEDICATION NAME] order and she said to give it. The RN stated that he was always anxious, that was normal. Resident 1 was so anxious he could not sit still." Surveyor asked LPN E how a change of condition was communicated between staff. LPN E stated that when a change occurs it gets written on the 24 hour board and is documented until it is resolved." An entry on a separate nursing note, not documented as a late entry, or dated/timed as to when actually documented in the record (Cross Reference F514), dated [DATE] at 1:00 PM states, Writer entered resident's room at lunch time with noon pill. Asked resident if he needed anything at that time. Resident took noon pill and was sitting up at bedside his norm, waved writer out of room towards door. Resident denied pain or discomfort." This entry was written by an RN, however, there is no RN assessment of Resident 1 to follow up on his significant change of condition that was documented at 7:00 AM on [DATE]. On [DATE] at 1:30 PM Surveyor interviewed RN Unit Manager F regarding Resident 1. RN F stated, "I was just the nurse on the floor from 10:00 AM until around 2 PM. I was told in report that he had been given prn [MEDICATION NAME]. I have dealt with him (Resident 1); he is rude and pushy eats lunch in his room and I went in to give him his meds. I asked him if he needed anything else and he waved me toward the door. The LPN told me she gave the PRN [MEDICATION NAME]. I didn't go into the room until around 12 noon for pills. He did not offer anything further. I eyeballed him he was in a t-shirt and boxers. I did not note any [MEDICAL CONDITION] or shortness of breath, nothing out of the ordinary." Surveyor asked RN F how changes of condition are communicated. RN F stated that when she is acting as the unit manager the 24 hour boards are collected and taken to the DON and then they review them. After the meeting we are assigned to follow up. Then we get back together and the DON reports off on what was done. There is no documentation on the 24 hour board regarding Resident 1 and any new medications, complaints or prns given. A nursing note dated [DATE] "late entry for [DATE]" no time noted, states, "Resident was noted to have 2+ [MEDICAL CONDITION] to bilateral lower extremities, calf to toes. RN notified of [MEDICAL CONDITION] and prn [MEDICATION NAME] given. Lung sounds were clear and resident encouraged to elevate legs on bed but insisted on sitting up with legs to side of bed. No further complaints." This note was written by an LPN. There is no RN documentation that an assessment was done for giving the PRN [MEDICATION NAME] or what parameters were used or why the physician was not contacted. A statement from CNA C dated [DATE] taken during the facility ' s internal investigation stated that Resident 1 was on his call light repeatedly from about 6:00 PM on. CNA C indicated Resident 1 kept complaining he couldn't breathe and he kept saying he felt like he was going to die. CNA C indicated notifying the nurse to what Resident 1 was saying and the nurse said she knew it. CNA C stated that she did turn up Resident 1's oxygen and notified the nurse right after doing that. On [DATE] at 2:20 PM Surveyor interviewed CNA C regarding Resident 1 on [DATE]. CNA C stated, "He had been on the call light a lot that night, especially after 6:00 PM it was like every ,[DATE] minutes. He kept telling me that he couldn't breathe, needed his MD and that he was gonna die. He was sitting on the side of the bed moving back and forth, uncomfortable, breathing heavily. I reported this to the nurse at least 5 times and she stated that she knew that and he had anxiety issues. He wanted an MD and I turned up the oxygen to 5 liters, I didn't know what else to do. I told the LPN that I turned it up and she said I couldn't do that. I offered to go and turn it down and she refused. I noticed that his legs were swollen not sure if they were before or not. I left at shift change. I know now that if I have an issue I can go to another nurse or call the DON." On [DATE] at 12:45 PM, Surveyor interviewed LPN G regarding the events of the PM shift on [DATE] regarding Resident 1. LPN G stated, "I got from day shift report that he was given prn [MEDICATION NAME] for his swollen legs. I do not recall his urine output. He lay down in bed all day and slept. After supper he was sitting at the foot of the bed and looked out the doorway. He did this every single night this was nothing new. (CNA C) came and told me that he complained that he couldn't breathe and needed an MD. (CNA C) stated that she turned up his oxygen because he couldn't breathe. I think (CNA C) told me a couple of times. I went and turned the O2 back down and explained that you cannot turn up oxygen on certain residents as it could be detrimental to their health. This aide thinks we do not respond quick enough to her concerns and we don't know how to do our job." LPN G continued on to state, "(Resident 1) was very anxious, he was beyond anxious he couldn't sit still. (Resident 1) told me that he was going to die tonight and if he dies that it will be on my conscience for the rest of my life. When he said that I asked him what he wanted me to do. (Resident 1) said, 'I don't know, you gotta do something look at my legs and feet how swollen they are.' I tried to elevate his legs on pillows, but he couldn't/wouldn't lay down. I did vital signs and they were starting to go up and his pulse ox was in the 80's and 70's but would bounce back up when I tried to calm him down. He kept asking for oxygen and I told him that he is already on it. I do not remember reporting this to the RN and I should have. I tried to get his legs up." Surveyor asked LPN G what actions were taken for Resident 1. LPN G stated that she gave a prn [MEDICATION NAME] also and a prn Tylenol PM. LPN G did not notify the PM RN of Resident 1's significant change of condition. Surveyor asked LPN G how she monitored output of Resident 1 after the PRN [MEDICATION NAME]. LPN G stated the CNA staff tells her of the output and she records it. LPN G stated that she did not notice any increase in Resident 1's output on [DATE]. There is no documentation of Resident 1's output on [DATE] on day or PM shift to monitor the prn [MEDICATION NAME], in fact, there is no mention of any output in the nursing notes or the Caretracker. Surveyor asked LPN G if Resident 1 asked that his physician be called. LPN G responded that he (Resident 1) "didn't tell me that, only the aide, I guess." Surveyor asked LPN G what is the procedure for a change of condition of a resident. LPN G responded that when a change of condition occurs, vital signs and data should be collected, and then report the information to the charge nurse, and or call the physician. Document the information on the 24 hour board and document what was done and ordered in the medical record. A late entry nursing note for 9:45 PM by LPN G states, "Res. C/O (arrow pointing up) increased swelling to BLE (Bilateral lower extremities). Upon assessment res. (arrow pointing up) anxiety ,[DATE]+ [MEDICAL CONDITION] PRN [MEDICATION NAME] 20 mg given. Requested pillow to elevate feet which was done although resident didn't elevate BLE's when pillows brought to room. Kept asking for O2 which O2 was on at 2 lm per nc T96.8, P76, R 20, BP ,[DATE], POX 93% with O2 on." This entry is signed by a LPN. No RN assessment was completed with this significant change of condition. Resident 1's physician was not called with his continued complaints of shortness of breath, [MEDICAL CONDITION] legs and restlessness. " On [DATE] at 4:00 PM Surveyor interviewed LPN D regarding Resident 1 on [DATE]. LPN D stated, "I worked another hall on PM shift and then I worked the NOC shift on his hallway. At about 10:00 PM, the PM LPN (LPN G) and I had report and then went out for a smoke break as I thought it would be the only one we got that night as I thought I would be alone in the building. (LPN G) stated to me that (Resident 1) told her that he was gonna die tonight and his death would be on her conscience for the rest of her life. I told (LPN G) that I would be mad if he died tonight because he said that. (LPN G) stated that she did a set of vital signs and they were fine, and he had all the PRNs that he could have. He was very restless and anxious and had C/O of his legs swelling but he wouldn't put them up. This occurred was around 10:00 PM when I came in from outside I had to do some staffing calls. The NOC aide came to me around 11:00 PM and stated that she thought (Resident 1) was dead. I went down to his room and he was sitting on the edge of the bed and leaning over almost folded in half. We placed him on his bed and I went to call everyone. The DON walked in (as she was working a NOC shift) and I told her what happened and she stated to follow the procedure for a death in the manual. I was collecting the paperwork and noted that he was a full code. I reported this to the DON. We know now that all full codes, regardless of witnessed or not should have CPR initiated. We have had inservice training on change of condition, assessments, using PRN's that have parameters, CPR, and staff not turning up O2. I thought that only witnessed codes get CPR." This interview indicates that LPN D was aware that Resident 1 told LPN G that he felt he was going to die and LPN D and LPN G went outside the facility to have a smoke break and did not go immediately to see what Resident 1's condition was prior to leaving the unit A nursing note dated [DATE] at 11:30 PM states, "Called to resident's room by CNA's on unit. Resident found by staff slumped over in bed and unresponsive. Upon entering room Resident bilat LE's mottled and cold, lips blue. No heart rate/pulse, no O2 level, no BP. DON in house and notified. Family notified and on their way in. DR on call paged and awaiting ret (return) phone call." There is no entry by the DON when informed that Resident 1 expired. The facility failed to initiate CPR as Resident 1 had requested a full code. The RN failed to comply with N6.03(1)(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. On [DATE], at 12:50 PM, Surveyor interviewed DON B regarding Resident 1. DON B stated, "I was not made aware of anything but Resident 1 getting the Tylenol PM. I was not made aware that he was short of breath. We did review the incident and we did several corrective actions and several inservices for areas for improvement that we found. The physician should have been called in the morning when he was short of breath and his feet swelled, the physician should have been called when the PRN [MEDICATION NAME] was given and in the evening when he still had shortness of breath...The procedure is to initiate CPR when a resident is a full code witnessed or unwitnessed. The NOC nurse should have initiated CPR but thought that it was only when it was witnessed arrest. The staff are to look at the chart if there is an arrest/or event. We have tried other stickers or bands but things change too often to make it an effective system. The staff is to go to the chart or send someone and find out from the original form if they are a code or no code." Surveyor asked DON B how staff is to follow up on a change of condition of any Resident. DON B stated, "We have a process called the Daily Clinical Review. That is where the 24 hour boards are collected and we review in the morning and expect follow up by the IDT (interdisciplinary team) in the afternoon to make sure that residents were followed up and documented on." It should be noted, there is no entry on the 24 hour board for Resident 1 on [DATE], but there should have been as he had a change in condition and then would have received follow up. The facility failed to provide Resident 1 care that was consistent with professional standards of nursing practice throughout the day on [DATE] by LPN failure to report significant changes in condition to the charge nurse or the physician, RN failure to assess Resident 1 ' s changing condition, and failure to implement the resident ' s plan of care and to provide cardiopulmonary resuscitation. This created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on [DATE] when: 1. A medical record review was conducted on Resident 1 2. LPN G and LPN E, and RN F were re-educated and counseled on change of condition, AMDA guidelines for physician notification, RN assessment and changes in condition, LPN to RN dialog, RN/LPN standards of practice, and [MEDICAL CONDITION] care path. plus all other licensed staff re-educated 3. A review of all other residents with [MEDICAL CONDITION] to make sure all monitoring devices were in place. 4. Licensed staff re-educated on CPR policy and procedure. 5. LPN D was counseled on not initiating CPR when Resident 1 was a full code. Cross Reference F242, F309, and F157.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 8 sampled residents requesting Full Code services (Resident 1) and for assessing, evaluating, and implementing interventions for a significant change of condition. Resident 1 had a significant change of condition that was identified in the nursing notes at 7:00 AM on [DATE]. The AM nurse and DON (Director of Nursing) were informed but no assessment, evaluation and implementation of interventions were taken. The change of condition worsened during the day and into the PM shift. No thorough assessment was done, no condition change was reported to a Registered Nurse (RN) or a physician as Resident 1 became worse. No such interventions occurred even when the resident told staff he was dying. When staff found Resident 1 pulseless and non-breathing on [DATE] at approximately 11:00 PM, CPR was not initiated, even though the resident had expressed a desire to be full code and had physician's orders [REDACTED]." The nurse that was caring for Resident 1 did not know he was a full code at that time and did not know that CPR should be initiated with an unwitnessed arrest. The lack of response to Resident 1's significant change of condition throughout the day shift, lack of RN assessment, not calling the physician to update the physician on Resident 1's status, and lack of response to initiate CPR, thus denying this resident his only chance at survival, resulted in a finding of Immediate Jeopardy which began on [DATE]. The facility was notified of Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope severity level of E (potential for harm that is not immediate jeopardy/pattern) because the facility has to fully implement and evaluate the effectiveness of its action plan. This has the potential to affect the 26 additional residents who were identified as wishing Full Code status (Residents 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34). Findings as follows: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is his own legal decision maker. Resident 1's Nursing Comprehensive Admission Data Collection and Assessment form, dated [DATE], done by a Licensed Practical Nurse (LPN), and was cosigned by the DON on [DATE] states that Resident 1 is alert and oriented to person place and time. Resident 1 also has 1 + [MEDICAL CONDITION] (swelling) to his ankles and feet (this means that when the area is depressed with a finger it leaves a slight indent and the indent disappears rapidly). The form also states that Resident 1 is not short of breath but the form indicates that Resident 1 becomes short of breath "a little on exertion." Crackles and wheezes were heard in Resident 1's lungs. Resident 1 also has a Foley catheter. Resident 1's admission orders [REDACTED]. Instructions for taking [MEDICATION NAME] are handwritten on the entry indicating "decrease extra fluid." The order does not indicate parameters as to how often and when to give it for "extra fluid." Resident 1 signed the facility's (CPR) Cardiopulmonary Resuscitation Consent form, dated [DATE], indicating, "It is my desire that: (a check mark was placed by Resuscitation) Resuscitation-I am expressing a desire to have CPR and /or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personal will be called." Resident 1's physician's orders [REDACTED]." Resident 1's nursing notes, dated [DATE] at 2:30 PM, indicate that he refused to have his vital signs taken. But it is documented that his pulse is 80 and regular and his breathing pattern normal and steady at 28 (abnormal). Resident 1 complained of being dizzy when lying in bed and did not want to take his medications. Resident 1 was talked into taking his medications. No follow up charting was documented regarding his elevated respirations or his complaints of dizziness. No RN assessment was completed for the changes in Resident 1 status. Resident 1 experienced a significant change in condition on [DATE]. Following is a chronological summary of the events of that day based on entries in the nursing notes, statements taken during the facility ' s internal investigation, and surveyor interviews of staff. On [DATE] at 7:00 AM a nursing note states, "Many and varied C/O (complaints) during the NOC. Uses call light to get staff assist. First C/O of not being able to sleep. Call placed to (MD name) (MD Name) on call and returned call. Order given for Tylenol PM 1 to 2 tabs at NOC, prn (as needed) to promote sleep. 1 tab given to trial how resident would respond. Minimal effect noted. Several hours after C/O SOB (shortness of breath). O2 (oxygen) on at 2 liters per nc (nasal cannula) BP ,[DATE], P 104, R 29, and PO 93%. No cyanosis noted, capillary refill good to finger tips. Also C/O itching to torso. Worked with resident on focusing on how he breathes. Inhaling through nose and exhaling slowly through mouth. Was effective. Also massage gently with lotion over back and torso. Resident indicated this helped. Then after a short period CNA (certified nursing assistants) reports that resident C/O feet hurt ,[DATE] + [MEDICAL CONDITION] noted to feet. Encouraged to elevate. Reported to AM nurse and (Name) DON." This entry was documented by a LPN. The facility staff did not have an RN assessment completed for the significant changes in Resident 1's condition including his complaints of shortness of breath and complaints of [MEDICAL CONDITION] painful feet. Statement from the NOC LPN Q dated [DATE] taken during the facility ' s internal investigation: LPN Q documented in her statement at about 3:00 AM Resident 1 had been complaining of SOB and vital signs along with lung sounds were done. Resident 1 did not take very deep inspirations even with encouragement, but LPN Q indicated she did not hear anything abnormal. At about ,[DATE] AM Resident 1 complained to the CNA's that his feet hurt and then it was noted by LPN Q that Resident 1 had ,[DATE] + [MEDICAL CONDITION]. LPN Q documented that it was "close to the end of her shift" so she reported what had occurred to the AM nurse to follow up. LPN Q did not call the MD that AM as it was close to end of shift and felt that it would be more likely that AM nurse would be able to contact primary care physician as opposed to physician on call who would not know resident as well. A statement from LPN E dated [DATE] taken during the facility ' s internal investigation stated that LPN E went to give Resident 1 his AM medications and Resident 1 asked LPN E to look at his calves and feet. LPN E noted that he had 2+ [MEDICAL CONDITION] bilaterally. The note continues to indicate that LPN E then asked RN F what Resident 1's normal was for the [MEDICAL CONDITION] to his legs. LPN E gave prn [MEDICATION NAME] per RN F direction for the [MEDICAL CONDITION]. LPN E gave report to RN F and left at around 10:30 AM. On [DATE] at 1:15 PM Surveyor interviewed LPN E regarding Resident 1. LPN E stated, "I worked that day from 6 AM to 10:00 AM. I gave him his meds and he was very anxious. He was anxious the night before. Noted that he had 2 + [MEDICAL CONDITION] in lower legs, I wanted his feet elevated due to the swelling but he wouldn't do it. I went and asked the RN about the PRN [MEDICATION NAME] order and she said to give it. The RN stated that he was always anxious, that was normal. Resident 1 was so anxious he could not sit still." Surveyor asked LPN E how a change of condition was communicated between staff. LPN E stated that when a change occurs it gets written on the 24 hour board and is documented until it is resolved." An entry on a separate nursing note, not documented as a late entry, or dated/timed as to when actually documented in the record (Cross Reference F514), dated [DATE] at 1:00 PM states, Writer entered resident's room at lunch time with noon pill. Asked resident if he needed anything at that time. Resident took noon pill and was sitting up at bedside his norm, waved writer out of room towards door. Resident denied pain or discomfort." This entry was written by an RN, however, there is no RN assessment of Resident 1 to follow up on his significant change of condition that was documented at 7:00 AM on [DATE]. On [DATE] at 1:30 PM Surveyor interviewed RN Unit Manager F regarding Resident 1. RN F stated, "I was just the nurse on the floor from 10:00 AM until around 2 PM. I was told in report that he had been given prn [MEDICATION NAME]. I have dealt with him (Resident 1); he is rude and pushy eats lunch in his room and I went in to give him his meds. I asked him if he needed anything else and he waved me toward the door. The LPN told me she gave the PRN [MEDICATION NAME]. I didn't go into the room until around 12 noon for pills. He did not offer anything further. I eyeballed him he was in a t-shirt and boxers. I did not note any [MEDICAL CONDITION] or shortness of breath, nothing out of the ordinary." Surveyor asked RN F how changes of condition are communicated. RN F stated that when she is acting as the unit manager the 24 hour boards are collected and taken to the DON and then they review them. After the meeting we are assigned to follow up. Then we get back together and the DON reports off on what was done. There is no documentation on the 24 hour board regarding Resident 1 and any new medications, complaints or prns given. A nursing note dated [DATE] "late entry for [DATE]" no time noted, states, "Resident was noted to have 2+ [MEDICAL CONDITION] to bilateral lower extremities, calf to toes. RN notified of [MEDICAL CONDITION] and prn [MEDICATION NAME] given. Lung sounds were clear and resident encouraged to elevate legs on bed but insisted on sitting up with legs to side of bed. No further complaints." This note was written by an LPN. There is no RN documentation that an assessment was done for giving the PRN [MEDICATION NAME] or what parameters were used or why the physician was not contacted. A statement from CNA C dated [DATE] taken during the facility ' s internal investigation stated that Resident 1 was on his call light repeatedly from about 6:00 PM on. CNA C indicated Resident 1 kept complaining he couldn't breathe and he kept saying he felt like he was going to die. CNA C indicated notifying the nurse to what Resident 1 was saying and the nurse said she knew it. CNA C stated that she did turn up Resident 1's oxygen and notified the nurse right after doing that. On [DATE] at 2:20 PM Surveyor interviewed CNA C regarding Resident 1 on [DATE]. CNA C stated, "He had been on the call light a lot that night, especially after 6:00 PM it was like every ,[DATE] minutes. He kept telling me that he couldn't breathe, needed his MD and that he was gonna die. He was sitting on the side of the bed moving back and forth, uncomfortable, breathing heavily. I reported this to the nurse at least 5 times and she stated that she knew that and he had anxiety issues. He wanted an MD and I turned up the oxygen to 5 liters, I didn't know what else to do. I told the LPN that I turned it up and she said I couldn't do that. I offered to go and turn it down and she refused. I noticed that his legs were swollen not sure if they were before or not. I left at shift change. I know now that if I have an issue I can go to another nurse or call the DON." On [DATE] at 12:45 PM, Surveyor interviewed LPN G regarding the events of the PM shift on [DATE] regarding Resident 1. LPN G stated, "I got from day shift report that he was given prn [MEDICATION NAME] for his swollen legs. I do not recall his urine output. He lay down in bed all day and slept. After supper he was sitting at the foot of the bed and looked out the doorway. He did this every single night this was nothing new. (CNA C) came and told me that he complained that he couldn't breathe and needed an MD. (CNA C) stated that she turned up his oxygen because he couldn't breathe. I think (CNA C) told me a couple of times. I went and turned the O2 back down and explained that you cannot turn up oxygen on certain residents as it could be detrimental to their health. This aide thinks we do not respond quick enough to her concerns and we don't know how to do our job." LPN G continued on to state, "(Resident 1) was very anxious, he was beyond anxious he couldn't sit still. (Resident 1) told me that he was going to die tonight and if he dies that it will be on my conscience for the rest of my life. When he said that I asked him what he wanted me to do. (Resident 1) said, 'I don't know, you gotta do something look at my legs and feet how swollen they are.' I tried to elevate his legs on pillows, but he couldn't/wouldn't lay down. I did vital signs and they were starting to go up and his pulse ox was in the 80's and 70's but would bounce back up when I tried to calm him down. He kept asking for oxygen and I told him that he is already on it. I do not remember reporting this to the RN and I should have. I tried to get his legs up." Surveyor asked LPN G what actions were taken for Resident 1. LPN G stated that she gave a prn [MEDICATION NAME] also and a prn Tylenol PM. LPN G did not notify the PM RN of Resident 1's significant change of condition. Surveyor asked LPN G how she monitored output of Resident 1 after the PRN [MEDICATION NAME]. LPN G stated the CNA staff tells her of the output and she records it. LPN G stated that she did not notice any increase in Resident 1's output on [DATE]. There is no documentation of Resident 1's output on [DATE] on day or PM shift to monitor the prn [MEDICATION NAME], in fact, there is no mention of any output in the nursing notes or the Caretracker. Surveyor asked LPN G if Resident 1 asked that his physician be called. LPN G responded that he (Resident 1) "didn't tell me that, only the aide, I guess." Surveyor asked LPN G what is the procedure for a change of condition of a resident. LPN G responded that when a change of condition occurs, vital signs and data should be collected, and then report the information to the charge nurse, and or call the physician. Document the information on the 24 hour board and document what was done and ordered in the medical record A late entry nursing note for 9:45 PM by LPN G states, "Res. C/O (arrow pointing up) increased swelling to BLE (Bilateral lower extremities). Upon assessment res. (arrow pointing up) anxiety ,[DATE]+ [MEDICAL CONDITION] PRN [MEDICATION NAME] 20 mg given. Requested pillow to elevate feet which was done although resident didn't elevate BLE's when pillows brought to room. Kept asking for O2 which O2 was on at 2 lm per nc T96.8, P76, R 20, BP ,[DATE], POX 93% with O2 on." This entry is signed by a LPN. No RN assessment was completed with this significant change of condition. Resident 1's physician was not called with his continued complaints of shortness of breath, [MEDICAL CONDITION] legs and restlessness. " On [DATE] at 4:00 PM Surveyor interviewed LPN D regarding Resident 1 on [DATE]. LPN D stated, "I worked another hall on PM shift and then I worked the NOC shift on his hallway. At about 10:00 PM, the PM LPN (LPN G) and I had report and then went out for a smoke break as I thought it would be the only one we got that night as I thought I would be alone in the building. (LPN G) stated to me that (Resident 1) told her that he was gonna die tonight and his death would be on her conscience for the rest of her life. I told (LPN G) that I would be mad if he died tonight because he said that. (LPN G) stated that she did a set of vital signs and they were fine, and he had all the PRNs that he could have. He was very restless and anxious and had C/O of his legs swelling but he wouldn't put them up. This occurred was around 10:00 PM when I came in from outside I had to do some staffing calls. The NOC aide came to me around 11:00 PM and stated that she thought (Resident 1) was dead. I went down to his room and he was sitting on the edge of the bed and leaning over almost folded in half. We placed him on his bed and I went to call everyone. The DON walked in (as she was working a NOC shift) and I told her what happened and she stated to follow the procedure for a death in the manual. I was collecting the paperwork and noted that he was a full code. I reported this to the DON. We know now that all full codes, regardless of witnessed or not should have CPR initiated. We have had inservice training on change of condition, assessments, using PRN's that have parameters, CPR, and staff not turning up O2. I thought that only witnessed codes get CPR." This interview indicates that LPN D was aware that Resident 1 told LPN G that he felt he was going to die and LPN D and LPN G went outside the facility to have a smoke break and did not go immediately to see what Resident 1's condition was prior to leaving the unit A nursing note dated [DATE] at 11:30 PM states, "Called to resident's room by CNA's on unit. Resident found by staff slumped over in bed and unresponsive. Upon entering room Resident bilat LE's mottled and cold, lips blue. No heart rate/pulse, no O2 level, no BP. DON in house and notified. Family notified and on their way in. DR on call paged and awaiting ret (return) phone call." There is no entry by the DON when informed that Resident 1 expired. The facility failed to initiate CPR as Resident 1 had requested a full code. The facility failed on multiple occasions to call Resident 1's physician to report significant changes of condition. Surveyor requested a copy of the urinary outputs for Resident 1 to find out the urinary output for [DATE] after Resident 1 received prn [MEDICATION NAME]. A review of Resident 1's Caretracker documentation intake and output record (ran at 5:03 PM on [DATE]) reveals that Resident 1 did not have any output recorded on [DATE]. Resident 1's average fluid intake from [DATE] to [DATE] (7 days) is 1770 cc a day total fluid intake and an average of the 7 days of urine output is 307 cc this is a fluid variance of 1440 cc a day greater intake than output. No nursing personal reviewed, analyzed and acted upon Resident 1's outputs that were exceeding his intakes by over 1000cc a day. On [DATE], at 12:50 PM, Surveyor interviewed DON B regarding Resident 1. DON B stated, "I was not made aware of anything but Resident 1 getting the Tylenol PM. I was not made aware that he was short of breath. We did review the incident and we did several corrective actions and several inservices for areas for improvement that we found. The physician should have been called in the morning when he was short of breath and his feet swelled, the physician should have been called when the PRN [MEDICATION NAME] was given and in the evening when he still had shortness of breath...The procedure is to initiate CPR when a resident is a full code witnessed or unwitnessed. The NOC nurse should have initiated CPR but thought that it was only when it was witnessed arrest. The staff are to look at the chart if there is an arrest/or event. We have tried other stickers or bands but things change too often to make it an effective system. The staff is to go to the chart or send someone and find out from the original form if they are a code or no code." Surveyor asked DON B how staff is to follow up on a change of condition of any Resident. DON B stated, "We have a process called the Daily Clinical Review. That is where the 24 hour boards are collected and we review in the morning and expect follow up by the IDT (interdisciplinary team) in the afternoon to make sure that residents were followed up and documented on." It should be noted, there is no entry on the 24 hour board for Resident 1 on [DATE], but there should have been as he had a change in condition and then would have received follow up. The facility failed to provide Resident 1 the care and treatment that he needed after he experienced a significant condition change on [DATE] and after he was found pulseless and breathless. The facility's failure to appropriately respond to Resident #1's significant change in condition and its failure to provide appropriate life saving CPR per the resident's wishes created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on [DATE] when: 1. A medical record review was conducted on Resident 1 2. LPN G and LPN E, and RN F were re-educated and counseled on change of condition, AMDA guidelines for physician notification, RN assessment and changes in condition, LPN to RN dialog, RN/LPN standards of practice, and [MEDICAL CONDITION] care path. plus all other licensed staff re-educated 3. A review of all other residents with [MEDICAL CONDITION] to make sure all monitoring devices were in place. 4. Licensed staff re-educated on CPR policy and procedure. 5. LPN D was counseled on not initiating CPR when Resident 1 was a full code.

Based on interview and record review, the facility did not provide 2 of 6 residents reviewed with appropriate supervision to prevent accidents. Resident 2's dysphagia was not assessed and care planned so that staff were monitoring Resident 2 during meals. On [DATE], Resident 2 choked and died at the facility. Resident 3 was known to the facility to have an incident of sexually inappropriate behavior towards a female resident on [DATE], [DATE], [DATE], [DATE], and [DATE]. Although the facility did assess this behavior, care planned for the behavior and did initiate some increased monitoring; Resident 3 was still able to have inappropriate sexual contact with female residents on 4 occasions after first noting the behavior. This is evidenced by: Example 1 Resident 2 was noted to have a choking episode on [DATE]. Resident 2 was sent to the hospital emergency room . Physician documentation from the [DATE] visit states, " ...choked on a soggy tuna sandwich PTA (prior to admission) and had stridor per NH staff. Vomited and better PTA. Has had FB (foreign body) sensation in throat since Beb when treated for [REDACTED]. Will f/u (follow up) with possible scoping as outpt. (outpatient)." Chest x-ray noted, "possible aspiration on the right lung." When Resident 2 returned to the nursing home there were no changes made to her care plan to prevent future choking episodes. The nursing notes indicate that Resident 2 was monitored for choking/swallowing problems from ,[DATE] through [DATE]. On [DATE] Resident 2 was reviewed by a facility speech language pathologist and was determined to be not appropriate for skilled therapy interventions. The therapist noted, "Pt. reports after choking episode she is eating slower and chewing more and paying closer attention to eating safely." There is no indication that the therapist reviewed Resident 2's [DIAGNOSES REDACTED]. A nutrition progress note dated [DATE] indicates no chewing /swallowing problems and does not indicate any increased monitoring may be needed to ensure safety. On [DATE] nursing staff sent a "physician order [REDACTED]. But relays she has "something in her throat" and was to see specialist a while ago. Could we have an ENT (ear nose and throat) consult to evaluate hoarseness, chronic c/o (complaints of) throat irritation." The MD agreed to the ENT consult. Nursing note dated [DATE] states, "Res daughter updated on res consult with ENT r/t chronic cough/c/o something in throat, appt with (ENT) on [DATE]." On [DATE] Resident 2 went to a consult with an ENT. The "report of consultation" form indicates, reason for consultation: "cough - states something in throat (chronic)." The "report of findings" states, "Thick mucous present Pt will need nebulizer treatments and antibiotics. PCP (primary care provider) to be contacted." Recommendations state, "Video swallow post antibiotics and follow up after that exam." The typed report from this ENT MD visit, dated [DATE], in a letter format to the PCP states, "Endoscopic examination today was not consistent with any significant degree of reflux, more over she's currently on Ranitidine twice daily. She did demonstrate significant ucopurulent mucous throughout the hypopharynx extending into the epiglottis and false vocal cords ...There is also a history of choking occasionally while eating. I think a video swallow exam especially given her history of CVA (cerebrovascular accident) is warranted to assess the severity of her aspiration risk ...Impression: Chronic cough suspect underlying etiology of chronic bronchitis, chronic lower airway reactivity/asthma? Suspect elevated aspiration risk ...longstanding history of chronic wet, productive cough ...there is a history of mild dysphagia in the form of occasional coughing and choking while eating. She does have a history of recurrent pneumonia this year as well as a hospitalization where she required a breathing treatment ..." There is no nursing note on [DATE] indicating the visit or any changes to be made as a result of the visit. On [DATE], there is a nursing note indicating that the hospital called to set up a speech evaluation and possible video swallow study for [DATE]. No changes were made to the care plan or increased monitoring of Resident 2's eating abilities. Nursing note [DATE] at 1945 (7:45 pm) states, "occasional non productive cough more after eating and drinking, some wheezing noted, all is improved after scheduled neb tx given." On [DATE] Resident 2 went for an outpatient modified barium swallow. The report from this procedure indicates, "treatment [DIAGNOSES REDACTED]. No cough noted during exam ...Pt demonstrated mild weak mastication and required extra time for oral prep on mixed, soft solid, and solid consistencies ...Mild delayed initiation of oral transit on soft solids, and solids d/t (due to) mild decreased lingual coordination. Premature bolus loss reduced lingual control/sensation ...history of pneumonia ...Mild delayed initiation of pharyngeal swallow d/t reduced sensation across consistencies ...flash penetration noted on thin liquids above level of vocal folds by spoon, straw, and cup on single swallows. Penetration to level of vocal folds on consecutive swallow attempt ...no aspiration ...Recommend general/thin diet per pt tolerance. Pt may require difficult to chew foods prepared into bite size pieces to aid mastication. No consecutive swallows on liquids ...Precautions/compensatory strategies: Sit at 90 degrees; small bites/sips; slow rate; no continuous cup drinking; upright position after intake for 20 minutes; alternate solid/liquid bolus ...If any changes in swallowing status occur refer pt for further swallow evaluation." Nursing note, dated [DATE] at 2030 (8:30 pm), states, Res was out to swallow study with (ENT physician) no paperwork returned. Daughter (name) called + said there were no new orders she knew of but she will make the f/u appt + then let us know to set up transportation." Resident 2 went to an appointment with the above noted information, to include recommendations, which were not conveyed to the facility timely. A nutrition progress note, dated [DATE] indicates no chewing /swallowing problems. There is no indication that Resident 2 may require increased monitoring or the recommendations that were made on the [DATE] ENT visit. On [DATE] Resident 2 went again to the ENT physician. The "report of consultation" stated, "Recommendations: eat slowly, small sips of fluids, smaller bits of food no diet restrictions at this time." Nursing note, dated [DATE] at 1040 (10:40 am), states, "Res went out to appt. to see (PCP) recommendation given and put on tx sheets." It should be noted that the nurse wrote "eat slowly, small sips of fluids, smaller bits of food no diet restrictions at this time" on an undated treatment sheet for Resident 2 the treatment sheet was put with the September treatment sheets but the information was not added to the October treatment sheet, and the information was not sent for a therapy referral or put on the 24 report sheet so others would be aware of the information received and the care plan was not updated. Resident 2's nutritional risks plan of care, initiated April of 2009, updated on [DATE], does not address the choking incident on [DATE], the ENT referrals, or the swallow study/ENT recommendations so that staff would supervise Resident 2 while eating to sure safety. Resident 2's cognitive assessment plan of care, initiated on [DATE], indicates a medical [DIAGNOSES REDACTED]." Interventions for this problem include: "Provide cues/direction with cares/activities as needed." Resident 2's care plan was not updated with the dysphagia risks or need to monitor Resident's 2's cognitive status with regard to ensuring the recommendations made by the ENT would be followed. Resident 2's quarterly Minimum Data Set (MDS) with a look back date of [DATE] for ADL (activities of daily living) indicate "eating how resident eats and drinks" is coded as "independent for self performance" however, the MDS notes "one person physical assist for support provided." On [DATE], Resident 2 was eating the evening meal in the main dining room of the facility. Resident 2 received a hamburger on a bun that was not altered in any way. Resident 2 was noted to cough and was told by staff to "take a drink of milk" to clear the airway. Resident 2 continued with difficulty, was noted to be turning cyanotic, staff initiated interventions to clear the airway but Resident 2 expired. Surveyor interviewed Dietary Aide (DA) H on [DATE] at 1:35 pm. DA H indicated that she had been in the dining room on [DATE] when Resident 2 had a choking incident. Surveyor provided DA H her written statement that she had documented on [DATE]. The statement reads, "(Resident 2) had been coughing and I told her to drink something and not to eat so fast and one of the CNA's also came over and we both saw (Resident 2's) lips turn blue and she (other CNA) ran for a nurse. I tried patting her (Resident 2) on the back hoping she would cough it up. The nurse came rushing ove rand applied the Heimlich maneuver. When that didn't work they took her into the hallway and closed the door." Surveyor asked if the documentation was as DA H remembered the events. DA H indicated that the documentation was accurate for the events. DA H also indicated that Resident 2 had half a hamburger still in her hand when she started choking. Surveyor asked DA H if she had ever been aware that Resident 2 had problems with choking or needed any dietary modifications or recommendations for eating. DA H indicated she had not been aware of any specific recommendations and that "sometimes" Resident 2 "coughs a lot when eating." Surveyor asked what DA H did when she noted Resident 2 coughing. DA H indicated that DA H would tell Resident 2 to "slow down and take a drink." Surveyor asked if DA H would tell nursing staff of the observations, DA H indicated that if there was no further coughing that she "probably would not." DA H was aware that Resident 2 had problems with coughing while eating previously and on [DATE] and did not immediately, or even after if Resident 2 cleared the cough, notify nursing staff so increased monitoring could be provided to Resident 2. A witness investigation statement, dated [DATE], written by CNA (certified nursing assistant) I states, "witnessed (Resident 2) wheezing and choking on something in dining room. Asked her if she was okay, she said yes. She continued talking to (another resident) to try to calm her (other resident) down. (Resident 2) was getting upset, as was (another resident) yelling across dining room to also tell (another resident) to shut up. A few minutes later (CNA C) said (Resident 2's) lips are turning blue." This statement notes that although Resident 2 showed signs of potential choking, CNA I, did not take immediate action to alert a nurse to monitor Resident 2. A witness investigation statement, dated [DATE], by CNA C states, "was in the dining room the night (Resident 2) died . I was passing coffee around the dining room when I saw (Resident 2) didn't look right. I went up to her and asked her if everything was okay. She shook her head no and I noticed her lips were just a little bit blue at that point. I told (CNA I) to go get a nurse because there was no nurse in sight. Some time had passed because (Resident 2's) lips turned even more blue and she was really pale. That is when I ran out of the dining room and screamed (Resident 2) was turning blue. Then the two nurses ran into the dining room." Surveyor interviewed CNA C on [DATE] at 3:35 pm. CNA C reviewed her statement, dated [DATE] and indicated that the information documented was as she remembered. CNA C indicated that the "nurses were supposed to be in the dining room." CNA C indicated that the nurses were usually not in the dining room at meals prior to the incident of [DATE] and are now more often in the dining room. Surveyor asked CNA C if she was aware that Resident 2 had problems with chewing/swallowing or choking. CNA C said that she had not been aware of any problems and that Resident 2 ate at an independent table in the dining room. CNA C indicated that if the resident had any problems the information would be on their diet cares, their care plans or the CNA care sheets and she wasn't aware of any information on Resident 2's problems eating until after the events of [DATE]. Surveyor interviewed Director of Nursing (DON) B on [DATE] at 4:10 pm. Surveyor reviewed Resident 2's history of the choking incident of [DATE], the recurrent upper respiratory infections, the ENT and swallowing study visits, and the physician recommendations for eating that were in Resident 2's medical record. DON B affirmed all information and indicated that there should have been a nurse in the dining room on [DATE], upon return from the swallow study the nurses should have initiated a therapy screen, the information from the swallow study and ENT visits should have been put on the 24 hour report so that nursing administration could follow up to ensure that action was taken, the recommendations should have been added to Resident 2's care plan and increased monitoring of Resident 2 should have been initiated to ensure that the staff were aware of the recommendations and that they were followed. The facility did not fully assess Resident 2's dysphagia, care plan the recommendations given after the swallow study, by the ENT and the PCP to ensure safety with meals and did not ensure that all staff were aware of Resident 2's recommendations to increase safety with meals and Resident 2 choked and died . Example 2 Resident 3 was admitted to the facility [DATE]. Resident 3 has diagnoses, documented on the list, as dementia, mild, Alzheimer's disease late, onset, mild moderate severity with loss over sexual impulses, per psych evaluation noted [DATE]. A short portable mental status questionnaire (SPMSQ) notes that on [DATE] Resident 3 scored a 4, 3 - 4 errors indicate "mild intellectual impairment." On [DATE], Resident scored a 6 on the SPMSQ, 5 0 7 errors indicate "moderate intellectual impairment." A social service progress note on [DATE] states, "It was reported that (Resident 3) asked a resident who is not oriented to give him a kiss. SSD (social services director) will monitor (Resident 3's) behaviors. Administrator reports speaking with (Resident 3) about that behavior which he reported understanding was not appropriate. This appears to be a one time instance, POA was made aware. SSD will continue to monitor. A social service progress note on [DATE] states, "There was an incident on this date in which (Resident 3) was witnessed attempting to touch another female resident inappropriately. SSD met with (Resident 3) to discuss the incident. He denied trying to touch this resident inappropriately and stated that he was just touching her arm to say hello. (Resident 3) acknowledged that he can't touch residents like that SSD discussed with him the difference between him touching this resident and the consentual relationship he has with another female resident. SSD completed a short portable mental status questionnaire and (Resident 3's) score reflected a moderate intellectual impairment. SSD left a message for (Resident 3's) POA requesting she call SSD to discuss the situation." A further note dated [DATE] indicates that Resident 3 was noted to have his penis out of his pants at the dining table and was moved to an all male table in the dining room. A mood and behavior symptom assessment/ plan of care initiated ,[DATE] indicates "presence of behavioral symptoms that may be harmful to self or others or interfering with function or care evidenced by: cognitive deficient: dementia, Socially inappropriate: (Resident 3) has demonstrated inappropriate sexual behaviors. He has attempted to touch a peer on her breast and previously asked the same resident for a kiss." The goal for this problem states, "(Resident 3) will not touch female residents or attempt to touch or solicit affection from other residents." The interventions for this problem include, "(Resident 3) will sit at an all male table. Monitor (Resident 3) around other female residents. (Resident 3) will eat at an all male table. If (Resident 3) is seen trying to touch or be affectionate w/ (with) unconsentual peer - remove him from the situation and remind him the behavior is not acceptable. (Resident 3) does have a female partner he is in a consentual relationship with. (Resident 3) will see a psychologist r/t his behaviors." There are 15 min checks and 1:1 interventions that were initiated and discontinued throughout the time from [DATE] through discharge on [DATE]. A psychological consultation was held on [DATE], the documentation of this visit states in part, "his advancing dementia and physical condition made return to an AL (assisted living) facility inadvisable. The presenting issue prompting this psych consult pertains to sexualized behavior. Early this year he developed a relationship with a consenting female and agreed to appropriate parameters regarding discrete sexual interaction; this relationship apparently hasn't been an issue. However, on ,[DATE] he wanted to give a non-competent female resident a kiss, and was made aware of its inappropriateness with this particular peer. The next incident was ,[DATE] when he was witnessed attempting to touch a non-competent female peer on the chest; he denied/minimized the behavior, and was again counseled regarding acceptable sexual interactions. He was placed on closer supervision. Later that day, he exposed his penis while sitting at the DR table, and was moved to an all-male table." The consultation continues, "Examination ...He seemed fairly alert and had a jovial manner, oftentimes covering his loss of memory with quips." The consultation continues, "diagnostic impression ...while his short-term memory appears very poor, he retains some higher order, abstract thinking ability. That means that while he is able to understand certain things when they are first explained to him, retaining this understanding is problematic." The consultation continues, "Recommendations ...the facility will need to continue monitoring his behavior and limiting access to non-competent female, etc." A nursing note, dated [DATE] at 1730 (5:30 pm), states, "CNA Witnessed resident grabbing a female resident's breast. CNA removed the female resident + educated resident (3) on the inappropriateness of his action. Resident laughed about the situation...Placed on 15 minute checks." The facility is aware that Resident 3 has previously been sexually inappropriate with female residents and that Resident 3 is not cognitively aware of the inappropriateness of his advances and is independently mobile in the facility in his wheelchair. A nursing note, dated [DATE] at 0940 (9:40 am), states, "Reported by dietary staff, resident touched a female resident inappropriately in dining room after breakfast. Resident removed from dining room and placed on one on one monitoring. A nursing note, dated [DATE] at 1900 (7:00 pm), states, "Resident was seen next to a female resident after dinner. Writer intervened immediately and removed the female resident, taking her to her room, before any incident could occur. Resident remains on 15 min checks." A late entry social service progress note, documented on [DATE] for [DATE], states, "SSD was notified of (Resident 3's) behaviors of inappropriately touching another resident on [DATE]. (Resident 3) was placed on 15 minute checks to monitor behaviors SSD did discuss behaviors with (Resident 3) and will continue to monitor." A Physician order [REDACTED]." The physician ordered antibiotics for a urinary tract infection. A social service progress note, dated [DATE], states, "SSD was notified of (Resident 3's) behaviors of inappropriately touching another resident over the weekend. (Resident 3) is still currently on 15 min checks to monitor behaviors. Nursing staff was notified SSD did discuss his behaviors with him and will continue to monitor." A social service progress note, dated [DATE], states "(Resident 3) had another incident of touching another resident on this date. (Resident 3) is on one on one supervision effective immediately. Nursing staff contacted his family a care conference is scheduled for this day. (Resident 3's) family is planning to attend." It was determined that the facility/family would pursue placement in an all male assisted living facility as 1:1 supervision was not practical for long term. A physician nursing home visit report, dated [DATE], states in part, "One week ago, the patient had an episode of confusion and increased sexual aggression. He was noted to have a urinary tract infection. We are treating him with antibiotics." A social service progress note, dated [DATE], states "(Resident 3) has not been demonstrating sexually inappropriate behaviors while 1:1 with staff. IDT (interdisciplinary team) feels that with staff having been inserviced as having a heightened sence (sic) of awareness as to behaviors, interactions and environment for those on 15 min checks it would be appropriate to DC (discontinue) one on one supervision on this date and begin 15 minute checks all departments are aware of the need to be aware of resident's behaviors and surroundings. SSD will continue to monitor moods and behaviors." A social service progress note, dated [DATE], states, "SSD has not witnessed any negative moods or behaviors. He continues to be OOR (out of room) in activities, in common areas and dining area. He has not been observed being inappropriate with other residents. SSD will continue to monitor. A social service progress note, dated [DATE], states, "SSD was notified that on [DATE], (Resident 3) had inappropriate sexual behaviors with another resident. (Resident 3) has begun one on one supervision. SSD called (Resident 3's) POA to notify her of the incident. She was comfortable with the interventions in place. SSD explained that it is our responsibility to keep all resident safe and due to the frequency and severity of his behaviors alternative placement may be necessary. SSD explained that an all male unit may be the best option." The notes continue through discharge on [DATE] indicating that Resident 3 continued on 1:1 supervision till discharge with no further inappropriate behaviors noted. Although the facility did assess Resident 3 as having exhibiting sexually inappropriate behavior, care planned interventions and did increase monitoring of Resident 3 periodically; Resident 3 was still able to have inappropriate sexual contact with female residents on 4 occasions after first noting the behavior. Surveyor interviewed Social Worker (SW) J on [DATE] at 4:00 pm. SW J indicated that she was aware of Resident 3's sexually inappropriate behaviors and the facility staff were working on monitoring Resident 3's whereabouts, doing 15 minute checks and when needed implementing 1:1 observation with Resident 3. However, Resident 3 continued to have incidents of sexually inappropriate behavior with female residents and the facility worked with the family and Resident 3 to have a discharge to another facility.