Every finding on record at Avina of Sun Prairie

Based on record review, interview, and policy review, the facility failed to ensure an allegation of neglect was reported to the state agency in accordance with regulatory requirements for one of one resident (Resident (R) 2) reviewed for reporting of alleged violations. R2's allegation was not reported to the state agency. Findings Include: Review of the facility's policy titled, Abuse and Neglect Policy dated 02/08/26, under Reporting/Response included: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse and do not result in serious bodily injury, or b. no later than twenty-four hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of R2's undated Face Sheet, found under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, morbid obesity, spinal fusion, and hypertension. Review of R2's Minimum Data Set (MDS) found under the MDS tab of the EMR with an Assessment Reference Date of 06/13/26 revealed a Brief Interview for Mental Status (BIMS) was 13 out of 15 indicating she was cognitively intact. Further review revealed the MDS indicated R2 required substantial maximum assist with activities of daily living (ADLS). Review of a written statement by Licensed Practical Nurse (LPN) 2 revealed on 06/13/26 at approximately 2:00PM revealed Emergency Medical Technicians (EMTS) entered the facility due to R2 calling 911 stating she was in severe pain, in the wrong wheelchair, and had not been checked on in hours. Review of the facility's abuse/neglect reporting records revealed there was no evidence that the allegation of neglect was reported to the state agency. During a phone interview with the Administrator on 08/12/26 at 9:32AM revealed he was not made aware that neglect was alleged on 06/13/26. He said he would have reported the allegation to the state and completed an investigation. LPN2 was not available for interview.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 3 errors in 29 opportunities that affected 1 out of 4 residents (R4) included in the medication pass task, which resulted in an error rate of 10.34%. R4 received three different eye drops, Latanoprost, Brinzolamide, and Timolol one after another, without any amount of wait time between each different type of eye drop. Evidenced by:Facility policy titled Administration of Eye Drops or Ointments, dated 4/9/2025 states in part: . Eye medications are administered as ordered by the physician and in accordance with professional standards of practice. If a second medication is required in the same eye, wait approximated time per manufacturer's specifications (usually 5 minutes). R4 was admitted to the facility on [DATE] with diagnoses of unspecified Glaucoma (an eye condition that damages the optic nerve, which can lead to vision loss or blindness), Type II Diabetes Mellitus (a condition where your body doesn't make enough insulin or doesn't use insulin properly, causing sugar to build up in the blood instead of entering cells for energy, leading to high blood sugar). R4's Minimum Data Set (MDS) Quarterly Assessment, dated 10/28/25 shows R4 has a Brief Interview of Mental Status (BIMS) score of 10 indicating R4 has moderate cognitive impairment. R4's physical orders, states, in part: . Latanoprost Solution 0.005% (percent). Instill 1 drop in both eyes two times a day related to UNSPECIFIED GLAUCOMA. Azopt Ophthalmic Suspension 1% (Brinzolamide). Instill one drop in both eyes two times a day for Glaucoma. Timolol Maleate Solution 0.5%. Instill 1 drop in both eyes two times a day for Glaucoma related to UNSPECIFIED GLAUCOMA. On 1/7/26 at 8:27 AM surveyor observed RN E administer R4's three different eye drops into each eye consecutively with no time in between drops. Surveyor asked RN E how long you should wait between eye drops. RN E responded she didn't know, she would have to ask someone and get back to surveyor. Right then DON B came around the corner. DON B was asked how long a nurse should wait between giving different types of consecutive eye drops. DON B stated 3-5 minutes. Surveyor asked DON B would you expect that RN E would wait 3-5 minutes between each eye drop. DON B stated yes.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 15 residents (R8) reviewed for change of condition. R8 was experiencing watery stools and nursing assessments were not performed by the facility.Evidenced by:The facility's Change of Condition policy, dated 1/5/25, states, in part: It is the policy of this facility to promptly identify, evaluate, address, and report a resident's change in condition.3. The nurse will complete a resident evaluation. 4. Phone calls to attending or on-call physicians should be made by the nurse who has collected pertinent information, including the resident's current symptoms and status, onset, duration, severity of the change in condition and available strategies to manage the change of condition in the facility, if appropriate.12. The staff will monitor and will document the residents' progress. 13. The nursing staff and Attending Physician will monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized.R8 admitted to the facility on [DATE] and has diagnoses that include, in part: non-infective gastroenteritis (inflammation of the stomach and intestines) and colitis (inflammation of the colon); gastroparesis (a chronic condition where the stomach muscles work poorly, slowing or stopping the movement of food);R8's Minimum Data Set (MDS), dated for completion on 10/31/25, indicates a Brief Interview of Mental Status (BIMS) score of 15, indicating R8 is cognitively intact.On 1/6/26 at 9:43 AM, Surveyor interviewed R8 during initial screening. R8 stated that R8 had been ill with emesis and diarrhea since January 1, 2026.R8's Care Plan Report states, in part: Focus: The resident has an alteration in gastrointestinal statis-chronic diarrhea. Goal: Maintain adequate hydration and appropriate output. Interventions/Tasks: .Give medications as ordered. Monitor/document side effects and effectiveness.R8's Physician Orders include Diphenoxylate-Atropine Oral Tablet (Lomotil-a prescription medication used to treat diarrhea) 2.5-0.025 mg (milligrams) Give 2 tablets orally every 6 hours as needed for diarrhea.R8's Bowel Function report indicates:1/1/26 3:57 PM Large watery/diarrhea1/1/26 7:43 PM Large watery/diarrhea1/2/26 5:58 AM No Bowel MovementR8's January 2026 Medication Administration Record indicates administration of Diphenoxylate-Atropine:1/1/26 5:10 PM effectiveR8's Progress Notes, dated 1/2/26 at 8:26 AM, states, in part: Resident c/o (complained of) loose stools. Loose watery stools charted over night and yesterday afternoon. NP (Nurse Practitioner) updated on loose stools and refusing breakfast this morning.Important to note: there is no documentation of nursing assessment.R8's Bowel Function report indicates:1/2/26 1:52 PM No Bowel Movement1/2/26 9:38 PM No Bowel Movement1/3/26 5:10 AM Not Applicable1/3/26 1:59 PM Large watery/diarrhea1/3/26 9:12 PM Medium loose1/4/26 5:01 AM Medium loose1/4/26 1:59 PM Medium watery/diarrhea1/4/26 9:12 PM Medium loose1/5/26 1:59 PM Large watery/diarrhea1/5/26 9:13 PM Large watery/diarrhea1/6/26 1:59 PM No bowel movement1/6/26 8:10 PM Large watery/diarrhea1/7/26 5:59 AM No bowel movement1/7/26 11:07 AM Medium watery/diarrheaR8's January 2026 Medication Administration Record indicates administration of Diphenoxylate-Atropine:1/1/26 5:10 PM effective1/5/26 11:07 PM effectiveImportant to note: no other doses of Diphenoxylate-Atropine are noted to be administered and there is documentation of nursing assessment.On 1/8/26 at 8:29 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) who stated that CNAs update the nurse about loose or watery bowel movements. CNA D stated we update if there is anything different. Surveyor asked if R8 had any changes in bowel movements recently. CNA D stated, last week R8 was loose, loose, loose; like watery, non-stop. It was going up her back and down and there was a strange odor. CNA D stated that the nurse was updated.On 1/8/26 at 8:40 AM, Surveyor interviewed RN E (Registered Nurse) who stated if a resident is having watery stool the situation needs to be assessed; smell, mucous, color, blood, Vital Signs, ask if the resident is feeling sick. It is a change of condition On 1/8/26 at 8:57 AM, Surveyor interviewed LPN F (Licensed Practical Nurse) who stated if a resident is having loose/watery stools there is to be abdominal assessment with bowel sounds and vital signs. LPN F stated the assessment would be documented in the progress notes. LPN F stated if the watery stools continued the assessments would continue and the doctor would continue to be updated.On 1/8/26 at 9:46 AM, Surveyor interviewed DON B (Director of Nursing) and asked about monitoring of bowel movements. DON B stated that consistency and frequency is monitored. Consistency other than formed is flagged on the electronic health record as it could be an indication of infection or there are some residents with chronic diarrhea. Surveyor asked what staff does for a resident with watery stools. DON B stated if the resident is chronic, they are treated with their PRNs (as needed medications). If the NP (Nurse Practitioner) put a plan in place, the plan is followed. DON B stated, we need to tease out what is going on. R8 has no other symptoms and no vital signs out of whack; R8 may have eaten something new on New Year's Eve. Surveyor reporting finding no documentation of resident assessment with vital signs. DON B stated that DON B would expect that bowel assessment and vital signs would be completed and documented for R8. No additional documentation provided by facility.

Based on observation, interview, and record review, the facility did not ensure a resident who is fed by and received medications by enteral means (also known as tube feeding, as way of sending nutrition and/or medications directly to the stomach or small intestine) receives the appropriate treatment and services for 1 of 1 Resident (R5) reviewed for tube feeding.LPN C administered a water flush and tube feeding without checking placement of R5's gastrostomy tube (a flexible tube inserted through the abdominal wall directly into the stomach, providing a pathway for nutrition, fluids, and medications).Evidenced by:The facility's Verifying Placement of Feeding Tube policy, dated 9/5/25, states, in part: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. Policy Explanation and Compliance Guidelines: 1. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified.4. Procedure for verifying placement of feeding tubes: .c. Verify tube placement: i. For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube making sure the tube is not dislodged.R5 admitted to the facility on [DATE] and has diagnoses that include: encounter for surgical aftercare following surgery on the digestive system; moderate protein-calorie malnutrition; gastrostomy status (having a surgically created opening (gastrostomy) into the stomach, usually via a tube (G-tube) for feeding or decompression, indicating the presence of this artificial opening and requiring ongoing care and management).R5's Physician Orders include:Enteral (through an artificial opening) Feed Order four times a day flush GT (gastrostomy tube) with 100 ml (milliliters) H2O (water) before and after feedEnteral Feed Order four times a day give Nepro 1 carton QID (four times per day), flush with 30 ml water before after [sic]On 1/6/26 at 11:54 AM, Surveyor observed LPN C (Licensed Practical Nurse) initiate R5's water flush and tube feeding. Surveyor did not note LPN C verifying placement of feeding tube. Following the procedure, Surveyor asked LPN C about protocol for initiation of a tube feeding; if placement of the tube is checked. LPN C stated yes, it is checked with instillation of air and auscultation (listening with a stethoscope). Surveyor asked if LPN C checked tube placement prior to R5's water flush and tube feeding. LPN C stated I did not. (of note, facility policy indicates c. Verify tube placement: i. For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube making sure the tube is not dislodged.)On 1/7/25 at 3:51 PM, Surveyor interviewed DON B (Director of Nursing) who stated that placement of the tube needs to be verified prior to water flush and feeding.

Based on record review, interview, and facility policy review, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for 1 of 1 resident's (R2) reviewed for medication self-administration out of 9 sampled residents. Findings include: Review of the facility's policy titled, Self Administration [sic] of Medication and Treatments and dated 04/22/24, revealed . If it is determined by a member of the interdisciplinary team, or the resident requests to self-administer, a self-administer assessment is completed, it is documented in the resident's chart and the physician is called for an order to self-administer medications and keep the medications at the bedside . Review of R2's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease. Review of R2's admission Minimum Data Set (MDS) located in the electronic medical record (EMR) under the MDS tab with an Assessment Reference Date (ARD) of 10/10/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R2 was moderately cognitively impaired. Review of R2's Physician's Orders located in the EMR under the Order tab, revealed on 10/03/24, the physician ordered Fluticasone-Salmeterol inhalation aerosol powder 250-50 MCG [microgram]/ACT [asthma control test] one puff orally two times a day and Tiotropium Bromide Monohydrate inhalation capsule 18 mcg inhale orally one time a day which was ordered on 10/04/14 by the physician. Special instructions to have resident rinse her mouth after use with water was also ordered. During an interview on 01/04/25 at 10:58 AM, Licensed Practical Nurse (LPN 1) stated, I offered to take the inhalers and put them in the medication cart for her, but the resident [R2] refused for me to do that. When asked what the nurses' next step should be, LPN1 replied, I need to let the MD [medical doctor] know and update the orders to reflect the resident could have the inhalers at the bedside. LPN1 reviewed the EMR of R2 and then stated, I did not see anything that says she [R2] can administer her own inhalers. When asked if R2 was allowed to keep the inhalers at the bedside and LPN1 stated, I believe so. During an interview on 01/04/25 at 3:30 PM, LPN2 stated, If there was an order for the inhalers to be at the bedside I would have left them there. So, every time I found them at the bedside, I would check her orders to see if anything had changed, then explain to the resident that I had to keep the inhalers on the med [medication] cart and give them to her when she needed them. I would come back to work, and the inhalers were back at her bedside, and I would take them again and put them in the med cart. During an interview on 01/04/25 at 5:05 PM, Director of Nursing (DON B) stated, If the resident is able to self-administer mediations, then the nurse will do an assessment, get MD order and then update the care plan. The DON B confirmed R2 had not been assessed or had MD orders to self-administer the inhalers that were ordered on 10/03/24 and 10/04/24.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 40 residents. Surveyor observed frozen drips on the ceiling inside of the facility's walk-in freezer and boxes of unsealed food (under the dripping) to have water damage. Surveyor observed hairlike dust adhered to the electrical cords and piping directly above the food preparation and serving area. Surveyor observed staff washing their hands for a lesser time than the current standards of practice and less than the time outlined by the facility's handwashing policy. Surveyor observed food to be in the facility's main kitchen and in the kitchenette to not have an expiration date, an open date, or a use by date on it. Surveyor observed the facility's meat slicer to be stored unclean with visible dried meat particles on it. Evidenced by: Example freezer On 8/20/24 at 9:10 AM Surveyor and DM E (Dietary Manager) observed frozen drops hanging from the ceiling inside of the facility's walk-in freezer. Surveyor and DM E also observed boxes opened and unsealed food to have frozen liquid on and in them. The boxes of food were as follows: fish fillets, corn, tater tots, crinkle cut French fries, and hot dogs. DM E indicated the freezer has had this concern for a while. Surveyor asked how DM E knows the food that is opened and unsealed by the manufacturer has not been contaminated from the dripping. DM E indicated she is unsure. DM E unfolded the flaps of the box of tater tots and untwisted the plastic bag exposing the food. DM E and Surveyor observed small shards of ice flake off the outside of the twisted bag and was land in direct contact with the tater tots. Example dust above food prep and service areas On 8/20/24 at 9:14 AM Surveyor and DM E observed two large electrical cords hanging directly above the food preparation counter to be covered in dust. DM E indicated staff from the maintenance department come in to clean the stove hoods once a month and they should also be cleaning these cords. Surveyor and DM E also observed piping over the food service area to be covered in dust. DM E indicated there is potential for dust to dislodge into the open food or onto the plates and covers used for food serving. On 8/21/24 at 10:00 AM Surveyor and NHA A (Nursing Home Administrator) observed the dust on the piping directly over the food service area. NHA A indicated the dust has potential to dislodge into the open food and the piping should be cleaned. Example handwashing On 8/20/24 at 9:03 AM Surveyor observed DA F (Dietary Aide) wash her hands and dry them for a total of 7 seconds. DA F indicated she is supposed to wash her hands for 20 seconds but the water from the faucet she was using was too hot to wash them for 20 seconds. On 8/21/24 at 9:36 AM Surveyor observed DA M perform hand hygiene from start to finish for 7 seconds. Surveyor also observed DA M use his bare hand to turn off the faucet before grabbing a paper towel to dry his hands. DA M indicated he is supposed to wash his hands for 20 seconds, but the water is too hot to wash his hands for 20 seconds. On 8/21/24 at 9:41 AM Surveyor observed DM E was her hands from start to finish for a total of 10 seconds. DM E indicated staff should wash their hands for 20 seconds, but the water is too hot to keep their hands in there that long. DM E indicated she has told the management team about this issue. Surveyor observed a sign placed above the sink indicating caution scolding hot water. On 8/21/24 at 10:00 AM NHA A indicated staff should wash their hands for 20 seconds total and kitchen staff could use a different sink to wash their hands if they can't perform hand hygiene in this sink. Example meat slicer On 8/20/24 at 9:15 AM DM E pulled a plastic cover off the facility's meat slicer. DM E and Surveyor observed small, dried meat particles on the facility meat slicer. DM E indicated the meat slicer should have been cleaned before it was stored. Example undated and unlabeled food Facility policy, entitled Food Brought in from Outside Sources and Personal Food Storage, undated, includes Food and beverages brought in from outside sources . will be labeled with the patient/resident's name and date and stored in the refrigerator/freezer apart from the facility food . On 8/20/24 at 8:58 AM Surveyor observed a Culver's bag with food inside and the bag did not have a date on it or a resident name. On 8/20/24 AT 9:14 AM Surveyor observed two purple-colored shakes in the facility's freezer with no resident name or date on them. On 8/20/24 at 9:14 AM DM E (Dietary Manager) indicated the nursing staff are responsible for maintaining the kitchenette refrigerator and all food should have a name and date on them. On 8/20/24 at 10:00 AM NHA A indicated it is the responsibility of all staff to maintain the refrigerator in the facility's kitchenette and all staff are to label and date food put in there.

Based on observation and interview, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment for 3 of 15 sampled residents (R30, R14, R24) and 3 supplemental residents (R1, R20, R35). R14, R1, R24, R35, R20, and R30 indicated that the dining room is always cold, and they have to wear a jacket or wrap up in a blanket to stay warm. R30 was observed getting blankets from his room and wrapping it around other residents in the dining room. Resident Council meeting minutes dated 7/19/24, indicated the facility was aware that resident's had concerns of it being too cold in the building. Evidenced by: Facility policy, entitled Environment-Quality of Life, dated 4/2023, with a revision date of 7/3/24, includes in part . The facility cares for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The facility provides a safe, clean, comfortable, and homelike environment . and includes . comfortable and safe temperature levels (71 - 81 degrees Fahrenheit) . Example 1 R14 admitted to the facility on [DATE]. R14's Minimum Data Set (MDS) dated [DATE] indicates, in part: a Brief Interview of Mental status (BIMS) score of 9 out of 15, indicating a moderate cognitive impairment. On 8//21/24 at 12:08 PM, Surveyor observed R14 huddled in blanket while sitting at the dining room table. R14 stated yes, it was always cold like that in this room. On 8/22/24 at 8:09 AM, Surveyor observed R14 again huddled in a blanket in the dining room. Example 2 R1 admitted to the facility on [DATE]. R1's MDS dated [DATE] indicates, in part: a BIMS score of 14 out of 15, indicating cognitively intact. On 8/21/24 at 12:10 PM, Surveyor observed R1 with a blanket around his shoulders in the dining room. R1 indicated that the dining room was freezing and that he always had to have his blanket with him. On 8/22/24 at 8:09 AM, Surveyor observed R1 again with a blanket around his shoulders in the dining room. R1 stated, it's cold in here again. Example 3 R30 admitted to the facility on [DATE]. R30's MDS dated [DATE] indicates, in part: a BIMS score of 15 out of 15, indicating cognitively intact. On 8/21/24 at 12:11 PM, Surveyor observed R30 leaving the dining room and getting extra blankets out of his room and putting them around the shoulders of other residents. R30 indicated that the dining room was always cold. Example 4 R35 was admitted to the facility on [DATE]. R35's MDS dated [DATE] indicates, in part: a BIMS score of 8 out of 15, indicating a moderate cognitive impairment. On 8/21/24 at 12:05 PM and again on 8/22/24 at 8:09 AM, Surveyor observed R35 huddled in a blanket sitting at the table in the dining room. R35 indicated that she is always cold in the dining room. Example 5 R24 was admitted to the facility on [DATE]. R24's MDS dated [DATE] indicates, in part: a BIMS score of 11 out of 15, indicating a moderate cognitive impairment. On 8/22/24 at 8:09 AM, Surveyor observed R24 wearing a jacket at the table in the dining room. R24 stated she always wears her jacket to the dining room because it is always cold in here. Example 6 R20 admitted to the facility on [DATE]. R20's MDS dated [DATE] indicates, in part: a BIMS score of 6 out of 15, indicating a severe cognitive impairment. On 8/21/24 at 12:05 PM, Surveyor observed R20 huddled under a blanket while sitting at a table in the dining room. R20 answered yes when asked if she was cold. On 8/21/24 at 12:05 PM, Surveyor took a reading of the air temperature in the dining room, which read 64 degrees Fahrenheit. On 8/21/24 at 12:13 PM, Surveyor interviewed Certified Nursing Assistant I (CNA), who indicated that the dining room was always cold, and she was glad she put her sweatshirt on before coming into the dining room. Surveyor observed CNA I getting a blanket for R20. CNA I indicated she didn't know how to raise the temperature in the dining room. On 8/22/24 at 08:09 AM, Surveyor took a reading of the air temperature in the dining room, which read 66.2 degrees Fahrenheit. On 8/22/24 at 10:35 AM, Surveyor interviewed NHA A (Nursing Home Administrator), who stated that residents had not brought concerns up about the temperature in the dining room since last year. Surveyor took a reading of the air temperature with NHA A, which read 67 degrees Fahrenheit. NHA A indicated that the acceptable air temperature range for the facility was between 71- and 81-degrees Fahrenheit, and that this was not an acceptable air temperature. On 8/22/24 at 11:58 AM, Surveyor interviewed Maintenance Director G who stated that he tries to keep the temperature in the building between 71-81 degrees Fahrenheit. Maintenance Director G indicated he was unsure what unit controlled the temperature in the dining room. Surveyor shared with Maintenance Director G the temperature readings that had been taken in the dining room. Maintenance Director G indicated that no part of the building should be that low of a temperature.

Based on observation, interview, and record review the facility did not provide food that accommodates resident allergies, intolerances, and preferences or who request a different meal choice for 3 of 15 sampled residents (R3, R17, and R25) out of a total sample of 18 and 1 supplemental resident (R33). Residents were not being served the menu items of their preferences or within parameters of their physician ordered diet, and at times were refused a substitution meal. This is evidenced by: The facility's policy entitled, Meal Identification and Preference Cards/Tickets with no reference date, includes in part: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences . The meal ID card/ticket should include the name of the individual, diet order, beverage preferences, food dislikes and any other applicable diet information . Meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored . Example 1 R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Obesity due to excess calories, Major depressive disorder, GERD (Gastro-Esophageal Reflux Disease), Prediabetes, and Unspecified abdominal pain. R3's most recent MDS (Minimal Data Set) with ARD (Assessment Reference Date) of 7/15/24 indicates R3's cognition is cognitively intact with a BIMS (Brief Interview of Mental Status) score of 14 out of 15. R3's Nutritional assessment dated [DATE], indicates in part: Food Preferences/Likes - On File . Food Dislikes - On File . R3's Mini Nutritional assessment dated [DATE], indicates a score of 10 out of 14, indicating resident could be at risk of malnutrition . R3's Care Plan includes in part: Focus dated 7/15/24: Alteration in nutritional status related to a therapeutic diet for management of CHF (Chronic Heart Failure) and CKD (chronic kidney disease). Goal: Will tolerate therapeutic diet as evidence by no weight changes equal to or greater than 7.5% through next care plan review. Intervention: Offer a substitute if less than 50% of the meal is consumed. Focus dated 7/9/24: The resident has GERD. Goal: The resident will remain free from discomfort, complications or symptoms related to diagnosis of GERD through review date. Intervention: Avoid activities that involve bending, lifting. Avoid snacks that aggravate the condition. (See Dietary). Avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take their time eating. Alternate food with sips of fluids . R3's Point of Care (POC) Nutritional History was reviewed, indicating that R3 had consumed less than 50% of 11 meals during the past 30 days. On 8/20/24 at 10:18 AM, Surveyor interviewed R3. R3 reported that the food is OK but that they can't get substitutions. R3 indicated that she is intolerant of spicy food due to her GERD, and last week she was served spicy food. When she asked to get something else, she was told she couldn't have anything else, and so she went without dinner and only ate candy that night. R3 said that Licensed Practical Nurse H (LPN) was working that night and aware of the situation. R3 stated she did not remember ever talking to dietary or filling out a likes/dislikes card indicating what her preferences and food intolerances are. (It is important to note that GERD is a chronic digestive disorder that occurs when stomach contents flow up into the esophagus. This reflux may damage the esophagus, pharynx, or respiratory tract. GERD can be exacerbated by eating spicy foods). On 8/21/24 at 12:32 PM, Surveyor reviewed R3's Lunchtime Meal Ticket. The dislike section was blank. Example 2 R17 was admitted to the facility on [DATE] with diagnoses that include, in part: Type 2 Diabetes Mellitus without complications, GERD, reduced mobility, and chronic pain. R17's most recent MDS with ARD of 8/5/24 indicates R17's cognition is cognitively intact with a BIMS score of 15 out of 15. R17's Nutritional assessment dated [DATE], indicates in part: Food Preferences/Likes - Noted in Kitchen . Food Dislikes - Noted in Kitchen . R17's Mini Nutritional assessment dated [DATE], indicates a score of 8 out of 14, suggests resident is at risk of malnutrition . R17's Care Plan includes in part: Focus dated 5/1/24: The resident has GERD. Goal: The resident will remain free from discomfort, complications or symptoms related to diagnosis of GERD through review date. Intervention: Dietary: avoid foods or beverages that tend to irritate esophageal lining, i.e. alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods. Focus dated 5/1/24: Alteration in nutritional status related to a therapeutic diet for diagnosis of Diabetes Mellitus. Goal: Will follow therapeutic diet as ordered and maintain weight with no significant changes through next care plan review. Intervention: Allow adequate time for the resident to consume food served. Offer a substitute if less than 50% of the meal is consumed. Serve the resident's diet as ordered . R17's Point of Care (POC) Nutritional History was reviewed, indicating that R17 had consumed less than 50% of 5 meals during the past 30 days. On 8/20/24 at 10:25 AM, Surveyor interviewed R17 who stated that the food is hit and miss. R17 indicated that she can't eat spicy foods and last week she was served spicy food for dinner, she believed it was spicy Italian sausage. When R17 told staff she could not eat that due to her GERD, she was told there were no substitutes, so she did not eat dinner that night. R17 stated she had some snacks in her room and that is all she had for dinner. R17 stated she told LPN H about this situation. R17 stated she didn't think it was right that residents were made to go without dinner. R17 indicated she had never talked to dietary or filled out a likes/dislikes card indicating what her preferences and food intolerances are. (It is important to note that in addition to R17's intolerance to spicy foods due to GERD, R17 is also a diabetic. Skipping meals can be especially dangerous for people with diabetes, skipping meals can lead to irregular spikes and drops in blood sugar levels). On 8/21/24 at 12:32 PM, Surveyor reviewed R17's Lunchtime Meal Ticket. The dislike section was blank. Example 3 R33 was admitted to the facility on [DATE] with diagnoses that include, in part: Unspecified sever protein-calorie malnutrition, GERD, chronic pain syndrome, reduced mobility, anxiety disorder unspecified, unspecified intestinal obstruction, and ulcerative colitis unspecified. R33's most recent MDS with ARD of 7/8/24 indicates R33's cognition is cognitively intact with a BIMS score of 14 out of 15. R33's Nutritional assessment dated [DATE], indicates in part: Food Preferences/Likes - On File . Food Dislikes - On File . R33's Mini Nutritional assessment dated [DATE], indicates a score of 4 out of 14, indicating resident could be malnourished . R33's Care Plan includes in part: Focus dated 6/1724: The resident has GERD. Goal: The resident will remain free from discomfort, complications and symptoms related to diagnosis of GERD through review date. Intervention: Dietary: avoid foods or beverages that tend to irritate esophageal lining, i.e. alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods. Focus dated 6/17/24: The resident has actual nutritional deficit related to Anorexia, history of surgical removal of intestine/bowel, severe protein calorie nutrition .Goal: The resident will improve her nutritional status with use of oral diet .through review date. Intervention: Encourage compliance with diet and supplement regiment .Provide and serve diet as ordered . R33's Point of Care (POC) Nutritional History was reviewed, indicating that R33 had consumed less than 50% of 23 meals during the past 30 days. On 8/21/24 at 08:01 AM, Surveyor interviewed R33 who stated that the food was OK. R33 indicated that she doesn't like cheese and is sometimes served food with cheese in it. R33 states she has told staff that she doesn't like cheese but sometimes they forget. R33 stated she has never filled out a card specifying what her likes/dislikes are. R33 said that she can usually get a substitution that doesn't have cheese. On 8/21/24 at 12:35 PM, Surveyor reviewed R33's Lunchtime Meal Ticket. The dislike section was blank. Example 4 R25 was admitted to the facility on [DATE] with diagnoses that include, in part: GERD, Major depressive disorder, Prediabetes, and diverticulosis of intestine part unspecified. R25's most recent MDS with ARD of 5/22/24 indicates R25's cognition is cognitively intact with a BIMS score of 15 out of 15. R25's Mini Nutritional assessment dated [DATE], indicates a score of 11 out of 14, indicating at risk of malnutrition . R25's Care Plan includes in part: Focus dated 5/16/24: The resident has GERD. Goal: The resident will remain free from discomfort, complications and symptoms related to diagnosis of GERD through review date. Intervention: Dietary: avoid foods or beverages that tend to irritate esophageal lining, i.e. alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods . (It is important to note that R25's care plan had no person-centered focus, goal, or interventions to address malnutrition, and that R25's Nutritional Assessment was completed during survey). On 8/20/24 at 2:20 PM, R25 indicated to Surveyor during Resident Council meeting that she does not always get the food according to her preferences and likes/dislikes. R25 indicated that usually she can get a substitution if she doesn't like something that is served. On 8/21/24 at 9:36 AM, Surveyor interviewed Dietary Aide F (DA), who indicated that they pass out menus the day prior for the residents who want to make alternate choices, including R25, R3, and R17. DA F stated that the dietary manager went around when residents were admitted and talked to them about their food preferences. Surveyor asked DA F if the food likes/dislikes should be listed on their meal ticket. DA F stated yes, they probably should. Surveyor asked DA F if residents could get a meal substitution if they were served something they didn't like. DA F stated yes, they could but they would have to notify the kitchen in advance. On 8/21/24 at 9:44 AM, Surveyor interviewed Dietary Manager E (DM). DM E stated that it is her practice to go talk to residents when they admit and find out their food preferences. DM E indicated that if a resident was served food that they couldn't eat, such as too spicy, that they would let the Certified Nursing Assistant (CNA) know and they could come to the kitchen and get a substitution from the Alternate Menu that is available anytime for residents. On 8/22/24 at 8:55 AM, Surveyor interviewed LPN H and asked if residents could get a meal substitution if they were unable to eat or didn't like something that was served on their tray. LPN H stated that they are supposed to be able to get substitutions, but that last week the CNA went to the kitchen to get something else for R3 and R17 and were told by kitchen staff that there was nothing else to give them. LPN H indicated that it is facility policy that residents make meal substitutions in advance, but that sometimes they might not know until they get their food that it is too spicy. Surveyor asked LPN H if the residents should have to go without dinner. LPN H replied no, that was never okay to have residents go hungry because a substitute was not available. On 8/22/24 at 10:35 AM, Surveyor interviewed Nursing Home Administrator A (NHA). NHA A indicated that she had no knowledge of R3 and R17 going without dinner and being told there were no substitutes available. NHA A agreed that was not appropriate, especially for diabetic residents. NHA A indicated that it is her expectation that if a resident voices a concern about their meal that they would be offered something else. On 8/22/24 at 10:48 AM, Surveyor interviewed DM E who stated she was not aware that R3 and R17 had gone without dinner and were told there was nothing else to give them. DM E stated she was not aware that R3 and R17 could not have spicy food. The facility's failure to provide food that accommodated resident preferences and intolerances due to various diagnosis, and failure to provide an alternate meal to resident's who requested them, resulted in residents skipping meals and/or eating candy or snacks for dinner.

Based on interview and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 1 residents (R47) reviewed for PIs out of a sample of 18 residents. Pressure Ulcer/Injury R47 was admitted to the facility 3/22/24 with diagnoses including, but not limited to, the following: paraplegia, functional injury at T10-T11 level of thoracic spinal cord, Stage IV right ischial pressure ulcer s/p (status post) excision and flap 2/22/24 with pseudomonas infection/osteomyelitis requiring prolonged course of IV (intravenous) antibiotics, Stage IV sacrococcygeal pressure injury, history of Methicillin Resistant Staphylococcus Aureus infection, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. On 5/25/24 R47 discharged home per her decision. R47's Admission MDS (Minimum Data Set) dated 3/28/24 indicates R47 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating she is cognitively intact. R47 is her own person. Admission Skin Assessment: 3/22/24 Coccyx 3.8 x 2.5 x 0.3, 50% slough 50% granulation; Stage 4 Full Thickness; Drainage Moderate: Serosanguineous; Periwound: WNL (Within Normal Limits); Wound Pain: No During R47's stay at the facility she went out to the wound clinic and a visiting wound physician assessed and measured R47's PI's weekly. On 4/19/24 R47's was seen at the wound clinic. The wound clinic documented the following new order: Wound care instructions: Location: sacral/coccyx wound, right ischial postoperative site. If necessary, take pain medicine 1 hour prior to starting wound care. Remove all dressings. Actively wash wound with antibacterial soap (i.e. Dial soap) and water using a washcloth. Rinse completely and pat dry with clean wash cloth or towel. Lightly moisten gauze with 0.25% (half-strength) Dakin's - Should be damp not soaking wet Pack wound lightly with the moistened gauze on coccyx wound. - Do not overpack -Should not overflow/lay on good tissue outside the wound Please do not get Dakin's on intact skin!! *Dressing changes to be done 2x a day for coccyx wound . On 4/26/24 R47 was seen at the wound clinic. The wound clinic documented the following new order: Location: coccyx If necessary, take pain medicine 1 hour prior to starting wound care. Remove all dressings. Firmly wash wound with antibacterial soap (i.e. Dial soap) and water using a washcloth. Rinse completely and pat dry with clean was cloth or towel. Lightly moisten gauze with 0.25% (half-strength) Dakins. Should be damp, not soaking wet. Pack wound lightly with moistened gauze. Do not over pack - the gauze should not fill the entire cavity. Cover with gauze and ABD pad or border dressing. *Dressing changes to be done daily by staff. Note the wound care orders were changed to 1 time per day. On 4/30/24 R47's TAR (Treatment Administration Record) demonstrates the facility entered and began completing the order from 4/26/24 (4 days later). On 8/20/24 at 1:55 PM, Surveyor spoke with R47. R47, she had concerns regarding her treatments not being done correctly. On 8/22/24 at 2:40 PM and 3:55 PM, Surveyors spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect staff to follow Physician orders. DON B stated, Yes. DON B stated, R47 would go out to the wound clinic and a visiting wound physician would also see R47 weekly to measure and assess her pressure injuries. DON B stated, the wound clinic and visiting wound physician agreed the facility will follow the wound clinic orders. DON B added, the wound clinic told us to please not change their orders. Surveyor asked DON B, did R47 express express concerns during her stay regarding pressure injury treatments. DON B stated, no. DON B stated, things went well during R47's stay and our interactions with her the majority of the time were cordial. Surveyor showed DON B the orders from the wound clinic and the TAR (Treatment Administration Record). Surveyor asked DON B, on 4/26/24 when the wound clinic changed R47's treatment to her coccyx would you expect staff to be following the new orders. DON B stated, Yes, it should have been entered correctly and in a timely manner. DON B stated, the order went from two (2) times per day to one (1) time a day but wasn't changed until 4/30/24. DON B agreed R47's new orders should have been entered and implemented in a timely manner.

Based on interview and record review the facility did not ensure prompt resolution of all grievances for 2 (R48 and R30) of 15 sampled residents of a total sample of 18. R48 and R30 voiced concerns during individual interviews regarding the facility not following up on voiced concerns/grievances. Staff reported they were aware of concerns voiced by R48 and R30 and reported these concerns to the Grievance Official, who did not follow the facility's grievance process. R48 reported to NHA A (Nursing Home Administrator) multiple times regarding a pair of missing pants. NHA A did not document the grievance on the grievance log and ensure the grievance was resolved. The facility did not ensure prompt resolution of voiced grievances. Evidenced by: The facility's policy, Grievance Guideline, revised 1/27/2017, indicates in part, the following: It is the policy of the facility to provide a system whereby residents, and/or their significant others or representatives, can voice concerns about the quality of services received at the facility. The facility will designate a Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; taking immediate action as necessary, to prevent further potential violations of an resident right while the alleged violation is being investigated; immediately reporting all alleged violations involving neglect, abuse, injuries of unknown source, misappropriation of resident property and/or exploitation, and taking appropriate corrective action in accordance with State law when indicated. At the time a grievance is noted, (either verbal or written) the resident or his/her representative may speak to any member of the facility staff and report the nature of the grievance or submit a written grievance form. The staff member will, at the time of the grievance, attempt to resolve the issue or direct the resident/representative to the appropriate department head or staff member for further action and/or notify the Grievance Officer. Upon notification of a resident grievance, information sufficient to identify the individual registering the concern, the name of the resident (if not the individual submitting the information), date of receipt, nature of concern, and location of the resident will be recorded. The Grievance Officer will route the grievance to the appropriate department head related to the grievance filed and an investigation of the grievance will be conducted. Based on the nature of the grievance, the Grievance Officer will initiate any additional interventions that are indicated at that time After thorough research has been conducted, the Department Head and/or Grievance Officer will work in tandem with staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to resolve the grievance effectively and expeditiously. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 7 days. The resident will be provided with a verbal follow up to their grievance including the following information: The name of the Department Head who conducted the follow up/investigation. The steps taken to investigate and resolve grievance. The final result of the grievance. Additionally, the resident may obtain written decision regarding his/her grievance upon request. Example 1 R30 was admitted , on 2/3/23, with diagnoses that include Anxiety Disorder, unspecified, Alcohol Dependence with Withdrawal, unspecified, and Impulsive Disorder, unspecified. R30's admission MDS (Minimum Data Set) with a target date of 2/6/23, indicates, in part: Brief Interview of Mental Status (BIMS) of 15, indicating cognitively intact. On 8/20/24 at 11:05 AM, Surveyor interviewed R30, who voiced frustration about his clothes being stolen. R30 stated that he has had clothes and other items missing from his room several times, and that he's afraid to leave anything valuable in his room, like his watch or phone, for fear of them being stolen. R30 stated he had reported these missing items to both NHA A and LPN H (Licensed Practical Nurse), and that nothing had ever happened after he reported it. R30 voiced feeling like he had no control over his room or his belongings. On 8/22/24 at 8:55 AM, Surveyor interviewed LPN H (Licensed Practical Nurse) who indicated she was aware that R30 had a concern with missing clothes. LPN H stated that when R30 voices these concerns, she helps him look in his room and then she reports it to administration. LPN H stated that she reports everything to administration so that missing items can be followed-up on and replaced if necessary. On 8/22/24 at 9:15 AM, Surveyor interviewed Housekeeping Manager D (HSK), who indicated that when a resident reports something missing, she assists in searching for the item and then goes to the administrator and lets them know something is missing and hasn't been found. HSK D stated that she keeps logs of missing items going back 3 months. HSK D said that she was aware of R30's concerns of his missing clothes, but that she did not have any notes or logs to track his items. HSK D stated that NHA A (Nursing Home Administrator) keeps a list of missing items as well. On 8/22/24 at 10:35 AM, Surveyor interviewed NHA A who indicated that a new Grievance Officer started only the week prior and that she was acting as the Grievance Officer until the new one was fully trained. NHA A stated that they did not have any grievances or logs for R30's missing clothes. NHA A indicated that according to their grievance policy, grievances can be written or verbal. When asked if R30's concerns had been followed up with by anyone, NHA A stated no because his clothes were usually found right away. NHA A agreed that in this instance they were not following their grievance policy. 30992 Example 2 R48 was admitted to the facility 12/29/23 and discharged home 1/30/24. R48's Admission MDS (Minimum Data Set) dated 1/4/24 indicates R48 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating she is cognitively intact. On 8/20/24 at 1:40 PM, Surveyor spoke with R48. R48 stated shortly after she arrived at the facility, she had a pair of black pants and a pair of beige [NAME] socks that went missing. R48 stated, she reported the missing items to NHA A (Nursing Home Administrator). R48 stated, I never heard back from her. R48 stated, she said to NHA A while she was leaving that she had not received reimbursement. R48 stated NHA A told her, I'll take care of that. R48 stated, she asked NHA A, if she has her word. R48 stated, NHA A replied, yes. R48 stated, NHA A's word was thrown out the window. R48 stated her pants and socks went missing at approximately the end of December. On 8/22/24 at 9:15 AM, Surveyor spoke with Hskp Mgr D (Housekeeping Manager). Surveyor asked Hskp Mgr D if something is missing what is the process for housekeeping. Hskp Mgr D stated, she will search for the item in closets, drawers, laundry) and ask other staff if they have seen the item. Hskp Mgr D stated, if the item is not found immediately she will notify NHA A (Nursing Home Administrator). Hskp Mgr D stated, hopefully the CNA's (Certified Nursing Assistant) didn't mix up and it went to the garbage versus the dirty laundry. Surveyor asked Hskp Mgr D, do you recall if R48 reported any missing items. Hskp Mgr D stated, she does not recall. Hskp Mgr D stated, the laundry staff member that was working during this time period is no longer employed at the facility. Hskp Mgr D stated, at that time I wasn't down in the laundry very much and doesn't recall R48 reporting any missing items. Hskp Mgr D stated, she does not retain a log of missing items. Hskp Mgr D stated, the facility will usually replace what goes missing. Surveyor asked Hskp Mgr D, is there a pair of black pants or [NAME] socks in the missing items. Hskp Mgr D stated, no. On 8/22/24 at 9:29 AM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, were you able to locate grievances from December and January 2024. NHA A stated, Not really. Surveyor asked NHA A, did R48 reports any grievances during her stay. NHA A stated, R48 was here on two (2) different occasions. NHA A stated, I think she had pants and we found or replaced them, I don't remember the socks. NHA A stated, we usually replace missing items even if the resident says a belonging is lost and the family says the resident never had the item, we still replace it. Surveyor asked NHA A, should you have documentation of grievances. NHA A stated, we try to get replacement as close as possible that resident is ok with. Surveyor asked NHA A, should grievances be documented. NHA A stated, Yes, I'm sorry I don't have that. Surveyor asked NHA A, should you follow up with individual reporting a grievance to ensure resolution. NHA A stated, Yes, we always do. It is important to note, there is no documentation of this grievance, investigation, or resolution. On 8/22/24 10:12 AM, NHA A (Nursing Home Administrator) spoke with Surveyor. NHA A stated, she just called R48 after Surveyor discussed R48's grievance with NHA A. NHA A stated, she knew she addressed this. NHA A stated, she now remembers that R48 did not want the item replaced she wanted the monetary reimbursement (money). NHA A stated she spoke with BOM C (Business Office Manager). NHA A stated, BOM C has the envelope and cash still in her desk as it was returned as undeliverable due to the street address being 1 digit off. NHA A stated, she is very upset and just learned R48 never received the payment. Surveyor asked NHA A, should BOM C have communicated to you that the $35.00 payment was returned as undeliverable. NHA A stated, yes. Surveyor observed hand written notes on the back of the envelope (by BOM C per NHA A) indicating BOM C called R48 on the following dates: Called 3/19/24 left message. Called 3/26 left message. Called 3/28 left message. Called 4/11 left message filed away. On 8/22/24 at 10:13 AM, Surveyor observed the envelope to be postmarked 3/6/24. Surveyor a USPS (United States Post Office) sticker on the front of the envelope indicating it was undeliverable. Surveyor observed $35.00 cash inside the envelope with a handwritten note to R48. On 8/22/24 at 2:06 PM, Surveyor spoke with BOM C (Business Office Manager). Surveyor asked BOM C how long she has been in this role. BOM C stated two (2) years. Surveyor asked BOM C, what is the process if a payment is mailed to a resident and then returned to the facility. BOM C stated, she tries calling quite a few times, will try family and email if there is an email on file. BOM C stated, the vast majority of residents do not utilize email. BOM C stated, she did not call R48's family member as R48 is her own person. Surveyor asked BOM C, did you notify NHA A that the $35.00 cash was returned to the facility. BOM C stated, No, I just told her today. BOM C stated, she called R48 a couple times and did not receive a response, so she filed the envelope containing $35.00 for R48's next stay or if she ever called me back. Surveyor asked BOM C, should you have notified NHA A that the envelope containing the $35.00 was returned. BOM C stated, she could have communicated it but it's a shared responsibility. BOM C stated, accountability wise that's a task she should be able to follow up on in a way. Surveyor asked BOM C, did you receive any training regarding what to do when a check/cash is returned. BOM C stated, she has annual Relias (computer based) training but has not received any training regarding a specified plan for payments that are returned.

Based on interview and record review, the facility did not ensure residents admitted with mental or psychosocial adjustment difficulties or history of trauma and/or PTSD (Post-Traumatic Stress Disorder) received appropriate person-centered and individualized treatment and services to meet their assessed needs for 2 of 18 sampled residents (R30 & R37). R37 has a diagnosis of PTSD, and his care plan does not address personalized potential triggers or person-centered and individualized treatment and services related to his PTSD. R30 does not have a formal diagnosis of PTSD, however, R30 indicated that he has experienced several traumatic experiences in his past that would indicate symptoms of PTSD. R30's care plan does not address his PTSD symptoms or potential triggers to meet assessed needs related to PTSD. Evidenced by: The facility policy, entitled, Treatment/Services for Mental/Psychosocial Concerns Policy, dated 9/29/22, states in part . The facility will ensure that, a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services .to attain the highest practicable mental and psychosocial well-being . Example 1 R37 was admitted , on 6/21/24, with diagnoses that include PTSD and Insomnia. R37's admission MDS (Minimum Data Set) with a target date of 6/21/24, indicates, in part: Brief Interview of Mental Status (BIMS) of 15, indicating R37 is cognitively intact. R37's care plan includes in part . Focus: The resident is new to the facility and potentially may be experiencing physical and cognitive problems which inhibit his ability to adjust to the new surroundings .May have some feelings of sadness, anxiety and despair related to losses associated with illness and placement in a long-term care facility .Date initiated: 6/4/24 . (Please note R37's care plan does not have a PTSD focus and doesn't describe expressions or indications of distress specific to R37 related to his PTSD diagnosis. R37's care plan is not individualized/personalized and specific to R37's history of trauma, feelings/expression of distress or indicators of distress to ensure R37's emotional and psychosocial needs are being met.) On 8/20/24 at 1:57 PM, Surveyor attempted to interview R37. R37 would not acknowledge or talk to Surveyor despite multiple attempts throughout the day. On 8/20/24 at 2:57 PM, Surveyor interviewed Resident Representative L (RR) who stated that R37 is in a lot of distressed mental anguish, that R37 was not in a good place mentally and that he has PTSD. Example 2 R30 was admitted , on 2/3/23, with diagnoses that include Anxiety Disorder, unspecified, Alcohol Dependence with Withdrawal, unspecified, and Impulsive Disorder, unspecified. R30's admission MDS (Minimum Data Set) with a target date of 2/6/23, indicates, in part: Brief Interview of Mental Status (BIMS) of 15, indicating cognitively intact. R30's care plan includes in part . Focus: The resident is new to the facility and potentially may be experiencing physical and cognitive problems which inhibit his ability to adjust to the new surroundings .May have some feelings of sadness, anxiety and despair related to losses associated with illness and placement in a long-term care facility .Date initiated: 2/7/23 . (Please note R30's care plan does not have a PTSD focus and doesn't describe expressions or indications of distress specific to R30 related to his PTSD symptoms. R30's care plan is not individualized/personalized and specific to R30's history of trauma, feelings/expression of distress or indicators of distress to ensure R30's emotional and psychosocial needs are being met.) R30's Brief Trauma Questionnaire dated 11/19/23 states in part . Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill? R30 answered Yes to this question .If the event happened, did you think your life was in danger or you might be seriously injured? . R30 answered Yes to this question . Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that you were very frightened, or you though you would be injured, or you received bruises, cuts, welts, lumps, or other injuries? . R30 answered Yes to this question . Not including any punishments or beatings you already reported, have you ever been attacked, beaten, or mugged by anyone, including friends, family members or strangers? . R30 answered Yes to this question . If the event happened, did you think your life was in danger or you might be seriously injured? . R30 answered Yes to this question . On 8/20/24 at 11:05 AM, Surveyor interviewed R30 who indicated that he was a past drug addict and had lived a hard life. R30 voiced frustration that staff were not adequately trained to deal with people who have issues like me. On 8/21/24 at 3:41 PM, Surveyor interviewed Certified Nursing Assistant J (CNA), who indicated she wasn't sure if R37 or R30 had PTSD, but she would look in their care plans for triggers and interventions. On 8/21/24 at 3:45 PM, Surveyor interviewed CNA K, who indicated she wasn't sure if R37 or R30 had a diagnosis of PTSD but that she would look in their care plan to know best how to care for someone if they did have PTSD. On 8/22/24 at 10:35 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated that R37 does have PTSD, and that PTSD should be on R37's care plan as a focus with personalized potential triggers and person-centered interventions. Surveyor reviewed R30's Brief Trauma Questionnaire with NHA A, and NHA A agreed that R30 had answered yes to many of the trauma questions, and that even without a formal diagnosis, R30 had many indicators of PTSD. NHA A indicated that R30 should have a personalized focus along with potential triggers and person-centered interventions on his care plan. The facility failed to create robust care plans for individuals suffering from trauma or PTSD, including personalized triggers and interventions, which resulted in staff being unaware of how best to provide trauma informed care to these residents.

Based on interview and record review the facility did not ensure that all injuries of unknown origin/serious bodily injury were thoroughly investigated for 1 of 3 sampled residents (R1) for change of condition. R1 had severe bleeding which led to a change of condition and death this was not thoroughly investigated. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: idiopathic progressive neuropathy, COVID-19, Chronic Obstructive Pulmonary Disease (COPD), centrilobular emphysema, severe protein-calorie malnutrition, displacement of femoral arterial graft (Bypass), malignant neoplasm of prostate, complete traumatic amputation of two or more right lesser toes, coronary artery dissection, supraventricular tachycardia, other ventricular tachycardia, peripheral vascular disease, nontraumatic ischemic infarction of muscle- right lower leg, anemia, occlusion and stenosis of bilateral vertebral arteries, chronic pain, and cervical disc disorder. On [DATE] in the morning, R1 had complained of pain to the back of his head and neck. R1 had an as needed (PRN) pain medication administered. R1's blood pressure (BP) (,d+[DATE]) was elevated at this time. R1 had breakfast delivered. R1 had his dressing changed to right groin incision without concerns, no bleeding present. Nurse updated R1's Nurse Practitioner (NP) on pain and blood pressure and received new orders to increase R1's scheduled pain medications. Nurse updated R1 on this new order and checked in on his pain level. R1 said it was a little better but not much and asked if he could have another pain pill when it was time. R1 was served lunch and ate. R1 had a second PRN pain medication administered around lunch time. Certified Nursing Assistant (CNA) saw resident on her last rounds, emptied his urinal, and asked if he needed anything. On [DATE] in the afternoon, R1 had a significant change of condition. Occupational Therapy (OT) was working with him and noted that he seemed off - she reported this to R1's nurse. Nurse explained to OT about his increased pain and increased pain medication, which could be attributing to his demeanor. OT then obtained a low blood pressure (,d+[DATE]), but she didn't feel the blood pressure was accurate because he was talking with her and drinking water at the time of the reading. OT reported blood pressure to R1's nurse, who said she'd re-take blood pressure with a different cuff. Shortly after this, PT went in by R1 and he was not responsive verbally to her. PT performed sternal rub (pain stimulus is a technique used to assess the consciousness of a person not responding to normal interaction) with a grunt noise in response and she then yelled for help. Nursing staff went running to room with assorted items BP machine, glucometer, Narcan (medication to treat narcotic overdose in an emergency situation), and oxygen. R1 was able to nod in response to questions from Director of Nursing (DON) and then he slumped forward, at this time he was still breathing and still had a pulse. Narcan was administered. Then R1 stopped breathing and pulse could not be palpated, and a code was called. In process of placing backboard behind R1 to start cardiopulmonary resuscitation (CPR; an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), it was seen that R1 had wet, bright red blood on draw sheet and bottom fitted sheet. Despite the efforts of the facility, R1 did pass away. Cause of death was noted to be hemorrhagic femoral bypass graft incision. On [DATE] at 12:14 PM, Surveyor interviewed DON B. Surveyor asked DON B if this should have been thoroughly investigated, DON B said we all talked a lot that night, after police left around 2300. On [DATE] at 4:17 PM, Surveyor interviewed DON B. Surveyor asked DON B if there should be a thorough investigation into this situation, DON B stated we didn't formally investigate, I guess, but we talked to all staff involved and made a timeline that is in soft file. On [DATE] at 6:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) if this should have been thoroughly investigated, NHA A said we made a timeline from interviewing the staff. NHA A provided timeline to Surveyor at this time. This event was unexpected and R1's death was untimely based on his plan to rehab and go home. This event should be investigated thoroughly as R1 had severe bleeding from an unknown source, change of condition which led to R1's death.

Based on interview and record review the facility did not maintain medical records on each resident that are complete; accurately documented; readily accessible, and systematically organized for 1 of 3 sampled residents (R1) for change of condition. R1's medical record is missing documentation of his change of condition and subsequent passing away from [DATE]. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: idiopathic progressive neuropathy, COVID-19, Chronic Obstructive Pulmonary Disease (COPD), centrilobular emphysema, sever protein-calorie malnutrition, displacement of femoral arterial graft (Bypass), malignant neoplasm of prostate, complete traumatic amputation of two or more right lesser toes, coronary artery dissection, supraventricular tachycardia, other ventricular tachycardia, peripheral vascular disease, nontraumatic ischemic infarction of muscle- right lower leg, anemia, occlusion and stenosis of bilateral vertebral arteries, chronic pain, and cervical disc disorder. R1's last progress note documents the following: [DATE] 1416 (2:16 PM) Patient alert and oriented, able to make needs known, and pleasant and cooperative with cares. Complained of ,d+[DATE] nerve pain starting from back of head/neck down spine and was observed crying out with positional changes. VS obtained and NP updated on VS/complaints of pain. PRN oxycodone administered at 0816 with mild effect and at 1220 with positive effect. New order received to increase Gabapentin from 200 mg (milligrams) TID (three times per day) to 300 mg TID; patient notified of new order and started dosage increase at lunch time. Dressing to right groin incisional site/right foot amputation site changed per order and patient tolerated without difficulty. No s/s (signs and symptoms) of infection noted at time of dressing change. 1 assist w/ADL's (with Activities of Daily Living), Incontinent of bowl and bladder during shift. Patient encouraged to stay hydrated. Appetite decreased. Patient currently resting in bed with eyes closed and appears to be in no acute distress at this time. Call bell within reach. Participates as scheduled. After the above noted, R1's medical record does not include his change of condition, the facility's actions including implementing cardiopulmonary resuscitation or R1 expiring at the facility Below is a synopsis of R1's change of condition, the facility's actions, and his passing: On [DATE] in the afternoon, R1 had a significant change of condition. Occupational Therapy (OT) was working with him and noted that he seemed off, she reported this to R1's nurse. Nurse explained to OT about his increased pain and increased pain medication, which could be attributing to his demeanor. OT then obtained a low blood pressure (,d+[DATE]), but she didn't feel the blood pressure was accurate because he was talking with her and drinking water at the time of the reading. OT reported blood pressure to R1's nurse, who said she'd re-take blood pressure with different cuff. Shortly after this, Physical Therapist (PT) went in by R1 and he was not responsive verbally to her. PT performed sternal rub (pain stimulus is a technique used to assess the consciousness of a person not responding to normal interaction) with a grunt noise in response and she then yelled for help. Nursing staff went running to room with assorted items BP machine, glucometer, Narcan (medication to treat narcotic overdose in an emergency situation), and oxygen. R1 was able to nod in response to questions from Director of Nursing (DON) and then he slumped forward, at this time he was still breathing and still had a pulse. Narcan was administered. Then R1 stopped breathing and pulse could not be palpated, and a code was called. In process of placing backboard behind R1 to start cardiopulmonary resuscitation (CPR; an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), it was seen that R1 had wet, bright red blood on draw sheet and bottom fitted sheet. Despite the efforts of the facility, R1 did pass away. Cause of death was noted to be hemorrhagic femoral bypass graft incision. On [DATE] at 4:17 PM, Surveyor interviewed DON B. Surveyor asked DON B if R1's medical record should include documentation on his change of condition and passing away, DON B stated, Absolutely, I wrote note and emailed it to NHA A (Nursing Home Administrator) and neither of us remembered to put it in his record.

Based on interview and record review, the facility did not ensure that all injuries of unknown origin/serious bodily injury were reported to the State Agency for 1 of 3 sampled residents (R1) for change of condition. R1 was discovered to have severe bleeding of unknown origin which led to a change of condition and death this was not reported to the State Agency. This is evidenced by: R1 admitted to the facility following a femoral artery bypass surgery and amputation of right foot's digits. R1 had the following diagnoses: idiopathic progressive neuropathy, COVID-19, (Chronic Obstructive Pulmonary Disease (COPD), centrilobular emphysema, sever protein-calorie malnutrition, displacement of femoral arterial graft (Bypass), malignant neoplasm of prostate, complete traumatic amputation of two or more right lesser toes, coronary artery dissection, supraventricular tachycardia, other ventricular tachycardia, peripheral vascular disease, nontraumatic ischemic infarction of muscle- right lower leg, anemia, occlusion and stenosis of bilateral vertebral arteries, chronic pain, and cervical disc disorder. On [DATE] in the morning, R1 had complained of pain to the back of his head and neck. R1 had an as needed (PRN) pain medication administered. R1's blood pressure (BP) (,d+[DATE]) was elevated at this time. R1 had breakfast delivered. R1 had his dressing changed to right groin incision without concerns, no bleeding present. Nurse updated R1's Nurse Practitioner (NP) on pain and blood pressure and received new orders to increase R1's scheduled pain medications. Nurse updated R1 on this new order and checked in on his pain level. R1 said it was a little better but not much and asked if he could have another pain pill when it was time. R1 was served lunch and ate. R1 had a second PRN pain medication administered around lunch time. Certified Nursing Assistant (CNA) saw resident on her last rounds, emptied his urinal, and asked if he needed anything. On [DATE] in the afternoon, R1 had a significant change of condition. Occupational Therapy (OT) was working with him and noted that he seemed off - she reported this to R1's nurse, who said she'd re-take blood pressure with a different cuff. Nurse explained to OT about his increased pain and increased pain medication, which could be attributing to his demeanor. OT then obtained a low blood pressure (,d+[DATE]), but she didn't feel the blood pressure was accurate because he was talking with her and drinking water at the time of the reading. OT reported blood pressure to R1's nurse. Shortly after this, Physical Therapy (PT) went in by R1 and he was not responsive verbally to her. PT performed sternal rub (pain stimulus is a technique used to assess the consciousness of a person not responding to normal interaction) with a grunt noise in response and she then yelled for help. Nursing staff ran into room with assorted items BP machine, glucometer, Narcan (medication to treat narcotic overdose in an emergency situation), and oxygen. R1 was able to nod in response to questions from Director of Nursing (DON) and then he slumped forward, at this time he was still breathing and still had a pulse. Narcan was administered. R1 stopped breathing and pulse could not be palpated, and a code was called. In process of placing backboard behind R1 to start CPR (cardiopulmonary resuscitation- an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped), it was noted R1 had wet, bright red blood on draw sheet and bottom fitted sheet. Despite the efforts of the facility, R1 passed away. Cause of death was noted to be hemorrhagic femoral bypass graft incision. On [DATE] at 12:14 PM, Surveyor interviewed DON B. Surveyor asked DON B if this should have been reported to the State Agency, DON B said didn't even think of that. On [DATE] at 6:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) if this should have been reported to the State Agency, NHA A said did not report, didn't know it should be. At the time of the incident R1 had severe bleeding of an unknown source, change of condition which led to R1's death. Based on the unknown source of severe bleeding this incident would be considered an injury of unknown origin and with serious bodily injury and would require a report to the state agency.

Based on observations, interviews, review of facility policy, and document review, it was determined the facility failed to follow the prepared menu for 36 of 39 residents who received a regular diet, a National Dysphagia Diet Level (NDDL) 3, or a NDDL 2 from the facility kitchen. Specifically, the facility failed to serve the correct portion size for vegetables during the lunch meal on 04/25/2023. Findings included: A review of the facility's undated policy and procedure titled, Menu Planning, indicated, Menu planning will be completed by the facility at least 2 weeks in advance of service and menus will be kept on file for a minimum of 90 days. The policy indicated, Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. The policy also indicated, Temporary changes to the menu will be noted on the menus substitution sheets and posted so the facility staff is aware of changes. The RD [Registered Dietitian] or designee will approve all permanent menu changes. During observations in the facility kitchen beginning on 04/25/2023 at 11:50 AM, Cook P served a 2-ounce (1/4 cup) portion of capri mixed vegetables to residents on regular, NDDL 3, and NDDL 2 diets. In an interview on 04/25/2023 at 11:58 AM, Cook P stated she referred to the portion book to know what size portions to serve. Cook P stated she was supposed to serve a 4-ounce portion of vegetables, but the residents did not like the vegetables, so she only gave them half a serving. Cook P stated for residents that requested a large portion of vegetables, she provided two 2-ounce servings. A review of the Menu Daily Spreadsheet Week 3 Tuesday, for 04/25/2023, indicated residents on regular, NDDL 3, and NDDL 2 diets were to receive a #8 scoop (1/2 cup) of mixed vegetables. A review of the facility Diet Type Report revealed that 36 of 39 residents residing at the facility received regular, NDDL 3, or NDDL 2 diets. In an interview on 04/26/2023 at 10:27 AM, RD R (Registered Dietitian) stated she expected the facility to follow the menu spreadsheet unless there was a food shortage. If there was a shortage, they could make a substitution and put it on the substitution log for her to review. RD R stated it was not appropriate to serve a half portion of vegetables. RD R stated if a resident did not like the vegetables, it needed to be individualized on the meal ticket for that resident. In an interview on 04/26/2023 at 11:49 AM, NHA A (Nursing Home Administrator) stated her expectation was that the kitchen staff followed the menu as written. NHA A stated if it was something that the residents did not like, staff could make a substitution and submit it to the RD for approval. In an interview on 04/27/2023 at 8:17 AM, DM Q (Dietary Manager) stated staff needed to follow the menus. DM Q stated if staff were changing the menu, they needed to replace the planned item with an equivalent and notify the residents of the change. DM Q stated it was not appropriate to serve a half portion of vegetables. In an interview on 04/27/2023 at 9:38 AM, DON B stated that she expected kitchen staff to follow the menus as written.

Based on observations, interviews, and facility policy review, the facility did not ensure that staff treated 19 of 29 residents resident with dignity and respect. Staff were noted to be wearing ear buds (inner ear headphones) to talk on the phone or listen to music while providing care to residents on the South Wing. Findings included: Review of a facility policy titled, Professional Appearance and Dress Code Guidelines for Employees, dated 02/01/2020, indicated, Cell Phones and PDA [personal digital assistant] Devices - Employees should not have any type of cell phone, pager, PDA or other personal media on their person in work areas, unless required for job duties. Personal media include earpieces, cameras, MP3 [digital music device] players and devices used for texting. Review of a facility policy titled, Dignity, dated 07/21/2022, indicated, Residents should not be excluded from conversations during activities or when care is being provided, nor should staff discuss residents in settings where others can overhear private or protected information or document in charts/electronic health records where others can see a resident's information. During an interview with R3 on 04/24/2023 at 10:15 AM, the resident, who resided on the South Hall, indicated staff were always on their phones and having conversations using ear buds while providing care. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. During an interview on 04/26/2023 at 10:55 AM, CNA G (Certified Nurse Aide) stated staff were not allowed to have earbuds or phones while on the floor. On 04/25/2023 at 1:21 PM, CNA F was observed on the South Hall near room [ROOM NUMBER], unwrapping a head scarf, and exposing a white ear bud in her left ear. During an interview on 04/26/2023 at 2:15 PM, CNA H stated some staff members used their ear buds while on the floor and assisting residents. During an interview on 04/26/2023 at 2:47 PM, CNA I indicated some residents had complained to him about staff having ear buds, and one resident stated all the CNAs were using their cell phones while working. During an interview on 04/26/2023 at 3:16 PM, LPN J (Licensed Practical Nurse) indicated there were staff who wore ear buds and used their phones to talk to friends while on the floor. When asked which staff members he had observed doing this, he stated he was not sure if there was a staff member he could exclude from that list. During an interview on 04/26/2023 at 3:41 PM, RN K (Registered Nurse) stated she had seen staff on the later shifts using ear buds and talking on their phones at the nurses' desk. During an interview with NHA A (Nursing Home Administrator) and DON B (Director of Nursing) on 04/27/2023 at 8:26 AM, NHA A stated staff should not be having conversations on their phones and using ear buds while providing care. NHA A and DON B stated staff liked to listen to music using their earbuds. NHA A and DON B stated things had changed since the COVID pandemic and that staff members' families now needed to have a way to get in touch with them. The DON B added, This is the culture we live in.

Based on interviews and record review, it was determined the facility failed to ensure a significant change Minimum Data Set (MDS) was completed within 14 days after hospice services were discontinued for 1 (R4) of 1 sampled resident who received hospice services. R4's hospice services were discontinued on 1/19/23. As of 4/26/23, a significant change MDS had not been completed. Findings included: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, revealed, An SCSA [Significant Change in Status Assessment] is required to be performed when a resident is receiving hospice services and then decides to discontinue those services. According to the RAI User's Manual, the SCSA assessment is required to be performed within 14 days of the effective date of hospice revocation, the expiration date of the certification of terminal illness, or the date of the physician's or medical director's order stating the resident is no longer terminally ill. R4 was readmitted on [DATE]. The MDS indicated the resident had active diagnoses that included encounter for palliative care, heart failure, and diabetes mellitus. According to the MDS, the resident received hospice services while a resident. A quarterly MDS dated [DATE] revealed R4 received hospice services while a resident. Review of an Order Summary Report, for active physician orders as of 04/01/2023, revealed no current physician's order for hospice services. Review of R4's care plan, dated as reviewed on 04/11/2023, revealed as of 01/23, R4 no longer required hospice services. Review of a Home Care Visit discharge summary, dated 01/19/2023, revealed R4 was admitted to a local hospice service on 06/15/2022 with a primary diagnosis of heart failure. The note indicated that on 01/19/2023, R4's hospice services ended because the resident no longer met the criteria for hospice services. As of 04/26/2023, there was no evidence in R4's medical record to indicate a significant change MDS was completed after the resident was discharged from hospice services. During an interview on 04/26/2023 at 8:37 AM, DON B (Director of Nursing) stated the facility did not have a policy for MDS assessments and used the Resident Assessment Instrument (RAI) User's Manual for guidance. During an interview on 04/26/2023 at 12:14 PM, NHA A (Nursing Home Administrator) stated the facility's MDS Coordinator, MDSC D, was not available for interview due to an emergency, but the Regional MDSC C, was available for interview via telephone. During a telephone interview on 04/26/2023 at 12:16 PM, MDSC C stated a significant change MDS should be completed any time a resident started or stopped hospice services. MDSC C reviewed R4's medical record during the interview and stated R4 was still on hospice services per the facility census. She then stated she noted the Home Care Visit in the resident's record indicating the resident had been discharged from hospice on 01/19/2023. MDSC C stated a significant change MDS should have been completed in January 2023. MDSC C stated she was responsible for completing audits to ensure MDS assessments were completed timely and accurately, and MDSC D was behind on completion of MDS assessments. MDSC C stated she did not know how the significant change MDS for R4 was overlooked. On 04/27/2023 at 9:20 AM, NHA A and DON B were interviewed simultaneously, and both stated a significant change MDS should have been completed when R4 was discharged from hospice services.

Based on observation, interview and record review, the facility did not ensure accurate administration of a medication for 1 of 3 residents observed (R4). Surveyor observed an incorrect dose of insulin prepared for R4. This is evidenced by: The facility's policy, titled, Preparation and Guidelines IIA2: Medication Administration-General Guidelines, with a revised date of December 2019, indicates, in part: Procedures: A. Preparation .4) FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away .b. Check # 2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR (Medication Administration Record) by reviewing the 5 Rights. c. Check # 3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights .B. Administration .2) Medications are administered in accordance with written orders of the prescriber . R4 was admitted to the facility with an original admitted [DATE], with diagnoses that include, in part: Type II diabetes mellitus; unspecified sequelae of cerebral infarction; and Type II Diabetes mellitus with proliferative diabetic retinopathy . R4's physician orders include in part: Insulin [MEDICATION(S)] Solution Inject 3 units subcutaneously with meals .; Insulin [MEDICATION(S)] Solution Inject as per sliding scale: .241-300 = 4 units subcutaneously after meals. (Of note, the entire dose was prepared at the mealtime) Review of R4's MAR (Medication Administration Record) notes scheduled administration times for: Insulin [MEDICATION(S)] Solution Inject 3 units: 8:00AM; 12:00PM; and 5:00PM. Insulin [MEDICATION(S)] Solution Sliding Scale: 9:00AM; 1:00PM; and 6:00PM On 10/10/22 at 12:00 PM, Surveyor observed LPN C (Licensed Practical Nurse) prepare R4's Insulin [MEDICATION(S)] for administration. LPN C reported that R4's blood sugar was 292 and per her sliding scale orders she would be receiving 4 units plus her regularly scheduled 3 units for a total of 7 units. Surveyor observed syringe after LPN prepared dose and noted 12 units in the syringe. Surveyor asked LPN C if she was ready to administer the insulin. LPN C indicated she was. Surveyor requested that LPN C check the prepared syringe for the correct dose prior to administration. LPN C indicated it was not 7 units. On 10/10/22 at approximately 2:45 PM Surveyor interviewed DON B (Director of Nursing) and reviewed observation made of LPN C's insulin preparation for R4. Surveyor asked DON B if 12 units would be an incorrect dose for R4 for that administration time. DON B indicated, correct.

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 a potential to affect all 41 residents who reside in the facility. Surveyor observed stove-hood unit to have loose dust on the frame and light fixtures directly above where food was being prepared. Surveyor observed food removed from original packaging and without an open date. Surveyor observed staff's personal food and beverage items stored with resident food items in facility walk in refrigerator. Surveyor observed food items in circulation past the manufacturer's expiration date in the freezer, walk-in refrigerator, and the resident refrigerator in the vending machine room. Surveyor observed two dented cans in circulation. Surveyor observed facility's ice machine to be unclean. Evidenced by: Stove Hood: On [DATE] at 9:00AM Surveyor observed hairlike dust particles under the hood along conduit and covering the light fixtures. Staff were preparing food directly underneath. During an interview, DM C (Dietary Manager) indicated there is potential for the dust to dislodge into food being prepared underneath stove-hood unit. DM C indicated MM D (Maintenance Man) is responsible for the upkeep of the stove-hood. No open dates: Facility policy, entitled Policy and Procedure Manual, dated 2014, includes, in part: Food Storage . Procedure #4: .Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled . Storage of Food and Supplies page 136. Procedure #6: All foods will be covered, labeled, and dated. Items should be stored in original packaging. If removed from its original packaging, wrap in clean moisture-proof material, or place it in a clean sanitized container with a tight-fitting lid. All packaging and containers should be labeled with the name of the food and expiration date. On [DATE] at 9:00AM during initial tour of the facility's kitchen, Surveyor observed the following food items to be removed from original manufacturer's packaging and opened. These items did not have an open date or an expiration/use by date on them: Cheerios, Rice Krispies, Frosted Flakes, Corn Flakes, Fruit Loops, Nilla Wafers, Silk milk, and canned fruit in cups. The food items were located in the main kitchen area in plastic bags on a shelf. During an interview, DM C indicated these items should have an open date on them. Staff Food: On [DATE] at 9:00AM during initial tour of the kitchen, Surveyor observed an opened soda, a grocery bag with food items, and a plastic container with leftover food in the walk-in facility refrigerator among other foods that were labeled and dated for resident meals. During an interview DM C indicated these items were staff items and should not be stored in with resident food. DM C indicated she has educated staff on not doing this and was disappointed to see it still an issue. Expired Food: Facility policy, entitled Policy and Procedure Manual, dated 2014, includes, in part: . There will be a written, comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of the food service department . Procedure #1: The food service manager is responsible for developing a cleaning schedule for the department. He/she will also monitor compliance and overall cleanliness and sanitation of the department. 2. The cleaning schedule will include: Each piece of equipment . Frequency of cleaning The Wisconsin Food Code 2016 includes, in part: .foods must be marked to indicate when food must be consumed, sold, or discarded not to exceed 7 total days at 41°F or below. On [DATE] at 9:00AM Surveyor observed the following expired foods in the walk in refrigerator, walk in freezer, and the resident refrigerator: opened pickles with an open date of [DATE], cookie dough dated [DATE], two cases of Ready Care Frozen Supplement dated [DATE], Stouffer's Frozen Meal dated ,d+[DATE] with current resident's name, Chobani yogurt dated [DATE] and labeled with current resident's name, undated/unlabeled unidentifiable food wrapped in aluminum foil, French onion dip expiration dated [DATE] and labeled with current resident's name, Unsweetened Almond Milk expiration dated [DATE], Activia yogurt with expiration date of [DATE], Activia yogurt with expiration date of [DATE] and labeled with current resident's name, a bag of unidentifiable food labeled with resident's name and dated [DATE], and 4 to go containers undated and unlabeled. DM C indicated the pickles are good for two or three months after opening and should have been thrown out. DM C indicated it was every employee's responsibility to remove expired and undated/unlabeled foods from circulation. Ice Machine: Facility policy, entitled Policy and Procedure Manual, dated 2014, includes, in part: . There will be a written, comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of the food service department . Procedure #1: The food service manager is responsible for developing a cleaning schedule for the department. He/she will also monitor compliance and overall cleanliness and sanitation of the department. 2. The cleaning schedule will include: Each piece of equipment . Frequency of cleaning On [DATE] at 9:00AM Surveyor observed green hardened calcified substance on the top opening crease of the length of the ice machine in the main kitchen preparation area. DM C indicated the facility just paid a service man to come clean the ice machine and this was not clean. DM C also indicated there is potential for the ice cubes to be contaminated as the substance was right over top of the opening where ice is being scooped out. Dented Cans: Facility policy, entitled Policy and Procedure Manual, dated 2014, includes, in part: Receiving Deliveries . Procedure #3: Reject the following: Cans that have signs of deterioration-swollen sides or ends, flawed seals or seams, dents, or rust. FDA Food Code 2017, section ,d+[DATE].15, includes, in part: Package Integrity. Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants such as [CONDITION(S)] botulinum may find their way into the food. In anaerobic conditions (lack of oxygen), [CONDITION(S)] toxin may be formed. Packaging defects may not be readily apparent. This is particularly the case with low acid canned foods. Close inspection of cans for imperfections or damage may reveal punctures or seam defects. In many cases, suspect packaging may have to be inspected by trained persons using magnifying equipment. Irreversible and even reversible swelling of cans (hard swells and flippers) may indicate can damage or imperfections (lack of an airtight, i.e., hermetic seal). Swollen cans may also indicate that not enough heat was applied during processing (under processing). Suspect cans must be returned and not offered for sale.

Based on observation and interview, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 of 2 complaint surveys. The facility's flooring is dated, worn, scratched and not homelike. The baseboards are worn, dingy, and warped. As evidenced by: NHA A (Nursing Home Administrator) stated the facility does not have a policy and procedure regarding homelike environment or floor care and maintenance. During this recertification survey from 3/13 - 3/16/22, Surveyor observed flooring throughout the facility to be dated, worn, scratched, peeling and not homelike. Surveyor observed the flooring in the lounge to be peeling and flaking. Surveyor observed the flooring to be dated, worn, and with excessive scratches throughout. Surveyor observed the most excessive scratches inside the front door and outside the dining room entrances/exits. Surveyor observed baseboards throughout the facility to be worn, dingy, and warped. On 3/15/22 at 11:21 AM, Surveyor spoke with NHA A. Surveyor asked NHA A if any resident/family/staff expressed concern to her regarding the floors. NHA A stated not that she is aware of. NHA A stated she knows the floors need attention, but is not sure how to wax the floors during COVID with fans running, etc. Note, if there is no COVID positive staff or residents it is acceptable to run fans while refinishing or replacing the flooring. NHA A stated the floors have not been waxed since 2016 (6 years ago). Surveyor and NHA A walked in the halls and observed concerns with the flooring and baseboards. NHA A stated she does not know if the floor is in need to be waxed or replaced. Surveyor asked NHA A, should the facility be homelike for residents. NHA A stated, As much as possible. NHA A stated she thinks there's nothing more to wax (floors are just worn out).

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring for change in condition for 2 residents (R2 and R3) of a total sample of 5 residents reviewed. On [DATE], R2 presented with a significant change in respiratory status when noted to be gasping for air. The facility failed to immediately complete a full nursing assessment of R2's condition, or consult with a physician, which delayed in R2 receiving needed emergency medical services. R2 was later transferred to the emergency room for acute respiratory distress, and subsequently died on [DATE]. On [DATE], R3 presented with a significant change of condition of sustained hypertension and an inability to talk. On [DATE] at 10:13 PM, R3's doctor requested nursing staff continue to monitor R3 for symptoms of hypertension. The facility had no evidence that nursing staff monitored or reassessed R3 for a 10 hour period on the night of [DATE] at 10:13 P.M. through [DATE] at 8:05 A.M. R3 was sent to the emergency room for altered mental status on [DATE] and subsequently died on [DATE]. The facility's failure to thoroughly assess residents experiencing a significant change in condition created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 2:50 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ findings. The jeopardy was removed and corected on [DATE] when the facility recognized the deficient practice and took steps to correct the deficient practice. This is being cited as past noncompliance. This is evidenced by: The facility's Change of Condition policy dated [DATE] states in part: Purpose: To provide prompt and appropriate assessment and intervention for change in resident's condition . Procedure: 1. Charge nurse should utilize SBAR (Situation, Background, Assessment, and Recommendation) worksheet to perform a head to toe assessment and gather pertinent background information of resident who demonstrates a change of condition. If nurse is not and RN (Registered Nurse), data may be gathered, but the LPN (Licensed Practical Nurse) must call the RN to assess and document findings 3. The Nurse Manager or Charge Nurse is to be notified immediately. 4. Complete eInteract: Change of Condition Assessment . 5. The Nurse Manager or Charge Nurse makes the final decision regarding immediate mode of action, which may include the following: a. Use the Signs and Symptoms eInteract tools/ Care Path. b. Complete a head to toe physical assessment of the resident, utilizing the eInteract: Tools/Care Path as indicated. e. Carry out all orders or directives given by physician . Example 1 R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was reviewed as a closed record. R2 had an APOAHC (activated power of attorney for health care). R2's admission MDS (Minimal Data Set) Assessment on [DATE] notes R2's BIMS (Brief Interview for Mental Status) score of 00 indicating R2 had severe cognitive impairment. Section G of the MDS notes R2 was dependent on staff assist of 2 with ADL's (activities of daily living). R2's Comprehensive Care Plan dated [DATE], states in part: The resident (R2) has altered cardiovascular status related to [DIAGNOSES REDACTED] . Goal: .will be free from complications of cardiac problems . Interventions: . Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of CAD ([MEDICAL CONDITION]): . shortness of breath . R2's physician orders [REDACTED]. On [DATE], DNR (Do Not Resuscitate) On [DATE], Oxygen at 2 liter per minute per nasal cannula, as needed for dyspnea (difficulty breathing). If this is an acute change for the patient call PCP with assessment . Of note, there is no evidence that R2 had received supplemental oxygen since admission on [DATE] until [DATE]. Review of R2's O2 sat (oxygen saturation) monitoring between [DATE] and [DATE] noted R2's oxygen saturation ranged from 95% to 99% on room air. On [DATE] at 7:00 AM it is documented R2's O2 sat was at 85% and at 9:44 AM, it is documented that R2's O2 sat was at 78%. Review of R2's Progress Notes, by LPN C (Licensed Practical Nurse): [DATE] at 7:00 AM, Event note: Went into pt. (patient) room met Pt. gasping for air. At that time pt.'s O2 sat was 85% on room air. Pt was place on O2 at 2 liter. Pt color change and pt. was responsive. Of note, there is no evidence R2 received a thorough RN assessment when R2 presented with an acute change of condition gasping for air and an oxygen saturation of 85% per physician order. Review of R2's vital sign monitoring: On [DATE] at 7:25 AM, R2's Pulse was 91. Of note, there is no evidence that the facility completed a full set of vital signs or a thorough RN assessment for R2's change of condition. On [DATE] at 9:42 AM R2's vital signs were documented: Temperature: 97.4 Pulse: 91, Respirations: 24, and B/P-,[DATE] Progress note on [DATE] at 10:33 AM states, Transfer to Hospital Summary: Writer went into pt.'s (room) to do dressing change on roommate. Pt. was having difficulty breathing (sic). Head of bed up O2 sat @ ,[DATE]% (sic). Increased O2 still couldn't get up to 90. Called wife to update Pt's condition and asked whether she wants writer to send husband to the ER (emergency room ) and she stated yes. On call Dr. (name) notified and an order was given to send to the ER for Eval (evaluation) and treat. 911 called and pt. was sent to the ER. Wife updated, DON updated and aware. [DATE] at 1:54 PM, Transfer to hospital Summary: 6:30 AM, Went into pt.'s room assessment pt. was having difficulty breathing. O2 sat at that time was 85% on room air. Pt. writer brought in O2 concentrator and placed pt. on 2 liter of O2. O2 sat increased to ,[DATE]%. Pt was alert. (7:00 AM) Writer told tech (Medication Technician) to give pain med to him. 7:38 AM, Med tech went to room and AM meds administered pt. had good interaction with tech talking, moving in bed and drank his fluids everything tolerated well. 9:15 AM, writer went into pt. room to change dressing on roommate. Pt. gasping for air, O2 sat taken it was ,[DATE] (sic) increased O2 to 3 L (liters. At that time came out to check pt.'s status and it was DNR. Writer call wife and asked if she wanted pt. sent to the ER and wife said yes. 9:30 AM On call Dr. (name) notified and order given for pt. to be sent to the ER. Then 911 called. Wife was notified. Of note, the facility did not immediately notify R2's physician or APOAHC at 6:30 AM when R2 presented with an acute change in condition. Review of EMS report for R2 dated [DATE], EMS was notified at 9:20 AM, and arrived at facility at 9:27 AM. EMS notes includes in part: Nurse . stated episode of dyspnea started at 6:00 AM, when she reported for work. Of note, this is a delay of ,[DATE].5 hours since R2's onset of symptoms without an RN assessment, On [DATE] at 4:30 PM, Surveyor interviewed LPN C on the phone about R2's change of condition on [DATE]. LPN C stated she was caring for R2 on [DATE]. In the morning about 6:30 AM, LPN C went into R2's room to assess R2 as R2 was having problems breathing. LPN C stated she started oxygen for R2's distress. Surveyor asked LPN C if she notified an RN (Registered Nurse) when she noted R2's change. LPN C stated she talked to the DON (Director of Nursing-who no longer works at the facility) but could not recall what time she talked to DON. LPN C stated later on [DATE], a CNA reported to LPN C that R2 was not breathing right, LPN C assessed R2, called the DON to tell her R2 was DNR, then called R2's wife, the doctor and 911 and increased his oxygen to 4 liters, then EMS came. Of note, an LPN by law and training cannot assess. This resident displayed a significant change in condition at 7AM. Subsequently, there was no systematic and continuous collection and analysis of data about the health status of the resident that culminated in the formulation of a nursing diagnosis, a nursing plan of care, and direct intervention (requirements of an RN in N6, Wisconsin Nurse Practice Act). Without an assessment and nursing diagnosis, staff had no direction on how to proceed, which contributed to the delay in notifying the physician and obtaining medical intervention. (Cross reference F580.) Example 2 R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 was reviewed as a closed record. R3's MDS (Minimum Data Set) assessment on [DATE] notes a BIMS (Brief Interview for Mental Status) score of 14 indicating R3 was cognitively intact. R3's Comprehensive Care Plan dated [DATE], states in part: The resident (R3) has altered cardiovascular/respiratory status r/t (related to) [DIAGNOSES REDACTED], pleural effusion, [MEDICAL CONDITION] Chronic SOB (shortness of breath) . hypertension. Goal: . will be free from complications of cardia problems . Interventions: Vital signs as ordered, indicated by symptoms. Notify MD of significant abnormalities . Monitor/document report PRN (as needed) any changes in lung sounds .any s/sx (signs/symptoms) of CAD ([MEDICAL CONDITION]) . Review of R3's History and Physical dated [DATE] . notes in part: Patient's blood pressure decreased during hospitalization and BP medications held and not restarted, will need to follow BP closely . R3's physician orders [REDACTED]. On [DATE], Full Code On [DATE], [MEDICATION NAME] ([MEDICATION NAME]) 40 MG (Milligrams) four tablets (total of 160 MG) 2 times per day every Monday, Wednesday, Friday and Sunday for [MEDICAL CONDITION] and Hypertension. On [DATE], [MEDICATION NAME] ER (Extended Release), 50 MG one time in a day . On [DATE], [MEDICATION NAME] ER 100 MG by mouth one time a day for hypertension On [DATE], [MEDICATION NAME] 80 MG by mouth one time only for Hypertension Review of R3's Progress Notes include in part: On [DATE] at 8:01 PM: Writer contacted on call MD (Medical Doctor, name) to report res (resident) b/p (Blood Pressure) ,[DATE] P (Pulse) 74. MD ordered writer to administer [MEDICATION NAME] . update NP (Nurse Practitioner name) in am . On [DATE] at 10:05 PM: Writer left message for on call MD to report res b/p of ,[DATE] P 79. Res nuero (sic) status at baseline. Res. states I don't know what's wrong with me, I can't talk. There was no documented assessment at 10:05 PM. (i.e. assessment of lung sounds/cardiac assessment). R3's Progress Notes on [DATE] were documented by an RN who no longer works at the facility. On [DATE] at 10:13 PM: On call MD (name) requested that nursing continue to monitor res for any symptoms related to HTN. Res is sleeping at this time will continue to monitor. Of note, there is no evidence that MD was told of R3 stating I can't talk Review of R3's vital sign monitoring notes: On [DATE] at 5: 46 PM, Temperature: 97.2, Pulse: 74, O2 sat: 98% On [DATE] at 7:52 PM, B/P: ,[DATE] On [DATE] at 10:05 PM- Pulse: 79, B/P: ,[DATE] On [DATE] at 11:36 PM O2 sat: 96% on room air. On [DATE] at 8:05 AM-Pulse: 76, B/P: ,[DATE] Of note, there is no evidence R3 was monitored for hypertension by nursing staff from [DATE] at 10:05 PM through [DATE] at 8:05 AM despite an MD order to monitor during the night. Review of R3's EMS report dated [DATE], EMS was notified at 8:01 AM, and arrived at 8:08 AM,. EMS notes includes in part: B/P ,[DATE], Alerted mental status, left facial droop . grip strength decreased on the left . On [DATE] at 4:00 PM, Surveyor interviewed CN G (Clinic Nurse) on the phone about R3's discharge from the facility on [DATE] and hospitalization . CN G stated R3 arrived at the Emergency Department on [DATE] at 8:50 AM, and was unresponsive. R3 was diagnosed with [REDACTED]. R3 was admitted to the hospital, was intubated and later placed on comfort care, R3 died at the hospital at 11:00 PM. On [DATE] at 9:25 AM, Surveyor interviewed NP D (Nurse Practitioner) about R3's change of condition on [DATE]. Surveyor reviewed R3's documented Progress notes and vital signs noted at 10:05 PM and not rechecked until [DATE] at 8:05 AM with NP D. NP D stated that she would have expected the nursing staff to have reassessed R3 and rechecked R3's B/P at least one more time during the night to see how R3 was doing. R3 presented with a change of condition in the evening of [DATE]. On [DATE] at 10:13 PM, R3's doctor requested staff continue to monitor R3 for symptoms of hypertension. The facility had no evidence that nursing staff monitored or reassessed R3 for a 10 hour period on the night of [DATE] at 10:13 P.M. through [DATE] at 8:05 A.M. The facility's failure to provide care consistent with current standards of practice for completing and RN assessment for a resident with a significant change in condition created a finding of IJ that began on [DATE]. On [DATE], the facility recognized the deficient practice (related to a different resident) of the facility nursing staff and immediately took the following steps to ensure the deficient practice does not occur again: -On [DATE], the facility immediately did the following and started an investigation. - R2 and R3 were sent to the hospital and did not return to the facility. -The medical record was reviewed as part of the investigation and root cause analysis was completed. -All residents' change of conditions were reviewed with 30 days prior to [DATE]. -Licensed staff were educated on the eInteract tools for change of condition on [DATE]. -Licensed staff completed education on acknowledging any assessment outside of baseline and immediately report to MD and Responsible Party per recognized standard of practice. -Licensed staff education of head to toe RN assess of body system as it relates to change of condition. -Licensed staff education in eInteract for nurses, clinical follow-up/alert charting per facility expectations and shift to shift report. Licensed staff completed quiz acknowledging competency in new process for MD notification. - Certified Nursing Assistant completed education on Stop and Watch and POC alerts. -Licensed staff were educated on procedures when an RN might not be available in the facility to notify on call RN and MD per standards of practice. - On [DATE], facility reviewed policy and procedure on Notification of Change in Resident Health Status in coordination with medical director including when to immediately notify a physician to ensure policy meet current standards of practice. Interact tool care path to ensure RN assessment is completed. - Nursing Managers and DON will conduct audits 5x/week for 4 weeks and weekly x 8 weeks and monthly x 3 months of residents experiencing a change of condition to ensure timely notification was completed. Results of the audits will be reviewed at the QAPI meeting for further recommendations.

Based on record review and interview, the facility did not immediately notify and consult with the resident's physician and the resident representative when a significant change in the resident's physical, mental, or psychosocial status occurred for 1 resident (R2) of a total sample of 5 residents reviewed. On [DATE] at 6:30 AM, R2 presented with a significant change in respiratory status of gasping for air. The facility did not immediately notify R2's physician and R2's APOAHC (Activated Power of Attorney for Health Care) until 9:30 AM, which delayed R2 in receiving EMS (Emergency Medical Services) for 3 hours. R2 was later transferred to the emergency room for acute respiratory distress and subsequently died at the hospital on [DATE]. The facility's failure to immediately notify R2's physician of R2's acute change in respiratory status, created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 2:50 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ finding. On [DATE], the facility recognized the deficient practice of the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on [DATE]. This is being cited as past noncompliance. This is evidenced by: The facility's undated policy Notification of Change in Resident Health Status states in part: The facility will consult the resident's physician . and when indicated notify the resident's legal representative . when there is: (B) Acute illness or significant change in the resident's physical . status (i.e. deterioration in health . The facility's Change of Condition policy dated [DATE] states in part: . The Nurse Manager or Charge Nurse makes the final decision regarding immediate mode of action, which may include the following: a. Use the Signs and Symptoms eInteract Tools/Care Path. (These tools are located on all Nurse Med Carts and at each Nurse's Station.) . c. Notify the physician and document. d. Notify the family/POA and document . The facility's eInteract document guides decision making of when to report to the MD/NP/PA (Medical Doctor/ Nurse Practitioner/Physician Assistant) and notes in part: Change in Condition: Immediate Notification-Any symptoms, sign or apparent discomfort that is: Acute or Sudden in onset, and: A marked change (i.e. more severe) in relation to usual symptoms. Under Vital Signs Report Immediately . Oxygen saturation less 90% and under Signs and Symptoms for Dyspnea (shortness of breath) it is noted the facility should provide Immediate notification to the MD/NP/PA for Acute onset of change from usual pattern . labored respirations or unstable vital signs. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was reviewed as a closed record. R2 had an APOAHC (activated power of attorney for health care) R2's admission MDS (Minimal Data Set) Assessment on [DATE] notes R2's BIMS (Brief Interview for Mental Status) score of 00 indicating R2 had severe cognitive impairment. Section G of the MDS notes R2 was dependent on staff assist of 2 with ADL's (activities of daily living). R2's Comprehensive Care Plan dated [DATE], states in part: The resident (R2) has altered cardiovascular status related to [DIAGNOSES REDACTED] . Goal: .will be free from complications of cardiac problems . Interventions: . Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of CAD ([MEDICAL CONDITION]): . shortness of breath . R2's physician orders [REDACTED]. On [DATE], DNR (Do Not Resuscitate) On [DATE], Oxygen at 2 liter per minute per nasal cannula, as needed for dyspnea. If this is an acute change for the patient call PCP with assessment . Of note, there is no evidence that R2 received supplemental oxygen since admission on [DATE] until [DATE]. Review of R2's O2 sat (oxygen saturation) monitoring between [DATE] and [DATE] noted R2's oxygen saturation ranged from 95% to 99% on room air. Review of R2's Progress Notes, notes the following entries by LPN C (Licensed Practical Nurse): [DATE] at 7:00 AM, Event note: Went into pt. (patient) room met Pt. gasping for air. At that time pt's O2 sat was 85% on room air. Pt was placed on O2 at 2 liter. Pt. color changed and pt. was responsive. Of note, there is no evidence R2's physician or APOAHC were immediately notified when R2 presented with an acute change of condition gasping for air and an oxygen saturation of 85%. [DATE] at 10:33 AM, Transfer to Hospital Summary: Writer went into pt.'s (room) to do a dressing change on roommate. Pt. was having difficulty breathing (sic). Head of bed up O2 sat @ ,[DATE]% (sic). Increased O2 still couldn't get up to 90%. Called wife to update Pt's condition and asked whether she wants writer to send husband to the ER (emergency room ) and she stated yes. On call Dr. (name) notified and an order was given to send to the ER for Eval (evaluation) and treat. 911 called and pt. was sent to the ER. Wife updated, DON updated and aware. [DATE] at 1:54 PM, Transfer to hospital Summary: 6:30 AM, Went into pt.'s room assessment pt. was having difficulty breathing. O2 sat at that time was 85% on room air. Writer brought in O2 concentrator and placed pt. on 2 liter of O2. O2 sat increased to ,[DATE]%. Pt was alert. (7:00 AM) Writer told tech (Medication Technician) to give pain med to him. 7:38 AM Med tech went to room and AM meds administered pt. had good interaction with tech talking, moving in bed and drank his fluids everything tolerated well. 9:15 AM Writer went into pt. room to change dressing on roommate met pt. gasping for air, O2 sat taken it was ,[DATE] (sic) increased O2 to 3 L (liters). At that time came out to check pt.'s status and it was DNR. Writer call wife and asked if she wanted pt. sent to the ER and wife said yes. 9:30 AM On call Dr. (name) notified and order given for pt. to be sent to the ER. Then 911 called. Wife was notified. Of note, the facility did not immediately notify R2's physician or APOAHC at 6:30 AM when R2 presented with an acute change in condition. Review of R2's vital sign documentation includes one entry on [DATE] at 9:43 AM, Temperature - 97.4, Pulse-91, Respirations-24, Blood Pressure-,[DATE], O2 sat -78%. Review of R2's EMS report dated [DATE], note includes, in part: EMS was notified at 9:20 AM, arrived at facility at 9:27 AM. Nurse . stated episode of dyspnea started at 6:00 AM when she reported for work. Of note, this is a delay of ,[DATE].5 hours since R2's onset of symptoms. On [DATE] at 4:30 PM, Surveyor interviewed LPN C on the phone about R2's change of condition on [DATE]. LPN C stated she was caring for R2 on [DATE]. In the morning about 6:30 AM, LPN C went into R2's room to assess R2 as R2 was having problems breathing. LPN C stated she started oxygen for R2's distress. Surveyor asked LPN C if she called R2's doctor when she noted R2's change in condition at 6:30 AM, LPN C stated she did not call the doctor when she noted R2's first attack and stated I should have called the doctor right away. LPN C stated later a CNA reported to LPN C R2 was not breathing right, LPN C assessed R2, called the DON to tell her R2 was DNR, then I called the wife, the doctor and 911 and increased his oxygen to 4 liters, then EMS came. On [DATE] at 9:10 AM, Surveyor interviewed NP D (Nurse Practitioner) about R2 change of condition on [DATE]. NP D reported to Surveyor that R2 went to the hospital on [DATE] and while at the hospital, the family decided to provide comfort care for R2, and R2 died on [DATE] at 3:00 PM. NP D stated R2's [DIAGNOSES REDACTED]. Surveyor asked NP D when the facility should have notified the doctor, NP D stated she would have expected the facility to immediately notify the doctor when R2's oxygen saturation was down to 85% at 6:30 AM on [DATE]. The facility's failure to provide care consistent with current standards of practice for staff notifying a physician for a resident with a significant change in condition created a finding of IJ that began on [DATE]. On [DATE], the facility recognized the deficient practice (related to a different resident) of the facility nursing staff and immediately took the following steps to ensure the deficient practice does not occur again: -R2 was sent to the hospital and did not return to the facility. -The medical record was reviewed as part of the investigation and root cause analysis completed. -All change of condition were reviewed within 30 days prior to [DATE]. - Licensed staff were educated on the eInteract tools for MD (Medical Doctor) notification on [DATE]. -Licensed staff completed education on acknowledging any assessment outside of baseline and immediately report to MD and Responsible Party per recognized standard of practice. -Licensed staff education in eInteract for nurses, clinical follow-up/alert charting per facility expectations and shift to shift report. -Licensed staff completed quiz acknowledging competency in new process for MD notification. - Certified Nursing Assistant completed education on Stop and Watch and POC alerts -Licensed staff were educated on procedures when an RN might not be available in the facility to notify on call RN and MD per standards of practice. -On [DATE] facility reviewed policy and procedure on Notification of Change in Resident Health Status in coordination with medical director including when to immediately notify a physician to ensure policy meets current standards of practice. - Nursing Managers and DON will conduct audits 5x/week for 4 weeks and weekly x 8 weeks and monthly x 3 months of residents experiencing a change of condition to ensure timely notification was completed. Results of the audits will be reviewed at the QAPI meeting for further recommendations.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 1 of 3 residents (R5) reviewed for falls. R5 sustained a fall in the facility resulting in a closed pelvic ring fracture and closed non displaced [MEDICAL CONDITION] humeral tuberosity. R5 had multiple previous self-transfer attempts. The facility failed to identify the pattern, root cause and appropriate interventions were not put into place to prevent further falls. Evidenced by: The facility's Fall Prevention Program policy, dated 10/8/18, includes, in part: The facility must ensure the resident environment remains as free of accident hazards as is possible; and each resident received adequate supervision and assistive devices to prevent accidents. Procedure: . 1. A Fall Prevention program will be implemented and maintained to assure the safety of all residents admitted to the facility. The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. 2. A fall Risk Committee will be responsible for reviewing resident falls, monitoring the effectiveness of fall preventions strategies, and for recommending individualized safety interventions. The Restorative nurse will be responsible for implementing and communicating resident-specific recommendations from the Fall Risk Committee to the nursing staff assigned to the resident. 5. The Restorative Nurse will be responsible for communicating any significant safety issues identified through the Fall Risk Committee to the Quality Assurance Committee for further review or corrective action plans as indicated. 9. Nursing staff will complete an Incident Report for each fall to determine factors contributing to the fall and interventions to reduce the risk of further falls. The facility's Fall Risk Assessment and Identification policy, dated, 10/8/18, includes, in part, the following: Policy Statement: To minimize the resident's potential for injury with early assessment and intervention for resident at risk. Procedure: 5. Any resident who experiences a fall will be reassessed and interventions will be implemented and evaluated by the Fall Committee. Recommendations and referrals will be made as determined by the Fall Committee. Findings include: R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5 is her own decision maker. R5's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/21/20, indicates R5 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R5 has moderate cognitive impairment. Transfers with minimum assistance of one person and ambulates with minimum assistance of one person. Uses toilet with minimum assistance of one person and is continent of bladder and bowel. No behaviors noted throughout the lookback period. R5's Care Plan addresses the following problems: Problem: The resident has a behavior problem r/t (related to) memory impairment, related to alcohol use, declines to wear brace and request/wait for assistance despite education and reminders, dated 7/26//20, includes, in part, the following approaches: Anticipate and meet the resident's needs. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Discuss risk vs benefit of taking brace off and/or walking without assistance. Problem: The resident is at risk for falls due to confusion, poor cognition, deconditioning, poor safety awareness, difficulty redirecting, impulsivity, and attempts to self-transfer, dated 7/15/20, includes, in part: the following approaches: Goal: The resident will be free of injury through the review date. Target date 10/25/20. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure the resident is wearing appropriate footwear. Follow facility fall protocol. Monitor for self-transfers as she does not remember she CANNOT transfer independently. PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed). Q (every) 2-3 hour toileting schedule. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter / remove any potential causes if possible. Educate resident/family/caregiver/IDT (Interdisciplinary Team) as to causes. Signs visible in room next to TV (television) for reminder to call for assistance before getting out of bed. The following interventions were added to the R5's Care Plan 0n 7/30/20 after R5 fell and fractured; red tape placed on call light to increase awareness and visual reminders for use, resident is difficult to redirect so use short statements to remind her to ask for help, resident is very impulsive and transfers independently so monitor for self-transfer attempts, signs visible in room next to TV for reminder to call for assistance before getting out of bed, ( in hand writing it states .on wall by head of bed not TV moved rooms since this.) It should be noted R5 fell and fractured on 7/30/20 these interventions were added after R5 fell and fractured. R5's CNA (Certified Nursing Assistant) Care Plan, updated 7/31/20, includes, in part, the following approaches: Toileting: 1A (assist) resident able to alert staff but prompt q 2-3 hours, low bed and floor mat. (Note: CNA care plan does not specifically address falls and fall prevention interventions and techniques.) R5's Fall/Incident Reports are as follows: 1. Date: 7/14/20, Time: 6:28 PM, Incident Location: Resident's room. Incident Type: Fall: Description of the incident: Resident was found on floor of her room in corner across from bed. I was getting up out of bed and fell . Immediate Action Taken; Resident vitals taken, neuros started, PCP (Primary Care Provider) updated, DON (Director of Nursing) updated. Injury: Skin tear left elbow. (Note: Facility did not identify the root cause or pattern at the time of the fall. R5 has history of [MEDICAL CONDITION], poor safety awareness, and poor cognition. R5 does have a BIMS of 12 but has poor cognition which prevents resident from understanding reminders.) 2. Date: 7/15/20, Time: 6:43 AM, Incident Location: Resident's Room. Incident Description: Staff found resident on floor next to bed, skin tear noted on right elbow. Resident lost balance trying to go to restroom. Immediate Action Taken: Assisted resident back to bed, neuros and VS (vital signs) WNL (within normal limits), PCP and DON updated, dressing on up right elbow. Re-enforce teaching on light use and the need to call for help. Resident stated she understood. Injury: Skin tear right elbow. 3. Date: 7/16/20, Time: 7:29 AM, Incident Location: Resident's Room. Incident Description: Resident found down in room on the floor near the bathroom door, partially on her left side, partially on her back. Was attempting to self-transfer to toilet without asking for assistance, no call light on, no back brace on, and improper footwear. VS stable. Resident had to use restroom, isn't used to asking for help so she got up to go. Immediate Action Taken: Assessed for injury. None noted. VS assessed and were WNL. PCP called and updated. Order for back x-ray. Called to schedule with mobile x-ray. Resident assisted into brace and then hoyered in w/c (wheelchair). Assisted with restroom needs. Injury: None (Note: This is the 2nd fall occurring between 6:43 AM and 7:29 AM in the last 2 days.) 4. Date: 7/16/20, Time: 5:21 PM, Incident Location: Resident's Room. Incident Description: Heard resident call for help while sitting across from room. Able to observe resident sliding to floor while self-transferring without brace on. Resident experienced a fall this AM (morning) and x-ray obtained - results pending. Discuss with resident again that we are very concerned for her safety. She needs to wear the brace and call for help. Resident states I did but writer confirms call light not activated and no verbalization until starting to fall. Resident expresses understanding of concern. Resident noted to have used call light following incident at least once in the following hour. I called for help but no one came. Immediate Action Taken: Call light not activated and resident observed calling for help as she fell . Injury: None (Note: Root cause not identified. This is the 2nd fall occurring between 5:21 PM and 6:28 PM in the last 3 days.) 5. Date: 7/21/20, Time: 10:32 AM, Incident Location: Resident's Room. Incident Description: Resident took herself to bathroom and left the walker and turning back to sit down on wheelchair lost the balance and went down on the knees while sitting in wheel chair. Immediate Action Taken: Redirected to use call light and call for help when needed. Resident verbalizes understanding. Injury: None. (Note: This is the 3rd fall occurring between 6:43 AM and 10:32 AM, where resident was attempting to use the restroom independently in the last 7 days.) 6. Date: 7/21/20, Time: 9:21 PM, Incident Location: Resident's Room. Incident Description: Heard call for assistance down the hall from resident's roommate, as resident was on the floor on her bottom in walkway near roommates side of the room. Resident had been self-transferring to the bathroom without assistance. fell on bottom. Reportedly did not hit head, did not lose consciousness. Did not have back brace on. Had been caught self-ambulating in room [ROOM NUMBER]x (times) by this writer earlier this shift and reminded to call for assistance. VS assessed, no injury. Resident stated she wanted to go to the restroom and didn't want to use call light. Immediate Action Taken: VS stable, No Injury. Assisted up and to toilet by staff. Injury: None (Note: This is the 4th fall this admission that resident has had attempting to go to the restroom.) 7. Date: 7/23/20, Time: 4:30 PM, Incident Location: Hallway. Incident Description: Resident was walking down hallway. When I saw her walking I ran towards her. As I was going towards her, she lost her balance and started stumbling towards the wall. She fell halfway and was caught and helped to lower to the ground. Immediate Action Taken: Resident was helped up and into wheelchair. I educated her on why she shouldn't be walking without assistance. Injury: None 8. Date: 7/30/20, Time: 8:00 AM, Incident Location: Resident's Room. Incident Description: Resident had fall with noted pain in left shoulder and left hip. Resident rated pain at 5. No deformities noted and no increased pain with palpation. Resident transferred to bed via Hoyer lift. Pain continued and resident sensitive to any movement. It was felt that she should have ER (emergency room ) evaluation and she was sent to the hospital. Resident notes that she was trying to use the bathroom. Immediate Action Taken: Resident was taken to the hospital. Injury: [MEDICAL CONDITION] greater tuberosity and pubis. (Note: This is the 4th fall between 6:43 AM and 10:32 AM and the 5th fall in which the resident was attempting to use the bathroom.) On 8/12/20 at 11:05 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B the process for documentation and interventions for falls. DON B stated, We keep them comfortable and keep them where they are until a Nurse is able to assess the resident and report to the DON. A Hoyer is used to get the resident back into bed or into a wheelchair. Vital signs and neuro checks are started, management is notified of the fall, as well as, the MD/NP, family, and risk management team. Interventions are put into place and the IDT team reviews all falls. Surveyor asked DON B if the IDT team was able to identify a root cause or pattern with R5's falls. DON B stated, Yes. Surveyor asked DON B if a pattern and/or root cause is identified if she would expect interventions to be put into place to address that pattern and/or root cause. DON B stated, Yes. Surveyor asked DON B if the facility has a restorative nurse. DON B stated, the facility has a restorative nurse who is also the MDS Nurse. They don't have the program set up at this time. (Note: According to the facility policy the Restorative Nurse is responsible for implementing and communication of resident-specific recommendations from the Fall Risk Committee to the nursing staff assigned to the resident and will be responsible for communicating any significant safety issues identified through the Fall Risk Committee to the Quality Assurance Committee for further review or corrective action plan.) On 8/12/20 at 5:55 PM, Surveyor interviewed CNA E regarding R5's toileting program. CNA E stated, I don't think she is on one right now. When she was first here she was to be toileted every 2 hours because she wouldn't use the call light and we would find her up walking around all the time. Surveyor asked CNA E how she knows what fall interventions are in place for a resident. CNA E stated that it is on the CNA care card. On 8/12/20 at 6:00 PM, Surveyor interviewed RN F (Registered Nurse). RN F is an agency nurse who has been in the facility since R5's admission. Surveyor asked RN F what she could tell surveyor about R5's falls. RN F stated, I tried to educate her many times but she wouldn't listen. She was always up trying to go to the bathroom. Initially education didn't work but since the fall on 7/30/20 she has been using her call light. The facility failed to identify the root cause and pattern of R5's falls. In failing to identify this they did not put interventions in place to prevent further falls resulting in a fall with fracture on 7/30/20.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 2 residents (R7) reviewed for medication errors. R7 was given medications for R10 which made his blood sugar level low. R7 required intravenous intervention in the ER (emergency room ) at the hospital and transferred from general care to IMC (internal medicine care). This is evidenced by: The facility did not provide Surveyor their current medication administration policy. Per the American Diabetes Association, Signs and symptoms of low blood sugar (happen quickly); each person's reaction to low blood sugar is different. Learn your own signs and symptoms of when your blood sugar is low. Taking time to write these symptoms down may help you learn your own symptoms of when your blood sugar is low. From milder, more common indicators to most severe, signs and symptoms of low blood sugar include: Feeling shaky, Being nervous or anxious, sweating, chills and clamminess, irritability or impatience, confusion, fast heartbeat, feeling lightheaded or dizzy, hunger, nausea, color draining from the skin (pallor), feeling sleepy, feeling weak or having no energy, blurred/impaired vision, tingling or numbness in the lips, tongue, or cheeks, headaches, coordination problems, clumsiness, nightmares or crying out during sleep, and [MEDICAL CONDITION]. R7 has the following Diagnoses: [REDACTED].) R7 should have received the following morning medications on 9/1/19: [MEDICATION NAME] 650 mg (milligrams) for pain, Multiple Vitamins- Mineral 1 tablet for supplement, Polyethylene [MEDICATION NAME] 3350 powder 17 G (grams) for constipation, Senna-[MEDICATION NAME] Sodium 8.6-50 mg 2 tablets for constipation, and [MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg for nutritional supplement. R10 has the following Diagnoses: [REDACTED]. R10 had the following medications ordered that R7 in turn received: Aspirin chewable 81 mg for heart health, [MEDICATION NAME] 0.0625 mg for heart health, Folic acid 1 mg for folate supplement, [MEDICATION NAME] 10 mg for Diabetes 30 minutes before meal, [MEDICATION NAME] HCl ([MEDICATION NAME]) 1000 mg for Diabetes, [MEDICATION NAME] delayed release 20 mg for protection of stomach while on [MEDICATION NAME] and aspirin, [MEDICATION NAME] XL extended release 24 hour 50 mg for hypertension, and Tylenol 1000 mg for pain. Nurse's Note for R7, dated 9/1/19 at 6:46 PM, documents the following: The resident was in wheelchair next to the med cart and was asked if his name was R10 and he responded in the affirmative. He was then given the morning medications for R10. About 15 later I walked past the room for R10 and saw a different resident in the room and I asked who he was and he states that he was R10. I then look into computer and looked at both chart and determined that I had given the Meds to the wrong person. Hospice was called and advised of the situation and stated that they were going to call their Doctor and the Family and determine what needed to be done. They called back about 45 minutes later and advised that they had called 911 and that the resident was going to be transported to the hospital for observation. (SIC) Incident Audit Report for R7 contains the following documentation: .incident date: 9/1/19 at 10:06 AM .incident location: Hallway .Level of Pain: PAINAD= 0 . (It is important to note there is not an assessment including vital signs (temperature, pulse, blood pressure, respirations) or blood sugar check present in this documentation for this medication error. R7 received medication that will lower a blood pressure, pulse and blood sugar.) R7's paperwork from emergency room documents the following: .reported medications that R7 received were: [MEDICATION NAME] 10 mg (for Diabetes to treat [MEDICAL CONDITION] (high blood sugar)), [MEDICATION NAME] 0.625 mg (for blood pressure and antiarrhythmic (treat heart failure and heart rhythm problems), [MEDICATION NAME] ER (extended release) 50 mg (beta blocker for high blood pressure), Tylenol 1000 mg (pain), and ASA (aspirin) 81 mg (blood thinner or nonsteroidal anti-[MEDICAL CONDITION] (relieve swelling)) .Spoke with poison control Recommends: [MEDICATION NAME] 12 hours monitoring if no [DIAGNOSES REDACTED] (low blood sugar). If [DIAGNOSES REDACTED] will need admission for at least 24 hours. Feed out of [DIAGNOSES REDACTED] if possible to avoid rebound [DIAGNOSES REDACTED]. For [MEDICATION NAME]; Patient may experience Nausea/vomiting. Electrolytes q6 hrs (every). Watch potassium .Patient with multiple episodes of [DIAGNOSES REDACTED] despite food and ultimately unable to control with oral intake. Initiated on a [MEDICATION NAME] drip, but will require q15 min (minute) blood sugar checks due to rapid drop. Initially admitted to gen (general) care but updated to IMC .BLOOD SUGARS: Blood sugar in the ER dropped to 59 at 1:06 PM and he was treated with food. Blood sugar upon recheck was 77 at 1:27 PM. Again on 9/1/19 at 2:07 PM he dropped to 66 and was treated with [MEDICATION NAME] drip d/t (due to) being unable to control his blood sugar dropping. Blood sugar upon recheck was 90 at 2:47 PM . RN E's Statement Medication Error, undated, documents the following: R7 had been sitting next to my cart. I asked if he was R10, to which he said yes. I then pulled the meds for R10 and gave them to R7. What could have done differently: I looked at the pictures afterwards and the pictures weren't overly clear. If you feel the picture is unclear, being new be sure to get another nurse or an aide to confirm a resident's identity would be a good plan. What meds were given: He got all of the meds. [MEDICATION NAME] 500 mg, [MEDICATION NAME] 10 mg; aspirin chewable 81 mg; [MEDICATION NAME] .0625 mg; folic acid 1 mg; [MEDICATION NAME] acl tablet 1000 mg; toporol extended release 24 hr; [MEDICATION NAME] delayed release 21 mg' Tylenol 1000 mg; ensure given. DON (Director of Nursing) must be notified immediately. Another RN notified the DON at the time of the incident. Hospice was updated- they contacted the physician and family, and hospice decided to send him out to the ER to be monitored. R10 was given all of his medications appropriately. R7 was given a multivitamin with minerals, [MEDICATION NAME]; senna [MEDICATION NAME]; [MEDICATION NAME]; charted against the Tylenol because he was already given that. Vital signs were monitored and documented. E-Interacts always need to be completed and sent to the hospital with a transfer of a resident. (SIC) RN [NAME] worked on the date of this incident, 9/1/19, and on 9/3/19 and 9/4/19 per the facilities nursing schedules. Education facility provided is entitled Occurrence Follow Up Protocol, undated, which does not discuss doing medication right checks, looking at resident pictures, double checking information or asking a co-worker if unsure who a resident is. R7 received R10's medications which included medication to lower a blood sugar. R7 was not a diabetic thus this medication drastically lowered R7's blood sugar which could be a life threatening situation. R7 was transferred to the hospital and received an intravenous (IV) drip of [MEDICATION NAME] (sugar) to increase his blood sugar to a normal level. On 9/5/19 at 5:24 PM, Surveyor was approached by NP F (Nurse Practioner) regarding R7 (resident). NP F stated she was reading the Hospital Note which stated R7 had to receive a [MEDICATION NAME] drip in order to keep his sugar up. NP F stated, per the Hospital Note, R7's blood sugar kept dropping and they couldn't get it up with food or juice, so R7 received a [MEDICATION NAME] drip. NP F stated, I didn't receive a phone call about this happening. On 9/5/19 at 4:56 PM, Surveyor interviewed DON B regarding medication error involving R7 that occurred on 9/1/19. Surveyor requested a list of medications received in error. DON B said that RN E, the nurse involved, gave the resident Ensure when the error was discovered. Surveyor asked DON B what education and follow up actions were taken after the incident. DON B informed Surveyor that education was provided to RN [NAME] yesterday (9/4/19). Surveyor asked what the education included and who was involved. DON B stated it was given to the nurse involved and she discussed the incident with him and that they reviewed to do six checks, look at the picture on the computer, double check information, and ask if you are unsure. Surveyor requested documentation of the education provided. DON B said it was on the administrator's computer, but she would get a copy.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 24 sampled residents (R11). R11, who is receiving an anticoagulant, on 4/18/19, experienced a fall with bruising. The facility did not monitor R11's bruising. Subsequently, on 5/3/19, R11 was sent to the ER (emergency room ) with increase in pain and bruising. R11's INR (lab test to monitor blood clotting time) was 13.3, indicating a significant bleed. R11 was admitted to the hospital and received PCC ([MEDICATION NAME] Complex Concentrate) to reverse the INR and received 1 unit PRBCs (Packed Red Blood Cells) secondary to low hemoglobin. There is no evidence the facility monitored R11's bruising. This is evidenced by: The facility's AA Healthcare Management policy, undated, includes, in part, the following: 9. All anticoagulation therapy requires close monitoring and it is critical that the resident is continuously assessed for adverse drug reactions such as bruising, bleeding gums, rectal bleeding, bloody urine, change in mental status, etc. All adverse reactions must be reported to the attending physician immediately and documented in the medical record. According to https://nursing.unboundmedicine.com/nursingcentral/view/(NAME)-Drug-Guide/ /all/[MEDICATION NAME]: Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; tarry, black stools; hematuria; fall in hematocrit or BP (blood pressure); guaiac-positive stools, urine, or nasogastric aspirate). Example 1 R11's [DIAGNOSES REDACTED]. R11 is her own decision maker. R11's MAR (Medication Administration Record), dated 4/1/19 - 5/3/19, includes, in part, the following: *[MEDICATION NAME] Tablet 2 mg (milligrams), give 1 tablet by mouth in the evening every Mon. (Monday) for Afib ([MEDICAL CONDITION] Fibrillation). *[MEDICATION NAME] Tablet 3 mg, give 1 tablet in the evening every Tue (Tuesday), Wed (Wednesday), Thu (Thursday), Fri (Friday), Sat (Saturday), Sun (Sunday) for Afib. R11's MARs indicated R11 received the [MEDICATION NAME] as ordered, R11's Progress Notes, include, in part, the following: 4/19/19, 11:51 (AM), Communication - with Physician. Situation: Bruising noted to left inner thigh - recent fall with use of [MEDICATION NAME]. Assessment/Appearance: dark purple 8 x (by) 10 cm (centimeter) - slight swelling noted to area - tender to touch. Recommendations: (NP Z) updated. Monitor for increased swlling (sic) or pain. R11's TAR (Treatment Administration Record), dated 4/1/19 - 5/3/19, includes, in part, the following: Monitor bruising to left inner thigh - with use of [MEDICATION NAME]. Update NP (Nurse Practitioner) if any increase swelling or pain to area every shift for falls/bruising. The TAR indicated R11's bruise is to be monitored 4/19/19 - 5/3/19. (It is important to know there is no documentation 4/19/19 - 4/30/19.) 5/3/19, 02:09 (AM), Health Status Note: Resident is having extreme pain in her left leg, with the slightest movement resident yells out in pain and cries, Writer noted left leg to be shorter than the right leg with the left hip to be extended out, Writer left a message with NP for further follow up, Writer encouraged resident during the night shift multiple times to revisit the ER (emergency room ) for evaluation and treatment, resident is her own person and has been persistent in refusing stating that she will not be able to withstand the ride to the hospital due to increased pain, Writer explained to resident the importance of being seen by the doctor to look at her hip and leg and control her pain she stated at this time she only wanted to take prn (as needed) [MEDICATION NAME] and will consider in the morning. 5/3/19, 05:40 (AM), Health Status Note: Res (Resident) transferred to (Hospital) ER for increased L (left) hip/leg pain. 5/3/19, 09:45 (AM), Communication - with Physician. Situation. Resident sent out to (Hospital) ER for continued left leg pain post fall and increased bruising. (NP Z) called and updated of transfer and Labs/INR. R11's ED (Emergency Department) Provider Notes, dated 5/3/19, 6:45 AM, includes, in part, the following: Patient Progress: CT (Computerized [NAME]ography) shows evidence of a comminuted, displaced intertrochanteric fracture. Orthopedic surgery is consulted, they are looking at images and will get back to me. In addition there is also pectineus and abductor hematoma as the abductor hematoma is approximately 9 cm. INR is pending. Labs show the patient's hemoglobin is only 8 and her INR is over 13. I do feel this is likely a clinical significant bleed and will reverse her INR with PCC, especially, because she would likely need surgery as well. R11's (Hospital) Discharge Summary, dated 5/8/19, includes, in part, the following: Hospital Course: Her INR which was elevated to 13, corrected to 1.3, but her HGB (hemoglobin) continued to trend down to 7.7 then to 6.9 on admission. She was transfused 1 unit PRBCs with appropriate response in HGB. In regards to her anticoagulation for prior history of embolic ischemic [MEDICAL CONDITION], given issues with elevated INRs, [MEDICATION NAME] was discontinued with initiation of Apixiban 5 mg BID (twice a day) which the patient will continue on discharge. On 5/20/19 at 9:38 AM, Surveyor interviewed NP Z via telephone. NP Z stated she was informed of a little bruise on 4/19/19. NP Z stated she gave an order to monitor R11's bruising and would have expected this to be done. On 5/21/19 at 3:15 PM, Surveyor interviewed IDON B (Interim Director of Nursing). IDON B stated she would expect staff to follow NP Z's orders and facility policy to monitor bruising on R11's inner thigh and document that the monitoring was done.

Based on observation, interview and record review, the facility did not provide necessary respiratory care and services, such as a Bi-PAP or Bi-Level (Bi-level Positive Airway Pressure), consistent with professional standards of practice, care plan, and physician's orders [REDACTED]. R4 was hospitalized due to desaturation as a result of facility staff not ensuring oxygen was connected to the [MEDICAL CONDITION] as ordered by the physician. The facility did not ensure R7's oxygen tubing, being administered to her [MEDICAL CONDITION], was changed and was observed to be visibly soiled. This is evidenced by: The facility policy, entitled Bi-Level Therapy, undated, provided by SMS (Specialized Medical Services) states, in part . Purpose: Bi-Level therapy is used to treat patients with obstructive sleep apnea who have difficulty tolerating [MEDICAL CONDITION] (Continuous Positive Air Pressure). The goals of this therapy include improve ventilation, improve quality of sleep, decrease hospitalization , improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve oxygen saturation during sleep, decrease work of breathing and improve lung compliance. Bi-Level machines are set with two pressures, Inspiration and Expiration. Procedure: 1. Verify physician orders 2. Assemble equipment at bedside 3. Observe universal precautions and wash your hands 4. Place system close to where the patient will be sleeping on a clean dry surface 5. Insert oxygen adapter and tubing if supplemental O2 is ordered 6. Place mask/pillows with headgear on patient and adjust to a proper fit 7. Ensure a proper fit and adjust as necessary. If excessive air leaks around the eyes and nose adjust the headgear. Resize mask for excessive leaks or to increase patient comfort. 8. If ordered, connect humidifier to Bi-Level unit. Fill humidifier with distilled or sterile water. 9. If ordered, adjust ramo to prescribed time R4 was admitted to the facility, on 10/7/15, and has [DIAGNOSES REDACTED]. Obstructive Sleep Apnea, [MEDICAL CONDITION], Major [MEDICAL CONDITIONS], Cauda Equina Syndrome, Obesity Hypoventilatio[DIAGNOSES REDACTED], Asthma, and [MEDICAL CONDITION]. R4's quarterly MDS (Minimum Data Set) assessment, on 5/3/19, notes R4 has a BIMS (Brief Interview for Mental Status) score of 15, indicating she is cognitively intact. MDS Section G-Functional Status indicates R4 is extensive assist with bed mobility, dressing, toilet use and personal hygiene, and is dependent with transfers. R4 was sent to the hospital Emergency Department (ED) on 5/20/19. Surveyor observed resident return to the facility on [DATE] at approximately 8:00AM. Hospital Report, titled, ED Provider Notes, state, in part . Patient states that she was placed on her [MEDICAL CONDITION] which she normally uses at night however the oxygen was not connected. She normally uses 2L (Liters) of oxygen via nasal cannula at baseline. After approximately 4 hr. (hours) the absence of oxygen was noted and the patient was placed on up to 6L. Her pulse oximeter continued to read in the mid 80's so EMS (Emergency Medical Services) was called. [AGE] year-old female presenting for oxygen desaturation. Patient with known history of hypoventilatio[DIAGNOSES REDACTED] may represent acute exacerbation. Upon presentation to the ED, the patient was hemodynamically stable with vitals within normal limits. She was able to maintain oxygen saturations in the low 90's with her baseline oxygen of 2L. She has no complaints of dyspnea or chest pain. Laboratory analysis was sent which demonstrated improvement in the patient's CO2 (Carbon [MEDICATION NAME]) retention with no major evidence of [MEDICAL CONDITION]. Impression: 1. Oxygen desaturation 2. [MEDICAL CONDITION] on antibiotics 3. History of obesity hypoventilatio[DIAGNOSES REDACTED] On 5/20/19 at 12:13PM, Surveyor interviewed R4. R4 states that in the middle of the night she woke up and was having difficulty breathing. She called for RN Q (Registered Nurse) who took her oxygen saturation and it was 77%. R4 states that she believes she was without oxygen for approximately 4 hours. RN Q checked R4's oxygen concentrator and realized the oxygen was not hooked up. RN Q hooked oxygen up to [MEDICAL CONDITION] and oxygen level increased to the 80's. R4 states she was sent to the hospital due to staff not being able to get oxygen saturation above 90%. Facility Progress Notes, reviewed by Surveyor, with most current note being from 5/20/19 at 3:08 AM, states the following, Resident complained of shortness of breath while on [MEDICAL CONDITION]. Writer checked her oxygen level, reading was 77% to (sic) connected [MEDICAL CONDITION] to concentrator sats went up to 84%, switched to nasal cannula and gave a nebulizer treatment. Sats went up to 89% but was still desating (decreasing) down to 86% and resident was occasionally complaining of shortness of breath. Writer called the on-call physician to request order to transfer to a hospital due to resident complaining of shortness of breath and desating. R4's TAR (Treatment Administration Record), from 5/2019, includes: [MEDICAL CONDITION] at (14/8) cm (centimeter) with 2L supplemental oxygen at bedtime for Obstructive Sleep Apnea. Remove in the AM (morning). (MONTH) also apply if napping and remove per schedule. On 5/22/19 at 12:59 PM, Surveyor interviewed RN Q. Surveyor asked RN Q to recount the incident with R4 on 5/20/19. RN Q states, R4 had [MEDICAL CONDITION] on and called to ask me to check her oxygen. Her oxygen was low and I checked her oxygen concentrator to make sure it was going into the [MEDICAL CONDITION]. I noticed at that time the oxygen was not hooked up correctly. The first time I checked her oxygen it was at 77%. The oxygen was not hooked to the concentrator from the [MEDICAL CONDITION]. R4 kept saying 'check my oxygen, check my oxygen,' over and over. Appeared to be struggling to breathe. I hooked up the oxygen and her saturation went up to 84%. After while, it went to 86% and R4 was still saying 'check my oxygen.' I then switched R4 to the nasal cannula to try that. Oxygen went up to 87%. I then turned the oxygen up to 3L/min (minute) and oxygen saturation went up to 89% but R4 kept destating. I sent her to the hospital due to not being able to keep sats at or above 90%. On 5/22/19 at 1:17 PM, Surveyor interviewed R4 regarding her low oxygen saturation. R4 states the following, I feel a little nervous, I can't think of everything to ask for or that needs to get done. I have feelings of apprehension now because they forgot my oxygen. Sometimes it makes me scared to go to sleep. It makes me anxious, sometimes I am afraid to go to sleep and I worry something may not get done. It depends on who the aides are. Surveyor asked if R4 knew which CNA (Certified Nursing Assistant) assisted her in bed on 5/20/19. R4 states, I am not sure who the aides were that night. R4 went on to state, I am always testing my oxygen nasal cannula now to make sure I still have oxygen. I can't tell until I start having trouble breathing if it is not working. Surveyor asked R4 what time she usually has [MEDICAL CONDITION] applied at night. R4 states, Normal time for [MEDICAL CONDITION] to go on is around 1 AM. I have not been feeling well due to recent hospitalization for Septic UTI (Urinary Tract Infection), so it may have been earlier. The staff don't offer to put on my [MEDICAL CONDITION], I have to ask and if I don't and I fall asleep, they just leave me without it. On 5/22/19 at 2:17 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and IDON B (Interim Director of Nursing). Surveyor asked if either of them were aware of R4's visit to the ED. NHA A stated she was minimally aware and IDON B stated she didn't know anything. NHA A stated she was told R4 was destating but that was all. Also stated that PM (evening) shift is heavy with agency staff. R4 is usually put into bed around 4:00 PM prior to supper so she does not have to wait. Surveyor asked NHA A and IDON B if staff should ensure that oxygen is hooked up to Bi-PAP if that is ordered. IDON B stated, Yes. The facility's failure to ensure R4 received the oxygen through [MEDICAL CONDITION] as ordered resulting in R4 desaturating and requiring a trip to the Emergency Department. R4 now verbalizes fear, anxiety and apprehension secondary to the incident on 5/20/19. The fear and anxiety have affected R4's psychosocial well-being and have caused psychosocial harm. Example 2 R92 was admitted to the facility, on 5/10/19, for short term-rehab for fracture of left femur. R92 has a Laryngeal stoma with a long-term [MEDICAL CONDITION] in place. R92 is alert and oriented and her own decision maker. R92's care plan, dated 5/10/19, notes, in part: R92 has [MEDICAL CONDITION]; use of oxygen; history of pneumonia. Goal: . no s/sx (signs/ symptoms) of infection . Interventions: [MEDICAL CONDITION] are secured at all times . Monitor site . R92 had no specific orders for changing of oxygen tubing or checking for cleanliness. On 5/20/19 at 11:10 AM, Surveyor observed a blue corrugated oxygen tube attached to R92's [MEDICAL CONDITION] for the delivery of oxygen. Surveyor asked R92 if she recalled when the tubing had last been changed, R92 stated she thought the tubing was from the hospital. Surveyor and LPN H (Licensed Practical Nurse) observed that this tubing was visibly soiled and had a brown substance (about 3 inches by 1/2 inch) adhered to the inside of the tubing. LPN H stated the tubing was dirty and needed to be changed. On 5/20/19 at 2:25 PM, Surveyor interviewed RT FF (Respiratory Therapist) about R92's oxygen tubing leading to R92's [MEDICAL CONDITION]. RT FF stated he had seen R92 3 times since her admission but had no documentation. Surveyor asked if there was a policy for changing R92's oxygen tubing, RT FF stated he was not sure. Surveyor observed R92's soiled tubing with RT FF and RT FF stated, I see what you mean. RT FF later reported to Surveyor that R92's oxygen tubing had been changed and wrote orders to change weekly and as needed.

Based on resident and staff interview and record review, the facility did not provide care for a resident with an indwelling catheter for 1 of 3 residents (R39) reviewed with an indwelling catheter out of a total sample of 24. R39's indwelling catheter was traumatically pulled out on three occasions during transfers. R39 was hospitalized with gross hematuria. R39 was found to have a bladder neck injury, requiring surgery and placed on antibiotics. This is evidenced by: R39's [DIAGNOSES REDACTED]. R39 is her own decision maker. R39's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/26/19, states R39 is cognitively intact and has an indwelling catheter. R39's Care Plan Focus: The resident has Urinary Catheter: Skin Breakdown; neuromuscular dysfunction of the bladder, Date Initiated 3/19/19, Revision on: 3/21/19, includes, in part, the following Interventions/Tasks: Catheter: the resident has (16 Fr) (Foley Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. R39's TAR (Treatment Administration Record), dated 4/1/19 - 5/2/19, includes, in part, the following: Foley Catheter (16) Fr, (10) cc (cubic centimeter) balloon, gravity drainage. Remove when wound healed and improved mobility. As needed, change catheter for drainage issues or leakage. (It is important to know there was no documentation R39's catheter was changed during this time period.) R39's SNF/NF (Skilled Nursing Facility/Nursing Facility) Transfer Form, dated 5/2/19, includes, in part, the following: Bladder Function: Urinary catheter in place (Date inserted 4/29/19). (It is important to know there is no documentation as to why R39 was sent to the hospital ER (emergency room ).) R39's (Hospital) Discharge Summary, dated 5/3/19, includes, in part, the following: (R39) has a chronic indwelling Foley and it has reportedly been changed the last 3/3 3 (out of 3) days. (R39) has now been having dark brown/red urine. She is unable to tell me how long this has been present. She also affirms being freezing cold the past 2 nights. ED (Emergency Department) Course: . Labs remarkable for WBC (white blood cells) 13.4, Hb (hemoglobin) 5.9, Hct (hematocrit) 19. UA (urinalysis) from chronic indwelling Foley with 3+ blood, + bacteria, + [MEDICATION NAME], 1+ leukocyte esterase, >100 WBC. Pt (patient) was given a dose of [MEDICATION NAME] and 2 units PRBC (packed red blood cells) have been ordered. UTI (urinary tract infection), urethral discharge in the setting of chronic indwelling Foley ([MEDICAL CONDITION] bladder), on IV (intravenous) [MEDICATION NAME] until culture returns. Her UA is abnormal. This morning, nursing notified me of discharge, as best as I can tell this appears to be urethral, has slow steady drainage of brownish discharge. I discussed with urology, they will plan to see patient. CT (Computerized [NAME]ography) urogram ordered to further evaluate if any urethral verses vaginal abnormality. (It is important to know R39 was discharged , on 5/3/19, from one hospital and directly admitted to another hospital for continued care.) R39's Hospital Progress Note, dated 5/11/19, includes, in part, the following: Assessment and Plan: Prior to admission she had a traumatic Foley removal and was replaced three separate times. She was admitted to the surgery service on (MONTH) 4th and went to the OR (operating room) due to concerns of [DIAGNOSES REDACTED] of the left groin. Surgery performed an I & D (incision and drainage) left groin but no purulence was appreciated and no evidence of necrosis. Gynecology was consulted intraop due to concerns of purulent vaginal discharge and found to have bacterial vaginosis, gyn (gynecology) has since signed off. Urology was consulted and a CT cystogram showed a small extravasation (force out (a fluid, especially blood) from the vessel that naturally contains it into the surrounding area) anteriorly consistent with traumatic Foley removal/placement . Chronic indwelling Foley: She has a chronic indwelling Foley catheter with bladder neck injury in the setting of trauma with urine leak to the pubic symphysis. Urology is following: * Foley to remain in place for 4 weeks and return to urology clinic for a repeat CT cystogram prior, * she has been on Meropenem while inpatient (urology recommendations), was told by surgery service Meropenem was ok'd by ID (Infectious Disease) the plan is switched to [MEDICATION NAME] 500 bid (twice a day) for total 2 weeks once discharged , then will need perioperative antibiotics for cystoscopy [MEDICATION NAME] mg (milligrams) once a day prior 500 mg the day of cystoscopy. On 5/17/19, Surveyor interviewed R39 via telephone. R39 stated her catheter had been pulled out 3 times in 3 days during transfers, staff did not assure the catheter bag went with R39 during the transfers, the bag was left hanging on either the bed or the wheelchair. R39 transfers with a full body lift. R39 stated the morning she was admitted to the hospital there was a large amount of blood on the pad she lays on. The nurse told R39 she would keep an eye on the amount of blood. R39 requested to go to the hospital to be checked out. R39 stated a short while later there was more blood on the pad, she did not feel well, was tired and weak and insisted she be sent to the hospital. At that time, the nurse agreed and sent R39 to the hospital to be checked out. On 5/21/19 at 11:15 AM, Surveyor interviewed NP CC (Nurse Practitioner) via telephone. NP CC stated R39 had informed her that her catheter had been pulled out during transfers, no one from the facility had called to let me know her catheter had been pulled out. NP CC stated she would expect staff to inform her a catheter was pulled out during a transfer. On 5/21/19 at 3:00 PM, Surveyor interviewed IDON B (Interim Director of Nursing). IDON B stated she did not know R39's catheter had been pulled out during transfers. IDON B stated she would expect staff to call the physician/nurse practitioner and inform them of the incident and to get an order to reinsert. IDON B stated she would expect the incident to be documented in R39's medical record, put on the 24 hour board and the incidents should have been investigated. On 5/21/19 at 3:25 PM, Surveyor interviewed CNA EE (Certified Nursing Assistant). CNA EE stated she was working, CNA EE does not remember the date, it was around 6:30 AM, she was asked to assist with R39's transfer out of bed. R39 was transferred with a full body lift and put into her wheelchair. R39's catheter bag was attached to the side of the bed. CNA EE stated no one removed the catheter bag from the bed during the transfer. CNA EE stated there was something lying next to the catheter bag, CNA EE thought it may have been the catheter. CNA EE stated a little while later the nurse came and stated R39 needed to lie down because R39's catheter has come out. CNA EE stated no one ever asked her about the transfer. On 5/22/19 at 9:00 AM, Surveyor interviewed LPN DD (Licensed Practical Nurse). LPN DD stated she worked 4/29/19 and 4/30/19 and one of these days R39's catheter got dislodged while she was in the shower. LPN DD stated she observed R39's catheter in the garbage with the balloon intact. LPN DD told the CNA to finish R39's shower and lay R39 down into her bed. LPN DD stated she reinserted R39's catheter, there was a small amount of blood tinged urine in the tray at first, this cleared pretty quick. There were no more concerns with R39's catheter throughout the day. R39 had her catheter traumatically pulled out on three occasions during transfers into and out of the wheelchair resulting in a bladder neck injury in the setting of trauma with urine leak to the pubic symphysis requiring hospitalization , surgery and antibiotic therapy.

Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R5) reviewed for falls. R5 sustained 12 falls during the past 11 months. Three (3) of the fall investigations (8/25/16, 9/15/16, and 2/24/17) indicate R5 was not wearing gripper socks at the time of her falls and that staff did not follow R5's care plan. The facility did not re-educate staff members regarding following R5's care plan to ensure that R5 is wearing gripper socks. The facility noted R5 has behavior symptoms, including lowering herself to the floor. Note, any change of plane (i.e. placing self on floor) is considered to be a fall. The facility did not Identify and track R5's behavior symptom of lowering herself to the floor, nor did the facility implement new interventions in attempt to prevent/reduce the occurrence of R5 lowering herself to the floor. R5 was noted to frequently lower herself to the floor. The facility failed to address these behaviors despite a noted increase in frequency. R5 lowered herself to the floor on 3/1/17 and 3/4/17. The facility did not investigate these falls or implement any additional interventions. R5 was diagnosed with [REDACTED]. Evidenced by: The facility policy Accidents and Incidents: Report, Investigation, Review and Analysis, dated July 2015, states as follows: The center strives to provide an environment that is free from hazards over which the center has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. The center provides safety for residents through the following: Risk Reduction: Falls and Injuries Program. The policy identifies an Avoidable Accident as An incident that occurred when the center failed to: 1. Identify environmental hazards and resident risk 2. Evaluate hazard and risk. Definitions: Implement interventions including adequate supervision consistent with resident goals, needs, care plan and current standard of practice, monitor and modify interventions. Proper action following a fall includes: Ascertaining if there were injuries and providing treatment as necessary; Determining what may have caused or contributed to the fall; Addressing the contributing factors of the fall; Revising the care plan and/or center practices to reduce the likelihood of another fall. 6. Complete the electronic accident/incident report. Incident Reviewed: 14. Reviews and approves the incident. 15. Attach supplemental documentation (staff interviews), 17 Reviews assigned report: A. All necessary data has been added to the report. b. Any recommendations have been appropriately accepted, declined deleted and/or implemented Care Responsibilities: 20. Track and trend accident/incident occurrences, investigations and the necessary follow up actions, which may include: Identifying a particular resident who is having repeated accident/incidents. Assisting in the identification of trends by nature of incident, type of injury, resident age, incidents by units, time of day, and day of week. Sorting accident/incident by resident as needed. 21. Inform the responsible individual for retraining the staff member(s), if staff retraining is required. 22. Provide a copy of the retraining objectives to the DON, after the training is complete. a. Attach the supplemental documentation (retraining) to the electronic accident/incident report. 23. Present and discuss electronic accident/incident report tracking and trending information and possible required actions, as applicable, at the Quality Assurance and Performance Improvement (QAPI) meeting. R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5's Annual Minimum (MDS) data set [DATE] indicates R5's Brief Interview for Mental Status (BIMS) score was 15, indicating she is cognitively intact. The MDS indicates R5 requires supervision and physical assist of 1 to walk in her room, extensive assist of 1 to ambulate on unit and toilet, and physical assist of 1 to transfer. R5 is her own person. R5's comprehensive care plan indicates R5 was independent with ambulation and transfers prior to the fracture and R5 was to ask for assistance with ambulation and transfers PRN (as needed). R5's Resident Care Card dated 4/10/17 indicates that since R5's fractured her right patella R5 continues to be an extensive assist of 2 stand pivot transfer - non-weight bearing to the right leg. The care plan indicates right leg immobilizer on at all times - check skin q (every) shift for s/s (signs/symptoms) of breakdown. Gripper socks only to prevent falls on at all times-except if she has shoes on. Behaviors: Crying/yelling out-encourage to use her words to tell you what's wrong, offer bathroom or tissues or call family if unable to console. Note, the Resident Care Card does not identify R5's behavior symptom of placing herself on the floor or related interventions. R5's Mood and Behavior Symptom Assessment/Plan of Care dated 7/2013 states: Assessment Presence of behavioral symptoms that may be harmful to self or others or interfering with function or care as evidenced by: 7/4/16 physical outbursts, cries/yells when family leave facility, continuous yelling/crying out, crying out with cares/ADLs/showers Obvious plan to gain attention by disrupting environment - eyes others to see their response and accelerate/de-accelerates depending upon success of disruption. Goal: R5 will use her words to verbalize to staff what she needs prior to becoming upset. Interventions: Ask R5 what she needs, offer to help in some way, Redirect behaviors and allow R5 to calm down. When R5 is crying out, staff will enter room and close door until needs are met to maintain privacy. Resident education. Provide 1:1 conversation with R5, offer to call R5's mother for comfort. Offer to play organ in lounge. Note, R5's Mood and Behavior Assessment/Plan of Care does not identify R5's behavior symptom of placing herself on the floor or related interventions. The facility implemented the following target behavior tracking entitled CORP-Target Behavior Program Summary Report. This report indicates and tracks R5's two identified targeted behavioral symptoms Target Behavior 1: Resident (R5) yells out from room or cries out without any apparent need for assistance. Intervention: provide 1:1 conversation, offer for resident (R5) to call mom for comfort. 2. Hitting/choking staff during ADL care. Intervention: Offer to get R5 some pudding as this is one of her favorite snacks. This tracking does not identify or monitor R5's behavior symptom of placing herself on the floor or related interventions. R5's CAA (Care Area Assessment) for behaviors dated 12/12/16 indicates R5 triggers for CAA d/t (due to) Parkinson's disease, unsteadiness, impaired coordination, impulsiveness, need for assist at times with bed mobility, transfers, and ADLs. CAA for behavioral symptoms states R5 tends to cry/scream during the evenings and early mornings. R5 will also scream and cry if another resident touches her rolling walker. She will cry loudly until someone is able to take care of her need/want. R5's Fall/Injury Assessment: Prevention and Management Care Plan has an intervention dated 2/13/17, Encourage/explain to not lay self on floor as attention seeking behavior; 5/12/16 Gripper socks on when in room in bed or in recliner when shoes are off. Three (3) of R5's fall investigations (8/25/16, 9/15/16, and 2/24/17) indicate R5 was not wearing gripper socks at the time of her fall and that staff did not follow R5's care plan. The facility did not educate staff members regarding following R5's care plan to ensure that R5 is wearing gripper socks. R5's Occurrence Reports state as follows: 8/25/16 Type: Fall, Location: Resident Room, Activity: Transferring, Witnesses: None, Nurses Note: Called to room by staff member who found Resident (R5) on floor. R5 on floor next to bed. Resident denied hitting head, but did report she was getting up out of bed. Noted to only have socks on. When questioned if she slipped, she said, Yes. Resident Statement of what happened: Resident questioned if she slipped when she got up and she responded, Yes. Footwear: Socks only, Note slipper socks was not selected. Conclusion: Resident fall without injury. Resident slipped when she got up secondary to wearing only socks. Care Plan is for shoes or gripper socks on when up. Root Cause: Staff did not follow plan. Injury: Bruise to left upper arm 9/15/16 Type: Fall, Location: Resident Room, Activity: In Bed, Witnesses: None, Nurses Note: R5 had been laying in bed, founding lying on R (Right) side holding head up off floor, on side of bed, head toward doorway, w/c (wheelchair) locked next to bed, call light was not on but was in reach when Resident was in bed. Resident Statement of what happened: Up then later stated bathroom; Independent for toileting: No Footwear: Socks only, Note slipper socks was not selected. Conclusion: Fall without injury - R5 ambulating and slipped secondary to ambulating with only socks on feet. Root cause: Due to R5 actional or internal risk factors. Injury: None 2/24/17 Type: Fall, Location: Resident Room, Activity: Transferring, Witnesses: None, Nurses Note: CNA came and got me from my office reporting R5 had fallen. Found in doorway of room on her hands and knees facing hallway. R5 was not crying. R5 was assessed and was able to get up on her own. Assisted to w/c and asked to sit in hallways near nurses station. Assessed for pain-denied. No skin issues noted. A&O (Alert and Oriented) x 3 (Person, place, and time) Neuro assessment completed. R5 did not have socks on. She stated that she was getting out of bed and in to w/c and she slipped. When found she was approximately 6 feet from bed and approximately 5 feet from w/c she was transferring on her hands and knees looking out in to hallway. Resident Statement of what happened: She reported she was transferring herself from the bed to the w/c. She wanted to come out in the hallway. Footwear: Socks only, Note slipper socks was not selected. Conclusion: Fall most likely as a result of slipping during transfer as only socks on feet when found. Gripper socks should have been on feet-when shoes off in bed. Root Cause: Staff did not follow plan. Injury: None R5's Resident Care Card dated 4/10/17 indicates Behaviors: Crying/yelling out-encourage to use her words to tell you what's wrong, offer bathroom or tissues or call family if unable to console. Note, the Resident Care Card does not identify R5's behavior symptom of placing herself on the floor or related interventions. R5's Mood and Behavior Symptom Assessment/Plan of Care dated 7/2013 states: Assessment Presence of behavioral symptoms that may be harmful to self or others or interfering with function or care as evidenced by: 7/4/16 physical outbursts, cries/yells when family leave facility, continuous yelling/crying out, crying out with cares/ADLs/showers Obvious plan to gain attention by disrupting environment - eyes others to see their response and accelerate/de-accelerates depending upon success of disruption. Goal: R5 will use her words to verbalize to staff what she needs prior to becoming upset. Interventions: Ask R5 what she needs, offer to help in some way, Redirect behaviors and allow R5 to calm down. When R5 is crying out, staff will enter room and close door until needs are met to maintain privacy. Resident education. Provide 1:1 conversation with R5, offer to call R5's mother for comfort. Offer to play organ in lounge. Note, R5's Mood and Behavior Assessment/Plan of Care does not identify R5's behavior symptom of placing herself on the floor or related interventions. The facility implemented the following target behavior tracking entitled CORP-Target Behavior Program Summary Report. This report indicates and tracks R5's two identified targeted behavioral symptoms Target Behavior 1: Resident (R5) yells out from room or cries out without any apparent need for assistance. Intervention: provide 1:1 conversation, offer for resident (R5) to call mom for comfort. 2. Hitting/choking staff during ADL care. Intervention: Offer to get R5 some pudding as this is one of her favorite snacks. This tracking does not identify or monitor R5's behavior symptom of placing herself on the floor or related interventions. R5's CAA (Care Area Assessment) for behaviors dated 12/12/16 indicates R5 triggers for CAA d/t (due to) Parkinson's disease, unsteadiness, impaired coordination, impulsiveness, need for assist at times with bed mobility, transfers, and ADLs. CAA for behavioral symptoms states R5 tends to cry/scream during the evenings and early mornings. R5 will also scream and cry if another resident touches her rolling walker. She will cry loudly until someone is able to take care of her need/want. 2/13/17 Type: Fall, Location: Resident Room, Activity: Sitting, Witnesses: None, Nurses Note: R5 was seen about 10:30 AM by writer sitting in her w/c in her room. R5 was assisted with the dependent lift to her wheelchair. No injury noted. ROM (Range of Motion) and neuro checks intact for R5. MD called and updated. Mom arrived just after putting R5 in chair and was updated. R5 reminded that she needs to ask for help and tell the staff what she needs. R5 has hx (history) of attention seeking behaviors. Also has a hx of placing herself on the floor to get the staff attention and attention of that of her parents. Note this fall investigation indicates R5 has a history of placing herself of the floor prior to 2/13/17. 3/7/16 Occurrence Report Type: Fall, Location: Resident Room, Activity: Transferring, Witnesses: Registered Nurse (RN) R, Nurses Note: While the RN(R) was counting medications at start of shift with PM RN, noted R5 purposely lowered herself to ground. R5 has a history of lowering herself to the ground. No injury noted. R5 was able to get up and assisted back to her bed. Resident Statement of what happened: N/A (Blank) Footwear: Slipper socks. Conclusion: R5 purposely lowered self to ground. Has a history of behavior seeking behaviors of lowering self to ground recently on 3/1/17 and 3/4/17 - witnessed by staff members. Encourage R5 to use her words when she needs assistance or wants attention. Mat to floor placed next to bed. Root Cause: Due to resident action or internal risk factors. Injury: None Noted. It is important to note that R5 sustained a Right Patella (Knee) fracture. Note, R5's care plan included the intervention dated 2/12/17 of mat to floor. There is no evidence the facility investigated falls on 3/1/17 and 3/4/17 as noted above. On 3/1/17 at 5:46 AM, a Nurses Note (NN) states as follows: Up most of the night yelling and crying, refused to get up to go to the bathroom. Refused pain meds. Stating she didn't need them. This writer standing by the desk and saw resident (R5) lay herself on the floor and cry to get up. R5 wanted to be picked up. Then called her mom and told her she was on the floor and layed back down on the floor. Assisted up and to the bathroom, then back to bed. R4 up rest of the night. Note, there is not fall investigation for this incident. On 3/4/17 at 12:50 PM a NN states as follows: Writer observed resident (R5) sitting in her w/c next to her bed use her bed to get onto her knees, lowered herself to the floor x2 (two times), and then scooted herself to the entrance of her room screaming and crying for someone to help her. R5 was assisted up off the floor and was offered help, R5 asked to be put back into bed, writer contacted her mom who stated she would call at 8:00 PM. Writer was admitting a new resident when writer was walking to nurse's desk, R5's dad was here asking why R5 was on the floor. Writer explained to him what R5 had been doing all shifts again (placing herself on the floor). R5 was assisted up off the floor. She has no apparent injuries. Her father stated to her If you behave, I'll go get you a hamburger. At that time R5 took her HS (bedtime) meds, administered lorazepam for increased restlessness. R5 appears to be having an increase in behaviors with screaming, yelling when assisted refuses assistance. Will continue to monitor. Note, there is no fall investigation for these incidents (2 occurrences). There are no additional NN from 3/5/17 - 3/7/17. A NN (Late Entry 3/8/17) for 3/7/17 at 11:00 PM states: while this writer was counting meds at med cart saw R5 lower herself to the floor and ask to help getting up. While this writer was finishing to go into a room to help her (R5) started crawling to her doorway to ask for help. This writer and the PM shift RN helped R5 up and R5 went back to bed. She later went with the CNA to the bathroom. R5 was not c/o (complaining of) pain at that time but was medicated for her foot pain later in the shift. In the Nursing Home to Hospital Transfer Form date 3/8/17 the facility indicated R5 has been placing herself on the floor 3-4x's per day. Behaviors of yelling, crying, screaming has greatly increased over the past month. An SBAR was completed on 3/8/17 for Increased right knee pain. Things that make the condition or symptom worse: movement, weight bearing. Things that make the condition or symptom better are: medication. This condition or symptom has occurred before: No. Other related information: R5 has been placing herself on the floor 3-4x's per day with increased behavior. Vitals: BP: 131/64, Pulse: 81, RR: 22, Temp 98.0, Pulse Oximetry: 92. 2. Functional Status Evaluation (compared to baseline, check all that you observe). Decreased mobility. Describe symptoms or signs: Will not bear weight on R (Right) leg. 9. Pain Evaluation: Does the resident have pain: Yes. Is the pain: New. Description of pain: R knee pain increased to point of not being able to bear weight. Intensity of pain: 8-9/10. Appearance: R5 is in room crying, unable to console, mother at bedside unable to console. R5 states R knee is horrible will not bear weight. Review & notify: Notified MD 3/8/17 at 1:00 PM. Recommendations of primary MD: Send to hospital for eval of new onset of R knee pain. On 3/8/17 the hospital x-ray indicate R5 sustained a right patella fracture. 3/8/18 at 10:15 PM, a NN states: R5 returned from ER around 6:15 PM and N.O. (New Order for) NWB (Non-Weight Bearing), follow up with orthopedics, immobilizer in place, can apply ice for swelling continue with current vicodin PRN (as needed) dosing. R5 is resting comfortably in bed at this time . On 4/12/17 at 2:25 PM, Surveyor spoke with DON B. Surveyor asked DON B if she was aware that R5 has been purposely lowering herself to the ground. DON B replied, Yes. Surveyor asked DON B how often R5 lowers herself to the ground. DON B stated R5 lowers herself to the ground, At least once a month. DON B stated R5 has behaviors of lowering herself to the floor, screaming and crying d she thinks a lot of it is attention seeking. DON B stated, that they try to get her to use her words regarding her needs. DON B stated that R5 has a history of lowering herself to the floor and used to do this when she lived at home with her parents prior to being admitted to the facility. Surveyor asked DON B if she knows or has asked R5 why she purposely lowers herself to the floor. DON B stated, She never tells you. DON B stated, sometimes it's that she wanted to get up. Surveyor asked if R5's parents were able to offer any insight into this behavior. DON B stated, No. DON B stated, no matter what we do it doesn't seem to get better. Surveyor asked DON B what have you done to address R5's behavior of lowering herself to the floor. DON B stated we remind her to use her words. Surveyor asked DON B if the facility has tried any other behavioral modifications related to R5 lowering herself on the floor. DON B stated, I don't have anything. DON B stated she has not got the facility's behavioral monitoring program up and running. DON B stated we just got a new social worker a few months ago and we are just starting to work on behavior monitoring. DON B stated we call mom and dad if R5 is screaming and crying. The facility did not document that they discussed the risks/benefits with R5 regarding placing herself on the floor nor are there any interventions to mitigate injury when she lowers self The facility did not identify and track R5's behavior symptom of lowering herself to the floor, nor did the facility implement new interventions in attempt to prevent/reduce the occurrence of R5 lowering herself to the floor. The facility did not investigated when R5 lowered herself to the floor on 3/1/17 or 3/4/17 (two occurrences), nor did the facility implement new interventions to prevent/reduce occurrence of R5 lowering herself to the floor. The facility did not provide risks/benefits to R5 to educate her on the possible risk lowering herself to the floor. The facility did not educate staff when they did not following the care plan. Staff document that R5 was lowering herself to the floor 3-4 times per day and that her behaviors of yelling, crying, and screaming had greatly increased over the past month leading up to the day R5 fell and fractured. The facility did not actively address R5's behavior symptom of lowering herself to the floor in order to prevent injury and future accidents.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without a pressure injury did not develop a pressure injury, and a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, for 3 of 5 sampled residents (R1, R2 and R3). Resident (R) 1 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for PI development. R1 was bed ridden and required extensive assist with bed mobility and required the head of the bed to be elevated greater than 30 degrees increasing the risk for sheer and PI. R1 was noted to have poor oral intake and staff did not provide R1 with needed assistance during meals. Interventions were not put in place to prevent R1 from developing a PI. R1 developed an unstageable PI to the buttock which deteriorated. R2 was admitted to the facility without a PI and was identified to be at risk for PI development. R2 is diabetic and had ill-fitting shoes. R3s dressing to his coccyx pressure injury came off when he was toileted and the nurse did not immediately replace it. It was off for more than 1 hour and 15 minutes. This is evidenced by the following: The facility's Pressure Ulcer Prevention/ Treatment Procedure dated July/15 includes in part, 1. Assess all resident upon admission using: Skin assessment, Skin integrity assessment, prevention and treatment care plan, Braden risk assessment. 2. Review assessments and identify individualized interventions using the skin integrity assessment. 2.c Manage nutrition- encourage intake. d. manage friction and shear. Elevate HOB (Head of Bed) no more than 30 degrees unless clinical condition warrants greater elevation.8. Provide education and training to staff as needed. Surveyor asked Director of Nursing (DON) B what Standard of Practice the facility follows for PI's. DON B indicated the facility follows the National Pressure Ulcer Advisory Panel (NPUAP) for the facility Standard of Practice (SOP) for wound care. DON B indicated that 2 of the nursing staff completed the wound certification training. Certification is pending. DON B indicated at this time no one at the facility is wound care certified. According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. Development and implementation of individualized programs of skin care; Built-in mechanisms to evaluate programs to ensure they are effective; Use of supportive offloading surfaces; Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and sheer; accurately document skin risk assessment, prevention strategies as well as resident response. Example 1 R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. R1 is on Hospice services. R1's Braden (skin assessment), dated 2/28/17, scored a 14, indicating R1was at moderate risk for PI development. R1's Braden continued to score a 14 on 3/7/17, 3/11/17, and 3/21/17. On 3/19/17 the skin grid documents R1's Braden score is 12 which equals high risk. To be noted: these were the only Brayden scores recorded for R1 although PI's developed after those dates. R1's Admission Minimum Data Set (MDS), dated [DATE], indicates The Brief Interview for Mental Status (BIMS) score was 9 which indicates R1 has moderate cognitive impairment. Section M0150 of the MDS indicates R1 is at risk for developing a PI. Section M0210 indicates R1 does not have any unhealed PI. Section G0110, Activities of Daily Living (ADL's) indicates R1 requires 2 staff and extensive assistance for bed mobility and Total Dependence for transfer. A Care Area Assessment (CAA) worksheet dated 3/7/17 includes in part; Triggering Conditions: Bed mobility extensive assistance. At risk of developing a PI -yes. Extrinsic risk factors: requires staff assistance to move sufficiently to relieve pressure over any one site confined to a bed or chair most of the time; requires pressure reducing mattress or seat cushion; requires regular schedule of turning. [MEDICATION NAME] Factors: Immobility and Incontinence; medications: [REDACTED]. Treatments and other factors: Newly admitted , devices that can cause pressure. Description of Problem: R1 is alert and oriented, able to make needs known. Care plan to monitor for any changes or concerns with skin integrity. Review of R1's Skin integrity assessment: Prevention and treatment Care Plan dated 2/28/17, includes in part, at risk, frequent turning, maximum remobilization, protect heels, manage moisture, nutrition, friction and shear, pressure reduction support surface if bed or chair bound. Goal: Will remain free of open areas, and will be cooperative with position changes. Interventions: staff to monitor skin with each bath/ wash up at least 2 times per week. Problem added 4/7/17- potential for skin breakdown. Goal- pt (patient) to be free of skin breakdown. Air mattress on pt bed set at 300 dated 3/21/17. Areas of Impairment dated 3/19/17: Stage 2 right buttock, SDTI (suspected deep tissue injury) left buttock. Interventions: monitor wound weekly and prn (when necessary), provide treatment per order, update MD (medical doctor) within 2 weeks if no evidence of healing, reposition and get up out of bed. Of note there is not a goal listed. ADL (activities of daily living) plan of care dated 4/10/17 includes: Air mattress due to potential for skin breakdown. Goal: Pt to be free of skin breakdown. Intervention: air mattress to be set at 300. R1's resident care card undated includes in part; skin - turn and reposition every 2 hours, float heels off bed, air mattress at 300. Feeding - Needs assistance with feeding. R1's admission skin assessment dated [DATE] indicates there are no skin issues. R1's skin assessment dated [DATE] indicates that R1 noted to have a bruise to her left buttock 4.0 cm (centimeters) x 2.0 cm and an abrasion to her right buttock 3.0 cm x 3.5 cm x 0.1 cm. R1's heels are marked as pink. R1's weekly skin assessment sheet completed by CNA's (certified nursing assistants) includes the following: 3/1/17 - no concerns and signed off by the nurse. 3/8/17 - no concerns and signed off by the nurse. 3/10/17 - no concerns and signed off by the nurse. 3/21/17 - left buttock is marked patch and right buttock has a scribble mark and is signed off by the nurse. 4/7/17 - no concerns and signed off by the nurse. Review of R1's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/ other documentation incudes in part; Left buttock: 3/19/17 location- left buttock/ coccyx, DTI/bruise, wound was present on admission- no. Stage DTI. Braden12. To be noted a Braden score of 12 equal's high risk for PI. 2cm x 4 cm x 0 (length x width x depth). Color- pink 3/22/17- DTI/ bruise 2.1 cm x 4.2 cm x 0 color-pink. 3/28/17 - DTI/bruise 2.1cm x 4.2 cm x 0 color pink. 4/3/17- DTI 3.8cm x 4.2cm x 0.1 color pink and red. First layer of skin gone on this area. 4/11/17 - Unstageable 2.1cm x 3.2 cm x 0.1 cm color of drainage pink, color of wound necrotic, odor - foul. Right buttock: 3/19/17 location- right buttock /coccyx, was wound present on admission- no. Stage 2 (3.5 cm x 3.0 cm x 0.1 cm) Color pink/red. 3/22/17 - stage 2 (3.5 cm x 3.0 cm x 0 cm) Color pink. 3/28/17- stage 2 (3.5 cm x 3.0 cm x 0 cm) Color pink. 4/3/17 - stage 2 (4.1 cm x 2.4 cm. 0.1 cm) Color pink and red. 4/11/17 - unstageable (6.0 cmx 4.2 cm x 0.1 cm) drainage is pink, color of wound is necrotic, and the odor is foul. It is important to know Registered Nurse (RN) C is doing the wound treatments at the facility. RN C completed the wound certification class and the certification results are pending. On 4/12/17 at 8:40 AM, Surveyor interviewed National Home Medical Equipment representative (NHME) H regarding the dates R1's mattress was delivered to the facility and what the various mattresses are rated for PI prevention/ treatment. R1 was admitted on [DATE] with a standard Panacea mattress which is used for pressure redistribution to help prevent PI. On 3/5/17 R1's mattress was changed to an Alternating Pressure mattress per an order by a Hospice nurse over the weekend. This mattress is used to treat a stage 1 PI. On 3/21/17 R1's mattress was changed to a Gel mattress overlay. This gel mattress overlay is used to treat a stage 1 or 2 PI. On 4/6/17 an order was placed for R1 to have a low air loss mattress. The company delivered the low air loss mattress on 4/7/17. R1 refused to get out of bed to have the mattress placed. On 4/8/17 the NHME Company delivered and set up the low air loss mattress for R1. NHME H indicated that the low air loss mattress is used to treat stage 3-4 PI. Review of R1's physician orders [REDACTED]. NS (normal saline) was to right buttock F/B (followed by) Allevyn, change every 3 days and prn. Of note the orders for the treatment to the buttocks was dated 3/19/17. R1's treatment administration record (TAR) dated 3/17 includes in part, Skin assessment with shower weekly the boxes are marked off to do this assessment. The nurse initialed the assessment on 3/1/7, 3/4/17, 3/8/17, 3/21/17, 3/24/17, 3/28/17, and 3/31/17. The remainder of the marked boxes does not have an initial to indicate that the skin assessment was completed. It is important to know that there is no documentation to show that skins checks were completed between 3/10/17-3/21/17. R1's PI was observed on 3/19/17. R1's treatment order for her right buttock is not signed out as being done on 3/31/17. Monitor bruise left buttock each shift dated 3/20/17 is not initialed on 3/20/17 evening shift and 3/28/17 night shift. Review of R1's TAR for 4/17 includes in part; new treatment order for coccyx wound; cleanse coccyx wound with NS, pat dry, apply calcium alginate to wound bed and cover with an occlusive dressing. Change every 2 days right and left. On 4/10/17 at 10:25 AM, Surveyor observed CNA S change R1's brief. R1's HOB (head of bed) was close to a 90 degree angle as R1 was sitting up in her bed on an air mattress set at 300. CNA S lowered the HOB to about a 45 degree angle and removed R1's brief. R1 was incontinent of stool. Surveyor noted a large dressing on R1's coccyx/ sacral area. CNA S indicated that R1 had two sores under the dressing. CNA S indicated that he was also a Licensed Practical Nurse (LPN) but his role at this facility is a CNA. After peri care was completed CNA S raised the HOB back up for R1. On 4/10/17 at 12:10 PM, Surveyor observed the lunch meal set in front of R1 who was sitting up in bed with oxygen on. The meal consisted of mashed potatoes/ gravy, squash, chocolate cake, and pureed tan meat. R1 had clear plastic cups in front with lids and a straw that contained her water. Surveyor noted an ensure clear (supplement) on her tray. R1 was not attempting to feed herself. R1's Family Member (FM) U was at bedside and questioned surveyor why they don't try to spoon it in to her. On 4/10/17 at 1:30 PM, Surveyor interviewed CNA S regarding R1 and the need for assistance with meals. CNA S indicated that R1 should have assistance to eat. CNA S indicated with the diet R1 is on she is to have someone in the room with her. CNA S again said R1 should have assistance with eating. On 4/11/17 at 7:45 AM, Surveyor observed Hospice CNA giving R1 a bed bath. On 4/11/17 at 8:00 AM, CNA F delivered the breakfast tray to R1. R1 was sitting in her bed with the HOB elevated to approximately 90 degrees. CNA F lifted the lid on the plate and mixed butter into the scrambled eggs. Surveyor asked CNA F what was in the cups. CNA F indicated she was not sure and put ice water in the yellow cup. Ensure clear was on the meal tray. CNA F left the room. R1 did not attempt to pick up her fork or spoon. On 4/11/17 at 8:40 AM, Surveyor observed R1 has not attempted to eat any of the scrambled eggs. Surveyor observed that no staff entered R1's room to assist her. On 4/11/17 at 8:45 AM, Surveyor asked CNA F who was carrying R1's breakfast tray out of her room if she requires assistance to eat. CNA F indicated that the staff try's to assist R1 but she refuses. Surveyor observed that the scrambled eggs were still on R1's plate in the same portion served. RN C was walking towards Surveyor. Surveyor asked RN C if R1 needs assistance with meals. RN C indicated no, she does not need assistance. On 4/11/17 at 11:45 AM, Surveyor observed R1's wound care with RN C. RN C removed the old dressing and a strong odor was noted. RN C said that the evening nurse usually does the treatment and it is 100 % slough. RN C cleansed the wounds and patted dry. RN C noted two additional areas of skin breakdown on the left and right lower buttock. Surveyor asked RN C to describe the odor. RN C indicated it was a pungent odor. RN C measured the wounds and indicated that the left buttock was 90 % slough and 10% necrotic and the right buttock was 100 % slough with some necrosis starting. RN C cut the calcium alginate and placed it on the wounds. RN C applied skin prep to the outer surface of the wounds. RN C asked CNA F to get a larger Replicare dressing as the one she brought into the room was not large enough. RN C indicated she was told the smaller dressing would cover the wounds. On 4/11/17 at 3:30 PM, Surveyor noted a telephone order for Allevyn to be used for the two new open areas to R1 left and right lower buttocks. On 4/11/17 at 5:45 PM, Surveyor interviewed NP E regarding R1 and the PI that developed in house. NP E indicated that she has not seen R1's PI. Surveyor asked NP E if she would expect to be called if a PI developed. NP E indicated that she would have come out to assess the PI if she would have been notified that a PI developed. Surveyor asked NP E when she would expect to be contacted. NP E indicated that if a PI developed, worsened, was draining, or not improving. Surveyor asked NP E if she was aware that the PI has a strong pungent odor. NP E was not aware of the odor. Surveyor asked NP E if she would have ordered a culture of the wound. NP E indicated not necessarily as the wound would have to really be scrubbed to get an accurate culture. NP E indicated that she might order an antibiotic. NP E indicated that this is the first she has heard about the PI and odor with the wound. NP E indicated she was told it was 2 stage 2's and not that big. NP E indicated that Hospice did not update her as well. NP E indicated that she was going to assess the wound. On 4/11/17 at 6:30 PM, NP E asked to update Surveyor regarding R1's wound. NP E indicated that the Hospice nurse called the wound a stage 2 on Sunday and ordered calcium alginate per the documentation on the computer. The Hospice nurse did not update NP E. NP E indicated that it is hard for R1 to breathe when lying down. NP E indicated she recommends the facility pre medicate R1 before dressing changes and try to get her off her bottom. NP E indicated that the wound may turn into a Kennedy ulcer as it is heading in that direction. NP E's notes for the observation of R1's wound include in part, ulceration of sacral area and bilateral upper buttocks examined. There are areas of slough and necrotic tissue noted bilaterally. There is peri wound excoriation but no acute inflammation or warmth. There is some foul smelling exudate noted on the dressing. There are bilateral superficial open areas on lower buttocks. No slough in these wound beds. No exposed bone. On 4/12/17 at 7:40 AM, Surveyor asked R1 if the MD would order an antibiotic, would you want to take it. R1 indicated yes, if it would help me. Surveyor asked R1 if the staff offer to reposition her. R1 shook her head up and down indicating yes. Surveyor asked R1 if she wants to be turned and repositioned. R1 shook her head up and down. R1 indicated I don't want to hurt, I want to be comfortable. On 4/12/17 at 8:05 AM, Surveyor observed CNA F place the breakfast tray in front of R1 who was sitting with her HOB 45 degrees. CNA F mixed butter in with the scrambled eggs and cut apart the eggs. CNA F left the room. Surveyor observed R1 looking at her eggs. On 4/12/17 at 8:10 AM, Surveyor observed CNA F return to R1's room and ask if R1 needed help. CNA F left the room saying I'll be back. R1 was looking at her plate of scrambled eggs. On 4/12/17 at 8:15 AM, Surveyor observed CNA F enter R1's room and asked R1 if she is going to eat. R1 was moaning. CNA F left the room and went into another resident's room [ROOM NUMBER] doors up the hall. R1 did not eat any of her scrambled eggs. On 4/12/17 at 9:05 AM, Hospice Nurse (HN) D came to the facility to make rounds. Surveyor interviewed HN D regarding R1. Surveyor asked HN D when the PI occurred. HN D indicated that R1 did not have a PI on admission. Surveyor asked HN D why the alternating pressure mattress was changed to the gel mattress. HN D indicated that the facility does not allow an alternating pressure mattress and the on call Hospice nurse was not aware of that. Surveyor asked HN D what the goal is for R1's PI. HN D indicated that the goal would be to keep the odor down if an odor were to develop, keep pain under control, and keep drainage under control. HN D indicated that he was not sure if the wound would heal but the goal is not have it increase in size. Surveyor asked HN D if antibiotics would be used if ordered. HN D indicated yes, the care plan indicates antibiotics for comfort if the wound became infected. Surveyor asked HN D if the MD or NP were updated with the wound. HN D indicated that yes, the MD and NP are involved and contacted. Surveyor indicated that NP E was in last evening and was not aware of the PI, size, or odor. HN D indicated that NP E has been off for a while. HN D indicated that R1 had Physical Therapy evaluate her for transfers and R1 was recently treated with [MEDICATION NAME] when the facility had an outbreak. On 4/12/17 at 10:20 AM, Surveyor observed R1 with her nebulizer administration via mask running. Surveyor asked LPN M to lift the covers at the foot of R1's bed. Surveyor observed R1's right heel on the mattress and R1's left heel semi floated. LPN M floated R1 heels. On 4/12/17 at 10:10 AM, Surveyor asked CNA T if she ever repositions R1. CNA T indicated that they will try to reposition R1. CNA T indicated that R1 will let CNA S reposition her. On 4/12/17 at 1:30 PM, Surveyor asked DON B about the alternating air mattress that was used for R1. DON B indicated that the facility does not use those and the Hospice nurse who was on call was not aware of that. Surveyor asked DON B if R1 should have stayed on that mattress. DON B indicated that the facility should have used the low air loss mattress right away. Example 2 R2 was admitted to the facility on [DATE] with a readmission date of [DATE]. R2 [DIAGNOSES REDACTED]. R2's Braden dated 10/10/16 scored a 16, indicating R2 was at minimal risk for PI development. R2's Significant change Minimum Data Set (MDS), dated [DATE], indicates The Brief Interview for Mental Status (BIMS) score was 14 which indicates R2 is cognitively intact. Section M0150 of the MDS indicates R2 is not at risk for developing a PI. Section M0210 indicates R2 does not have any unhealed PI. Section G0110, Activities of Daily Living (ADL's) indicates R2 requires 2 staff and extensive assistance for bed mobility and extensive assist for transfer. A Care Area Assessment (CAA) worksheet dated 7/14/16 includes in part; Triggering Conditions: Bed mobility extensive assistance. Frequent urinary incontinence - always incontinent, Frequency of bowel incontinence- frequently incontinent. Risk of developing a PI -yes. Extrinsic risk factors: Pressure, requires pressure reducing mattress or seat cushion; requires regular schedule of turning. [MEDICATION NAME] Factors: Immobility, altered mental status, cognitive loss. medications: [REDACTED]. Treatments and other factors: Newly admitted . Description of Problem: R2 is alert and oriented, able to make needs known, 2 assist with bed mobility, 1 assist with set up for ADL's, 1 assist with peri care, 2 assist with transfers and ambulation. Care plan to minimize risks. A Care Area Assessment (CAA) worksheet dated 10/18/16 includes in part; Triggering Conditions: Bed mobility extensive assistance. Frequent urinary incontinence - always incontinent, Frequency of bowel incontinence- frequently incontinent. Risk of developing a PI -yes. Number of unstageable pressure ulcers due to suspected deep tissue injury (SDTI) in evolution - 1. Extrinsic pressure ulcers- assess location, size, stage, presence of odors, and condition of surrounding skin. Extrinsic risk factors: Pressure, confined to a bed or chair all or most of the time, requires pressure reducing mattress or seat cushion; requires regular schedule of turning. [MEDICATION NAME] Factors: Immobility, incontinence, poor nutrition. medications: [REDACTED]. Treatments and other factors: Newly admitted or readmitted devices that can cause pressure. Description of Problem: R2 is alert and oriented x 3, able to make needs known. SDTI to right lateral foot. Will wear shoe down to meals, off when in room. Offloading pressure to feet. Care plan to monitor for any changes or concerns with skin integrity. Review of R2's Skin integrity assessment: Prevention and treatment Care Plan dated 7/5/16, includes in part, at risk, frequent turning, maximum remobilization, protect heels, manage moisture, nutrition, friction and shear. Goal: Will be cooperative with position changes. Interventions: inspect skin for s/s (signs and symptoms) of breakdown. Problem added 10/13/16- scab to right lateral mid foot. Goal: scab will heal without s/s infection. Interventions: shoes on to go to meals, otherwise off when in room, therapy to monitor for foot pedal, offload right foot, wound treatment as ordered, monitor wound, update MD if no evidence of healing. Diabetes Care Plan dated 3/11/16 includes in part, monitor skin for irritation. Diabetes foot checks were written in without a date next to it. Resident Care Card undated includes in part; Grooming-Diabetic shoes -apply q (every) AM (morning), Skin- no compression stockings or shoes until further notice except to meals, Heels up with pillows as needed to float heels in bed, wound to right outer foot, check feet r/t (related to) use of special shoes, monitor for reddened/open areas. Feeding- assist to dining room there and back with meals-sore foot- until healed. To be noted, Surveyor observed R2 self-propel to the dining room and back independently for the breakfast and lunch meals for a total of 9 times. Surveyor requested R2's weekly skin assessment sheets that the CNA's complete for September 2016 and October 2016 prior to 10/13/16. DON B gave Surveyor two skin assessment sheets. 10/12/16 and 10/19/16 shower sheets documents no skin concerns and is signed off by the nurse. DON B indicated she was unable to locate any other skin assessment sheets in this time frame. To be noted; R2 developed a SDTI on 10/13/16 and the shower sheet 10/19/16 indicates no skin concerns. Review of R2's treatment administration record (TAR) dated 9/16 and 10/16, diabetic foot checks documented they were completed on the evening shift except 9/4/16 was not initialed. R2's TAR dated 10/13/16 includes in part; Skin prep right outer foot every shift until healed. R2's TAR dated 11/16 includes in part; no sting barrier film spray, apply to right outer foot every shift until healed. R2's TAR dated 12/16 includes in part; no sting barrier film spray, apply to right outer foot every shift until healed. R2's TAR dated1/17 includes in part; [MEDICATION NAME] to right lateral foot and left great toe bid (twice daily). Warm water soak 15 minutes right foot bid x 7 days dated 1/3/17-1/10/17. Remove [MEDICATION NAME] boarder on Wednesday 1/12/17, if healed no need to re- apply, if wound is open cover with [MEDICATION NAME] and change every 4 days until healed. [MEDICATION NAME] is documented as removed on 1/25/17. R2's TAR dated 2/17 includes in part; [MEDICATION NAME] ointment to wounds on right and left ankle bid. Cover with clean sock until resolved. If not resolved in 2 weeks, notify NP. Allevyn to right foot ulcer change every 3rd day dated 2/21/17. R2's TAR dated 3/17 includes in part; Cleanse wound to right foot with normal saline (NS). Apply Santyl to wound base. Cover with gauze dressing every other day and prn (when necessary) dated 3/17/17. R2's TAR dated 4/17 includes in part; Santyl to wound right lateral foot daily after cleansing with NS and cover with dry dressing dated 4/1/17. R2's Skin Grid - Pressure /[MEDICAL CONDITION] Ulcer/Other form dated 10/13/16 includes in part; was wound present on admission- no. Site- right lateral mid foot. Pressure- scab. Stage- unstageable. 1.4 cm x 1.8 cm (width x length) color - black. Braden score-16 (minimal risk). The following wound measurements are as follows: 10/18/16 - unstageable, 0.5cm x 0.5 cm. Color - yellow/black. 10/25/16 - unstageable, 0.8cm x 0.7 cm. Color - Black. 11/3/16 - unstageable, 1.2 cm x 1.2 cm. Color - scab. 11/8/16 - unstageable, 0.8 cm x 1.0 cm < 0.1 cm depth. Color - red/pink. 11/18/16- unstageable, 0.8 cm x 1.0 cm < 0.1 cm depth. Color - red/black. 11/22/16- unstageable, 0.7 cm x 0.7cm < 0.1 cm depth. Color - red/black. 12/4/16 and 12/21/16 - unstageable, 0.3 cm x 0.3cm < 0.1 cm depth. Color - red/black. 12/28/16- unstageable, 0.6 cm x 0.6cm. Color - red scab. 1/4/17- unstageable, 0.8 cm x 0.8cm Color - scab. 1/11/17 and 1/18/17- unstageable, 0.7 cm x 0.7cm Color - scab. 2/1/17- unstageable, 0.5 cm x 0.5cm < 0.1 cm depth. Color - scab. 2/7/17- unstageable, 0.8 cm x 0.7cm < 0.1 cm depth. Color - yellow. 2/14/17- unstageable, 0.8 cm x 0.6cm < 0.1 cm depth. Color - scab. 2/21/17- unstageable, 0.8 cm x 0.6cm < 0.1 cm depth. Color -slough. 2/28/17- unstageable, 1.0 cm x 1.0cm < 0.1 cm depth. Color - scab/ 25% slough. 3/6/17- unstageable, 0.9 cm x 0.9 cm < 0.1 cm depth. Color -slough. 3/14/17- unstageable, 0.6 cm x 0.6 cm < 0.1 cm depth. Color - red/black. 3/21/17- unstageable, 0.6 cm x 0.3 cm < 0.1 cm depth. Color - Necrotic/slough. 3/28/17- unstageable, 0.5 cm x 0.3 cm < 0.1 cm depth. Color - red/slough. 4/3/17- unstageable, 0.6 cm x 0.5 cm < 0.1 cm depth. Color - pink/yellow 60% slough. 4/10/17- unstageable, 0.5 cm x 0.4 cm <0.1 cm depth. Color- 90% slough, 10% pink. To be noted, the above measurements were not listed on the wound sheet at the end of survey but were observed while RN C did the treatment and measurements. On 4/10/17 at 1:00 PM, Surveyor observed R2's wound treatment with RN C. R2 was wearing a slipper on his right foot and shoe on the left foot. R2 indicated that he could not sleep last night due to the pain in his foot from the diabetic shoe. Surveyor asked R2 if he was having pain right now. R2 indicated no. RNC indicated the MD recently increased his pain medication. RN C indicated that R2 does not like to wear socks. Surveyor asked RN C how R2 developed this wound. RN C indicated it was from his old pair of shoes. RN C indicated that R2 did see Podiatry and has new diabetic shoes to wear and there is a schedule in the treatment book for the times to wear the shoes. RN C completed the wound treatment. Surveyor observed slough in the wound and asked RN C to describe the wound. RN C indicated that the wound was 90% slough and 10 % pink. R2 indicated he does not like to wear those tight stockings as they hurt his feet. RN C indicated that R2 has been on antibiotics for [MEDICAL CONDITION] in his right foot. Review of R2's nursing notes dated 10/16/16 at 8:00 AM include in part, NP E updated on right lateral foot scab. New orders received. SBAR (situation, background, assessment, and recommendation) form sent to NP E includes in part; appearance- scab like area with some redness around edges- appears to be from R2's shoe. New orders for skin prep from NP E. Nursing notes dated 10/18/16 at 3:10 AM includes in part; skin prep applied to area at outer side of foot, area red and hard. IDT (interdisciplinary department team) note on 12/8/16 12:30 PM, includes in part; area to right lateral foot improving. Area remains with necrotic tissue. Continue current plan of care. Skin prep to area every shift. Nursing notes dated 12/14/16 at 3:30 PM includes in part; continues with area to right lateral foot. Area remains with necrotic tissue. Continue current plan of care. Skin prep to area every shift. MD progress note dated 1/3/17 at 1:45 PM includes in part, seen today for a routine visit and right foot pain with swelling. Pertinent history: about 7-10 days of pain along right lateral foot with bump and sore present. R2 did get a new pair of shoes several weeks ago. No drainage and pain with pressure on this area. Right lateral foot eschar with surrounding redness about 3 cm and warmth, tender no fluctuance. Nursing notes dated 1/3/17 at 1:50 PM includes in part; MD here to see R2. Order received for antibiotic and foot soaks. Nursing notes dated 1/5/17 at 10:00 PM includes in part; foot soak done. Scab intact. R2 indicated that the wound is tender to the touch. Nursing notes dated 1/6/17 at 9:00 PM includes in part; nursing order, R2 to wear slippers, no shoes, no TED's (compression socks) R2 developed a wound on his left foot. Monitor wounds. Update NP E on day 7. Right foot soaked, scab intact. Nursing notes dated 1/7/17 at 1:30 PM includes in part; nursing order, Blister intact to left foot. Foot soak done on right foot. Scab intact. Continues on antibiotic. Nursing notes dated 1/12/17 at 10:10 AM includes in part; NP E assessed R2's wounds. Order for [MEDICATION NAME] treatment and a referral to podiatry. Nursing notes dated 1/14/17 at 1:30 PM includes in part; R2 indicated the right lateral wound is painful to the touch. No drainage noted. Nursing notes dated 1/20/17 at 5:00 PM includes in part; R2 returned to the facility from an appointment with podiatry. Order received for [MEDICATION NAME] to right lateral foot wound. Nursing notes dated 2/11/17 at 11:00 AM includes in part; redness, [DIAGNOSES REDACTED] noted to left foot outer and right foot inner, over arch. Call placed to MD. Orders received. Nursing notes dated 2/14/17 at 10:30 AM includes in part; R2 continues on antibiotic. Areas to bilateral feet remain scabbed. No drainage. Redness surrounding scabbed areas. MD progress note dated 2/14/17 at 3:26 PM includes in part, seen today for follow up on [MEDICAL CONDITION] and Pressure area, and diabetic foot assessment. Treatment to date: has ill - fitting shoes and recently saw podiatry and recommendation for shoes to prevent ulcers. Extremities: ulcer over right lateral mid foot about 1 cm eschar and not stageable. Nursing notes dated 2/16/17 at 5:45 PM includes in part; new order received for [MEDICATION NAME] to left and right ankle. Nursing notes dated 3/1/17 at 3:00 PM includes in part; R2 out for appointment. Casting done for new shoes. Nursing notes dated 3/16/17 at 1:30 PM includes in part; DON B left a message for NP E to consider changing wound treatment as wound is stagnant with slough.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers, and a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, for 1 of 1 sampled residents (Resident 6). Resident 6 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Interventions were not put in place to prevent Resident 6 from developing a PU. Resident 6 developed an avoidable unstageable PU to the right foot. On 1/21/16 at 3:38 PM Surveyor interviewed the facility Director of Nursing (DON) B who is currently responsible for wound care. Of note, DON B is currently not wound care certified. Surveyor asked DON B what Standard of Practice DON B follows for PU's. DON B is unaware if the facility follows a Standard of Practice (SOP) for wound care. This is evidenced by the following: The facility's Wound Care Policy dated 7/15 and entitled Wound Prevention and Management states in part; Pressure Ulcer (PU) Prevention/Treatment: At risk (15-18) the following interventions are efforts to stabilize, reduce or remove underlying risk factors frequent turning, pressure reduction support surface if bed or chair-bound; Moderate risk (13-14) turning schedule use foam wedges for 30 degree lateral positioning, pressure reduction support surface; High risk: increase frequency of turning, turning schedule use foam wedges for 30 degree lateral positioning, pressure reduction support surface. 2. A. Manage Pressure: use support surfaces on bed or wheelchair; offload heel pressure; use turning and repositioning. D. elevate head of bed (HOB) no more than 30 degrees unless clinical condition warrants greater elevation. According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. Development and implementation of individualized programs of skin care; Built-in mechanisms to evaluate programs to ensure they are effective; Use of supportive offloading surfaces; Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and sheer; accurately document skin risk assessment, prevention strategies as well as resident response. Resident 6 has [DIAGNOSES REDACTED]. Resident 6's Braden assessment, dated 11/28/15, indicates Resident 6 scored a 13, indicating Resident 6 was at moderate risk for PU development. The Braden assessment indicated the following: Sensory Perception: slightly limited; Moisture: very moist; Activity: Bedfast; Mobility: very limited; Nutrition: adequate; Friction or sheer: potential problem. Resident 6's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/15, indicates A Brief Interview for Mental Status (BIMS) was unable to be completed with Resident 6 indicating Resident 6 has severe cognitive impairment. Section M0150 of the MDS indicates Resident 6 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 6 requires 2 staff and extensive assistance for bed mobility and transfer did not occur. (Of note Resident 6 is bed- ridden). A Care Area Assessment (CAA) worksheet dated 9/16/15 states in part; Triggering Conditions: Bed mobility extensive assistance; frequent urinary incontinence; frequent bowel incontinence; at risk of developing a PU; Extrinsic risk factors: requires regular schedule of turning; needs special mattress or seat cushion to reduce or relieve pressure; [MEDICATION NAME] Factors: immobility, incontinence, altered mental status, cognitive loss, [DIAGNOSES REDACTED]. all or most of time in bed; he is assisted by staff to turn and reposition every 2 hours and as needed to help prevent any adverse changes in skin. Resident 6's plan of care entitled Skin Integrity re-written 12/20/15 states in part; Assessment/Problem: Braden Risk Assessment at risk frequent turning, manage moisture, nutrition, friction and shear; At risk related to: diabetes mellitus; bowel and bladder incontinence; Goal: will be cooperative with position changes; will demonstrate healing without signs and symptoms of infection; Interventions: protect elbows and heels if being exposed to friction; air mattress; reposition every 2 hours and as needed; lift do not slide resident; use assistive devices to reduce friction and facilitate movement; Areas of impairment: Right foot lateral blister. The following is a brief history of Resident 6's skin integrity. Physician Telephone Order dated 10/15/15 states in part; discontinue air mattress. On 1/21/16 at 3:38 PM Surveyor interviewed Director of Nursing (DON) B regarding the discontinuation of the air mattress DON B stated Resident 6 had not developed a PU in the four years he was at the facility. The facility felt the air mattress was no longer needed so it was discontinued. Surveyor asked DON B if Resident 6's PU risk factors had improved on 10/15/15 such that Resident 6 was not at risk for PU development. DON B stated Resident 6 remained at risk; he just had not developed a PU and the facility felt he no longer required the air mattress. Surveyor asked DON B if it was possible the air mattress was a factor in helping prevent PU development DON B stated it appears it could have been. Nursing notes dated 11/16/15 at 4:30 AM state in part; red area to right medial heel that is blanchable; skin has soft texture. Order for skin prep was initiated will continue to float heels and keep pillow between ankles to prevent heels from touching and increase {sic} pressure risk. Physician Telephone Order dated 11/16/15 states in part; apply skin prep to bilateral heels twice daily to prevent PU; float heels in bed and keep feet separate when in bed. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 11/28/15 states in part; Present on Admit: No; Location: right lateral foot (outside of foot); pressure blister; Stage: Suspected Deep Tissue Injury (SDTI); Length: 2.2 centimeters (cm) Width: 1.1 cm; Depth: none A Situation, Background, Assessment and Request (SBAR) Form dated 11/28/15, states in part; Situation: Open area to coccyx and purple area to right lateral heel Request: during every 2 hour check and change found purple skin to right lateral heel; diffuse purple at skin surface 2.3 cm x 1.0 cm. Open area to coccyx 3.2 cm x 1.2 cm; utilize standing orders per nurse practitioner; fluid filled blister to right lateral foot at base of 5th toe 2.2 cm x 1.1 cm. Physician Telephone Order dated 11/28/15 states in part; skin prep twice daily (BID) to right lateral foot blister and purple area. Monitor right lateral foot for signs and symptoms of infection every shift times 72 hours. Barrier cream to buttocks/coccyx BID to treat protect. Nursing notes dated 11/29/15 at 3:30 AM state in part; blister to right lateral foot dark purple appears to be intact. Open area (OA) to coccyx pink cream applied. Purple area to right lateral heel noted; no signs of infection. Nursing notes dated 12/2/15 at 11:10 AM state in part; skin prep to bilateral heels, right lateral foot remains with fluid filled blister; heels off bed. Nursing notes dated 12/5/15 at 2:00 PM state in part; OA to coccyx appears unchanged barrier cream applied; heels intact and up off bed; skin prep applied to blister to right lateral foot remains intact. Nursing notes dated 12/7/15 at 11:30 AM state in part; purple area center location {sic} resolved; OA to coccyx resolved; skin prep continues to bilateral heels and blister right foot. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 12/7/15 states in part; Stage: SDTI; Length: 3.2 cm; Width: 2.0 cm; Depth: none; Color: black A SBAR form dated 12/10/15 states in part; Situation: open area to sacrum Physician Telephone Order dated 12/10/15 states in part; Allevyn to coccyx/sacrum change every 3 days and as needed for PU. Of note, on 1/21/16 at 3:38 PM Surveyor interviewed DON B regarding the PU to the coccyx/sacrum. DON B stated the area to the coccyx/sacrum was a Stage 2 but is now healed. Surveyor asked DON B what the facility did once the PU was discovered on the coccyx/sacrum; DON B stated we reinstituted the air mattress. Nursing notes dated 12/11/15 at 5:00 AM state in part; heels elevated; area over right foot is intact; Allevyn to coccyx; repositioned every 2 hours and as needed. Nursing notes dated 12/11/15 at 11:50 AM state in part; right lateral foot blister intact and firm; air Mattress in place. Nursing notes dated 12/13/15 at 2:40 PM state in part; wound on right outer foot intact skin prep applied; Allevyn changed to coccyx no open area. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 12/14/15 states in part; Stage: SDTI; Length: 3.0 cm; Width: 2.0 cm; Depth: none; Color: black Nursing notes dated 12/16/15 at 1:55 PM state in part; Allevyn change to coccyx no OA; skin prep to intact blister right lateral foot . Nursing notes dated 12/19/15 at 3:15 PM states in part; blister to right lateral foot appears re-absorbed and firm; not open skin prep applied. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 12/21/15 states in part; Stage: SDTI; Length: 2.7 cm; Width: 1.7 cm; Depth: none; Color: black Nursing notes dated 12/23/15 at 12:00 PM state in part; areas to coccyx/sacrum have resolved. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 12/28/15 states in part; Stage: SDTI; Length: 2.7 cm; Width: 1.7 cm; Depth: none; Color: black Nursing notes dated 12/29/16 at 3:15 AM state in part; blister to right foot is healing. Nursing notes dated 1/1/16 at 3:20 PM state in part; skin prep to right lateral blister; heels floated. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 1/4/16 states in part; Stage: SDTI; Length: 2.7 cm; Width: 1.7 cm; Depth: none; Color: black Nursing notes dated 1/4/16 at 8:35 PM state in part; skin prep to heels and right lateral scabbed over blister. Nursing notes 1/6/16 at 11:45 AM state in part; dried blister to right lateral foot intact. Nursing notes dated 1/8/16 at 10:00 PM states in part; right lateral foot has firm brownish area. physician progress notes [REDACTED]. Associated Signs and Symptoms: per staff, ulcer was first noticed to be a blood filled blister (deep tissue injury) which subsequently decompressed and assumed a leathery appearance. Vascular Assessment: right dorsal pedal pulse weak/thread; right posterior tibial pulses weak/thready. Integumentary: wound right lateral foot is necrotic tissue, unstageable, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 2.7 cm x 1.7 cm wound bed is 76-100 percent dry, black eschar. Plan: wound right lateral foot; Wound cleansing and Dressing: protect periwound with Skin Prep, change daily; Pressure Relief/Offloading: Follow facility PU prevention policy/protocol; pressure redistribution mattress per facility protocol. Plan of Care: PU over the lateral aspect of his foot that will be treated with skin prep and monitored; pressure offloading per facility protocols. Of note, the right foot ulcer has worsened from a SDTI to now an unstageable PU. The facility did not recognize the PU had worsened from a SDTI to an unstageable PU until after the Resident 6 was assessed by the physician. Nursing notes dated 1/10/16 at 7:45 PM states in part; skin prep to right lateral blister is blackened. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 1/11/16 states in part; Stage: Unstageable; Length: 2.5 cm; Width: 1.6 cm; Depth: none; Color: black Nursing notes dated 1/12/16 at 2:50 PM state in part; firm brownish reabsorbed blister remains to right lateral foot. Nursing notes dated 1/16/16 at 12:00 PM state in part; right lateral foot dried. The facility's Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other Form dated 1/18/16 states in part; Stage: Unstageable; Length: 2.6 cm; Width: 1.8 cm; Depth: none; Color: black Nursing notes dated 1/19/16 at 4:50 PM states in part; right lateral foot dried. Nursing notes dated 1/20/16 at 10:45 PM state in part; right lateral blister black and hardened. On 1/21/16 at 12:35 PM Surveyor asked DON B regarding Resident 6's right foot ulcer. DON B stated the PU is located on the lateral plantar surface of the right foot. DON B stated the PU started out as a SDTI and is now unstageable. Surveyor asked DON B how Resident 6 developed a PU to the lateral plantar (walking surface of foot) surface of the right foot. DON B stated Resident 6's foot pressed against the footboard of his bed causing the PU. Surveyor asked DON B how the facility concluded that the PU was caused by Resident 6's foot pressing against the foot board. DON B stated Resident 6 is a tall man and during the investigation into how the PU developed we concluded it was due to Resident 6 sliding down in bed and the plantar surface of Resident 6's foot pressing on the footboard. DON B stated once the PU developed we initiated an extender on Resident 6's bed, placed a cushion on his bed to offload his heels and we re-initiated the air mattress. On 1/21/16 at 1:05 PM Surveyor observed Resident 6's unstageable PU with DON B. Resident 6 was lying on his back on an air mattress; Resident 6's heels were offloaded with a foam cushion. DON B stated to Surveyor that Resident 6 continues to receive skin prep to the unstageable PU and the area is left open to air. Surveyor noted the unstageable PU which appeared the size of a grape with 100% black eschar. The ulcer was located on the right foot on the lateral plantar surface located on the metatarsal head (part of the long bone of the 5th toe) of the 5th digit. On 1/21/16 at 3:38 PM Surveyor interviewed DON B regarding Resident 6's unstageable PU. Surveyor asked DON B if the facility follows a wound care SOP (Standard of Practice) DON B stated she was not aware of a wound care SOP. Surveyor asked DON B if the facility has a wound care certified nurse on staff; DON B stated, no but I will be attending the wound care course in March. Surveyor asked DON B about Resident 6's PU interventions prior to Resident 6 developing the PU. DON B stated we had the air mattress but we discontinued it since he had not had a PU in four years. We continued to reposition him every 2 hours. Surveyor asked DON B if Resident 6 remained at moderate risk for PU development as he is bed-bound, requires extensive assist with his ADL's and has [DIAGNOSES REDACTED]. Surveyor asked DON B what the facility implemented once the PU developed. DON B stated we repositioned every 2 hours, put a pillow between the legs, and a cushion under his legs to offload heels, added the extender to the bed, and re-initiated the air mattress. DON B stated to Surveyor I just do not see how we could have prevented the PU from developing. Resident 6 has not changed and his feet hitting the foot board of the bed is no different than any other resident's feet hitting the foot board of the bed; this happens all the time. Surveyor asked DON B what staff should do if they observe a resident:s feet pressing against the foot board of the bed. DON B stated the resident should be repositioned. Surveyor asked DON B if staff observed a resident sliding down in bed frequently with their feet pressed against the foot board would she expect staff to report these observations. DON B stated she would expect staff to report such observations. On 1/21/16 at 4:30 PM Surveyor interviewed Certified Nursing Assistant (CNA) C regarding Resident 6. CNA C stated she has worked at the facility for 3 years. Surveyor asked CNA C how frequently she works with Resident 6 CNA C stated all the time. Surveyor asked CNA C how frequently Resident 6 is repositioned CNA C stated at least every 2 hours. Surveyor asked CNA C if she has observed Resident 6's to be slid down in bed. CNA C stated Resident 6 would frequently slide down in bed and would need a boost up in bed especially if the nurses gave him his pills and his head of the bed was left up or after meals. CNA C stated he does not move himself and is in bed all the time. Surveyor asked CNA C if she ever recalled Resident 6's feet touching the footboard of the bed. CNA C stated yes every time we would go into reposition him he would have his feet against the foot board. When Surveyor asked CNA C if she ever reported these observations to anyone CNA C stated no. Surveyor asked CNA C if she has observed Resident 6's feet against the footboard recently. CNA C stated not since the new bed has been lengthened and we are using the foam cushion under his legs. On 1/21/15 at 4:50 PM Surveyor interviewed CNA D regarding Resident 6. CNA D stated she has worked at the facility for 2 1/2 years. Surveyor asked CNA D how frequently she works with Resident 6 CNA D stated she works with Resident 6 frequently. When Surveyor asked CNA D how frequently Resident 6 is repositioned, CNA D stated at least every 2 hours. Surveyor asked CNA D if she has observed Resident 6 to be slid down in bed. CNA D stated it is very common for Resident 6 to slide down in bed especially when his head of the bed is left up. Surveyor asked CNA D if she ever recalled Resident 6's feet touching the footboard of the bed. CNA D stated that would happen a lot, but it is better now that we have a longer bed and he has the cushion under his legs. When Surveyor asked CNA D if she ever reported these observations to anyone, CNA D stated I would tell the nurse. Surveyor asked if the nurse would give her instruction when she reported these observations CNA D stated no. Resident 6 developed an avoidable unstageable PU to the right foot. The facility failed to implement interventions to ensure Resident 6's foot was not pressing against the foot board creating pressure until after an unstageable PU developed. Staff had knowledge of Resident 6 frequently sliding down in bed with his feet against the footboard as reported by frontline staff. The facility's failure to re-evaluate Resident 6's plan of care an implement interventions resulted in Resident 6 developing an avoidable unstageable PU.

Based on interview and record review, the facility did not ensure that the resident has the right to be free from physical abuse for 1 of 5 residents reviewed (Resident 1). Resident 1 alleged that Registered Nurse (RN) C slapped her arm during the night shift. Director of Nursing (DON) B and Nursing Home Administrator (NHA) A were informed of the allegation. DON B and NHA A did not place protective measures from further potential abuse, during their investigation. RN C was allowed to work, despite the facility's failure to complete an investigation. Resident 1 maintains that the allegation occurred and that she was negatively affected by the alleged abuse from RN C. Certified Nursing Assistant (CNA) F was aware of the allegation and did not report this to facility staff. The facility did not complete an investigation into this allegation, so therefore was not able to determine that the incident did or did not occur. This is evidenced by: The facility's policy titled "Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property" revised April, 2013 states in part, "(Facility name) prohibits the mistreatment, neglect, and abuse of residents ...Physical Abuse: Physical Abuse includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. It also includes controlling behavior through corporal punishments ....Identification: 1. Identify events, such as resident-to-resident altercations, bruising of residents, occurrences, patterns, and trends that may constitute abuse, neglect, and/or mistreatment ...Protection: 1. Provide for the immediate safety of the resident upon identification of potential abuse, neglect, mistreatment, injuries of unknown source, and/or misappropriation of resident property ...Suspend identified employee(s) immediately pending outcome of the investigation..." Resident 1 has [DIAGNOSES REDACTED]." The facility completed a quarterly Minimum Data Set (MDS) assessment, with a reference date of 2/15/15. This MDS assessment notes that Resident 1 scored 14 points on the Brief Interview for Mental Status (BIMS), indicating that Resident 1 is cognitively intact. In Section D, Mood, Resident 1 scored five points, indicating mild depression. Section I, Active Diagnoses, indicates that Resident 1 has anxiety disorder and depression. Surveyor spoke with Resident 1 on 3/12/15 at 7:20 AM. Resident 1 stated that some of the staff at the facility are okay, and some are kind of snotty. Resident 1 stated that recently, a nurse named (RN C) was putting Icy Hot on her back and she slapped her arm. Resident 1 stated that she was having back spasms from a previously broken back and that she needed Icy Hot. Resident 1 said that she was sitting on the side of her bed and (RN C) was on her left side. Resident 1 stated that she slapped her left arm. Surveyor asked Resident 1 how hard her arm was slapped. Resident 1 stated that it was with as much intensity that it would knock a glass of water off of her table. Surveyor asked Resident 1 if this was the first time something like this has happened between her and (RN C). Resident 1 stated that a few nights before, on or around 3/2/15 she had a "run in" with (RN C) as well. Surveyor stated that she brought in her pills, set them on the table and there were no pills in the cup. Resident 1 stated that (RN C) stated that she had her "pegged as a liar." Resident 1 began to cry at this point in the interview. Surveyor asked Resident 1 about when the slap occurred. Resident 1 stated that she believed it occurred on 3/5/15, shortly before midnight. Resident 1 stated that she was slapped and just said, "Geez" to (RN C). Resident 1 stated that she started to cry when she was slapped. Resident 1 continued to cry and stated, "I am [AGE] years-old, living in a nursing home, to have someone slap you-it really sucks. No one has the right to put their hands on anyone." Resident 1 stated that then (RN C) left the room. Surveyor asked Resident 1 if there were any other staff in the room when the incident occurred. Resident 1 stated that there was not. Resident 1 stated that she sat on the edge of her bed for a while and was crying. Resident 1 stated that a CNA came in, but she did not understand what she was saying. Resident 1 stated that she then called her daughter and left her a message on her cell phone. Resident 1 stated that (CNA E) came into her room and she told him what had happened. (CNA E) stated, "Wait a minute, she slapped you?" (CNA E) left and then returned. Resident 1 stated that she then told (CNA E) to call her daughter and tell her to not delete her previous message. Resident 1 stated that (CNA E) did this. Surveyor asked Resident 1 if she was aware if (CNA E) told anyone at the facility. Resident 1 stated that she did not know. Resident 1 stated that (Licensed Practical Nurse (LPN) D) came in her room that morning between 5:00 AM and 6:00 AM. Resident 1 stated that (LPN D) said, "So you think you got slapped last night?" Resident 1 stated that she was mad with that comment. Resident 1 stated that she showed her cell phone to (LPN D) and that her daughter was called. Resident 1 stated that she was not able to show Surveyor the call log, as it only holds so many calls. Resident 1 stated that she has not spoken with (Director of Nursing (DON) B) about the incident, but that she has passed messages along that she would like to speak with her. Resident 1 stated that she spoke with (Nursing Home Administrator (NHA) A) about the incident the day before yesterday, on 3/10/15. Resident 1 stated that (NHA A) asked her what happened and told her that she filled out the paper work and was looking into this. Resident 1 stated that she has not talked to anyone else yet. Resident 1 stated that (RN C) has worked twice with her since the incident and that there were aides with her when she came into her room. Surveyor spoke with CNA E on 3/12/15 at 8:20 AM. CNA E stated that the night the incident occurred with (Resident 1) was a perfectly fine night. CNA E stated that between 5:00 AM and 5:30 AM, (Resident 1) asked for some medications and the nurse, (RN C) said that it was too early. CNA E stated that (Resident 1) told him that (RN C) hit her on the arm and (Resident 1) was upset at this time. CNA E stated that she told him that it happened earlier when (RN C) brought in her Icy Hot. CNA E stated that she left her room and told the day shift nurse what had been said. CNA E stated that (RN C) was standing there and he asked (RN C) if this had happened. (RN C) stated that it did not. CNA E stated that he looked at (Resident 1's) arm and did not see anything. CNA E stated that the other nights that he worked with (Resident 1) and (RN C) he accompanied (RN C) into (Resident 1's) room. CNA E stated that he did not pass this information on to (NHA A). Surveyor asked CNA E about Resident 1 requesting for him to call her daughter. CNA E stated that he did not remember when (Resident 1) asked me to call her daughter to tell her not to delete the voicemail from earlier. CNA E stated that he was not sure if the facility knows that he placed this call. CNA E stated that he did not write a statement but that he was working on the statement now. CNA E stated that he started writing the statement today. Surveyor spoke with CNA F on 3/12/15 at 2:00 PM. CNA F stated that one time last week, she came to work and (Resident 1) was crying and said that one of the nurses slapped her at night. CNA F stated that she thinks that (Resident 1) said it was in the arm. CNA F stated that she asked (Resident 1) why the nurse would do that, and (Resident 1) stated that it was because she is stupid. Surveyor asked CNA F if she told anyone about this. CNA F stated that she did not tell anyone and was waiting to ask (CNA G). CNA F stated that (CNA G) has not worked so; she has not talked to anyone about it. CNA F stated that (Resident 1) told (CNA E) about the incident as well. CNA F stated that she told her to tell the DON as well. Surveyor spoke with LPN D on 3/12/15 at 9:15 AM. LPN D stated that she was at the desk on 3/7/15 around 5:30 AM and (CNA E) came around the corner and said to (RN C) that (Resident 1) wanted meds. LPN D then stated that (CNA E) came back and said that (Resident 1) got hit. LPN D stated that she went in and spoke with (Resident 1) and stated, "You told the CNA that the nurse slapped you?" LPN D stated that (Resident 1) stated that (RN C) held up her shirt and then slapped her arm. LPN D stated that she looked at both arms and there were no injuries. LPN D asked Resident 1 what time the incident occurred and Resident 1 stated that it was earlier in the night shift. LPN D stated that she looked at (Resident 1's) phone and noted that her daughter was called at 11 "something." LPN D stated that there is only one nurse on the night shift and that she was not coming in that night. LPN D stated that she called (DON B) who called (NHA A). LPN D stated that the night shift ends at 6:30 AM and that (RN C) did not go into that room after the allegation came in. Surveyor asked LPN D what was done for protection. LPN D stated that she did not see (RN C) go into others rooms. Surveyor asked LPN D about (RN C's) reaction when she became aware of the allegation. LPN D stated that (RN C) said that she did not slap the resident and then stated that she can't give her meds. On 3/12/15 at 8:50 AM, Surveyor asked NHA A about the specifics of the allegation of physical abuse reported to her. NHA A stated that the word "slapped" was used when it was reported to her. On 3/12/15 at 10:58 AM, Surveyor asked LPN D what she reported to DON B on 3/7/15. LPN D stated that she told DON B that (Resident 1) alleged that she was slapped, not flicked. Surveyor spoke with DON B and NHA A on 3/12/15 at 8:58 AM. NHA A stated that the situation occurred on the night of Friday, 3/6/15 into the morning of Saturday, 3/7/15. NHA A stated that the day shift nurse reported this, that she slapped her. DON B stated that (CNA E) reported this to herself and the nurse. Surveyor asked DON B how the incident went from a "slap" to a "flick" per her documentation. DON B stated that (Resident 1) felt safe in the building and there was no mark on (Resident 1), so this was not reported. NHA A stated that the allegation was made on Saturday, and the facility implemented having two people in the room for cares with (Resident 1). DON B stated that she was called by (LPN D). Surveyor asked NHA A if (Resident 1's) statement of being slapped by (RN C) was an allegation of abuse. NHA A stated, "Yes, this is an allegation." Surveyor asked NHA A about the facility's process when an allegation of abuse is made against a staff member. NHA A stated that an investigation is started and that she reports and does the investigation together. Surveyor asked NHA A about when the facility sends allegations of abuse into the State. NHA A stated that it is their policy to send in the initial report in 24 hours. NHA A stated that throughout the week, (Resident 1) has been fixating on this incident. Surveyor spoke with NHA A and DON on 3/12/15 at 12:37 PM. NHA A stated that she spoke with (RN C) about the situation on 3/9/15, as she was still here at the facility from her night shift. NHA A stated that (RN C) reiterated her perception of what happened and was given education about being careful in her physical contact with residents. NHA A stated that this was not written up. Surveyor asked NHA A how she protects residents from further potential abuse. NHA A stated that she would remove the staff member or family member and report this to the State and then begin to investigate. NHA A stated that she would send the staff person home and not allow to work, during the investigation. Surveyor asked NHA A and DON B why this was not completed on 3/7/15, as (RN C) continued to work. DON B stated that she thought that it was not an allegation at the time the incident was reported and that in this situation, she felt there was no abuse, so that's why (RN C) was allowed to work. DON B and NHA A each stated that they knew it was not abuse on Saturday, 3/7/15. NHA A again stated that she did not think this was a situation of abuse. Surveyor asked NHA A how she came to this conclusion. NHA A stated that her conclusion was that there was no abuse. DON B stated that she used both the words "flick and slap" when she reported the incident to (NHA A). LPN D wrote the following: "Witness Investigation Statement, Date of Incident: 3/7/15. Time Identified: 0530 (5:30 AM). (CNA E) came to desk at 0530 to state that Resident wanted her medication and noc RN (RN C) stated she was on her way. About 2 min (minutes) later, (CNA E) came back and stated that resident told him that the noc RN had slapped her arm when she put the Ice Hot on. Writer took Resident's meds to her room. Spoke about incident c (with) resident. Shirt up so the nurse could put the Ice Hot and the nurse said to her that she couldn't reach her back and slapped her arm to get it out of the way. Res stated that the nurse knew that she was slapping her and she (Resident 1) thought the act was intentional. When writer asked Resident if she felt safe she states that she did. I also asked when the incident occurred, Res stated it was early in the noc and grabbed her phone and told me that she called her daughter to tell her and said the time was 11:54 PM. Writer examined Res skin and on injury noted. ? (no) c/o pain c examination. Resident also stated that she had mentioned it to staff person after it happened but told staff person not to tell the nurse." NHA A wrote a "Progress Note" dated 3/12/15 as follows: "Late Entry for 3/7/15. (DON B) called writer/NHA about resident concern. Resident in (room number) reported to staff that noc nurse slapped resident's arm & Resident was interviewed/assessed by staff. Resident stated that it was more of flick to her back of her arm. Resident reported to be fine. No c/o (complaints of) pain/red marks. Resident felt safe & had no problem continuing to work with noc nurse. At this time DON & NHA/writer decided that it did not feel like abuse. Resident stated she was good all day to staff with no concerns. DON & NHA/writer decided to have 2 staff to go in with cares for resident." It is important to note that the above statement, written by NHA A was completed during the survey on 3/12/15. The facility does not have evidence that Resident 1 stated that the incident was a "flick." In addition, there is no supporting evidence that Resident 1 "felt safe & had no problem continuing to work with noc nurse." The facility did not ensure that Resident 1 was free from physical abuse. Cross Reference F225, F226

Based on observation, interview and record review the facility did not immediately consult with the resident's physician when there was an accident involving the resident which results in injury and has the potential for requiring physician intervention or a need to alter treatment significantly for 1 of 6 residents (Resident 4). Resident 4 fell in the bathroom and sustained a burn from the heater in the bathroom. Resident 4's physician was not provided accurate information regarding the burn to enable the physician to order the appropriate treatment. This is evidenced by the following: Resident 4 has been a long term resident of the facility and was recently readmitted on [DATE] following a 10 day hospital stay. Resident 4's [DIAGNOSES REDACTED]. Resident 4's most recent Minimum Data Set, assessment reference date 11/26/14, includes the following: Brief Interview for Mental Status was 14 indicating no impairment, Needs extensive assistance from 1 person for toileting, not steady moving on and off the toilet and only able to stabilize with human assistance, Range of Motion impairment on lower limbs bilaterally. Resident 4's care plan for falls, rewritten 7/14/14, indicates 2 staff assist with the EZ stand (mechanical stand lift) for transfers. Resident 4's care plan for skin was updated on the following days: -11/14 abrasion to right abdomen, treatment right abdominal abrasion until resolved. -11/22/14 to include: Burn to right abdomen area and right groin/lateral thigh. -12/2/14 the care plan was updated again to include treatment as ordered to area on right abdomen and right groin/lateral thigh. On 12/10/14, at approximately 8:50 AM, Resident 4 asked Surveyor to talk. Resident 4 told Surveyor that on November 21 staff took her to the bathroom. Resident 4 was left alone in the bathroom. Resident 4 stated the heater was on and it got so hot. The call light was on but nobody came to help, so Resident 4 attempted to stand up on the EZ stand to turn the heater down and she fell . Resident 4 stated she yelled for help and when staff arrived she told them she got burned on her leg. Resident 4 stated they told her spouse it was just a skin tear. Resident 4 stated it is a bad burn and hurt a lot and the facility did not do anything about it. Surveyor then reviewed Resident 4's medical record and noted the following: -SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note, dated 11/21/14. The change in condition is-Fall on 11/21/14. Since this started has it gotten-Better. Request-Monitor vital signs. Nursing Notes-Resident fell off toilet. Was found on floor by RN (Registered Nurse). Sustained 0.3 cm by 0.1 skin tear on right hand. Alert and oriented times 3. Denies pain. (Nurse Practitioner (NP) D) informed. Orders received to monitor vital signs and neurological checks per facility protocol. Form completed by RN C. -SBAR, dated 11/22/14. The change in condition is-Right abdominal blister and right outer lateral thigh area. Nursing notes-Resident called for writer to assess her right abdominal area blister 4 cm x 2 cm and right thigh 10 cm x 1.5 cm outer lateral abrasion area intact. No drainage noted to both areas. Resident informed that these area were obtained by the fall 11/23/14 (SIC 11/21/14). Writer notified on-call doctor with new orders. Resident 4's fall report indicates on 11/21/14 at 9:30 AM, RN C "heard a cry in resident's room" and immediately investigated the noise. RN C found Resident 4 on the floor. Was put on toilet by 2 CNAs using the EZ stand. Resident 4 claims that she moved over and slid to the floor. The report indicates the call light was on. Conclusion by DON B on 11/24/14 was that Resident 4 was toileted and remained in EZ stand sling. Resident 4 attempted to reposition self and slipped from toilet to floor. Staff educated that residents cannot remain attached to a mechanical lift unless attended. Staff interviews of the incident on 11/21/14: --RN C-Heard cry from resident's bathroom. Investigated cry immediately and found resident on floor. --Medical Records (MR) F-Heard an overhead page stat help to room. Went into room and heard someone yelling for help in the bathroom. I opened the bathroom door and saw the stand lift in the bathroom with Resident 4 hanging from the sling with her arms above her head and her lower body between the wall and the toilet. The stand lift sling was still attached to the resident and the stand lift. The floor nurse, business office manager and employee training and development (ETD) came into the room and we unhooked the sling from Resident 4 and the stand lift. We had to lift Resident 4 back onto the toilet because we could not get the stand lift out of the bathroom. We got Resident 4 back onto the toilet and hooked her back up to the stand lift and got Resident 4 back into her wheelchair. Resident 4 "stated that her leg got burnt by the heater many times during the process of all of us getting her off the floor and back into her chair." --Business Office Manager E-Heard RN C overhead page help to room. When I got in the room Resident 4 was on the floor between the toilet and the wall. MR F and RN C were also in the bathroom trying to assist resident into a position to be lifted up. Resident 4 was saying her leg was burning. MR F made sure heater was off and tried to protect Resident 4's skin from touching heater. Resident 4's nursing notes include: -11/21/14 no entry -11/22/14 at 9:00 PM, Writer assessed resident's right abdominal blister area and right anterior outer thigh abrasion area with measurement to be approximate as right abdominal area 4 cm by 2 cm blister intact and right lateral outer abrasion area 10 cm by 1.5 cm intact. No drainage noted to both areas. Writer notified on-call doctor. On-call nurse manager aware. -11/23/14 at 10:00 AM, right abdominal blister intact and right lateral outer thigh intact. No drainage noted to both areas. No pain noted to areas. -11/24/14 at 9:40 AM, care plan updated with new skin concern. -11/24/14 at 1:00 PM, interdisciplinary team met, care plan reviewed. -11/24/14 at 1:40 PM, NP D updated on wounds to right abdomen and upper thigh. -11/27/14 2:50 PM Resident 4 left building with family. -11/30/14 at 9:15 PM, Resident 4 returned to facility. No skin tears nor bruises noted. -12/1/14 at 1:45 PM, writer left voice mail with NP D with lab results and requesting [MEDICATION NAME] to right lateral thigh. Awaiting call back. -12/1/14 at 5:00 PM, NP D returned call. Will see resident on 12/2/14. -12/2/14 at 2:00 PM, NP here and assessed 2 skin disruptions to right abdomen and right groin/lateral thigh. New treatment orders received. Resident 4's skin grids were initiated on 12/1/14: -Right hip distal burn, 3 cm by 13 cm, color black. -Right hip proximal burn, 1.7 cm by 6.4 cm, color tan. NP D saw Resident 4 on 12/2/14 and noted: -Resident 4 had a fall on 11/21/14 off the toilet and she was burned by the heater in her room on her abdomen. Resident 4 had a blister that did open up and now has some redness around the scab. Resident 4 reports some sensitivity to the area. Skin: right lower abdomen with large oblong scabbed area and smaller oblong scabbed area just to the right of that. No drainage noted but there is a half inch of redness surrounding area, slightly warm. Burn: Scabbed over burned area to lower right abdomen/groin measuring 3 cm by 13 cm and 1.7 cm by 6.4 cm. NP D ordered [MEDICATION NAME] twice a day until healed. A review of Resident 4's physician orders [REDACTED]. On 12/10/14, at 10:53 AM, Surveyor interviewed DON B who stated there should have been an incident report for Resident 4's wounds but there was not one. DON B stated the situation was not well documented. DON B then stated she did not think it was a heat source burn and that it was investigated. DON B stated it was identified that Resident 4 should not have been left alone in the bathroom and staff education was provided. On 12/10/14, at 1:03 PM, Surveyor interviewed DON B regarding the incident. DON B stated she spoke with RN C today and RN C stated after the fall on 11/21/14 Resident 4 said her leg was burning. RN C stated she looked at the area and saw nothing. RN C stated there was nothing there. DON B stated on 11/22/14 the nurse noted an abrasion and blister and got orders to monitor. DON B stated on 11/27/14 Resident 4 left on pass with her husband. DON B told Resident 4's husband to put barrier cream on the area but Resident 4 did not like that so Resident 4's husband put on A&D ointment. DON B stated on 12/1/14 she looked and Resident 4's leg and called for a different treatment. On 12/10/14, at 3:14 PM, Surveyor observed DON B complete the treatment to [MEDICAL CONDITION] Resident 4. DON B measured the abdominal burn as 1.5 cm by 6.2 cm. Surveyor noted the burn to be yellow with rolling edges surrounded by approximately 0.1 cm pink skin. DON B measured the thigh burn as 3.5 cm by 12.2 cm. Surveyor noted the burn to have an inner dark brown area with a leathery appearance with approximately 0.1 cm yellow shiny skin and then an outer red edge of approximately 0.2 cm. Surveyor also noted some peeling skin around the lower edge of the burn. On 12/10/14, at 4:58 PM, Surveyor interviewed NP D via phone. NP D stated there was a call regarding the fall for Resident 4 on 11/21/14 that indicated Resident 4 fell from the toilet while connected to the EZ stand and there was no injury except a skin tear to her hand. On 11/24/14 NP D called for an update and was told there was a bruise to her abdomen and thigh. NP D stated she was again called on 12/1/14 and decided to see Resident 4 the following day. NP D stated she saw Resident 4 on 12/2/14 at the facility and NP D stated it was a burn. NP D stated it was hard to say what level the burn was because she did not see it right away but that it was at least a 2nd degree burn but between a 2nd and 3rd degree burn based on what she saw on 12/2/14. NP D stated she thinks the facility told her it was a burn on 12/1/14 that is why she came in to see Resident 4 and that she was not told prior that it was a burn. NP D stated if the facility would have told her sooner that Resident 4 had a burn she would have seen her sooner. NP D stated it is hard to say now because she did not see the original blister but that she probably would have ordered something to try to keep the blister intact when it originally occurred. The facility did not inform Resident 4's physician that Resident 4 stated she was burned for 11 days, thus delaying possible treatment. Cross reference F323

Based on observation, interview and record review the facility did not ensure the environment remains free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident 4). Resident 4 was left unattended in the bathroom while attached to the mechanical stand lift. Resident 4 then fell and sustained a burn from the heater in the bathroom. This is evidenced by the following: Resident 4 has been a long term resident of the facility and was recently readmitted on [DATE] following a 10 day hospital stay. Resident 4's [DIAGNOSES REDACTED]. Resident 4's most recent Minimum Data Set, assessment reference date 11/26/14, includes the following: Brief Interview for Mental Status was 14 indicating no impairment, Needs extensive assistance from 1 person for toileting, not steady moving on and off the toilet and only able to stabilize with human assistance, Range of Motion impairment on lower limbs bilaterally. Resident 4's care plan for falls, rewritten 7/14/14, indicates 2 staff assist with the EZ stand (mechanical stand lift) for transfers. Resident 4's care plan for skin was updated on the following days: -11/14 abrasion to right abdomen, treatment right abdominal abrasion until resolved. -11/22/14 to include: Burn to right abdomen area and right groin/lateral thigh. -12/2/14 the care plan was updated again to include treatment as ordered to area on right abdomen and right groin/lateral thigh. On 12/10/14, at approximately 8:50 AM, Resident 4 asked Surveyor to talk. Resident 4 told Surveyor that on November 21 staff took her to the bathroom. Resident 4 was left alone in the bathroom. Resident 4 stated the heater was on and it got so hot. The call light was on but nobody came to help, so Resident 4 attempted to stand up on the EZ stand to turn the heater down and she fell . Resident 4 stated she yelled for help and when staff arrived she told them she got burned on her leg. Resident 4 stated they told her spouse it was just a skin tear. Resident 4 stated it is a bad burn and hurt a lot and the facility did not do anything about it. Surveyor then reviewed Resident 4's medical record and noted the following: -SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note, dated 11/21/14. The change in condition is-Fall on 11/21/14. Since this started has it gotten-Better. Request-Monitor vital signs. Nursing Notes-Resident fell off toilet. Was found on floor by RN (Registered Nurse). Sustained 0.3 cm by 0.1 skin tear on right hand. Alert and oriented times 3. Denies pain. (Nurse Practitioner (NP) D) informed. Orders received to monitor vital signs and neurological checks per facility protocol. Form completed by RN C. -SBAR, dated 11/22/14. The change in condition is-Right abdominal blister and right outer lateral thigh area. Nursing notes-Resident called for writer to assess her right abdominal area blister 4 cm x 2 cm and right thigh 10 cm x 1.5 cm outer lateral abrasion area intact. No drainage noted to both areas. Resident informed that these area were obtained by the fall 11/23/14 (SIC 11/21/14). Writer notified on-call doctor with new orders. Resident 4's fall report indicates on 11/21/14 at 9:30 AM, RN C "heard a cry in resident's room" and immediately investigated the noise. RN C found Resident 4 on the floor. Was put on toilet by 2 CNAs using the EZ stand. Resident 4 claims that she moved over and slid to the floor. The report indicates the call light was on. Conclusion by DON B on 11/24/14 was that Resident 4 was toileted and remained in EZ stand sling. Resident 4 attempted to reposition self and slipped from toilet to floor. Staff educated that residents cannot remain attached to a mechanical lift unless attended. Staff interviews of the incident on 11/21/14: --RN C-Heard cry from resident's bathroom. Investigated cry immediately and found resident on floor. --Medical Records (MR) F-Heard an overhead page stat help to room. Went into room and heard someone yelling for help in the bathroom. I opened the bathroom door and saw the stand lift in the bathroom with Resident 4 hanging from the sling with her arms above her head and her lower body between the wall and the toilet. The stand lift sling was still attached to the resident and the stand lift. The floor nurse, business office manager and employee training and development (ETD) came into the room and we unhooked the sling from Resident 4 and the stand lift. We had to lift Resident 4 back onto the toilet because we could not get the stand lift out of the bathroom. We got Resident 4 back onto the toilet and hooked her back up to the stand lift and got Resident 4 back into her wheelchair. Resident 4 "stated that her leg got burnt by the heater many times during the process of all of us getting her off the floor and back into her chair." --Business Office Manager E-Heard RN C overhead page help to room. When I got in the room Resident 4 was on the floor between the toilet and the wall. MR F and RN C were also in the bathroom trying to assist resident into a position to be lifted up. Resident 4 was saying her leg was burning. MR F made sure heater was off and tried to protect Resident 4's skin from touching heater. --CNA I-Resident called out from room. RN came in and found resident on floor. When I came I assisted in getting resident into chair. --There was no statement from ETD G regarding the incident or who the CNAs were that left Resident 4 unattended. Resident 4's nursing notes include: -11/21/14 no entry -11/22/14 at 9:00 PM, Writer assessed resident's right abdominal blister area and right anterior outer thigh abrasion area with measurement to be approximate as right abdominal area 4 cm by 2 cm blister intact and right lateral outer abrasion area 10 cm by 1.5 cm intact. No drainage noted to both areas. Writer notified on-call doctor. On-call nurse manager aware. -11/23/14 at 10:00 AM, right abdominal blister intact and right lateral outer thigh intact. No drainage noted to both areas. No pain noted to areas. -11/24/14 at 9:40 AM, care plan updated with new skin concern. -11/24/14 at 1:00 PM, interdisciplinary team met, care plan reviewed. -11/24/14 at 1:40 PM, NP D updated on wounds to right abdomen and upper thigh. -11/27/14 2:50 PM Resident 4 left building with family. -11/30/14 at 9:15 PM, Resident 4 returned to facility. No skin tears nor bruises noted. -12/1/14 at 1:45 PM, writer left voice mail with NP D with lab results and requesting Silvadene to right lateral thigh. Awaiting call back. -12/1/14 at 5:00 PM, NP D returned call. Will see resident on 12/2/14. -12/2/14 at 2:00 PM, NP here and assessed 2 skin disruptions to right abdomen and right groin/lateral thigh. New treatment orders received. Resident 4's skin grids were initiated on 12/1/14: -Right hip distal burn, 3 cm by 13 cm, color black. -Right hip proximal burn, 1.7 cm by 6.4 cm, color tan. NP D saw Resident 4 on 12/2/14 and noted: -Resident 4 had a fall on 11/21/14 off the toilet and she was burned by the heater in her room on her abdomen. Resident 4 had a blister that did open up and now has some redness around the scab. Resident 4 reports some sensitivity to the area. Skin: right lower abdomen with large oblong scabbed area and smaller oblong scabbed area just to the right of that. No drainage noted but there is a half inch of redness surrounding area, slightly warm. Burn: Scabbed over burned area to lower right abdomen/groin measuring 3 cm by 13 cm and 1.7 cm by 6.4 cm. NP D ordered Silvadene twice a day until healed. On 12/10/14, at 10:45 AM, Surveyor observed the wall heater in Resident 4's bathroom. The bathroom is approximately 3 feet wide. The heater was on the wall to the right of the toilet about 1.5 feet away. On the heater was a sticker that states "Caution: High temperature, Risk of fire, Keep electrical cords, drapery, furnishings and other combustibles at least 3 feet from the front of the heater." Surveyor turned on the heater and within less than 1 minute the heater was hot to the touch and Surveyor was not able to hold hand on the metal grill. On 12/10/14, at 10:53 AM, Surveyor interviewed DON B who stated there should have been an incident report for Resident 4's wounds but there was not one. DON B stated the situation was not well documented. DON B then stated she did not think it was a heat source burn and that it was investigated. DON B stated it was identified that Resident 4 should not have been left alone in the bathroom and staff education was provided. Surveyor then requested Maintenance Supervisor (MS) H and DON B to test the temperature of the heater in Resident 4's room. MS H used an infrared thermometer from the kitchen and stated he had not used it before. Within a minute the thermometer read 100 degrees Fahrenheit (F) however the temperature kept changing with the hot air coming out of the heater, the metal temperature and the exhaust fan moving air. DON B agreed the grill was hot to the touch and not able to hold her hand on the grate. MS H stated there are 11 bathrooms with 16 rooms (some rooms share a bathroom) with a wall heater. On 12/10/14, at 11:30 AM, Surveyor with MS H tested additional bathrooms. Surveyor used her thermometer with direct contact to the metal to get a better reading. The following temperatures were obtained: Resident 4's room-100 F in 30 seconds, 115 F in 60 seconds, 136 F in 90 seconds. Room 124-the heater was on in the middle position upon entering. MS H turned the heater up and in 32 seconds it was 115 F, 138 F in 60 seconds and 144 F in 90 seconds. Room 126-the heater was turned on but the control knob had been removed. This heater appeared to be a newer model. MS H put a knob on the heater and turned it up. The temperature climbed very fast and by 2 minutes it was over 160 F. Room 128-the heater was on in the mid temperature range. Upon turning the heater up it reached 115 F in 80 seconds and 120 degrees in 105 seconds. On 12/10/14 at 11:30 AM, Surveyor tested additional bathroom heaters. The heater in the shared bathroom between room 107 and 108 climbed to 183.1 degrees after 90 seconds. The heater in the shared bathroom between room 105 and 106 climbed to 195.2 degrees after 90 seconds. The heater in the shared bathroom between room 101 and 102 climbed to 164.5 degrees after 90 seconds. Following obtaining the temperatures MS H set all the heaters to the mid temperature range and removed the knobs so they could not be adjusted. The manufactures operating instructions for the Dayton Fan-Forced Wall Heater includes in the General Safety Information: 4. This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. 6. Grille and discharge air are hot when in use. On 12/10/14, at 1:03 PM, Surveyor interviewed DON B regarding the incident. DON B stated she spoke with RN C today and RN C stated after the fall on 11/21/14 Resident 4 said her leg was burning. RN C stated she looked at the area and saw nothing. RN C stated there was nothing there. DON B stated on 11/22/14 the nurse noted an abrasion and blister and got orders to monitor. DON B stated on 11/27/14 Resident 4 left on pass with her husband. DON B told Resident 4's husband to put barrier cream on the area but Resident 4 did not like that so Resident 4's husband put on A&D ointment. DON B stated on 12/1/14 she looked and Resident 4's leg and called for a different treatment. On 12/10/14, at 3:14 PM, Surveyor observed DON B complete the treatment to the burns on Resident 4. DON B measured the abdominal burn as 1.5 cm by 6.2 cm. Surveyor noted the burn to be yellow with rolling edges surrounded by approximately 0.1 cm pink skin. DON B measured the thigh burn as 3.5 cm by 12.2 cm. Surveyor noted the burn to have an inner dark brown area with a leathery appearance with approximately 0.1 cm yellow shiny skin and then an outer red edge of approximately 0.2 cm. Surveyor also noted some peeling skin around the lower edge of the burn. On 12/10/14, in the afternoon, ETC G wrote a statement that there was a recent in-service regarding falls. Safety precautions with mechanical lifts, safe transfers and always using gait belts for non-lift transfers has been repeated during all CNA in-services and new employee orientation since September 2014. This was repeated to the CNAs involved and all others present on 11/21/14 after Resident 4's fall. There is no documentation who was educated or when the education took place. On 12/10/14, at 4:58 PM, Surveyor interviewed NP D via phone. NP D stated there was a call regarding the fall for Resident 4 on 11/21/14 that indicated Resident 4 fell from the toilet while connected to the EZ stand and there was no injury except a skin tear to her hand. On 11/24/14 NP D called for an update and was told there was a bruise to her abdomen and thigh. NP D stated she was again called on 12/1/14 and decided to see Resident 4 the following day. NP D stated she saw Resident 4 on 12/2/14 at the facility and NP D stated it was a burn. NP D stated it was hard to say what level the burn was because she did not see it right away but that it was at least a 2nd degree burn but between a 2nd and 3rd degree burn based on what she saw on 12/2/14. NP D stated she thinks the facility told her it was a burn on 12/1/14 that is why she came in to see Resident 4 and that she was not told prior that it was a burn. NP D stated if the facility would have told her sooner that Resident 4 had a burn she would have seen her sooner. NP D stated it is hard to say now because she did not see the original blister but that she probably would have ordered something to try to keep the blister intact when it originally occurred. The facility did not address the concern of the bathroom heaters causing a resident to receive burns until Surveyor began looking into the incident.

Based on record review and interview 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 3 of 8 residents (Residents 2, 6 and 9) and 1 supplemental resident (Resident 19). Resident 2 was taking narcotic medications for pain and the facility did not implement a plan of care to address the side effects including constipation. Resident 2 became constipated and the facility did not follow procedures to alleviate the constipation and Resident 2 was hospitalized for [REDACTED]. Resident 9 had two periods where she did not have a bowel movement in 3 days. The facility did not intervene to promote Resident 9 to have a bowel movement. Resident 6 did not have a bowel movement for more than 3 days. The facility did not intervene to help promote a bowl movement for Resident 6. Resident 19 was noted with an alteration in her skin. The facility did not document on follow up when it waw noted. This is evidenced by the following: The facility's policy for "Constipation," dated June 2013, includes the following: The facility recognizes constipation is the most frequent complaint of older people regarding bowel function. Actual constipation is defined as three or more days without defecation...Contributing factors include: Medication that slows bowel mobility, inadequate fiber in the diet, inadequate fluid intake, decreased physical activity, immobility... Standard bowel care to relieve constipation with a provider order may include Milk of Magnesia 30 ml after eight shifts of no bowel movement, [MEDICATION NAME] Suppository if no results from the milk of magnesia, fleets enema if no results from the [MEDICATION NAME] suppository. The facility's policy for "Management of Constipation," dated July 2012, includes the following: 1. Review resident assessment information including: MDS (minimum data set), nurse's notes, history of incontinence, medication administration record, nutrition services notes, CareTracker reports... 3. Initiate a plan to reduce or eliminate contributing factors when possible... 5. Initiate/update the Alteration in Bowel Elimination Care Plan on all residents identified with constipation. 6. Document elimination results using CareTracker... 8. Review factors affecting constipation. On 4/8/14, at 2:25 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the bowel movement report is run every morning for any resident without a bowel movement in 9 shifts (3 days) and then it is decided what the resident needs for medications. DON B stated any medications including as needed medications should be documented on the Medication Administration Record. DON B also stated that bowel sounds should be assessed if there is no bowel movement for 3 days. Example 1 Resident 2 was admitted to the facility on [DATE] with current diagnoses, per the [DIAGNOSES REDACTED]. Resident 2's "Bowel Data Collection and Assessment" was last completed on 11/27/13. The assessment indicates Resident 2 is always incontinent and is unable to feel the urge for a bowel movement due to paralysis. The assessment also notes a history of assisted stimulation every three days. Resident 2's "Alteration in Bowel Elimination Plan of Care," dated 12/2013, indicates Resident 2 is incontinent of formed soft stools. Interventions include: Monitor bowel elimination using CareTracker, provide medication as ordered to aid in elimination as ordered. The care plan does not indicate a concern for constipation. Resident 2's Minimum Data Set, reference date 2/26/14, includes the following: Bowel continence-Always incontinent; Toileting-extensive assist of 1 person with physical assist. Resident 2's CareTracker for bowel movements for March indicate two large bowel movements on 3/2/14 and a small bowel movement on 3/3/14. The next bowel movement was a small bowel movement on 3/10/14. Resident 2 did not have any additional bowel movements until after he was sent to the hospital on [DATE]. Resident 2's physician orders [REDACTED]. [MEDICATION NAME] 15 mg every three hours as needed for pain. (Possible side effects include constipation.) [MEDICATION NAME] 10 mg suppository daily as needed for constipation. 3/3/14-telephone order for [MEDICATION NAME] 5-10 mg 1-2 tabs daily prn. (Possible side effects include constipation.) 3/7/14-order for digital rectal stimulation by RN as needed for severe constipation. Per Resident 2's MAR this was not provided from 3/7/14-hospitalization . Resident 2's MAR for March indicates the following medications were given: [MEDICATION NAME] 15 mg was given 43 times between 3/1/14-3/13/14. [MEDICATION NAME] 5 mg was given on 3/4/14 and 3 times on 3/5/14. [MEDICATION NAME] Suppository was given on 3/2/14, 3/5/14, 3/7/14, 3/8/14 and 3/13/14. There is no indication there was a result from the suppository on any day except 3/2/14. On 3/13/14 Resident 2's nursing notes indicate at 10:15 AM a call was placed to Resident 2's physician for bowel medication orders and to report Resident 2 did not eat breakfast due to abdominal discomfort and Resident 2 did not take his insulin. At 11:55 AM Resident 2's nursing notes indicate orders were received. On 3/13/14, at 11:50 AM, The following orders, referenced in the above nursing note, were received via telephone for Resident 2: Bowel Regime medications: Milk of Magnesium 30 ml once daily as needed [MEDICATION NAME] 10 mg 1-2 tabs daily as needed Fleets enema once daily as needed Magnesium [MEDICATION NAME] drink 1/2 bottle daily as needed [MEDICATION NAME] 10 mg suppository every other day alternate with Senna 8.6 mg every other day. On 3/13/14, at 3:30 PM, RN I completed a SBAR (situation, background, assessment, request) Communication Form. The form indicates Resident 2 was having abdominal pain, distention and a headache made worse by eating and better by passing gas. The form also notes decreased bowel sounds and indicates last date of bowel movement as 3/13/14 (please note that this bowel movement was noted to be a small from manual evacuation). RN I requested Resident 2 be transferred to the hospital. RN I's notes indicate Resident 2 began complaining of abdominal pain and needed something to help with bowel movements. Resident 2 was given multiple bowel medication to help with evacuation of stool. Digital stimulation performed with small results. Resident 2 complains of shortness of breath and headache and "his head is going to pop off." Call placed to physician for order to send to hospital. 3/13/14 nursing note, 4:30 PM Resident 2 was transferred to the hospital for lower abdominal pain and constipation. No bowel movement for 4 days "Resident insisting on going to the hospital." Resident 2's hospital discharge, dated 3/15/14 indicates an admission [DIAGNOSES REDACTED]. Resident 2 was admitted to the hospital 3/13/14 until 3/15/14. Per the hospital summary Resident 2 presented to the emergency room with "increasing abdominal distention and last bowel movement nearly 1 week ago." Efforts to assist with stooling have been ineffective. Resident 2 was found to have "heavy stool burden" on CT and was given [MEDICATION NAME]. Resident 2 had double fleets enema which appeared to resolve his obstipation. The [MEDICATION NAME] was discontinued as Resident 2 felt this might be contributing to the obstipation. On 4/8/14, at 2:00 PM, Surveyor interviewed RN I regarding monitoring for constipation. RN I stated the nurse prints a report from CareTracker every morning for any resident that has not had a bowel movement in 3 days. RN I stated small bowel movements do not count as it could be just a smear, so they look at medium or larger. If a resident has not had a bowel movement in 3 days they will give milk of magnesium, if no result give a suppository and if still no result will give an enema all given over the course of a day. During this time the nurse will also assess the resident including listening for bowel sounds. The CNAs (Certified Nursing Assistants) are to record the bowel movements and if a resident is independent in the bathroom they will ask the resident if they had a bowel movement. RN I stated she recalled the events of 3/13/13 with Resident 2. RN I stated Director of Nursing (DON) B brought to RN I's attention that Resident 2 did not have a bowel movement. RN I stated she recalled giving Resident 2 the magnesium [MEDICATION NAME] but she did not sign out the medication as Resident 2 was yelling from his room that he wanted something to help him go. RN I stated she did not know if any bowel medications were given on previous days. RN I also stated a bowel assessment is completed quarterly and Resident 2's should have been done in February. RN I and Surveyor reviewed Resident 2's medical record and noted the only bowel medications ordered prior to 3/13/14 was a [MEDICATION NAME] suppository as needed. RN I stated residents need to have bowel medications scheduled when taking narcotic medication and Resident 2 takes a lot of them. RN I stated Resident 2 needs to be on bowel medications. Resident 2 was taking narcotic medications and [MEDICATION NAME] which can contribute to constipation. Resident 2 was not on a program to prevent constipation. There was no care plan developed, no documentation of bowel assessments when no bowel movements were recorded for multiple days in a row. Resident 2 was hospitalized with obstipation. Example 2 Resident 9's physician's orders [REDACTED]. -Milk of Magnesia 30 ml daily as needed for constipation -[MEDICATION NAME] 100 mg twice a day as needed for constipation -[MEDICATION NAME] EC 10 mg by mouth daily as needed for constipation -[MEDICATION NAME] Suppository daily as needed for constipation Resident 9's CareTracker report indicates Resident 9 had a medium bowel movement on 3/1/14 and did not have another bowel movement until 3/5/14. Also, Resident 9 had a bowel movement an extra large bowel movement on 3/21/14 and did not have another bowel movement recorded until 3/27/14. Resident 9's Medication Administration Record does not indicate that any medications or other interventions were used during either time frame to assist Resident 9 with a bowel movement. Example 3 Resident 6's physician's orders [REDACTED]. -Milk of Magnesia 30 ml daily as needed for constipation -[MEDICATION NAME] 10 ml suppository daily as needed for constipation Resident 6's CareTracker report indicates Resident 6 had a water bowel movement on 3/31/14. Resident 6's next bowel movement is not documented until 4/5/14. Resident 6's Medication Administration Record indicates Resident 6 did not receive any as needed medications when she did not have a bowel movement for more than 3 days. Example 4 Resident 19 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. On 4/17/14, at 3:36 PM, Surveyor interviewed Nurse Practitioner (NP) T who saw Resident 19 on 4/3/14. NP T noted a scab/wound approximately 1 cm diameter on Resident 19's left posterior leg. NP T stated Resident 19 told her it was from staff bumping her leg on the mechanical lift. NP T's notes indicate Resident 19's left leg had [DIAGNOSES REDACTED] (redness) and was warm/hot to the touch. NP T began an antibiotic to treat [MEDICAL CONDITION] for Resident 19. On 4/17/14, at 4:06 PM, Surveyor interviewed Director of Nursing (DON) B and Registered Nurse (RN) J regarding Resident 19's skin. RN J stated she recalled NP T commenting on the spot on Resident 19's leg. RN J stated she was not aware of the open area prior to being notified by NP T and RN J stated she did speak to the nurse about it. DON B stated she was not aware of the open area but would expect there to be documentation in the record about it and to investigate how it happened. Surveyor reviewed Resident 19's medical record and there was no documentation about the open area on her leg.

Based on interview and record review, the facility did not 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 2 of 5 residents reviewed (Residents 1 and 2). Resident 1 was noted to have a change in condition that included increased [MEDICAL CONDITION] to the lower extremity, shortness of breath, and back pain. The facility failed to act upon their observations of this change in condition. Resident 1 was ultimately sent out to the hospital and diagnosed with [REDACTED]. The facility did not respond to Resident 1's change in condition. In addition, Resident 1 was noted to be noncompliant with his fluid restriction. The facility did not address this with a physician. Resident 1 indicated that he had back pain, which was not previously noted. The facility did not assess the back pain. Resident 1 had a lumbar vertebral fracture. Resident 2 was on a physician ordered 1800 cc fluid restriction. The facility did not monitor/ document or notify the physician when Resident 2 did not meet the daily fluid needs. This is evidenced by the following: The facility's policy titled, "Pain Management" revised July, 2012, states, "...Purpose: Reduce physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. Procedure: Members of the IDT will advocate for resident comfort and find clinically appropriate, cost-effective ways of achieving it...7. Identify the potential cause(s) for the resident's pain. 8. Determine appropriate interventions to manage the pain and side effects...16. Notify provided if interventions are not effective in achieving resident comfort and/or function goals within 24 hours..." The facility's policy titled "Notification of Resident Change in Condition" revised July, 2011, states, "Extendicare Health Services, Inc. (EHSI) clinicians will immediately inform the resident, consult with the resident's physician...when there is a significant change in the resident's physical, mental, or psychosocial status...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 (unless requested to do otherwise). 2. Notify the Physician and family or legal representative immediately, if there is a significant change in condition, regardless of time...3. Document in Nurses Notes the times notification was made and the names of the person(s) to whom you spoke..." The facility indicated that they also follow the American Medical Directors Associations standards for significant change in condition and physician notification. According to "Protocols for Physician Notification", "...Back: Injuries or complaints...If abrupt of severe pain related to a fall or injury, 1. Look for signs/symptoms of fracture or other acute injuries. 2. Pain assessment (Location, character, severity). 3. Vital signs. 4. Neurological assessment, including movement and sensation below level of [MEDICAL CONDITION]: 1. Vital signs 2. Assess for respiratory difficulty. 3. Weigh patient and record weight variance 4. Assess location, extent and severity of [MEDICAL CONDITION]. 5. Description of [MEDICAL CONDITION], pitting, non-pitting. 6. Measure [MEDICAL CONDITION] area and if location of [MEDICAL CONDITION] permits. 7. Assess for pain, tenderness or redness in [MEDICAL CONDITION] area...Shortness of Breath (dyspnea): 1. Vital signs including details of pulse and respirations. 2. Full cardiac lung assessment. 3. Description of breath sounds. 4. Level of consciousness. 5. If severe, pulse oximetry. 6. Assess for [MEDICAL CONDITION]" AMDA's "Acute Change in Condition" states, "...Report [MEDICAL CONDITION]-sudden onset in resident with lung, heart or kidney disease; accompanied by sudden onset of shortness of breath and/or chest pain; sudden onset in one leg; loss of sensation in swollen leg; sudden onset with tenderness and redness..." Example 1 According to "Admission Record" dated 12/23/13, Resident 1 has [DIAGNOSES REDACTED]. Resident 1 went out of the facility three times per week for [MEDICAL TREATMENT] during his stay at the facility. Resident 1's "Respiratory: Plan of Care" dated 11/4/13 states the following interventions: O2 as ordered, report adventitious breath sounds, vital signs each day, monitor for cyanosis, shortness of breath, change in level of consciousness, update physician/family as needed, meds and treatments as ordered, consult as needed. Resident 1's "Cardiovascular/Circulatory: Plan of Care" dated 11/4/13 indicates and interventions of "monitor for sigh (SIC) and symptoms of [MEDICAL CONDITION]." Resident 1's "Plan of Care: Pain Management" dated 11/4/13 states, "Problem-Alteration in comfort related to pain secondary to: LBKA (left [MEDICAL CONDITION]; Interventions: administer pain medication as ordered. Monitor and record effectiveness, side effects of medication prn (as needed), observe notify Provider for s/s (signs and symptoms) of constipation...assess verbal and not-verbal signs and symptoms of pain unrelieved by ordered treatments/medication. Report to provider signs and symptoms of distress or pain unrelieved by treatments/medications. Observe during rest and during movement for pain. Identify participation factors of pain...Provide alternative comfort measures: position change, relaxation techniques, encourage mobility, physical activity as tolerated to prevent stiffness/contracture, smooth lines ...discuss concerns regarding pain management with the Provider and consulting pharmacist prn..." "Nutrition Services Request/Change Order" dated 12/21/13 states, "Fluid restriction 1500 mL/24 hr." It is important to note that the facility did not address Resident 1's poor adherence to his fluid restriction in any plan of care. "Initial Nursing Facility Care Note" dated 11/26/13 states, "...Exam...Extremities: left [MEDICAL CONDITION] dressing not removed, right leg 2+ [MEDICAL CONDITION] and dressings in place ..." "Nursing Facility Acute Visit" dated 11/25/13 states, "...Symptoms: patient reports increased difficulty breathing. Unable to lie down at all due to shortness of breath...Staff reports oxygen sats always in the mid to high 90's with oxygen...does have history of pleural effusions with thoracentesis..." "Progress Notes" dated 12/10/13 at 4:14 AM state, "Lg (large) fluid filled blister to R (right) outer calf weeping & saturating dressing. Dressing to RLE (right lower extremity) A'd (changed), R foot cool to touch. Moves toes easily. ? (no) ? (increased) redness. Sleeping up in w/c (wheelchair) much of the noc (night). Enc to lay down and ? (elevate) right foot..." 12/10/13 "Progress Notes" at 11:00 PM state, "Blister to the R calf filled again @ this time. Draining clear serous drainage saturating dressing. +4 [MEDICAL CONDITION] to R foot apparent. Pedal pulse present. Moves toes s (without) difficulty. Res. refusing to keep R leg elevated. Keeps stating, 'I can't'..." "Progress Notes" dated 12/11/13 at 3:00 PM, state, "Res c/o (complains of) ? (increased) SOB. LS diminished all lobes. Res O2 sat 77-95% on 3 L (liters) O2 NC (nasal canula). BP (blood pressure) 112/60, P (pulse) 94, R foot +4 [MEDICAL CONDITION]. Res face is puffy, arms puffy. NP (nurse practitioner) (name) on unit updated. She assessed res. Order received and noted to send Res to St. Mary's ER Eval and tx (treat) for acute respiratory distress..." The facility did not monitor and immediately act upon Resident 1's change in condition that was first noted on 12/10/13 with increase in fluid in blisters and [MEDICAL CONDITION] that went from a baseline of +2 to +4 to the lower extremity. "Nursing Facility Acute Visit" dated 12/11/13 states, "(Resident 1)...is seen today for chief complaint for dyspnea as reported by patient and nurse. Symptoms: asked to see for acute dyspnea. Patient states not feeling well for past several days. He reports increased SOB (shortness of breath), productive cough of yellow phlegm. Has [MEDICAL TREATMENT] treatment yesterday with no improvement in symptoms. Nurse notes today change in status. Tells me he is shaking and cold. Patient states he feels 'terrible'...Extremities: 3+ [MEDICAL CONDITION] on right up to the mid tibia with weeping. A (assessment): acute respiratory distress (primary encounter diagnosis) Comment: with tachypnea, [MEDICAL CONDITION] and rigors, consider pneumonia [MEDICAL CONDITION]. Plan: send to ER for further evaluation...Patient is a full code..." Discharge Summary, dated 12/18/13 states, "Discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION] 3. Pneumonia 4. [MEDICAL CONDITION]" "Nursing Facility Transition Note" dated 12/19/13 states, "(Resident 1) was readmitted from (hospital name) Hospital Medical Center on 12/18/13 for continued care. He was admitted with change in mental status, fever and dyspnea. Initial impression was that of [MEDICAL CONDITION] syndrome...Exam:...Extremities: 2+ [MEDICAL CONDITION] on right up to the mid tibia. Progress Notes dated 12/21/13 note that Resident 1 is not compliant with his fluid restriction. 12/22/13 Progress Notes indicate that Resident 1 is not compliant with his fluid restriction. 12/23/13 Progress Notes state, "...c/o back pain 8/10. Prn pain pill given. Effective. Sitting up makes pain worse..." The pain identified on 12/23/13 is in a new location for the resident. The facility did not complete an assessment to determine the cause of the back pain. There is no evidence that the facility consulted with a physician regarding Resident 1's noncompliance with the fluid restriction. "Nursing Facility Acute Visit" dated 12/24/13 states, "S. (subjective) (Resident 1) is a [AGE] year old male who is seen today for follow up for [MEDICAL CONDITIONS] and Pain: right leg as reported by patient and nurse. Symptoms: staff left message last night requesting increase in pain or anxiety medications. Reports that patient does not sleep well. Calls frequently, sits up on edge of bed, then lies back down. He tells me that breathing is about the same, at baseline...Treatment to date: recent hospitalization for [MEDICAL CONDITION], pneumonia [MEDICAL CONDITION] syndrome...Continues on [MEDICAL TREATMENT] 3 times per week. On [MEDICATION NAME], inhalers and nebs. O: (objective)...Lungs: few rales both lower lobes, wheezing diffusely throughout both lungs ...Extremities: 2+ [MEDICAL CONDITION] on the right up to the foot, 1+ on calf..." Progress Notes dated 12/27/13 note that Resident 1 is noncompliant with his fluid restriction. Progress Notes dated 12/28/13 at 1:15 AM, state, "Dressing to RLE A'd d/t (due to) saturated c serous drainage. +3-4 [MEDICAL CONDITION] up to knee. Top of foot reddened. Unable to palpate pedal pulse. Enc to keep R leg elevated. ? SOB when laying down. O2 sat 98% c O2 @ 3L..." Progress Notes dated 12/29/13 at 5:00 AM state, "Given [MEDICATION NAME] for R ? (lower) ext (extremity) pain & [MEDICATION NAME] for anxiety @ 0330 (3:30 AM). Res relaxing comfortably @ this time..." Progress Notes dated 12/29/13 at 1:25 PM state, "...Non compliant with fluid restriction filling glass @ sink in his room. Discussed importance of fluid restriction and ways to ? thirst..." Progress Notes from 10:00 PM on this date state, "...C/o pain to back and SOB. [MEDICATION NAME] and [MEDICATION NAME] given with little effect..." The facility did not complete an assessment related to cause Resident 1's new back pain. The facility did not inform a physician of Resident 1's continued noncompliance with his fluid restriction or that his pain medications were ineffective. Progress Notes dated 12/30/13 at 3:00 AM state, "Given [MEDICATION NAME] & tyl (Tylenol) this shift for c/o back and leg pain c some relief. RLE dressing A'd. +3-4 [MEDICAL CONDITION] to R foot. ?'d amount of serous drainage. ? SOB c any activity. Sitting at bedside table most of noc. Cups of H2O found in drawer of bedside table. A&O X 3. Appears anxious. Using call light freq. At X's (times) res. states he doesn't know what he needs. Given prn [MEDICATION NAME] c little relief of SOB noted." Progress Notes dated 12/30/13 at 4:30 PM indicate that Resident 1 remains noncompliant with the fluid restriction and is using water from the sink in his room. The facility did not address Resident 1's noted change in condition on 12/30/13 and probable increase in fluid intake. Progress Notes dated 12/31/13 at 1:00 AM state, "Using call light freq. Often doesn't need anything when staff enter room. Neb tx given at 2330 (11:30 PM) for ? SOB. Res very restless. Lays down in bed for a few minutes then requests assist to sit @ bedside. O2 sat 98% c O2 at 3 L. RLE dressing dry. Facial [MEDICAL CONDITION] apparent. Will continue to monitor." 4:20 PM Progress Notes state, "...Facial [MEDICAL CONDITION] noted..." There is no evidence that the facility notified the physician of the new symptom of facial [MEDICAL CONDITION]. The facility did not document a progress note on Resident 1 on 1/1/14. Progress Notes dated 1/2/14 at 4:00 AM state, "Restless most of shift. Given prn pain meds c some relief of RLE...+3 [MEDICAL CONDITION] to R foot. Prn [MEDICATION NAME] given for SOB & wheezing. ? weakness noted. Requires assist to sit up at bedside. Following fluid restriction. 0600 (6:00 AM) Res c/o ? back pain and ? SOB. Wheezing audible. Res insists on being transferred to hospital. Order received..." "Physician's Telephone Orders" dated 1/2/14 states, "Diagnosis-Back pain, ? SOB-Send to St. Mary's Hospital ER for evaluation." "Hospital Encounter" notes for Resident 1 dated 1/2/14 states, " ...Comes in again with increased dyspnea ...CXR (chest x-ray): Single AP (anterior/posterior) view demonstrates enlarged right pleural effusion compared to CXR 12/17... Assessment/Plan: Patient is [AGE] year old male admitted with recurrent acute on chronic [MEDICAL CONDITION] w: acute on chronic hypoxic [MEDICAL CONDITION] patient's presenting symptoms, physical exam findings, and initial radiographic and laboratory data in the context of his chronic comorbidities is felt to place him at high risk for further clinical deterioration..." An X-ray of Resident 1's spine was completed on 1/7/14 which notes a mild Lumbar-1 compression fracture of intermediate age. "EHSI-I/O (intake/output) Detail Report" notes that Resident 1 consumed 1720 mL of fluids on 12/26/13, 1700 mL on 12/27/14, and 1680 mL of fluids on 12/30/13. There is no evidence that this information was provided to a physician. Surveyor spoke with Registered Nurse (RN) C on 2/5/14 at 1:02 PM. RN C stated that she documents when she calls the physician. Surveyor asked RN C if she called the physician on 12/10/13 when she noted that Resident 1 had fluid filled blisters and weepiness to the lower extremity and increase in [MEDICAL CONDITION] to the right foot. RN C stated that she did not remember if she called. Surveyor asked RN C if she ever did any assessment to Resident 1's back on 12/23/13, as it was the first noted back pain. RN C stated that she did not. Surveyor asked RN C if she called a physician on 12/29/13 when (Resident 1) complained of back pain and medications were given that were not effective. RN C stated that if she did call she would have left a message and that she could not say if she did. Surveyor asked RN C if she called on 12/30/13 when (Resident 1) had increase in [MEDICAL CONDITION], shortness of breath with any activity and the water was found in (Resident 1's) drawer. RN C stated that she did not know if she called or not, "probably not." Surveyor asked RN C if she addressed (Resident 1's) restlessness and facial [MEDICAL CONDITION] noted on 12/31/13. RN C stated that from what she remembers, the facial [MEDICAL CONDITION] was not a new thing. Surveyor spoke with Director of Nursing (DON) B and Nursing Home Administrator (NHA) A on 2/5/14 at 1:40 PM. DON B stated that the facility uses the AMDA guidelines for their standard of practice related to change of condition and physician notification. Surveyor asked DON B stated that (Resident 1's) [MEDICAL CONDITION] did fluctuate during his stay but it going to plus four would indicate a significant change and a SBAR form should have been filled out. DON B stated that an assessment should have been done for (Resident 1's) back pain on 12/23/14 since this was new. Surveyor asked DON B about the facility's process regarding fluid restrictions and when a resident does not adhere to the recommended fluid intake. DON B stated that she would expect staff to educate so that the resident knows why there is a fluid restriction and then to go over signs and symptoms related to this. DON B stated that the facility would allow residents the choice to do what they want but the facility would state that they could not give extra fluids. DON B stated that the physician is to be made aware of this but not every day or every shift. Surveyor asked DON B if staff should have called the physician regarding (Resident 1) on 12/28/13. DON B stated that she would expect notification. DON B stated that if pain meds were administered and not effective, the physician should be called. Surveyor asked DON B if a physician should be notified for the extra water intake as it related to the finding of water cups found in (Resident 1's) drawer. DON B stated that this was how (Resident 1) was and this was consistently a problem. Surveyor asked if a physician should be notified regarding the change in condition of (Resident 1) on 12/31/13. DON B stated that staff should have called. The facility policy titled "Fluid Restriction" with an effective date of April 2010 states the following; but not all inclusive: Extendicare Health Services, Inc. (EHSI) strives to assure that all residents with a fluid restriction are receiving appropriate fluid amounts according to the resident's physician's orders [REDACTED]. Nursing Service Responsibilities: * Intakes will be monitored until a pattern of intake has been determined. Intake monitoring may be discontinued if the Interdisciplinary Team(IDT) feels the resident will remain compliant with the restriction. Nutritional Services Responsibilities- Registered Dietician(RD) or Nutritional Service Manager(NSM): *Evaluate the fluid restriction order relative to other dietary restrictions and visit with the resident/family to discuss restrictions and obtain beverage preferences. *Include in the documentation the resident and/ or family member's response to the fluid restriction. *If the resident does not agree/comply with the fluid restriction, refer to "Refusal of Medication, Treatment and Dietary Restriction" procedure located in the Clinical Administrative Manual. Nursing Services and Nutritional Departments: *Monitor the residents hydration status and make recommendations for fluid restrictions changes as needed Example 2 Resident 2 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident 2's physician's orders [REDACTED]. Review of Resident 2 discharge summary dated 1/15/14 indicates that upon return to the facility Resident 2 was to receive an 1800cc fluid restriction. Please note this is a 300 cc fluid restriction increase from initial orders. Review of Resident 2's Nutritional Care plan with an initial date of 8/13 with a goal of Resident will be free of dehydration as evidenced by, Good Skin Turgor, labs etc... and interventions dated 1/16/14 1800 cc fld/d (fluids per day) Nursing 720cc's, Dietary 1080cc's. On 2/5/14 at 11:00 Am Surveyor asked NHA A where the fluid intakes for Resident 2 were located. NHA A stated that the intakes are documented in caretracker. Surveyor requested the intakes from 1/15/14 to 2/5/14 for Resident 2. Review of the EHSI- I/O Chart Details Reports the following fluid intakes for Resident 2: 1/15/14: 230 cc's 1/16/14: 540cc's 1/17/14: 720cc's 1/18/14: 440 cc's 1/19/14: 950cc's 1/22/14: 860cc's 1/23/14: 920 cc's 1/24/14: 860 cc's 1/25/14: 480 cc's 1/30/14: 840 cc's 1/31/14: 980 cc's 2/1/14: 575 cc's On 2/5/14 at 1:10 PM, Surveyor interviewed RN/CM (Registered Nurse/Case Manager) E regarding who monitors the 24 hour fluid intakes for Resident 2. RN/CM E stated, "I am not sure I will find out." On 2/5/14 at 1:20 PM, Surveyor interviewed LPN (Licensed Practical Nurse) D regarding the process for monitoring a resident if on a fluid restriction. LPN D stated, "The Case Managers print off the report for the 24 hour fluid intakes, and then the case managers tells us if the resident is over or under it is the floor nurses responsibility to call the doctor." Surveyor then asked LPN D if LPN D was notified that Resident 2 was either over or under the 1800 cc fluid restriction since the Resident 2's return on 1/15/14, LPN D stated, "No." On 2/5/14 at 2:00 PM, Surveyor interviewed DON B regarding the process for Residents on fluid restrictions. DON B stated, "The I/O Chart detail Report is printed off daily by the dietary manager and given to the me(DON) at the morning meeting, and any Residents who have intakes under 1000cc's are monitored for signs and symptoms of dehydration. We do not have a hydration assessment form. After the Dietary Manager prints the reports, anyone less than 1000cc's is brought to the morning triage meeting, then copies are made of the reports and the reports are brought to the floor nurses who monitor for signs and symptoms of dehydration, and if dehydration is noted the nurse calls the doctor." Surveyor asked DON B for documentation that Resident 2 was monitored/assessed for hydration status on the dates that Resident 2 was under the 1000cc fluid total, DON B stated, "There is no record of an assessment occurring, no documentation of an assessment occurring."

Based on record review and interview in 1 of 13 total residents reviewed (Residents 12), the facility did not provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well - being in accordance with the comprehensive assessment and plan of care. Resident 12's admission orders [REDACTED]. This was not available and the facility did not give Resident 12 any nutrition for 26 hours. In the meantime, the facility administered [MEDICATION NAME] and by 8AM the following morning, the resident's blood sugar level had dropped to 50 mg/dl. After giving [MEDICATION NAME], the nurse did not re-check the blood sugar level until an hour later. Resident 12 was eventually sent to the ER (emergency room ) for evaluation. The facility's failure to provide Resident 12 with nutritional feeding, despite having received insulin, resulted in a finding of immediate jeopardy, which began on 2/26/13. The NHA was notified of this finding on 2/27/13. The immediate jeopardy was removed on 2/27/13 however, the deficient practice continues at a severity and scope level of D (potential for harm that is not immediate jeopardy / isolated) until all staff have been inserviced and re - educated. This is evidenced by the following: Example 1 Resident 12 was admitted to the facility around noon on 2/25/13. Resident 12's [DIAGNOSES REDACTED]. Resident 12's admission orders [REDACTED] *Nutrition: Nepro @ (at) 46 ml / hr and autoflush 25 ml / hr free water. *[MEDICATION NAME] 10 units SQ (subcutaneous) q (every) day at 10:00 pm *Humalog Insulin sliding scale checked (blood glucose) every 6 hours. *[MEDICATION NAME] Emergency 1 mg (milligram) kit For [DIAGNOSES REDACTED]. as needed if NPO without IV (Intravenous) access for blood glucose < (less than) 70 mg / dl. Resident 12's record contains the following documentation: 2/25/13 Nurses Progress Note - 11:20 pm: "Resident was admitted from (Hospital name) around noon to this facility... Resident appears alert to self and others, with minimal verbalization. Res (Resident) has dubhoff NG tube... Res receives tube feeding of Nepro @ 46 ml / hr to run continuous." 2/2013 MAR (Medication Administration Record): NG tube feeding Nepro @ 46 ml / hr. (Please note - there are no staff initials noted to this entry as evidence this order had been initiated, completed or carried out.) 2/2013 MAR: "[MEDICATION NAME]. Give 10 units under the skin every day at 2200 (10:00 pm)." (Please note - this medication was administered on 2/25/13 at 10:00 pm as evidenced by staff initials.) 2/2013 MAR: Accuchecks QID (four times a day) 0730 (7:30 am), 1130 (11:30 am), 1630 (4:30 pm), 2200 (10:00 pm). (This MAR indicated [REDACTED]. Please note, as stated above, Resident 12's physician admit orders instruct staff to check blood glucose every 6 hours, not QID) 2/26/13 SBAR (Situation Background Assessment Request) Physician / NP (Nurse Practitioner) / PA (Physician Assistant) Communication and Progress Note - 2:00 pm: Res (with) BG (blood glucose) 50. Unable to assess regarding s/s (signs and symptoms) low BG. Rec'd (received) glucogan 1 mg IM per orders. Re (check) 89. Disc (discussed) (with) CM (Case Manager) issues of TF (tube feeding) (not) being provided by pharmacy. CM f/u (follow up) (with) call to pharmacy. Writer monitor BG as ordered." 2/26/13 Nurses Progress Note - 3:00 pm: "...Nepro had not arrived from pharmacy. Call placed around 1030 - 11 am to pharmacy asking where tube feeding was. Expressed significant need for tube feeding to be sent stat d/t (due to) no intake since noon on 2/25/13. Re - called pharmacy around noon. Stated they were just notified that needed STAT Nepro and it would be 1 - 1 & 1/2 hours before they could get here. Pharmacy was made aware this was unacceptable. Stated they could do nothing else. Family called and was made aware Res had nothing nutrition wise for 24 hours. Family was unhappy and concerned for mother's health and wellbeing. (Name) NP was called around noon - 1 pm notified that Resident had not received tube feeding. NP stated she could do nothing, stated to check with dietitian to see if [MEDICATION NAME] solution could be given. Asked if could give IV [MEDICATION NAME] (with) NS (normal saline). Stated no. Dietician called pharmacy to determine a [MEDICATION NAME] concentration to give Res. Pharmacy suggested / stated not to administer. Meanwhile family had called back and stating wanted mother to be sent to ER for evaluation. NP was called back to get order to send to ER." Resident 12's Hospital ER notes dated 2/26/13 state: "Patient is a [AGE] year old female with history [MEDICAL CONDITION] right sided [MEDICAL CONDITION], DM, [MEDICAL CONDITION] with RVR (Rapid Ventricular Rate), stage IV CKD ([MEDICAL CONDITION])...who is admitted with concern for [MEDICAL CONDITION] with RVR, elevated troponin, and [DIAGNOSES REDACTED]." Interviews Admitting Nurse 2/25/13 On 2/26/13 at 4:22 pm Surveyor spoke with RN (Registered Nurse) G regarding several topics including Resident 12's admission Nepro orders. RN G admitted Resident 12 to the facility on [DATE]. RN G told Surveyor that Resident 12 arrived to the facility about noon on 2/25/13. RN G stated she faxed the admission orders [REDACTED]. RN G stated she knew the Nepro would not get to the facility until sometime between 8:00 pm (2/25/13) and 2:00 am (2/26/13). RN G stated she did report to the PM nurse the need for Resident 12 to begin her tube feeding. On 2/27/13 at 8:55 am Surveyor again spoke with RN G and asked RN G why she had not called a physician when the facility did not have the Nepro upon Resident 12's admission, and she (RN G) knew the Nepro would not get to the facility until between 8:00 pm (2/25/13) and 2:00 am (2/26/13)? RN G stated "It didn't cross my mind to call the physician about it." PM Nurse 2/25/13 On 3/5/13 at 2:30 pm Surveyor spoke with RN L via telephone regarding several topics including Resident 12's Nepro feeding. RN L was the PM nurse caring for Resident 12 on 2/25/13, the day Resident 12 was admitted to the facility. RN L told Surveyor that she was not aware of Resident 12's admission to the facility until she was making first rounds and saw Resident 12 in her room. RN L stated she went to the nurse who had just given her report to ask about Resident 12. RN L stated she did not recall which nurse this was, but this nurse also did not know about Resident 12. RN L stated she then went to RN G, the admitting nurse, and got report which included Resident 12's diagnoses. RN L stated RN G was still working on Resident 12's admission orders [REDACTED]. RN L went on to state that by the time her shift was over, 10:30 pm (2/25/13), RN G was still in the facility and still working on Resident 12's admission orders [REDACTED]'s orders, MAR indicated [REDACTED]. RN L stated she was aware Resident 12's Nepro had not yet arrived. Surveyor asked RN L if she was concerned that Resident 12 had not had any tube feeding since admission, and if she felt a physician should be notified of this? RN L stated she was not concerned because Resident 12 was still going through the admission process and that RN G was still working on the orders. Surveyor asked RN L if at any time she thought to review Resident 12's admission orders [REDACTED]? RN L stated she did not think to look at the orders and stated again RN G was "still working on the orders." Night Nurse 2/25/13 On 2/27/13 at 9:22 am Surveyor spoke with RN K regarding Resident 12's Nepro orders. RN K was the nurse who cared for Resident 12 from late evening on 2/25/13 through the night until the day shift of 2/26/13. RN K told Surveyor that she had expected Resident 12's Nepro to arrive to the facility by 1:30 am (2/26/13), but "They (pharmacy delivery) did not have it." Surveyor asked RN K if she felt a call to the physician was needed when the Nepro had not arrived and that Resident 12 had had no feeding since admit. RN K stated: "I didn't think to call the doctor. I figured the day shift would take care of it.... I told days the Nepro had not arrived. I took it upon myself to set up the pump to be ready. I suppose I could have called the doctor but I didn't.... days could figure it out." (Please know that RN K was the nurse who administered Resident 12's [MEDICATION NAME] at 10:00 pm on 2/25/13 as evidenced by RN K's initials on the MAR.) Day Nurse 2/26/13 On 2/27/13 at approximately 9:30 am Survey spoke with RN F via telephone regarding Resident 12 and her Nepro order. RN F was the day nurse who worked with Resident 12 on 2/26/13, the day Resident 12 was sent to the ER for evaluation. RN F told Surveyor that on the morning of 2/26/13 she was told Resident 12's Nepro was to be delivered that morning. RN F stated she was unaware that Resident 12 had the [DIAGNOSES REDACTED]. RN F found Resident 12's blood glucose to be 50 mg / dl. RN F stated RN G was right there and informed her that Resident 12's Nepro had not arrived yet, that Resident 12 had not had any nutrition since her admission, and that Resident 12's blood glucose was 50 mg / dl. RN F stated RN G went to work to see what had happened to the Nepro. RN F stated she wanted to give Resident 12 IV [MEDICATION NAME] (because of the low blood glucose), but she could not find [MEDICATION NAME] solution quickly enough. RN F stated: "I said screw it, I'm going to give it IM." Documentation shows that RN F administered [MEDICATION NAME] 1 mg IM to Resident 12. RN F stated she rechecked the blood glucose around 9:00 am and it was 89 mg / dl. RN F stated she knows she "should have checked it (the blood glucose) sooner" but stated so much was happening at the time. RN F stated once Resident 12's blood glucose came up she felt it was safe for her (RN F) to continue with caring for the other residents. RN F stated: "My reality was ... once she (Resident 12) was stable; I needed to change my focus and priority to the rest of the residents". RN F stated she continued her medication pass and knew that RN G was working on getting the Nepro. On 2/27/13 at 2:30 pm Surveyor again spoke with RN F, in person this time. Surveyor asked RN F what kind of condition Resident 12 was in when her blood sugar was at 50 mg / dl on the morning of 2/26/13 at 8:00 am? RN F stated: "She was 100% fine. There were no outward signs of a low blood sugar. She was not cold and clammy, she was tracking with her eyes..." Surveyor asked RN F why she had documented: "Unable to assess regarding s/s low BG" in the SBAR note on 2/26/13? RN F stated she was saying that she did not see any signs or symptoms of a low blood sugar, not that she didn't assess for them. Nurse Practitioner On 2/27/13 at 9:05 am Surveyor spoke with NP M via telephone regarding Resident 12's Nepro orders. NP M stated a message had been left for her, by the facility on 2/26/13 around 10 - 11:00 am to inform her of Resident 12's admit to the facility, and need to clarify orders. NP M stated it was not until around noon on 2/26/13 that she actually spoke with someone from the facility who informed her that Resident 12 had been over 24 hours without nutritional intake. NP M stated she informed staff to contact the dietitian to see if there was a comparable substitute, and to inform the family. NP M stated she was told there was no comparable substitute for the Nepro. NP M stated due to computer access restrictions, she was unable to get information regarding Resident 12's medical history from the hospital in which she had just been discharged . NP M gave instructions to the facility to transfer Resident 12 to the hospital ER for evaluation. Surveyor asked NP M what her expectations would have been regarding Resident 12's tube feeding orders. NP M stated: "First of all, I would expect them (the facility) not to take a patient if they don't have the tube feeding. They must have known. That is why we check beforehand." Surveyor asked NP M when she would have expected to have been informed of the absence of the Nepro. NP M stated: "I would have expected them to call me right after she got here (to the facility)." DON On 2/27/13 at 1:25 pm Surveyor spoke with DON (Director of Nursing) B regarding several topics including Resident 12, her Nepro orders and MD / NP notification. Surveyor asked DON B if the facility had known that Resident 12 would need continuous Nepro tube feedings before Resident 12 arrived to the facility. DON B stated "If we would have read the notes (pre admission notes) we would have." Surveyor asked DON B if these "notes" had been available to the facility prior to Resident 12's admission. DON B stated they had. Surveyor asked DON B if, in the absence of blood glucose parameters, she would have expected staff to immediately notify the physician when Resident 12's blood glucose was 50 mg / dl requiring [MEDICATION NAME] to be administered. DON B stated "yes." Surveyor asked DON B when she would have expected facility staff to notify the physician or NP that the facility did not have any Nepro. DON B stated she would have expected the staff to "call right away for a substitute, or whatever orders they would give." DON B went on to state: "I would have expected each nurse who worked with her (Resident 12) to call until the issue was resolved, or call me or the Medical Director." The failure for the facility to provide Resident 12, who has the [DIAGNOSES REDACTED]. The facility removed the immediate jeopardy on 2/27/13 when: *Notification of NP of blood glucose results and Center response. *Review of all diabetic residents' blood glucose values within past 24 hours to ensure that residents have parameters, that values are within parameters, and if not, that notifications were completed. *Re - education of Nurses regarding following MD orders, obtaining blood glucose values, obtaining and follow up on blood glucose levels outside of parameters. Also, on notifications and review of insulin administration when a diabetic resident if not receiving nutritional intake, as well as using "Rule of 15", when addressing [DIAGNOSES REDACTED]. Education to include notification of DON / Nurse Managers when resident blood glucose outside of parameters, when diabetic is not receiving enough nutritional intakes, or when res. is treated for [REDACTED]. *Center will complete on - sight visit to review resident and record prior to accepting admissions from referral source. *DON or designee will designate nurse to complete each admission. IDT will be informed of assigned nurse, and will do everything possible to minimize distractions and interruptions while admission being completed, to ensure completion and verifications, and clarifications completed timely. *DON will ensure that IDT reviews new re - admissions, and 24 hour report for residents with changes in condition, at daily clinical meetings, and ensures issues identified related to diabetic care and tube feedings were addressed according to policy and procedure. *Results of these reviews will be documented on the Clinical Follow Up form, and will be compiled and presented monthly to the Center QPI Committee for 3 months. *Set up meeting with referral source to ensure improved communication and continuity of care.

Based on record review and interview in 1 of 13 residents reviewed (Resident 12), the facility did not immediately consult with a physician and notify the resident's legal representative when there was a need to alter treatment significantly and when a significant change in the resident's physical, mental, or psychosocial status occurred. Resident 12's admission orders [REDACTED]. The facility did not consult with a physician when this nutritional supplement was not immediately available at the facility, and when the expected delivery of this nutritional supplement did not occur. Resident 12 subsequently went 26 hours without nutritional intake. In the meantime, a nurse gave [MEDICATION NAME]. When the resident's blood sugar level dropped to 50 mg/dl requiring [MEDICATION NAME] IM (intramuscularly), the nurse did not immediately consult with a physician. The facility's failure to consult with a physician regarding Resident 12's lack of nutritional feeding and her drop in her blood sugar level created a finding of immediate jeopardy, which began on 2/26/13. The facility was notified of this finding on 2/27/13. The immediate jeopardy was removed on 2/27/13 however, the deficient practice continues at a severity and scope level of D (potential for harm that is not immediate jeopardy / isolated) until all staff have been inserviced and re - educated. This is evidenced by the following: Resident 12 was admitted to the facility on [DATE]. Resident 12's [DIAGNOSES REDACTED]. Resident 12's admission orders [REDACTED] *Nutrition: Nepro @ (at) 46 ml / hr and autoflush 25 ml / hr free water. *[MEDICATION NAME] 10 units SQ (subcutaneous) q (every) day at 10:00 pm *Humalog Insulin sliding scale checked (blood glucose) every 6 hours. *[MEDICATION NAME] Emergency 1 mg (milligram) kit for [DIAGNOSES REDACTED]. as needed if NPO without IV (Intravenous) access for blood glucose < (less than) 70 mg / dl. Resident 12's record contains the following documentation: 2/25/13 Nurses Progress Note - 11:20 pm: "Resident was admitted from (Hospital name) around noon to this facility... Resident appears alert to self and others, with minimal verbalization. Res (Resident) has dubhoff NG tube... Res receives tube feeding of Nepro @ 46 ml / hr to run continuous." 2/2013 MAR (Medication Administration Record): NG tube feeding Nepro @ 46 ml / hr. (Please note - there are no staff initials noted to this entry as evidence that this order had been initiated, completed or carried out.) 2/2013 MAR: "[MEDICATION NAME]. Give 10 units under the skin every day at 2200 (10:00 pm)." (Please note - this medication was administered on 2/25/13 at 10:00 pm as evidenced by staff initials.) 2/2013 MAR: Accuchecks QID (four times a day) 0730 (7:30 am), 1130 (11:30 am), 1630 (4:30 pm), 2200 (10:00 pm). (This MAR indicated [REDACTED]. Please note, as stated above, Resident 12's physician's admit orders instruct staff to check blood glucose every 6 hours, not QID.) 2/26/13 SBAR (Situation Background Assessment Request) Physician / NP (Nurse Practitioner) / PA (Physician Assistant) Communication and Progress Note - 2:00 pm: Res (with) BG (blood glucose) 50. Unable to assess regarding s/s (signs and symptoms) low BG. Rec'd (received) glucogan 1 mg IM per orders. Re (check) 89. Disc (discussed) (with) CM (Case Manager) issues of TF (tube feeding) (not) being provided by pharmacy. CM f/u (follow up) (with) call to pharmacy. Writer monitor BG as ordered." 2/26/13 Nurses Progress Note - 3:00 pm: "...Nepro had not arrived from pharmacy. Call placed around 1030 - 11 am to pharmacy asking where tube feeding was. Expressed significant need for tube feeding to be sent stat d/t (due to) no intake since noon on 2/25/13. Re - called pharmacy around noon. Stated they were just notified that needed STAT Nepro and it would be 1 - 1 & 1/2 hours before they could get here. Pharmacy was made aware this was unacceptable. Stated they could do nothing else. Family called and was made aware Res had nothing nutrition wise for 24 hours. Family was unhappy and concerned for mother's health and wellbeing. (Name) NP was called around noon - 1 pm notified that Resident had not received tube feeding. NP stated she could do nothing, stated to check with dietitian to see if [MEDICATION NAME] solution could be given. Asked if could give IV [MEDICATION NAME] (with) NS (normal saline). Stated, no. Dietician called pharmacy to determine a [MEDICATION NAME] concentration to give Res. Pharmacy suggested / stated not to administer. Meanwhile family had called back and stating wanted mother to be sent to ER for evaluation. NP was called back to get order to send to ER." Resident 12's Hospital ER notes dated 2/26/13 state: "Patient is a [AGE] year old female with history [MEDICAL CONDITION] right sided [MEDICAL CONDITION], DM, [MEDICAL CONDITION] with RVR (Rapid Ventricular Rate), stage IV (4) CKD ([MEDICAL CONDITION])...who is admitted with concern for [MEDICAL CONDITION] with RVR, elevated troponin, and [DIAGNOSES REDACTED]." Interviews Admitting Nurse 2/25/13 On 2/26/13 at 4:22 pm Surveyor spoke with RN (Registered Nurse) G regarding several topics including Resident 12's admission Nepro orders. RN G admitted Resident 12 to the facility on [DATE]. RN G told Surveyor that Resident 12 arrived to the facility about noon on 2/25/13. RN G stated she faxed the admission orders [REDACTED]. RN G stated she knew the Nepro would not get to the facility until sometime between 8:00 pm (2/25/13) and 2:00 am (2/26/13). RN G stated she did report to the PM nurse the need for Resident 12 to begin her tube feeding. Surveyor asked RN G when a physician had been notified that the facility did not have the Nepro for Resident 12. RN G stated she had spoken to the NP on 2/26/13 sometime between 12:00 pm - 1:00 pm. (Please note this is approximately 24 hours after Resident 1 was admitted to the facility with an order for [REDACTED]. On 2/27/13 at 8:55 am Surveyor again spoke with RN G and asked RN G why she had not called a physician when the facility did not have the Nepro upon Resident 12's admission, and she (RN G) knew the Nepro would not get to the facility until between 8:00 pm (2/25/13) and 2:00 am (2/26/13)? RN G stated "It didn't cross my mind to call the physician about it." PM Nurse 2/25/13 On 3/5/13 at 2:30 pm Surveyor spoke with RN L via telephone regarding several topics including Resident 12's Nepro feeding. RN L was the PM nurse caring for Resident 12 on 2/25/13, the day Resident 12 was admitted to the facility. RN L told Surveyor that she was not aware of Resident 12's admission to the facility until she was making first rounds and saw Resident 12 in her room. RN L stated she went to the nurse who had just given her report to ask about Resident 12. RN L stated she did not recall which nurse this was, but this nurse also did not know about Resident 12. RN L stated she then went to RN G, the admitting nurse, and got report which included Resident 12's diagnoses. RN L stated RN G was still working on Resident 12's admission orders [REDACTED]. RN L stated that by the time her shift was over, 10:30 pm (2/25/13), RN G was still in the facility and still working on Resident 12's admission orders [REDACTED]. Surveyor asked RN L if she was concerned that Resident 12 had not had any tube feeding since admission, and if she felt a physician should be notified of this? RN L stated she was not concerned because Resident 12 was still going through the admission process and that RN G was still working on the orders. Surveyor asked RN L if at any time she thought to review Resident 12's admission orders [REDACTED]. RN L stated she did not think to look at the orders and stated again RN G was "still working on the orders." Night Nurse 2/25/13 On 2/27/13 at 9:22 am Surveyor spoke with RN K via telephone regarding Resident 12's Nepro orders. RN K was the nurse who cared for Resident 12 from late evening on 2/25/13 through the night, until the day shift of 2/26/13. RN K told Surveyor that she had expected Resident 12's Nepro to arrive to the facility by 1:30 am (2/26/13), but "They (pharmacy delivery) did not have it." Surveyor asked RN K if she felt a call to the physician was needed when the Nepro had not arrived and that Resident 12 had had no feeding since admit. RN K stated: "I didn't think to call the doctor. I figured the day shift would take care of it.... I told days the Nepro had not arrived. I took it upon myself to set up the pump to be ready. I suppose I could have called the doctor but I didn't.... days could figure it out." (Please know that RN K was the nurse who administered Resident 12's [MEDICATION NAME] at 10:00 pm on 2/25/13 as evidenced by RN K's initials on the MAR.) Day Nurse 2/26/13 On 2/27/13 at approximately 9:30 am Survey spoke with RN F via telephone regarding Resident 12 and her Nepro order. RN F was the day nurse who worked with Resident 12 on 2/26/13, the day Resident 12 was sent to the ER for evaluation. RN F told Surveyor that on the morning of 2/26/13 she was told Resident 12's Nepro was to be delivered that morning. RN F stated she was unaware that Resident 12 had the [DIAGNOSES REDACTED]. RN F found Resident 12's blood glucose to be 50 mg / dl. RN F stated RN G was right there and informed her that Resident 12's Nepro had not arrived yet, that Resident 12 had not had any nutrition since her admission, and that Resident 12's blood glucose was 50 mg / dl. RN F stated RN G went to work to see what had happened to the Nepro. RN F stated she wanted to give Resident 12 IV [MEDICATION NAME] (because of the low blood glucose), but she could not find [MEDICATION NAME] solution quickly enough. RN F stated: "I said screw it, I'm going to give it IM." Documentation shows that RN F administered [MEDICATION NAME] 1 mg IM to Resident 12. RN F stated she rechecked the blood sugar around 9:00 am and it was 89 mg / dl. RN F stated she knows she "should have checked it (the blood glucose) sooner" but stated so much was happening at the time. RN F stated once Resident 12's blood glucose came up she felt it was safe for her (RN F) to continue with caring for the other residents. RN F stated: "My reality was ... once she (Resident 12) was stable, I needed to change my focus and priority to the rest of the residents". RN F stated she continued her medication pass and knew that RN G was working on the Nepro. RN F stated since Resident 12 had stabilized she did not call the physician and felt that RN G was taking over that aspect of Resident 12's care. On 2/27/13 at 2:30 pm Surveyor again spoke with RN F, in person this time. Surveyor asked RN F what kind of condition Resident 12 was in when her blood sugar was at 50 mg / dl on the morning of 2/26/13 at 8:00 am? RN F stated: "She was 100% fine. There were no outward signs of a low blood sugar. She was not cold and clammy, she was tracking with her eyes..." Surveyor asked RN F why she had documented: "Unable to assess regarding s/s low BG" in the SBAR note on 2/26/13? RN F stated she was saying that she did not see any signs or symptoms of a low blood sugar, not that she didn't assess for them. Nurse Practitioner On 2/27/13 at 9:05 am Surveyor spoke with NP M via telephone regarding Resident 12's Nepro orders. NP M stated a message had been left for her, by the facility on 2/26/13 around 10 - 11:00 am to inform her of Resident 12's admit to the facility, and need to clarify orders. NP M stated it was not until around noon on 2/26/13 that she actually spoke with someone from the facility who informed her that Resident 12 had been over 24 hours without nutritional intake. NP M stated she informed staff to contact the dietitian to see if there was a comparable substitute and to inform the family. NP M stated she was told there was no comparable substitute for the Nepro. NP M stated due to computer access restrictions, she was unable to get information regarding Resident 12's medical history from the hospital in which she had just been discharged . Instructions were given to the facility to transfer Resident 12 to the hospital ER for evaluation. Surveyor asked NP M what her expectations would have been regarding Resident 12's tube feeding orders. NP M stated: "First of all, I would expect them (the facility) not to take a patient if they don't have the tube feeding. They must have known. That is why we check beforehand." Surveyor asked NP M when she would have expected to have been informed of the absence of the Nepro. NP M stated: "I would have expected them to call me right after she got here (to the facility)." DON On 2/27/13 at 1:25 pm Surveyor spoke with DON (Director of Nursing) B regarding several topics including Resident 12, her Nepro orders, and MD / NP notification. Surveyor asked DON B if the facility had known that Resident 12 would need continuous Nepro tube feedings before Resident 12 arrived to the facility. DON B stated "If we would have read the notes (pre admission notes) we would have." Surveyor asked DON B if these "notes" had been available to the facility prior to Resident 12's admission. DON B stated they had. Surveyor asked DON B if, in the absence of blood glucose parameters, she would have expected staff to immediately notify the physician when Resident 12's blood glucose was 50 mg / dl requiring [MEDICATION NAME] to be administered. DON B stated "yes". Surveyor asked DON B when she would have expected facility staff to notify the physician or NP that the facility did not have any Nepro. DON B stated she would have expected the staff to "call right away for a substitute, or whatever orders they would give." DON B went on to state: "I would have expected each nurse who worked with her (Resident 12) to call until the issue was resolved, or call me or the Medical Director." The failure for the facility to immediately consult with a physician and notify the resident's legal representative when there was a need to alter treatment significantly and when there was a significant change in condition created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 2/27/13 when: *Notification of NP of blood glucose results and Center response. *Review of all diabetic residents' blood glucose values within past 24 hours to ensure that residents have parameters, that values are within parameters, and if not, that notifications were completed. *Re - education of Nurses regarding following MD orders, obtaining blood glucose values, obtaining and follow up on blood glucose levels outside of parameters. Also, on notifications and review of insulin administration when a diabetic resident if not receiving nutritional intake, as well as using "Rule of 15", when addressing [DIAGNOSES REDACTED]. Education to include notification of DON / Nurse Managers when resident blood glucose outside of parameters, when diabetic is not receiving enough nutritional intake, or when res. is treated for [REDACTED]. *Center will complete on - sight visit to review resident and record prior to accepting admissions from referral source. *DON or designee will designate nurse to complete each admission. IDT will be informed of assigned nurse, and will do everything possible to minimize distractions and interruptions while admission is being completed, to ensure completion and verifications, and clarifications completed timely. *DON will ensure that IDT reviews new re - admissions, and 24 hour report for residents with changes in condition, at daily clinical meetings, and ensures issues identified related to diabetic care and tube feedings were addressed according to policy and procedure. *Results of these reviews will be documented on the Clinical Follow Up form, and will be compiled and presented monthly to the Center QPI Committee for 3 months. *Set up meeting with referral source to ensure improved communication and continuity of care.