Every finding on record at Bear Canyon Rehabilitation Center

Based on record review and interview, the facility failed to maintain complete and accurate clinical records for 1 (R #2) of 1 (R #2) resident reviewed, when the facility failed to document required neurological assessments (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) after R #2 experienced an unwitnessed fall. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are:A. Record review of the facility's falls management policy, revised on 01/15/26, revealed the following:Residents who sustained a head injury from a fall or experienced an unwitnessed fall were expected to undergo neurological checks (neuro checks; a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status) per facility policy.The facility is expected to document the circumstances of the fall, the post fall assessment, and the patient outcome. B. Record review of R #2's face sheet revealed an admission date of 08/20/23. C. Record review of R #2's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/28/26, revealed R #2 had the following diagnoses:Non-Alzheimer's dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Muscle weakness (generalized).Repeated falls. D. Record review of R #2's nursing progress notes, dated 05/26/26 at 8:20 pm, revealed R #2 was found lying on the bathroom floor after an unwitnessed fall. Neurological checks for R #2 were started per facility protocol after the fall. E. Record review of R #2's electronic health record (EHR), dated 07/30/26, revealed R #2's neurological assessments and follow ups after the fall on 05/26/26 were not available in R #2's EHR. F. On 07/30/26 at 12:46 pm, during an interview, the DON stated the facility's post fall neurological monitoring protocol requires neurological assessments every 15 minutes for the first hour, then every 30 minutes for a total of four assessments, followed by an hourly assessment for a total of four assessments. The DON stated the neurological assessments are documented on a paper neurological assessment form that is expected to be uploaded into the resident's EHR. The DON stated the neurological assessment forms for R #2 after the fall on 05/26/26, were not present in R #2's EHR. The DON stated she could not determine whether the neurological assessments had been completed for R #2 because they were not documented in R #2's EHR. The DON stated it was the facility's expectation all required neurological assessments be completed and documented. The DON stated if neurological assessments are not documented, the facility cannot determine whether changes in the resident's condition occurred or whether timely interventions would have been implemented.

Based on record review and interviews, the facility failed to submit the required incident summary report and five-day follow-up investigation results to the State Agency for 1 (R #2) of 1 (R #2) resident reviewed for a fall with injury. If the facility does not submit the incident summary report and the summary of the facility's investigation to the State Agency within the required timeframe, the State Agency is unable to appropriately review the allegation for further investigation. The findings are: A. Record review of the facility's accidents and incidents policy, revised on 03/01/24, revealed the following:Facility staff are expected to report, review, and investigate all accidents and incidents involving a resident.The Administrator and/or Director of Nursing (DON) will verify state reporting occurred within required timeframes and by the appropriate reporting method. B. Record review of R #2's face sheet revealed an admission date of 08/20/23. C. Record review of R #2's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/28/26, revealed R #2 had the following diagnoses:Non-Alzheimer's dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Muscle weakness (generalized).Repeated falls. D. Record review of R #2's nursing progress notes, dated 04/26/26, revealed R #2 experienced a fall at 3:00 pm due to an unsteady gait. R #2 struck his head and sustained a head laceration (a cut or tear in the skin) and was transferred to the hospital for evaluation. E. Record review of R #2's hospital Discharge summary, dated [DATE], revealed R #2 was diagnosed with a scalp hematoma (a collection of blood beneath the scalp caused by trauma) after the fall. F. On 07/30/26 at 4:05 pm, during an interview, the DON stated it was the facility's expectation to report any falls resulting in injury or a change in condition requiring transfer to the hospital to the State Agency. The DON stated R #2's fall on 04/26/26 should have been reported to the State Agency because R #2 sustained a head laceration and required transfer to the hospital for an evaluation. The DON stated failure to submit a report for a reportable event could prevent the State Agency from conducting the appropriate regulatory review or investigation to determine whether corrective actions were necessary to prevent similar occurrences. G. On 07/30/26 at 4:30 pm, during an interview, the Administrator (ADM) stated it was the facility's expectation to report incidents involving major injuries, abuse, neglect, or residents transferred to the hospital for evaluation after a serious incident to the State Agency. The ADM stated the facility's expectation was, When in doubt, report. The ADM stated R #2's fall on 04/26/26 should have been reported because the resident was transferred to the hospital following the fall. The ADM stated he did not find documentation indicating R #2's fall on 04/26/26 had been reported to the State Agency. The ADM stated failure to submit a report for a reportable event could prevent the State Agency from reviewing the incident and determining whether the facility's response and corrective actions were appropriate to ensure resident safety.

Based on observation and interviews, the facility failed to provide a safe and homelike environment for all residents on the 600 unit by not maintaining the hallway, including preventing a chair and table from being placed against the handrail and staff storing personal belongings on the chair and table. If the facility fails to maintain a safe and homelike environment, then residents are likely to feel uncomfortable, and existing health issues could worsen.The findings are:A. On 06/25/26 at 3:15 pm, during an observation of the 600 unit, a bedside table with a drink cup, a plate of salad, and a chair with an open tote bag was positioned in the unit hallway in front of the handrail, without facility staff nearby. B. On 06/25/26 at 3:22 pm, during an interview, Registered Nurse (RN) #1 stated the facility staff should never leave items in the hallways, especially open drink containers, food items, purses, bags, or other personal belongings. She stated residents could pick up unattended items or trip on the bedside table and chairs. C. On 06/25/26 at 3:38 pm, during an interview, the Director of Nursing (DON) stated leaving a bedside table unattended with a laptop computer, a plate of food, a drink, and a personal tote bag on a chair was unacceptable. She stated her expectation is for nurses and certified nursing assistants (CNAs) to avoid leaving items in the unit hallways that are accessible to multiple residents. The DON stated leaving items unattended in the hallways is unsafe because residents could easily access the items on the table and inside the open tote bag.

Based on observation and interviews, the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) regarding residents of the 600-nursing unit, where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 06/25/26 at 3:15 pm, during an observation of the 600 unit, an unattended bedside table was positioned in the hallway with a computer containing residents' protected health information, including names and room numbers, visible to anyone walking by. B. On 06/25/26 at 3:22 pm, during an interview, Registered Nurse (RN) #1 stated residents' PHI should not be left unattended, because unauthorized individuals could easily access the information. C. On 06/26/26 at 10:13 am, during an interview, the Director of Nursing (DON) stated the unattended computer left open in the 600 unit, with residents' medical records visible and accessible to anyone, should not have been left unattended. She stated her expectation is for nursing staff to understand the importance of safeguarding resident records.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: Food items in the dry storage were labeled and dated. This deficient practice is likely to affect all 127 residents listed on the resident census list provided by the Administrator on 05/04/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly, and safe food handling practices are not adhered to. The findings are:A. On 05/07/26 at 11:05 am, during an observation of the main kitchen dry storage, revealed the following:Three 12-quart containers of cereal were unlabeled and undated. B. On 05/07/26 at 11:06 am, during an interview, the District Dietary Manager (DDM) stated the three cereal containers were not properly labeled or dated and should have been. The DDM stated if food is not properly labeled or dated, residents can become ill.

Based on observation and interview, the facility failed to ensure the outdoor trash bin was covered to minimize odors and prevent pests or rodents. If staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to all 127 residents listed on the facility census.The finding are:A. On 05/07/26 at 10:53 am, during an observation, the outdoor trash bin located outside the facility's main kitchen was not covered and exposing waste material to the environment.B. On 05/07/2026 at 10:54 am, during an interview, the District Dietary Manager (DDM) stated it was her expectation the outdoor trash bin remained closed at all times. The DDM stated it was the responsibility of all kitchen staff to ensure the outdoor trash bins lid was closed. The DDM stated leaving the outdoor trash bin open could attract pests or rodents.

Based on observations, record review, and interviews, the facility failed to ensure residents were treated with dignity and respect for 2 (R #9 and R #17) of 2 (R #9 and R #17) residents reviewed for resident dignity, when staff failed to:Refrain from using personal cell phones while feeding R #9, who required assistance with eating.Ensure R #17's bed linens were clean and free from urine stains.This deficient practice is likely to result in residents feeling unimportant to facility staff and may increase the risk of choking and infection.The findings are: Staff Cell Phone Use:R #9:A. Record review of the facility's Personal Cell Phone Policy, revision date of 07/01/22, revealed the following: Cell phones and other portable communication devices should never be used in any way that would distract from resident care or customer service. While at work, staff were expected to exercise professional discretion regarding the use of personal cell phones and other electronic communication devices. B. Record review of R #9's care plan, dated 01/17/26, revealed R #9 required staff assistance while eating. C. On 05/06/26 at 12:09 PM, during an observation, Certified Nursing Assistant (CNA) #1 was observed attempting to feed R #9 while also using her personal cell phone. D. On 05/06/26 at 12:14 PM, during an interview, CNA #1 stated the facility's policy did not allow personal cell phone use while feeding residents. CNA #1 stated if staff use their cell phones while feeding a resident, the resident could choke. CNA #1 stated she was using her personal cell phone while trying to assist R #9 with feeding and should not have. E. On 05/11/26 at 1:41 PM, during an interview, the Director of Nursing (DON) stated it was her expectation that facility staff do not use their personal cell phones while feeding residents who require assistance. The DON stated if staff were using a personal cell phone while feeding a resident, there was a risk of the resident choking, and it could affect the resident's dignity. Bed Linens: R #17:F. Record review of R #17's face sheet revealed an admission date of 11/21/25 and the following diagnoses:Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland). G. Record review of R #17's care plan, dated 11/24/25, revealed R #17 required assistance with activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care related to cognitive decline. H. On 05/04/26, at 10:26 AM, during an observation, R #17's bed linens were observed to have urine stains present. I. On 05/04/26, at 12:07 PM, during an observation, R #17's bed linens were observed to have urine stains present. J. On 05/06/26, at 11:59 AM, during an observation, R #17's bed linens were observed to have urine stains present. K. On 05/07/26, at 1:48 PM, during an observation, R #17's bed linens were observed to have urine stains present. L. On 05/07/26 at 1:57 PM, during an interview, the Licensed Practical Nurse (LPN) #8 stated if residents soiled their linens, the bed linens should be changed immediately or in a timely manner and not several hours later. The LPN #8 stated if residents' bed linens aren't changed when soiled, it could lead to infection or impact the resident's psychosocial well-being. M. On 05/11/26 at 1:41 PM, during an interview, the DON stated it was her expectation residents' soiled bed linens be changed daily and promptly when noted to be soiled. The DON stated if soiled bed linens are not changed in a timely manner, the resident is at risk of infection or compromised dignity. The DON stated R #17's bed linens should have been changed as soon as possible once they contained urine on them.

Based on record review and interviews, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was reviewed for accuracy and completion for 3 (R #'s 5, 7, and 8) of 3 (R #'s 5, 7, and 8) residents reviewed. If the facility fails to review PASARR screenings for accuracy and completion, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care. The findings are: R #5:A. Record review of R #5's face sheet revealed R #5 was initially admitted into the facility on [DATE] with the following diagnoses:Major depressive disorder (an episode of depression with mild symptoms that cause functional impairment).Anxiety disorder (symptoms of fear or anxiety that cause impairment). Unspecified psychosis (mental states featuring hallucinations, delusions, or severe disorganized behavior when the cause is unclear or not yet determined). B. Record review of R #5's PASARR Level 1 Identification Screen, dated 03/19/24, revealed staff documented the resident did not have diagnoses such as depression, anxiety, and psychosis. C. Record review of R #5's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/05/26, revealed R #5 has current anxiety disorder, depression, and psychotic disorder diagnoses. R #7:D. Record review of R #7's PASARR Level 1 Identification Screen, dated 10/14/22, revealed staff documented the resident did not have a diagnosis such as bipolar disorder. E. Record review of R #7's face sheet revealed R #7 was initially admitted into the facility on [DATE] with a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). F. Record review of R #7's MDS, dated [DATE], revealed R #7 has a current bipolar disorder diagnosis. R #8:G. Record review of R #8's face sheet revealed R #8 was initially admitted into the facility on [DATE] with a diagnosis of paranoid schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly). H. Record review of R #8's PASARR Level 1 Identification Screen, dated 12/05/25, revealed staff documented the resident did not have a diagnosis such as schizophrenia. I. Record review of R #8's MDS, dated [DATE], revealed R #8 has a current schizophrenia diagnosis. J. On 05/08/26 at 4:55 pm, during an interview, the Admissions Director (AD) stated the PASARR is used to track residents with developmental disabilities and mental health diagnoses. The AD stated the purpose of the PASARR is to ensure residents receive the appropriate level of care and services. The AD reviewed the PASARRs for R #5, R #7, and R #8 and stated each resident's PASARR was inaccurate and did not include the appropriate psychiatric diagnoses. The AD stated if the PASARRs for residents are inaccurate, the residents might not receive the necessary care and services they need.

Based on record review and interviews, the facility failed to develop a comprehensive, person-centered care plan for 3 (R #'s 2, 6, and 9) of 3 (R #'s 2, 6, and 9) residents reviewed for care planning, when staff failed to:Develop R #2's care plan to include activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) needs. Develop R #6's care plan to include dental care needs. Develop R #9's care plan to include hospice services use. These deficient practices are likely to result in residents not having needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of the facility's Person-Centered Care Plan Policy, revised date 09/15/2025, revealed the following: The facility must develop and implement a person-centered care plan for each resident consistent with resident rights, measurable objectives and timeframes to meet a residents' medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. The care plan will be prepared by the interdisciplinary team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident). R #2: B. Record review of R #2's face sheet revealed an admission date of 03/16/26 and included the following diagnoses: Fracture of fifth lumbar vertebra (lowest and largest bone of the spine). Displaced fracture of seventh cervical vertebra (largest neck bone). Fracture of sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis). Multiple fractures of ribs, right side. Collapsed vertebra (a break or crack in a vertebra that causes the bone to collapse). Reduced mobility. Difficulty in walking. Generalized muscle weakness. Fracture of second thoracic vertebra (spinal bone in the upper back). Wedge compression fracture of third lumbar vertebra (when the front part of a vertebra collapses while the back remains intact). Fracture of shaft of right fibula (calf bone of the leg). Fracture of right foot. Fracture of left foot. C. Record review of R #2's minimum data set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/22/26, revealed R #2 required substantial/maximal assistance (helper does more than half the effort) with showers/baths, and R #2 was dependent (helper does all the effort) with toileting hygiene. D. Record review of R #2's Comprehensive Care Plan, dated 04/19/26, revealed a care plan had not been developed to address R #2's activities of daily living needs and dependence on staff for showering/bathing and toileting hygiene. E. On 05/12/26 at 1:02 pm, during an interview, the Director or Nursing (DON) stated that it was her expectation that residents who depend on staff for hygiene needs, including showers, would be care planned. The DON stated that if ADL needs have not been properly care planned, staff may not be aware of the residents' needs, which can directly impact resident care. The DON stated R #2's ADL needs were not reflected in the care plan and should have been. R #6: F. Record review of R #6's face sheet revealed an admission date of 01/10/26 and the following diagnoses: Alzheimer's Disease (a disease which causes irreversible changes in memory, thinking and behavior). Dental Caries (tooth decay). G. Record review of R #6's appointment consultation visit form, dated 02/19/26, revealed R #6 had two teeth removed. H. Record review of R #6's comprehensive care plan, dated 03/08/26, revealed a care plan had not been developed to address R #6's dental care needs. I. On 05/11/26 at 3:04 pm, during an interview, the DON stated it was her expectation dental services be care planned for R #6. The DON stated if dental services are not included in a resident's plan of care, then it can directly impact the resident's care. R #9: J. Record review of R # 9's face sheet revealed an admission date of 01/16/26 with the following diagnoses: Heart failure (impaired heart function). Sarcopenia (a condition where a person loses muscle strength and muscle mass). Osteoporosis with current pathological fracture (a condition where a fracture is present and the bones are very weak and break easily). K. Record review of R #9's physician orders, dated 02/23/26, revealed an order for hospice services. L. Record review of R #9's care plan, dated 03/01/26, revealed R #9's use of hospice services was not included in R #9's care plan. M. On 05/05/26 at 11:18 am, during an interview, the hospice nurse stated R #9 was currently receiving hospice services. N. On 05/13/26 at 12:59 pm, during an interview, the DON stated it is her expectation hospice services be care planned. The DON stated if hospice care and services are not communicated to the IDT and throughout the facility, resident's care may not be appropriately coordinated. The DON stated hospice services was not included in R #9's care plan and should have been.

Based on observations, record review, and interviews, the facility failed to properly secure and store medications located in the facility medication carts and medication storage room, when:The facility staff did not lock medication carts (moveable equipment used for the storage, transport, and administration of medications) in the 300-hall, 400-hall, and 500-hall while staff were not present.The facility staff left loose medication pills in the 300-hall medication cart. Medications were pre-poured (the practice of preparing and pouring medications in advance of their scheduled administration time, which carries significant risks) prior to administration and left in the medication cart located in the 300-hall. The facility did not ensure the 600-hall medication refrigerator temperatures were properly maintained within the appropriate temperature range (36 to 46 degrees Fahrenheit).If the facility fails to secure medication carts, properly store medications, or prevent the pre pouring of medications, residents may experience unauthorized access to medications and an increased risk of medications becoming unusable for administration, thereby not receiving the full therapeutic benefit of their prescribed treatments.The findings are: Unlocked Medication Carts: A. Record review of the facility's medication storage and disposal policy, dated 02/2026, revealed prescription and over the counter medications (OTC; medications sold to individuals without a prescription) will be kept in an area or container that is locked. B. On 05/04/26 at 5:39 AM, during an observation, the 300-hall medication cart was left unlocked and unattended. C. On 05/04/26 at 5:40 AM, during an interview, the Licensed Practical Nurse (LPN) #5 stated the medication carts should always be locked when unattended. The LPN #5 stated if a medication cart is unlocked and unattended, a resident could access medications not prescribed to them. The LPN #5 stated the 300-hall medication cart was left unlocked and should not have been. D. On 05/04/26 at 5:42 AM, during an observation, the 400-hall medication cart was left unlocked and unattended. E. On 05/04/26 at 5:43 AM, during an interview, the LPN #6 stated the medication cart should be locked when unattended. The LPN #6 stated if a medication cart is unlocked and left unattended, then a resident could access medications not prescribed to them. The LPN #6 stated the 400-hall medication cart was left unlocked and should not have been. F. On 05/08/26 at 9:21 AM, during an observation, the memory care unit medication cart was left unlocked and unattended. G. On 05/08/26 at 9:25 AM, during an interview, the LPN #2 stated the medication cart should be locked when not attended. LPN #2 stated if a medication cart is left unlocked and unattended, a resident could access medications not prescribed to them and become ill. The LPN #2 stated the memory care unit medication cart was left unlocked and should not have been. H. On 05/08/26 at 11:22 AM, during an observation, the 500-hall medication cart was left unlocked and unattended. I. On 05/08/26 at 11:23 AM, during an interview, the LPN #3 stated the 500-hall medication cart was left unlocked and should not have been. J. On 05/08/26 at 1:25 PM, during an interview, the Director of Nursing (DON) stated it is her expectation that medication carts are always locked when the nurse or certified medication aids are not present with the cart. The DON stated if carts are left unlocked and unattended there is the risk a resident, visitor, or other staff could access the cart and take medications not prescribed to them. Loose Pills in the Medication Carts: K. On 05/06/26 at 12:38 PM, during an observation, multiple loose pills were found in the second drawer on the left side of the 300-hall medication cart. L. On 05/06/26 at 12:40 PM, during an interview, the LPN #1 stated the nursing and certified medication aides are responsible for keeping the medication carts clean and free of loose pills. The LPN #1 stated if someone were to access the cart, they could take medications not meant for them. The LPN #1 stated there is also a potential the pills could be administered to a resident by mistake. M. On 05/08/26 at 1:25 PM, during an interview, the DON stated the medication carts should not have loose pills in the drawers. The DON stated the medication carts should always be clean. Pre-Poured Medications: N. On 05/06/26 at 12:45 PM, during an observation, pre poured medications were found in three medication cups, each containing multiple pills, located in the top right drawer of the 300 hall medication cart. O. On 05/06/26 at 12:47 PM, during an interview, the LPN #1 stated there should not be any pre-poured medications in the medication cart drawers. The LPN #1 stated if someone were to have access to the cart, they could take medications not meant for them, and there is the potential for negative outcomes. P. On 05/08/26 at 1:25 PM, during an interview, the DON stated medications should not be pre-poured and then stored in the medication carts. Medication Refrigerator: Q. On 05/07/26 at 9:57 AM, during an observation, the medication refrigerator in the 600-hall medication room registered a temperature of 50 degrees Fahrenheit (F; a scale of temperature on which water freezes at 32 degrees and boils at 212 degrees under standard conditions), which exceeded the appropriate temperature range of 36-degree F to 46-degree F. R. On 05/07/26 at 9:58 AM, during an interview, the LPN #2 stated the 600-hall medication refrigerator should be 36 degrees F to 46 degrees F, and 50 degrees F is too high of a temperature. S. On 05/08/26 at 1:25 PM, during an interview, the DON stated it is her expectation medication refrigerators are to be within the appropriate temperature range of 36 degrees F to 46 degrees F. The DON stated if the medications are out of this range, they can become ineffective.

Based on observation, record review, and interviews, the facility failed to maintain a sanitary environment to prevent the transmission risk of infectious agents for 2 (R #9, and R# 13) of 2 (R #9, and R #13) residents, when:Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage was not present outside of R #9's room. Personal Protective Equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) was not readily available for staff use in R #9's room. R #9 and R #13's urinary catheter (indwelling catheter; a thin, flexible tube which drains urine from the bladder) collection bags (also called a drainage bag; a device connected to the catheter tubing and collects urine) were lying or dragging on the floor. These deficient practices have the potential to expose staff and other residents to infectious diseases. The findings are: Enhanced Barrier Precautions and PPE: A. Record review of the facility's Enhanced Barrier Precautions policy, date revised 05/01/25, revealed the following: EBP are utilized for residents with indwelling medical devices, including urinary catheters. Gown and gloves are required during high-contact resident care activities, including urinary catheter care. PPE should be readily accessible and located outside the resident's room. B. Record review of R #9's face sheet revealed an admission date of 01/16/26, with the following diagnosis: Benign Prostatic Hyperplasia (BPH; enlarged prostate) with Lower Urinary Tract Symptoms (various symptoms involving urination). C. Record review of R #9's physician orders, dated 04/21/26, revealed an order for an indwelling catheter (a thin, sterile tube inserted into the bladder to drain urine). D. On 05/07/26 at 2:46 pm, during an observation, EBP signage was not present outside of R #9's room as required, and PPE was not available for staff use in R #9's room. E. On 05/07/26 at 2:51 pm, during an interview, the Licensed Practical Nurse (LPN) #8 stated PPE should be readily available for staff use and staff should use PPE when providing direct care for residents with urinary catheters. The LPN #8 stated if proper PPE is not worn during care, the resident could develop an infection. F. On 05/07/26 at 3:41 pm, during an interview, the Director of Nursing (DON) stated it is her expectation that PPE should be readily available for staff use and PPE should be always worn when providing direct care to residents who have a urinary catheter or other care areas that require the PPE protocol. The DON stated if PPE is not worn, transmission of infection can occur. Urinary Catheter Bags: R #9: G. Record review of R #9's face sheet revealed an admission date of 01/16/26, with the following diagnosis: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. H. Record review of R #9's physician orders, dated 04/21/26, revealed the following: Indwelling catheter for diagnosis of obstructive and reflux uropathy (a blockage of the urinary tract which prevents proper flow/drainage of urine). I. On 05/07/26 at 8:50 am, during an observation, R #9 was lying in his bed with his urinary catheter bag lying on the floor under the bed. R #13: J. Record review of R #13's face sheet revealed an admission date of 09/21/23 with the following diagnosis: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. K. Record review of R #13's physician orders, dated 10/17/24, revealed the following: Indwelling catheter for diagnosis of obstructive uropathy. L. On 05/06/26 at 9:41 am, during an observation, R #13 was sitting in his wheelchair outside of the activities room with his urinary catheter bag lying on the ground. M. On 05/07/26 at 10:04 am, during an observation, R #13 was in his wheelchair outside of his room with his urinary catheter bag dragging on the ground. N. On 05/07/26 at 2:44 pm, during an interview, the LPN #1 stated urinary catheter bags should not be touching the floor. The LPN #1 stated if a urinary catheter bag is touching the floor, there is a risk of infection. O. On 05/08/26 at 1:24 pm, during an interview, the DON stated it is her expectation urinary catheter bags are not allowed to sit or drag on the floor. The DON stated there is an increased risk of infection if the urinary catheter bags are allowed to sit or drag on the floor.

Based on record review and interview, the facility failed to ensure advanced directives (documents providing an individual's wishes for emergency and lifesaving care) were accurate in the electronic health record (EHR) for 1 (R #133) of 2 (R #2 and #133) resident, when: The facility failed to ensure that the advance directive form was signed by the resident and/or their legal representative to validate the resident's Do Not Resuscitate (DNR; lifesaving measures are not desired) status. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.The findings are: A. Record review of R #133's face sheet revealed and admission date of 11/04/25 and did not include a code status (information that lets the resident's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping). B. Record review of R #133's care plan, dated 11/05/25, revealed a code status of DNR. C. Record review of R #133's Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form, dated 02/19/26, revealed a DNR code status. R #133's MOST form was not signed by either the resident or the Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care). D. On 05/12/26 at 1:02 pm, during an interview, the Director of Nursing (DON) stated her expectation was R #133's MOST form be signed by either the resident or the resident representative. The DON stated if the resident or representative has not signed the MOST form, there is no way of ensuring this was the resident or resident representative's choice and could result in the resident's wishes not being honored.

Based on record review and interview, the facility failed to complete a Significant Change (a major decline or improvement in a resident's physical or mental condition that is not self limiting, affects more than one area of health status, and requires review and potential care plan revision) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #2) of 2 (R #2 and R #133) resident, when: R #2 experienced an unplanned weight loss problem of 13.44 percent (%) within 30 days. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are:A. Record review of R #2's face sheet revealed an admission date of 03/16/26. B. Record review of R #2's weight tracking documentation, located in the electronic health record (EHR), revealed the following: Dated 03/25/26, R #2 weighed 185.3 pounds (lbs). Dated 04/10/26, R #2 weighed 180.0 lbs.Dated 04/17/26, R #2 weighed 167.4 lbs.Dated 04/22/26, R #2 weighed 160.4 lbs.Dated 04/30/26, R #2 weighed 160.0 lbs.Dated 05/01/26, R #2 weighed 160.2 lbs. C. Record review of R #2's MDS assessment reports, located in the EHR, revealed the facility did not to complete a Significant Change MDS after R #2's unplanned weight loss from 03/25/26 to 05/01/26. D. On 05/12/26 at 1:02 pm, during an interview, the Director of Nursing (DON) stated a Change in Condition MDS for R #2 was not completed following the significant weight change. The DON stated it was her expectation that a Significant Change MDS was completed and submitted within 14 days as required for R #2's unplanned weight loss.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment was accurate for 1 (R #131) of 2 (R #131 and #133) resident, when:The facility did not change R #131's discharge MDS status from return anticipated (returning to the facility) to return not anticipated (not returning to the facility).This deficient practice is likely to result in residents' needs not being met.The findings are:A. Record review of R #131's face sheet revealed an admission date of 12/04/25 and a discharge date of 01/29/26. B. Record review of R #131's discharge MDS, dated [DATE], revealed R #131 was discharged to the hospital with an anticipated return to the facility. C. Record review of R #131's electronic health record (EHR), dated 05/07/26, revealed R #131 did not return to the facility. R #131's discharge- return anticipated MDS was not updated to reflect R #131's discharge status of not returning to the facility. D. On 05/12/26 at 1:08 pm, during an interview, the Director of Nursing (DON) stated her expectation was for the MDS assessments to accurately reflect the resident's current status in the facility. She stated R #131's discharge MDS was inaccurate and should have been changed to reflect R #131's discharge-return not anticipated status.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #80) of 1 (R #80) resident, when:R #80 was provided oxygen therapy without a physician's order. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:A. Record review of R #80's face sheet revealed R #80 was originally admitted into the facility on [DATE] with a diagnosis of chronic respiratory failure (inability of the respiratory system to maintain adequate oxygenation or carbon dioxide elimination). B. Record review of R #80's care plan, dated 03/31/26, revealed the care plan did not include interventions addressing oxygen therapy, oxygen safety, or the monitoring of oxygen use. C. Record review of R #80's active physician orders, dated 05/07/26, revealed a physician's order for oxygen therapy was not present. D. On 05/07/26 at 10:15 am, during an observation and interview, R #80 was observed sitting in her room using oxygen through a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). R #80 stated she has been using oxygen for a long time. R #80 stated she typically used 5 liters per minute (LPM) of oxygen throughout the night and between 2 to 5 LPM throughout the day. E. On 05/11/26 at 11:48 am, during an interview, the Director of Nursing (DON) stated residents who require oxygen should have an active physician's order for oxygen use and oxygen use should be addressed in the resident's care plan. The DON stated she was aware that R #80 used oxygen. The DON reviewed R #80's physician orders and stated the record did not include an active physician order for oxygen therapy. The DON stated R #80 should have had an active physician order and care plan interventions which addressed oxygen use.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) for 1 (R #2) of 3 (R #2, #12, and #133) residents reviewed for ADL care provided to dependent residents, when staff failed to: Provide baths/showers per the facility bathing schedule. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #2's face sheet revealed an admission date of 03/16/26 and included the following diagnoses:Reduced mobility.Difficulty in walking.Generalized muscle weakness. B. Record review of the facility's shower schedule revealed R #2's scheduled shower days are Wednesday and Saturday during the daytime. C. Record review of R #2's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/22/26, revealed R #2 is dependent for staff assistance and requires substantial/maximal assistance with showering/bathing. D. Record review of R #2's documentation survey report (ADL tracking form), dated 03/16/26 through 03/31/26, revealed R #2's bathing (baths/showers) was not documented as being completed. E. Record review of R #2's shower sheets, dated 03/16/26 through 03/31/26, revealed R #2 was offered or provided 2 baths/showers out of 4 opportunities. F. Record review of R #2's documentation survey report, dated 04/01/26 through 04/30/26, revealed R #2 was offered or provided 1 bath/shower out of 9 opportunities. G. Record review of R #2's shower sheets, dated 04/01/26 through 04/30/26, revealed R #2 was offered or provided 3 baths/showers out of 9 opportunities. H. On 05/04/26 at 12:01 pm, during an interview, R #2 stated she is not receiving showers according to the facility's shower schedule. She said she wants showers, but she is not given them as the facility is supposed to provide. I. On 05/12/26 at 1:02 pm, during an interview, the Director of Nursing (DON) stated she thinks R #2 was being offered showers on days that were not scheduled to make up for showers that were missed on the scheduled days. She stated it was her expectation for Certified Nursing Assistants (CNAs) to offer residents showers on their scheduled days. The DON stated R #2 was not offered or given enough showers per the facility shower schedule and should have.

Based on record review, observations, and interviews, the facility failed to ensure call lights were accessible and within reach for residents at risk for falls and injury. This failure occurred for 3 (R #3, R #4, and R #5) of 3 (R #3, R #4, and R #5) reviewed and created the potential for accidents, delayed response to resident needs, and injury. The findings are:R # 3AA. Record review of the facility's Call Light Policy dated 07/15/25 revealed staff will ensure call lights are within reach of the patient and secured as needed.BB. Record review of R #3's facesheet revealed R #3 was admitted to the facility on [DATE] with diagnosis: Repeated falls, Difficulty in walking, Muscle waste (reduction in the power exerted by muscles) and atrophy (partial or complete wasting away of a part of the body), Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infraction affection right dominant side.CC. On 12/17/25 at 12:25 p.m., during an observation of R #3 lying in bed resting, a white call light with a coiled cord was lying on the floor next to the resident bed. The call light was partially extended beneath the bedside area; the call light was positioned on the floor near the bed frame and bedside table legs.DD. On 12/17/25 at 12:28 p.m., during an interview with Certified Nurse Aide (CNA) #1, she stated the call light should not be under the bed, she stated if the call light is not in reach of the resident the resident could reach over and fall on the ground and get hurt. R #4EE. Record review of R #4 facesheet revealed R #4 was admitted to the facility on [DATE] with diagnosis of: Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Insomnia, Muscle weakness, Lack of coordination.F. F. Record review of R # 4 Annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/30/25 with a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) of 12 (8-12 is moderately impaired).GG. On 12/17/25 at 12:32 p.m., during an observation of R #3 lying in bed asleep, the call light was lying on the floor, positioned under the bed frame in close proximity of the wheels and base of an oxygen concentrator.HH. On 12/17/25 at 12:42 p.m., during an interview with CNA #2, she stated the call light should not be under the foot of the bed, she stated the call light should be secured to the side of the pillow so the residents can reach the call light when they need help. She stated if the call light is on the floor the resident could attempt to get the call light and fall out of bed.R #5I. I. Record review of R #5's facesheet revealed he was admitted on [DATE] with diagnosis of: Seizures (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) Muscle spasm Contracture (a shortening of muscles around joints causing joint stiffness and immobility) left hand, hip, and kneeJ.J. Record review of R #5's MDS revealed he has a BIMS of 12.K K On 12/17/25 at 3:25 p.m., during an observation of R #5 lying in bed revealed the call light was laid on top of the air pump used to operate the resident specialty mattress at the foot of the bed.L L. On 12/17/25 at 3:46 p.m., during an interview with CNA #3, she stated the call light should not be laying at the foot of the bed, she stated the call light should be in reach of the resident. She stated if the call light is not in reach of the resident, then the resident could not call for help if he needs it. M. On 12/18/25 at 10:43 a.m., during an interview with Director of Nursing (DON), she stated all call lights should be clipped to the resident's beds so all residents could reach their call lights when they need assistance.

Based on record review, observation and interview, the facility failed to ensure medications were stored securely when a medication cart remained unlocked and unattended on the 500 Hall. This failure created the potential for unauthorized access to medications, including controlled substances, for 1 of 1 medication carts observed.The findings are:A. Record review of the facility's Medication Storage and Security Policy, revised January 2025, revealed the facility requires all medications to be kept secured at all times. The policy states medication carts must remain locked when not in the direct possession of licensed staff, and controlled substances must be stored in a separately locked, permanently affixed compartment. The policy further states staff must ensure medications are protected from unauthorized access by residents, visitors, or staff.B. On 12/18/25 at 8:06 a.m., observation of the 500 Hall revealed a medication cart positioned in the hallway with the drawers unlocked and the nursing computer left open with the medication administration record (MAR). No staff were present in the immediate area, and the cart remained unattended and accessible to residents walking through the hallway.C. On 12/18/25 at 8:08 a.m., during an interview, RN #1 stated she had just stepped away for a moment into a resident's room and stated she left the cart unlocked. RN #1 stated the cart contained narcotics stored inside the locked box, but the remaining drawers contained other resident medications. RN #1 stated, If the medication cart is left unlocked a resident could get into the cart and take medication that does not belong to them.D. On 12/18/25 at 1:32 p.m., during an interview with Director of Nursing (DON), stated it is her expectation all medications carts should remained locked at all times. She stated if the medication carts are not locked then a resident could go into the medication cart and take medication that does not belong to them.

Based on a record review and interviews, the facility failed to update physician's orders for 1 (R #1) of 1 (R #1) resident who received supplemental oxygen, when the resident required a greater oxygen flow rate. If staff fail to update the physician's orders, then the resident may not receive the services for optimum health. The findings are: A. Record review of R #1's face sheet revealed an admission date of 06/06/25 with the following diagnoses:- Chronic obstructive pulmonary disease (COPD; lung disease)- Acute and chronic respiratory failures with hypercapnia (an excessive amount of carbon dioxide in the blood),- Hypoxia (a low level of oxygen in the blood).B. Record review of R #1's physician orders, dated 06/06/25, revealed an active order to titrate oxygen between 1 to 5 liters per minute (L/min) to maintain oxygen saturation between 88% and 92%.C. Record review of R #1's oxygen vitals log, dated 05/06/25 through 06/11/25, revealed the following:-On 05/17/25 at 12:55 p.m., the oxygen flow rate was 6 L/mi. -On 05/17/25 at 7:43 p.m., the oxygen flow rate was 6 L/min.-On 05/19/25 at 7:39 a.m., the oxygen flow rate was 6 L/min. -On 05/20/25 at 9:55 p.m., the oxygen flow rate was 6 L/min. D. Record review of R #1's progress note, dated 06/11/25, revealed the resident had an oxygen saturation of 79% on 6 L/min. The resident was transported to the hospital for acute respiratory failure.E. On 07/30/25 at 2:15 p.m., during an interview with the Director of Nursing (DON), she stated the resident's oxygen order required titration between 1 to 5 L/min. She confirmed the resident was on 6 L/min at times, and the order should have been updated when the flow exceeded the prescribed range. She stated the resident had fluctuating oxygen needs, but she could not provide documentation to show staff notified the resident's provider.F. On 07/30/25 at 2:49 p.m., during an interview with the Administrator, she stated a new order was necessary if the resident received an oxygen flow rate higher than the prescribed dose of 1 to 5 L/min.G. On 08/04/25 at 10:30 a.m., during an interview with the Medical Director, he stated the facility should follow orders as written.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for showering for 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice could likely to affect the dignity and health of the residents. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE], with the following diagnosis: 1. Chronic Obstructive Pulmonary Disease (COPD; is an ongoing lung condition caused by damage to the lungs), 2. Syncope workup (a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, typically from low blood pressure), 3. Severe sepsis, (infection with systemic manifestations of sepsis along with sepsis-related tissue hypoperfusion or organ dysfunction), 4. Acute chronic hypoxic respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), 5. 2/2 left-sided pneumonia (pneumonia that affects both lungs at the same time), 6. Colitis (an inflammation of the lining of the colon), 7. Diarrhea ( the condition of having at least three loose, liquid, or watery bowel movements in a day). B. Record review of R #1's care plan dated 02/17/25 revealed R #1 requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene. C. Record review of facility's shower schedule (no date) revealed R #1 was scheduled to receive a shower every Monday and Thursday during the night shift. D. Record review of R #1's discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment dated [DATE], Section GG revealed R #1 requires supervision or touching assistance by a helper for showering and bathing. E. Record review of R #1's electronic health record (EHR) revealed R #1 received one shower on 02/20/25 and did not reveal any additional documentation of R #1 refusing showers. F. On 04/17/25 at 8:53 am, during an interview, son of R #1 stated that he had a concern with the quality of care for R#1, due to only receiving one shower the entire time since admitted to the facility. He said his mom had health issues that required more frequent showering and expected the facility to assist her, but they did not. G. On 04/17/25 at 9:40 am, during an interview, Director of Nursing (DON) stated R #1 was at the facility briefly in February of 2025. R #1 was experiencing breathing issues, so her son wanted her to be evaluated at the hospital and chose not to return. R #1 was discharged on [DATE]. The DON confirmed that the facility had documented evidence of one shower during R #1's stay at the facility. She stated that she expects every shower or refusal to be documented.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #42) of 3 (R #31, #42 and #58) residents when they failed to monitor R #42 for signs and symptoms of stroke and to treat R #42 with blood thinning medication as ordered. This deficient practice is likely to result in residents experiencing worsened conditions or death. The findings are: A. Record review of R #42's face sheet revealed an admitted [DATE] and included the following diagnoses: - Cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Reduced mobility, - Peripheral vascular disease (PVD; disorder that causes abnormal narrowing of arteries). B. Record review of R #42's hospital discharge records, dated 10/23/24, revealed the following : - An order for clopidogrel (blood thinning medication) tablet, 75 milligrams (mg) daily. Route: Oral (by mouth). Date first scheduled: 10/11/24. - History of pontine cerebrovascular disease (a life-threatening blockage of blood flow to part of the brainstem). Patient was hospitalized in February 2024 for transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period of time) in the setting of medication noncompliance (failure to take prescribed medications as directed by a healthcare provider). Continue home medication Lipitor (medication that lowers the amount of fats in the blood), 890 mg daily and Plavix (brand name for clopidogrel) 75 mg daily. - Discharge summary notes: On 09/19/24 [information included on discharge summary from a previous hospitalization ] patient was cleared to resume Plavix by gastrointestinal (GI; diseases affecting the stomach and intestines) specialist on 09/18/24 after his recent episode of GI bleed. - During his hospitalization , there were not any reported signs of overt (obvious) GI bleed, and hemoglobin (protein in red blood cells) remained stable around baseline. C. Record review of R #42's history and physical (H&P), dated 10/24/24, revealed the following: - The resident had a history of pontine cerebrovascular accident (CVA; stroke) and TIA. - The record did not mention treatment to prevent another CVA. D. Record review of R #42's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/29/24, revealed the following: - Active diagnoses: CVA, TIA, or Stroke. - Medications: The resident did not receive an antiplatelets (medication that prevents blood clots) or anticoagulants (blood thinner). E. Record review of R #42's Medication Administration Records (MAR), dated October 2025 through February 6, 2025, revealed there was no order for or instructions for staff to administer clopidogrel, 75 mg to R #42. F. Record review of R #42's Treatment Administration Records (TAR), dated December 2024 through February 2025, revealed the following: - Diagnoses included unspecified sequelae of cerebral infarction and PVD. - The record did not instruct staff to monitor for signs and symptoms of stroke. G. Record review of R #42's quarterly MDS, dated [DATE], revealed the following: - Active Diagnoses: CVA, TIA or Stroke. - Medications: The resident did not receive an antiplatelet and/or anticoagulant. H. Record review of R #42's current physician orders, dated February 2025, revealed the record did not contain an order for clopidogrel, 75 mg or any other antiplatelet or blood thinner medication. I. On 02/04/25 at 9:28 am during an interview, R #42 stated he needed to be on a blood thinner. He stated he used to be on heparin (blood thinning medication), but when he came to the facility from the hospital, the facility staff did not give him the blood thinner. J. On 02/06/25 at 4:58 pm during an interview with the Medical Director (MD), he stated R #42's hospital discharge records contained an order for clopidogrel 75 mg, and R #42 should have received the medication while at the facility. He verified staff did not administer the clopidogrel to R #42 since his admission to the facility [10/23/24]. He reviewed R #42's medical record and stated someone at the facility dropped the ball. K. On 02/07/25 at 9:18 am during an interview with the Director of Nursing (DON), she confirmed that she was responsible for verifying the admission orders during the post admission resident review, but she missed the order for clopidogrel, therefore it was not ordered and was not being administered to R #42. L. On 02/07/25 at 10:47 am during an interview, the Nurse Practitioner (NP) stated the order for clopidogrel 75 mg was on R #42's admission orders from the hospital, but the orders were not clear about how long the resident should continue to take the medication. She stated staff should have administered the clopidogrel to R #42 based on the admission orders from the hospital. M. On 02/25/25 at 12:47 pm during an interview with the Administrator and the DON, they stated the R #42 had multiple diagnoses, and he had complex medical needs. They stated the resident's stroke occurred over a year ago, and it was not the primary reason for his admission to the facility. The Administrator and the DON stated the resident had an initial care plan meeting on 10/27/25, and he attended the meeting. They stated the resident had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact; but he did not mention that he should take a blood thinning medication. The Administrator and the DON confirmed R #42's medical record did not instruct staff to monitor the resident for signs and symptoms of stroke. They stated they monitor all residents for signs of a change of condition. The Administrator and the DON confirmed they did not treat the resident for his history of CVA. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 02/07/25 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 02/07/25 at 3:15 pm. Implementation of the POR was verified onsite on 02/10/25 by conducting record reviews and staff interviews. Scope and Severity was reduced to Level 2, E. Plan of Removal: All residents have the potential to be affected by this alleged deficient practice. The following corrections were completed by 02/07/25: - Audit all residents with a diagnosis of CVA to ensure antiplatelet therapy was in place as ordered. - Audit of recent admissions to ensure accurate medication reconciliation, review, and continuation of medications and treatments. - All licensed staff educated regarding medication transcription, medication reconciliation upon admission, and documentation in the resident's chart. - During morning clinical meetings, medication reconciliation audits occur for new admissions and medication order changes. - Nurse Practice Educator or Designee will begin education on 02/07/25 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing (DON) or designee will audit five random residents three times a week to ensure all medications reconciliations have occurred. - The DON or designee will bring results of audits to Quality Assurance and Performance Improvement (QAPI) committee for further recommendations based on tracking and trending. It will be presented monthly for the next two months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

Based on record review and interview, the facility failed to administer clopidogrel (blood thinning medication used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease) as ordered by the physician for 1 (R #42) of 3 (R #31, #42 and #58) residents reviewed for medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffer prolonged illness. The findings are: Cross Reference findings from F684. A. Record review of R #42's face sheet revealed an initial admitted [DATE] and included the following diagnoses: - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Congestive systolic and diastolic heart failure, - Peripheral vascular disease (disorder that causes abnormal narrowing of arteries). B. Record review of R #42's hospital discharge records, dated 10/23/24, revealed the following : - An order for clopidogrel (blood thinning medication) tablet, 75 milligrams (mg) daily. Route: Oral (by mouth). Date first scheduled: 10/11/24. - Continue home medication Lipitor (medication that lowers the amount of fats in the blood), 890 mg daily and Plavix (brand name for clopidogrel) 75 mg daily. C. Record review of R #42's Medication Administration Records (MAR), dated October 2025 through February 6, 2025, revealed staff did not administer clopidogrel, 75 mg to R #42. D. On 02/06/25 at 4:58 pm during an interview with the Medical Director (MD), he stated R #42's hospital discharge records contained an order for clopidogrel 75 mg on admission to the facility. He verified staff missed the order and did not administer clopidogrel to R #42 since the resident's admission to the facility on [DATE]. E. On 02/07/25 at 9:18 am during an interview, the Director of Nursing (DON) stated she missed the resident's order for clopidogrel when she verified R #42's admission orders. F. On 02/07/25 at 10:47 am during an interview, the Nurse Practitioner (NP) stated R #42's hospital discharge orders included an order for clopidogrel. She stated R #42 should have received clopidogrel while at the facility. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 02/07/25 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 02/07/25 at 3:15 pm. Implementation of the POR was verified onsite on 02/10/25 by conducting record reviews and staff interviews. Scope and Severity was reduced to Level 2, E. Plan of Removal: All residents have the potential to be affected by this alleged deficient practice. The following corrections were completed by 02/07/25: - Audit all residents with a diagnosis of CVA to ensure antiplatelet therapy was in place as ordered. - Audit of recent admissions to ensure accurate medication reconciliation, review, and continuation of medications and treatments. - All licensed staff educated regarding medication transcription, medication reconciliation upon admission, and documentation in the resident's chart. - During morning clinical meetings, medication reconciliation audits occur for new admissions and medication order changes. - Nurse Practice Educator or Designee will begin education on 02/07/25 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing (DON) or designee will audit five random residents three times a week to ensure all medications reconciliation have occurred. - The DON or designee will bring results of audits to Quality Assurance and Performance Improvement (QAPI) committee for further recommendations based on tracking and trending. It will be presented monthly for the next two months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

Based on record review and interview the facility failed to provide quality of care for 1 (R #5) of 3 (R #5, 6, and 7) residents reviewed when they failed to: 1. Identify a change in condition for seven days, 2. Notify the Physician and Power of Attorney (POA; someone to make decisions for you when you are no longer to make them) of the decline, 3. Assess for the cause of the decline and provide treatment, 4. Send the resident to the hospital and waited 15 hours after the request by the POA. This deficient practice likely resulted in further decline for R #5 and a delay in providing life saving treatment. The findings are: A. Record review of R #5's face sheet indicated R #5 was originally admitted to the facility on [DATE] with the following diagnoses: - Multiple sclerosis [a potentially disabling disease of the brain and spinal cord (central nervous system)], - Trigeminal neuralgia (a chronic pain disorder that causes intense pain attacks in your face), - Neuromuscular dysfunction of the bladder (condition that affects bladder function due to nervous system injury or disease), - Suprapubic catheter (tube that is inserted into your abdomen to drain urine), - Antibiotic resistance, - Methicillin resistant staphyloccus aureus infection (MRSA; a staph bacteria that is resistant to many antibiotics), - Bacteremia (bacteria in the blood), - Metabolic encephalopathy (a change in brain function due to an underlying cause), - Severe sepsis with septic shock (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), - Acute kidney failure (an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), - Dysphagia (difficulty swallowing foods and liquids), - Protein calorie malnutrition (not enough calories). - This is not an all inclusive list. B. Record review of the hospice's consult form for R #5, dated [DATE], indicated R #5 accepted hospice on [DATE] with a diagnosis of multiple sclerosis. C. Record review of a sepsis assessment for R #5, dated [DATE], indicated the following: - For Question #3, Neurological, staff documented the following: - Is there slow mental status? Yes. - Are there any new or worsening confusion? Yes. - Is there any new/worsening confusion? Yes. - Is there any new/worsening agitation? Yes. - For Question #4, Plan, staff documented the following: - Were positive findings identified (any two positive vital signs or any one system finding present)? Yes . - Current diagnosis and/or history of sepsis? Yes. - Type of follow-up needed? Every six hours. Positive finding and/or practitioner recommendation. D. Record review of the nursing progress notes for R #5 revealed the following: - Dated [DATE] at 3:16 pm, R #5 refused medications and stated, I don't want it. The resident put her hands against her face/mouth and attempted to push away the medication when staff tried to administer it. Hospice made aware. The note did not indicate if staff notified the POA or hospice physician. - Dated [DATE] at 12:59 am, R #5 was crying, called out for help, and refused her medications. Hospice nurse to order Haloperidol (an anitpsychotic medication) intramuscularly (IM) and all other medications in liquid form. The note did not indicate if staff notified the POA or hospice. - Dated [DATE] at 5:38 pm, Hospice nurse and Certified Nursing Assistant saw R #5. R #5 was responding verbally. The resident was able to mention her name softly when staff asked. The resident refused all medications except Gabapentin (medication to treat seizures and pain) and drank two cups of water with staff assistance. - Dated [DATE] at 3:36 pm, R #5 was not eating or taking medication. The hospice nurse was in the facility when R #5's POA called the facility. The POA stated he no longer wanted his sister (R #5) to be on hospice when staff informed him of R #5's declining status. Facility staff stated they would send him a new advanced directive form (a legal document to provide instructions for medical care that goes into effect when an individual cannot communicate their wishes), and he needed to fill it out and send it back. The note revealed R #5 would remain on hospice services and would remain a Do Not Resuscitate (DNR; lifesaving measures are not desired) until the facility received the Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form back indicating the new interventions. The note did not indicate if staff notified the hospice physician. - Dated [DATE] at 4:09 pm, R #5's vital signs were ,d+[DATE] blood pressure (BP; normal is ,d+[DATE]), 97.8 degrees ( ) Fahrenheit (F) temperature (98.6 F is normal), 80 pulse (normal is 60 to 100), 92 percent (%) oxygen saturation (the amount of oxygen in the blood. Normal is in the 90%s) on 2 liters (L) of oxygen, 17 breaths per minute (bpm; normal is 12 to 20). - Dated [DATE] at 10:51 pm, the Director of Nursing (DON) contacted Nurse #1, who was working at the facility with R #5 that evening. The DON told the nurse if the family wanted R #5 sent to the hospital then the resident needed to be sent to the hospital. Nurse #1 contacted the ambulance company and requested a transport for R #5. The ambulance dispatch asked why R #5 needed to be transported to the hospital. Nurse #1 told the ambulance dispatch the family requested for the resident to go, and R #5 was on hospice. Nurse #1 explained multiple times to the ambulance dispatch the family requested the transport. Nurse #1 stated she would contact the DON to see if she could explain it to the ambulance dispatch so they would better understand why R #5 needed to go to the hospital. Nurse #1 also called a different ambulance service, but they requested insurance paperwork and information. Nurse #1 waited for a response from the DON on the transport. - Dated [DATE] at 6:53 am, the dayshift nurse, Nurse #2, called the ambulance again to have R #5 picked up and taken to the hospital. Nurse #2 completed an assessment on R #5 and the resident's vitals were: blood pressure ,d+[DATE], pulse 49, respirations 10, temperature 99.9 F, and oxygen saturation 79%. Staff turned up R #5's oxygen administration to 4 liters per minute, and the resident's oxygen saturation went up to 96 %. R #5' urine output was 50 cubic centimeter (cc) and was dark. E. Record review of the hospital's documentation for R #5 indicated the following: - R #5 arrived to the hospital on [DATE]. - R #5 was unresponsive at her facility that morning, [DATE]. - Once in the emergency department, R #5 was noted to be hypotensive (low blood pressure), bradypneic (abnormally slow breathing rate), was subsequently intubated (a tube is inserted into trachea to help breathe), and started on vasopressors (help raise blood pressure when the blood pressure is so low that enough blood cannot get to the organs). - Computed tomography (CT; uses several X-ray images and computer processing to create cross sectional images) was consistent with bilateral lower lobe atelectasis (the collapse of the lower parts of both lungs). - CT scan of abdomen/pelvis with stercoral colitis (abdominal pain, abdominal distension, constipation, nausea and/or vomiting, and loss of appetite) with cystitis (infection or inflammation of the urinary bladder caused by bacteria). - Other significant findings included metabolic acidosis (acids build up in the body due to poor kidney function) and acute kidney injury (AKI; when the kidneys cannot filter waste products from the blood) with oliguria (low urine output). - R #5 was admitted to medical intensive care unit (MICU) for further work up and management. - Critical Care Attestation indicated ongoing acute issues continued to contribute to current critical state. At time of evaluation, patient was critically ill and had a high probablity of imminent lift or limb threatening deterioration due to acute central nervous system compromise and respiratory failure. To stabilize critical patient, support vital functions, and prevent further decline, bedside assessment was completed to include interpreting cardiac monitoring and resuscitating the patient with mechanical ventilator mangement. F. On [DATE] at 12:24 pm, during an interview with R #5's brother/POA, he stated they told his sister when they offered hospice services that they would be able to offer more care for her, and they told him the same thing. He stated he signed the paperwork. The POA stated he received a call from a friend a couple of weeks later. The friend had gone to the facility and saw R #5 on [DATE]. The POA stated his friend told him that R #5 looked awful and did not seem like she was going to make it through the day. The POA stated that was when he called the facility and spoke with the nurse. The POA stated staff told him R #5 was on hospice care, and she was a DNR status. The POA stated the staff told him the interventions were limited unless he no longer wanted hospice. The POA stated staff told him he would need to change R #5's code status for interventions, The POA stated he wanted to change R #5's code status, and he wanted his sister to go to the hospital. He stated he also spoke with hospice and told them the same thing. He stated he wanted his sister's code status changed, he wanted his sister to go out to the hospital, and he no longer wanted hospice services. He stated there was a delay in getting his sister sent to the hospital, and she did not go out until the next day. G. On [DATE] at 9:00 am, during an interview with R #5, she stated she thought she would get more of her needs met when she went on hospice. She stated she agreed to go on hospice. R #5 stated she did not feel like anyone listened to her and like she got less care on hospice. R #5 stated that she was pretty out of it before she was sent to the hospital on [DATE] so she did not remember a lot of what happened. She stated that she almost died . She stated she was a full code status (life saving interventions desired) and not on hospice since she returned from the hospital. H. On [DATE] at 11:30 am, during an interview with the DON, she stated she spoke with one of the hospice providers on [DATE], and she thought it was the Hospice DON. The DON stated the hospice staff told her hospice was fine with sending R #5 out to the hospital. The DON called Nurse #1 on [DATE] and told her to send R #5 to the hospital, because that was what the family wanted. The DON could not recall the exact time she spoke to Nurse #1, but stated it was later in the day. The DON stated Nurse #1 called Emergency Services Dispatch on [DATE], and the dispatch staff asked why R #5 needed to go to the hospital. Nurse #1 told dispatch staff that the family requested the resident to be sent out. The DON said she received another call from Nurse #1, because she was concerned she did not have the resident's new/updated MOST form. The DON told Nurse #1 that R #5's brother verbally stated he wanted R #5 to be sent to the hospital and wanted her to be a full code; therefore, the facility needed to follow those wishes. The DON said Nurse #1 called Emergency Services Dispatch to tell them that R #5 was a full code, and the family wanted her to be sent out. The DON stated the Emergency Services Dispatch told Nurse #1 that they would come pick the resident up when they could, because it was not an emergency. The DON stated Nurse #2 completed an assessment on R #5 during the morning shift on [DATE] and found R #5 was declining. The DON stated the resident's vitals indicated she was very close to dying. Nurse #2 called Emergency Services Dispatch again to take R #1 to the hospital due to her condition was an emergency. The DON stated R #5's decline was expected. She stated did not keep R #5's brother/POA informed of the resident's decline, because he was not that involved in R #5's care.

Based on record review and interview, the facility failed to: 1. Provide oversight of shower sheets to identify wounds, 2. Accurately document new skin impairments on Skin Checks, 3. Update and implement new preventative measures, treatment, and orders when new skin impairments were identified for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for pressure wound injuries. This deficient practice could like result in new pressure injuries, pain, or significant decline in health status. The findings are: A. Record review of R #1's current electronic health record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Polyosteoarthritis [five or more joints have arthritis (a painful inflammation and stiffness of the joints) at the same time], - Age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue), - Peripheral autonomic neuropathy (damage to the autonomic nervous system, which controls involuntary body functions such as heart rate, perspiration, blood pressure, digestion, loss of bladder control), - Psoriasis (a skin disease that causes a rash with itchy, scaly patches). - These diagnoses are not all-inclusive and do not include all of R #1's diagnoses. B. Record review of R #1's Braden Scale for Predicting Pressure Score Risk (an assessment tool used to assess and document a resident's risk for developing pressure injuries), dated [DATE], showed a score of 11, which indicated a high risk to acquire pressure sores. C. Record review of R #1's care plan, review date [DATE], revealed the following: - R#1 required extensive assistance of one with bed mobility, changing, dressing, and personal hygiene. - R#1 was at risk risk for skin breakdown related to decreased mobility, and frail fragile skin. - Staff to implement the following interventions: - Observe skin for signs and symptoms of skin breakdown, such as redness,cracking, blistering, decrease sensation, and skin that does not blanche (change to white color when pressure is applied) easily. - Evaluate for any localized skin problems, such as dryness, redness,pustules, inflammation. - Assist resident in turning and reposition every two hours. - Pressure redistribution surface to bed, low air loss mattress (a mattresses designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) - The care plan did not contain interventions related to the resident's refusals of nail care and scratching at wounds. D. Record review of the facility policy, titled NSG236 Skin Integrity and Wound Mangement #6, revision date [DATE], stated, The licensed nurse will perform and document skin inspections .weekly .and with any significant change in condition. E. Record review of R #1's Skin Check forms, dated [DATE], revealed nursing staff documented the following: - On [DATE], the resident had new skin wounds. An open area to the resident's right hip, an abrasion which measured approximately 1 inch (in) by 0.75 in; a scab to the resident's anterior (palm) right hand, which measured 0.5 in by 0.5 in; and redness to the resident's right antecubital space (the space inside the crook of the elbow). - On [DATE], the resident had a previously identified skin wound initially thought to be from self-scratching will now be re-classified as unstageable pressure with new SWIFT (Swift technology - a digital program that visualizes and measures wounds accurately, and automatically tracks wound healing progression and management) photo, located at the right hip and right elbow. A skin tear/bruise was located at the right elbow. F. Record review of R #1's Skin and Wound Evaluations (an evaluation performed to document and determine the appropriate treatment for a wound), dated [DATE], revealed staff documented the following: - On [DATE], the resident had a front right hip abrasion which measured 2.52 cm (centimeters) long, 3.37 cm wide. - On [DATE], the resident had a front right hip wound which measured 1.9 cm length, 3.0 cm width. - On [DATE], the resident had a right hip wound reclassified as pressure injury, unstageable [a full-thickness injury in which the base of the wound is obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dry, black, hard dead tissue)]. G. Record review of R #1's Skin Check forms (a medical form used to track and assess skin issues and conditions), dated [DATE], revealed nursing staff documented the following: - On [DATE], the resident had a Stage 3 pressure ulcer (a pressure sore that has full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) located on the right hip; A skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. H. Record review of R #1's Skin Assessment, dated [DATE], revealed staff documented the resident had a in-house acquired (wound developed after admission to a healthcare facility) right hip pressure wound, stage 3, full thickness skin loss, which measured 0 centimeter (cm) by 0 cm by 0 cm and classified as resolved. Staff noted a foam dressing was placed on the area for protection, and wound care orders were to be discontinued on [DATE]. I. Record review of R #1's physician's orders, dated [DATE], revealed the record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE]. J. Record review of a physician progress note for R #1, dated [DATE], MD #1 indicated the Stage 3 pressure was healed and measured 0 cm by 0 cm, with no measurable depth and an area of 0 cm2. K. Record review of R #1's shower sheets, dated [DATE], staff documented the following: - On[DATE], the resident had reddened areas and an open area on R #1's hips, scratches on R #1's lower back, and the resident refused nail care. - On [DATE], the resident had reddened areas, an open area, and a darkened area on both of R #1's hips, scratches on R #1's lower back, and the resident refused nail care. - On [DATE], the resident had reddened areas and an open area on R #1's hips, a wound on the lower back, and the resident needed nail care but refused. The staff also documented that R #1 takes off dressings. L. Record review of R #1's Skin Check forms, dated [DATE], revealed the following: - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. M. Record review of R #1's Skin and Wound Evaluations revealed staff documented the following: - The record did not contain skin and wound evaluations between [DATE] to [DATE]. - On [DATE], the resident had a right shoulder, blister which measured 1.89 cm by 0.89 cm. - On [DATE], the resident had a right shoulder Stage 2 pressure ulcer (an ulcer that has a break in the top two layers of skin, usually open with swelling, discoloration, and pain), which measured 1.63 cm by 1.22 cm. - On [DATE], the resident had a sacrum wound, which was unstageable, with slough and/or eschar, and measured 5.7 cm by 3.3 cm, Staff noted the following interventions: foam dressing, mattress with pump, pillows, repositioning every one to two hours, practitioner notified. - On [DATE], the resident had a unstageable sacrum (the large, triangular bone at the base of the spine) wound, which measured 6.04 cm by 3.07 cm. - On [DATE], the resident had a front left hip, unstageable, deep tissue injury (DTI; persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin, or blood-filled blisters caused by damage to the underlying soft tissues), unstageable, which measured 3.04 cm length by 3.21 cm. Applied betadine foam (a type of antiseptic). - On [DATE], the resident had a front left hip, unstageable pressure ulcer, slough and/or eschar, which measured 3.24 cm by 2.93 cm. - On [DATE], the resident had an unstageable front right hip pressure wound which measured 6.56 cm by 4.85 cm. - On [DATE], the resident had an unstageable front right hip wound, new, in-house acquired, which measured 8 cm length, 8.9 cm width, with full thickness skin and tissue loss, 100% of the wound is eschar filled, redness, inflammation, warmth, light exudate (a fluid released by a wound), serosanguineous (drainage containing blood), no odor after cleansing. N. Record review of R #1's physician's orders for R #1 revealed the following: - The record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE] through [DATE]. - A wound care order, start date [DATE], for unstageable pressure ulcer of the sacrum. Cleanse the wound with Vashe (name brand of a type of a saline based wound cleanser), paint the area around the wound with Betadine (a type of a topical antiseptic that provides infection protection), apply a skin layer of Therahoney (wound healing ointment), cover with Calcium Alginate (wound dressing), and cover the wound with foam dressing. Every day shift and as needed. - A wound care order, start date of [DATE], for unstageable pressure ulcer of the right hip. Cleans the wound with wound cleanser or Vashe, skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled or missing. - A wound care order, start date of [DATE], for unstageable pressure ulcer of the left hip. Cleanse the wound with wound cleanser or Vashe, skin prep to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled, or missing. - A wound care order, start date of [DATE], for a blister located on the right shoulder. Clean with Vashe, paint the wound with Betadine, skin prep to surrounding area, and cover with foam dressing for protection. Every day shift. - A wound care order, start date of [DATE], to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following as needed orders, every night shift. - An order for doxycycline hyclate oral tablet (an antibiotic used to treat infections), 100 milligrams (mg). Give one tablet by mouth two times a day for wound infection for ten days. O. Record review of R #1's Treatment Administration Record (TAR), dated [DATE], revealed the following: - Wound care unstageable pressure sacrum: Cleanse with wound cleanser or Vashe and pat dry. Paint intact peri-wound with Betadine. Apply thin layer of Therahoney to open area, then cover with Calcium Alginate. Skin prep to surrounding skin. Cover with foam dressing, every day shift for sacral pressure ulcer. Start Date -[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care unstageable pressure ulcer right hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for right hip pressure ulcer. Start Date -[DATE] 6:00; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care unstageable pressure ulcer left hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for left hip pressure ulcer. Start Date -[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care blister right posterior shoulder: Cleanse with wound cleanser or Vashe and pat dry. Generously paint with Betadine. Skin prep to surrounding skin. Cover with foam dressing for protection. As needed (PRN) for right shoulder blister. Start Date -[DATE] 6:15 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Staff to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following night (pm) orders. Every night shift for right shoulder, bilateral hips, and sacrum . Start Date -[DATE] 6:00 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Doxycycline hyclate oral tablet, 100 mg. Give 1 tablet by mouth two times a day for wound infection for ten days. Start Date -[DATE] 8:00 pm; discharge date -[DATE] 8:37 am. Staff administered the medication on [DATE], [DATE], [DATE]. P. Record review of R #1's nursing progress notes revealed the following: - On [DATE], facility staff notified the on-call provider that R #1 had symptoms of infection in the right hip. A physician's order for Doxycycline (an antibiotic used to treat infections), 100 mg, twice a day was received. - On [DATE] 6:27 pm, staff documented the resident's vitals as: blood pressure ,d+[DATE] (normal less than or equal to ,d+[DATE]) , pulse 94 (normal ,d+[DATE]), respiratory rate 16 (normal 12 to 18), temperature 99.7 (normal 97 to 99), pulse oximetry [a test used to measure the oxygen level (oxygen saturation) of the blood] 90 percent (%) (normal 95% to 100%). - On [DATE], R #1 developed a wet cough, (a cough that produces mucus or phlegm). - On [DATE] 7:41 am, staff documented the resident's vitals as: blood pressure ,d+[DATE], pulse 87, respiratory rate 17.0, temperature 97.7, pulse oximetry 92.0%. - On [DATE], R #1 had a change in condition of vital signs, with a pulse oximetry reading of oxygen 87%, altered levels of consciousness, and labored breathing. R #1 was transported to the emergency room . Q. Record review of R #1's hospital records, admitted [DATE], stated the following: - The resident was admitted with diagnoses of: - Severe sepsis (a serious infection usually caused when bacteria make toxins that cause the immune system to attack the body's own organs and tissues). - Decubitus ulcer (a pressure sore of damage to the skin and tissue underneath in the over the bony region of the very end of the spine) of coccyx. - Decubitus ulcer of hip. - Decubitus ulcer of shoulder blade. - Infection caused by multi-drug resistant bacteria. - Decubitus ulcer with full thickness skin loss involving damage of subcutaneous (beneath, or under, all the layers of the skin) tissue of right hip. - The list is not all inclusive and does not include all of R #1's diagnoses. -R #1 was admitted to the Intensive Care Unit for a septic (infected, or denoting infection) cough, secondary (relating to a medical condition that arises as a result of another disorder, disease process, or injury) to infected decubitus wounds. R #1 underwent incision and drainage [involves cutting and draining purulent (thick, white, and pus-like) contents from an abscess (a pocket of pus)] surgery of her right buttock and sacrum on [DATE]. Right hip and sacral eschars were removed. A culture of the sacral wound was positive for methicillin-sensitive staphylococcus aureus (MSSA; a type of infection, commonly known as a staph infection.) A culture of the fluid removed from R #1's right hip abscess, on [DATE], revealed a heavy growth of staphylococcus aureus (group of spherical bacteria that causes infections). - R #1 did not return to the facility. On [DATE], R #1 was admitted to Hospice. She expired on [DATE] at 6:50 am. R. On [DATE] at 9:22 am, during an interview with the Wound Care Nurse (WCN), she stated she became aware of R #1's wounds on [DATE] after the floor nurse alerted her. She said she was not aware of the resident's wounds between [DATE] and [DATE], because there was not a physician's order to treat them. She said R #1 had the original, right, front hip wound, a resolved Stage 3 pressure, which became unstageable; an unstageable to the sacrum; an unstageable to the left, front hip; and a right posterior (back) shoulder, Stage 2 pressure injury. The WCN stated she reassessed R #1's wounds on [DATE] and saw redness around the right, front hip and the other wounds. She said all the wounds had eschar. S. On [DATE] at 12:47 pm, during an interview, Certified Nursing Assistant (CNA) #1 reviewed and confirmed she completed the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]. She reported R #1 was getting red, and there were not treatment orders to address the areas of redness or the scratching. She stated R #1 would scratch at the sides of her hips and would remove the dressings that covered the wounds during the month of December. The CNA stated the wounds were scabbed and appeared to look like road rash, prior to healing. The scratched areas then would heal with a scab. The CNA reported R #1 would dig in her back with her long nails. She stated she spoke to the Assistant Director of Nursing (ADON) about her concerns for R #1, but she could not recall the date she reported it to the ADON. The CNA stated one of R #1's hip wounds healed, but then the wound came back. She reported the wound on R #1's right hip was red and healed. The CNA did not recall when the resident's left side got a wound but said it was red and started to become moist. She stated the wound on R #1's back (sacral area) was dark and black. CNA #1 reported she was not aware of any wounds to R #1's shoulder. She stated there was a mark on the resident's shoulder that looked like a pimple, but it would not have been something she would mark on a shower sheet. T. On [DATE] at 2:27 pm, during an interview with Registered Nurse (RN) #1, she stated when a CNA finds a new wound on a resident, the nurse will assess the wound and talk about it with the WCN. RN#1 stated staff should document new areas of redness on the resident. RN #1 stated the wound on R #1's right hip would bleed, and she would put a dressing on it. She said she did this maybe once or twice. She confirmed there were no orders for wound treatment for the resident's right hip wound. She stated the orders for treatments for R #1's right hip were discontinued on [DATE]. She stated R #1 needed orders for any treatments, and the WCN usually puts the orders into the resident's medical record. RN #1 stated she asked the WCN to check on R #1's right hip wound prior to going on leave on [DATE]. RN #1 did not remember seeing any scratches on R #1's left hip. She stated she saw the wound on the resident's back twice, and the wound was dark in the center with a scab and red outside the scab prior. The RN said she verberally reported this to the WCN prior to going on leave on [DATE]. U. On [DATE] at 9:15 am, during an interview, the ADON stated the process for identifying skin care issues for a resident included documenting on the shower sheet and communicating it to the nurse on the floor. He stated staff should document a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline, in physical, cognitive, behavioral, or functional domains). The ADON stated scratches and redness on hips were considered a change in condition, and staff should have created a change in condition record for R #1's skin conditions that staff identified on the shower sheets on [DATE] and [DATE]. The ADON said changes in scabs and open areas are also considered a change in condition He said staff should document a CIC in the resident's medical record, and the doctor will write an order for it. The ADON said CIC documents are reviewed by the unit manager, and staff also document it in a progress note. The ADON said the nurse who completed a CIC assessment was responsible to notify the provider. He said it did not have to be the WCN who notified the provider regarding CICs completed for a change in skin condition. The ADON stated R #1's medical record did not contain skin assessments, documentation of a conversation, or progress notes regarding the skin concerns documented on R #1's shower sheet dated [DATE]. The ADON confirmed he signed off on the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]; and that indicated the shower task was completed. The ADON stated the CNA was then given direction to follow-up with the nurse. V. On [DATE] at 9:41 am, during an interview, the WCN stated residents with scratches and scabs required skin assessments. She reviewed R #1's shower sheets dated, [DATE], [DATE], [DATE], and [DATE]. She said she was not aware of the changes identified on the resident's shower sheets, but staff should have made her aware, prior to [DATE]. The WCN stated staff can put foam dressing on the areas that are reddened and blanchable (when pressing an area of the body with a finger and releasing, the area should become pale and then return to its normal color). She said, if the area was opened, the granulation (the development of new tissue and blood vessels in a wound during the healing process) of the wound determined the type of protective dressing. She confirmed R #1's medical record did not contain orders for any type of dressings, prior to [DATE]. The WCN stated she expected to see the wounds documented on skin checks, because she reviewed skin checks and not CIC documentation. She stated there was a problem with staff informing her about the wounds. W. On [DATE] at 10:21 am, during an interview with the Director of Nursing (DON), she stated there was not a system to trigger change in condition for skin conditions documented on shower sheets that identified skin concerns. She stated new skin concerns were triggered by the skin check sheets. The DON stated if there was something new on the skin check then the WCN would do an assessment, but if the skin concern was not new then a skin assessment would not be triggered. The DON said the nurses address the skin check concerns the next day and create a CIC document for the skin concerns. The DON reviewed R #1's shower sheets for December, 2023 and stated the CNA should have alerted the WCN. The DON stated staff should have documented the new wound areas on the resident's skin checks. The DON stated R #1's skin checks stated right hip, which suggested there was a current injury to that area. She said the WCN would need to follow-up on that documentation. The DON stated there was a breakdown in communication. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 1:54 pm. Implementation of the POR was onsite on [DATE] by conducting observations, record reviews, and staff interviews. Scope and severity was lowered to D. Plan of removal: On [DATE], the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Beginning [DATE], the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee: Nurses will be educated on Genesis wound processes which include the DIMES, timely and accurate identification, and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. Center Nurses will be educated on responsibility regarding wound basics, wound evaluation, wound treatments, and documentation. CNA's will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes), and stop and watch. The Market Skin Team Health Lead will audit the skin integrity process weekly. The Skin Team Health Lead / DON will be responsible for the skin integrity process in the center and to make sure assessments, communications, and treatments are documented.

Based on observation, interview and record review, the facility failed to provide the required supervision for 1 (R #74) of 3 (R # 9, 74, and 78) residents reviewed when R #74 ate food from another resident's plate that was not within his ordered diet texture. This deficient practice could likely result in R #74 choking, needing to have the Heimlich maneuver (procedure for dislodging an obstruction from a person's windpipe) performed on him, be resuscitated (revived from unconsciousness), suctioned (removal of food) and could potentially cause death if this resident is not closely monitored by staff. The findings are: A. On [DATE] at 8:19 am during a random observation, breakfast was served on the 100 unit and two residents sat at a table. One resident (R #74) tried to take food off of resident (R #78) plate. She (R #78) slapped his (R #74) hand. He (R #74) attempted two more times, R #78 stopped him. Approximately five minutes later, R #78 left the table and exited the dining room. R #74 grabbed the bread off of R #78's plate and began to eat it. R #74 ate all of the remaining bread left on R #78's plate. Staff members that were in the dining room were not aware of R #74's behavior .Two Certified Nurse Assistance (CNA) assisted other residents with eating and the nurse was sitting at a chair working on the computer. B. Record review of the hospital documentation indicated R #74 was admitted to the hospital on [DATE] from a skilled nursing facility (previous facility) where he had choked on a ham sandwich and went into cardiac arrest (heart attack). Resident was on a dysphagia advanced diet (foods that are moist and bite sized) while at the skilled nursing facility (previous facility). It was unclear how R #74 got the ham sandwich. Resident was admitted to the MICU (medical intensive care unit) and was intubated (tube inserted into windpipe to aid in breathing). R #74 failed three swallow studies while in the hospital and a feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) was placed. He was discharged to the current facility on [DATE]. C. Record review of the face sheet for R #74 indicated the following: R #74 was admitted to the current facility on [DATE]. He was admitted as a full code (all necessary interventions) and he had a diagnosis of Dysphagia (difficulty swallowing food or liquid), Feeding Tube, Dementia (decreased ability to think and remember, emotional problems, problems with language, decreased motivation) with behaviors. This is not an all inclusive list of diagnoses. D. Record review of the physician orders dated [DATE] indicated R #74 was ordered a regular diet, dysphagia puree texture, thick liquids-nectar consistency (thicker than water but able to be poured or sipped). Double portions and with direct staff supervision on unit . E. Record review of the physician orders dated [DATE] indicated that R #74 was to be monitored for behaviors every shift: yelling, profanity, refusal of care, throwing food, eating off of other resident plates, agitation. F. On [DATE] at 11:30 am, during an interview, the Speech, Language Pathologist (SLP) stated R #74 was on a puree diet with nectar thick liquids for his regular meals. She stated he is impulsive and they are aware of his behavior of taking food off of other residents' plates. The SLP stated R #74 had a history of choking. He had choked at a previous facility and was admitted to the hospital. After the hospital he came to this facility. She stated she does want R #74 supervised while eating in the dining room. The SLP stated supervised eating to her means as long as someone is in the dining area, not sitting right next to the resident. She stated she had evaluated R #74 a couple of times to take him off of puree food, but she never felt comfortable enough making him dysphagia advanced diet (moist and bite sized) for his meals due to the risk. G. On [DATE] at 4:15 pm, during an interview, Registered Nurse (RN) #8 stated R #74 had behaviors. He will cuss and yell out, he will wander around a little bit and he takes food off of other residents' plates. She stated R #74's behavior of taking food off of others plates was last seen a couple of months ago when he first came to that unit. She stated when she is monitoring the dining room she is unable to watch only him because she has to watch everyone in the dining room on the unit. H. On [DATE] at 4:19 pm, during an interview, Certified Nursing Assistant (CNA) #12 stated R #74 was on a puree diet only. CNA #12 stated R #74 takes food from others residents' plates almost daily. She stated staff try to manage him by not letting him linger in the dining room very long after he has finished his meal. CNA #12 stated she is not sure if he needs to be directly monitored (which meant having staff sit and watch him eat) but he needs to be watched. I. On [DATE] at 11:41 am, during an interview, Unit Director (UD) stated R #74 came into the facility on a feeding tube. Then he was taken off of the feeding tube and had been puree and nectar thick liquid. She was aware that he takes food off of other residents' plates. She stated everyone was keeping their eyes open for residents taking food. She stated they have a couple of residents who require feeding assistance, so they put those residents at one table. She stated if a staff member observed a resident trying to take food off of another resident's plate they should stop and re-direct them. J. On [DATE] at 10:21 am, during an interview, CNA #11 stated he was aware that R #74's diet was puree texture. CNA #11 stated R #74 frequently tries to take food off of other residents' plates. He stated that they have to constantly keep an eye on him because of this. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced on [DATE] at 5:25 pm to the Center Executive Director/Administrator in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 1:05 pm. Implementation of the POR was verified onsite on [DATE] by conducting observations, record review and staff interviews. Plan of removal: All staff in the building on [DATE] were immediately educated by the Director of Nursing (DON) and Nurse Practice Educator (NPE) regarding the proper monitoring of residents on altered diets. The staff were educated on their responsibility to know the diet of each resident they are monitoring, properly monitor the residents as they eat to ensure that they are only eating their ordered diet, and redirect any residents who attempt to eat food that is not on their own plate. On [DATE] the DON and the Dietary Manager completed an audit of all residents in the center in order to identify all residents who are on altered diets and to compare the resident diet orders in our electronic health record (EHR) to the resident meal cards. On [DATE] the DON/Designee completed staff interviews to screen residents with altered diets for behaviors of grabbing food from other resident's plates. Resident care plans were updated for individualized behavior. Additional staff will be stationed in the dining rooms for all meals served in the dining rooms to monitor residents on altered diets until the center can ensure that sufficient monitoring is occurring.

Based on interview and record review, the facility failed to ensure that residents are free from neglect for 1 (R #10) of 3 (R #10, 11 and 12) residents reviewed for death by: not providing any intervention for R #10 when she began to experience anxiety around feeling like she was short of breath. This deficient practice likely resulted in R #10 feeling extreme anxiety, distress and that she was being ignored within the 24 hours before her passing. The findings are: A. Record review of dashboard in the medical record for R #10 indicated that R #10 was admitted on [DATE] and passed on [DATE]. B. Record review of the medical diagnoses for R #10 revealed the following: Pneumonitis (general inflammation of lung tissue) due to inhalation of food or vomit, Dysarthria (motor speech disorder) and Anarthria (a loss of control over the speech muscles and is a severe form of Dysarthria), Dyspagia (difficulty with swallowing), Gastro-Esophageal Reflux Disease (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Depression (is a common and serious mental illness that affects your mood and interest in life), Anxiety Disorder (persistent and excessive distress that affects daily life), Chronic Respiratory Failure with Hypoxia (when your respiratory system is unable to remove enough carbon dioxide from your blood, causing it to build up in your body), Hernia (part of your insides bulges through an opening or weakness in the muscle or tissue that contains it), Osteoarthritis (inflammation of one or more joints. It is the most common form of arthritis that affects joints in the hand, spine, knees and hips). This is not an all inclusive list. R #10 did not have Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) listed as a diagnosis. C. Record review of the Minimum Data Set (MDS) on [DATE], indicated that R #10 was noted as having a BIMS of (Brief Interview for Mental Status) of 15 (,d+[DATE] severely Impaired cognition, ,d+[DATE] moderately impaired, 13 -15 intact cognition) 15 meaning no cognitive deficit. D. Record review of R #10's medical record indicated that R #10 was on Hospice for Chronic Respiratory Failure starting [DATE]. E. Record review of the physician orders indicated that R #10 had an order for the following: -Continuous 4 liters of oxygen (O2) on admission [DATE]. -Ativan (Lorazepam 0.5 mg) give on tablet by mouth every 4 hours as needed for anxiety [DATE]. -Morphine Give 0.25 mg by mouth every 1 hour as needed for pain and SOB (shortness of breath)[DATE]. F. Record review of the nursing progress notes dated [DATE] at 14:02 (2:02 pm) indicated the following, pt (patient) called 911 at least 8 times during shift and was alternating with calling the son. She was telling 911 she can't breathe on which fire department showed up but she was doing ok on their assessment. Diversional therapy (client centered practice [that] recognizes that leisure and recreational experiences are the right of all individuals) was provided to pt but to no avail. Pt able to use call light and make needs known although for the most times would rather yell instead. Hospice came to see pt and changed medications, d/c (discharge) pravastatin (to help lower bad cholesterol and fats) and start lasix for edema (reduce extra fluid in the body). Will continue to monitor pt . regular. Temperature 98.4 Route: Forehead (non-contact) Pulse 95 Regular, Respirations 20 regular, O2 93.0 % Oxygen via Nasal Cannula, Blood Pressure ,d+[DATE] G. Record review of the nursing progress notes dated [DATE] at 18:35 (6:35 pm) City Fire Lieutenant contacted writer (Former Unit Manager) and stated that pt from our facility continues to call 911. Writer personally checked on pt several times throughout the day d/t (due to) being notified early this morning that pt was doing this [calling 911]. Pt was never noted in distress of any kind. Writer was notified by Lieutenant that if pt continues to call 911 the police department would be contacted to come to facility and cite the person in charge of pt. Writer notified pt's POA (Power of Attorney), (name of person) via telephone. (name of POA) stated he will contact pt to ask her to stop calling 911. H. Record review of the medical record did not reveal that any other assessments were completed for R #10 on [DATE]. I. On [DATE] at 11:17 am, during an interview with son/POA, he stated that R #10 had only been at the facility for a short time. On [DATE] she was complaining to him and calling 911 telling them that she couldn't breathe. She called him around 11 times that day. He stated that he also called 911 and informed them that his mother told him that she was having a hard time breathing. He stated that he was not sure if emergency medical services ever went out to the facility to check on her. He stated that he did talk to the facility several times that day and they assured him that she was medically fine and was just having anxiety. He stated that at 4:30 am [[DATE]] the facility called him and told him that she had died . He was shocked and upset because he believed the facility that she was just having anxiety. J. On [DATE] 11:50 am, during an interview with the Hospice Case Manager, she stated that R #10 was admitted [DATE] with a diagnosis of chronic respiratory failure and hypoxia. She stated that on [DATE] the [hospice] nurse went to the facility to see her at 3:30 pm. She assessed her and noted that she was anxious and wanted to go home. There is a note about R #10 calling the son and 911 all day. She had Lorazepam on order for anxiety but the nurse did not indicate in her note that she requested that R #10 take the anxiety medication. Her oxygen saturation level was 90% on 4 liters. K. On [DATE] at 8:04 am, during an interview with POA and family member, he stated that on the day she passed she kept calling 911 and they called him so he could get her to stop calling 911. He said that the last phone call from the facility to him came in around 9:00 pm. The facility asked him to talk to R #10 and to re-assure her that she was fine. He called is mom and told her that the facility had checked her out and that she was fine. He stated that he should have gone down there and saw her in person but the facility kept telling him that she was fine. L. Record review of the 911 transcripts (no times were documented on the transcripts) of some of the calls made by R #10 revealed the following: R #10 told the 911 operator over 20 times during the multiple phone calls, that she could not breathe and needed help. The operator called the facility and spoke with male #1 who stated the following: Male #1: answered phone and stated name of the facility and asked how he could help the person. Operator stated that one of the residents from the facility was calling them and the operator wasn't clear what the resident needed. Male #1 stated that there wasn't anything urgent at the facility and they have nurses and full staff. Operator told Male #1 residents name and he stated that they have been having this problem, and that this patient had behavioral issues. Operator asked if Male #1 would go check on her because she keeps calling. Her son/POA called 911 and told the operator that his mother kept calling him and telling him she couldn't breathe and asked the operator to send an ambulance to check on her. Operator called the facility back after the phone call with her son/POA. Male #2 answered the call and the operator told him that the son of one of the residents at the facility just called them and said that his mom was requesting 911. Operator stated that he was reaching out to see what the situation was before sending anyone out and stated R #10's name. Male #2 said yeah, just a senile patient with mental issues and things of that nature. Male #2 told the operator that there were nurses and CNAs on the halls and there wasn't anything urgent. Operator stated okay and to call 911 if they needed anything and the call ended. The last transcribed call that was made to 911 Operator was from the facility [on [DATE]] indicating that they had a resident (R #10) that had gone unresponsive. She still had a pulse and barely any chest rise. M. Record review of the nursing progress notes indicated that on [DATE] Pt cardiac arrested at 0340, (am) this nurse initiated CPR with the aid of 4 other nurses, Emergency Medical Services (ems) called, ems took over code at 0345 . time of death 0420 (am). N. Record review of the Office of the Medical Examiners autopsy report indicated that the autopsy was completed on [DATE] and the cause of death for R #10 was atherosclerotic and hypertensive cardiovascular disease (is a heart problem that is caused by hardening of arteries), Other significant findings were amyotrophic lateral sclerosis (ALS is a nervous system disease that affects nerve cells in the brain and spinal cord and causes loss of muscle control). Manner of death was found to be natural. O. On [DATE] at 8:04 am, during an interview with POA and family member, he stated that he went into his mother's (R #10) phone and pulled the times from the phone for the 911 calls. The following are the times of the phone calls to 911: 1. 10:20 am lasted 10 min 35 secs 2. 10:45 am lasted 2 min 59 secs 3. 11:57 am 26 secs 4. 12:03 pm 1 min 16 secs 5. 12:08 pm 45 secs 6. 12:09 pm 6 min 35 secs 7. 12:49 pm 2 min 38 secs 8. 2:41 pm 9 min 42 secs 9. 3:04 pm 2 min 24 secs 10. 4:17 pm 6 min 43 secs 11. 4:45 pm 2 min 47 secs 12. 5:23 pm 11 min 32 secs 911 calls stop. The POA stated that after the 911 phone calls stopped he received a total of 18 phone calls from his mother and they stopped sometime around 9 pm. The POA stated that during those 18 phone calls to him from his mother he continued to reassure her that she was fine. He stated that if he were to describe his mother on the phone calls to him he would say she sounded desperate, overwhelmed, and frantic, stating she couldn't breathe. He stated that to his knowledge when his mother (R #10) was at a different facility they never made him aware that she called 911 and that this was a behavior for her. Yes, she did have panic attacks and anxiety before and was taking medications for this. He stated that the facility kept telling him that she was just anxious but otherwise fine. P. Record review of R #10's o2 saturations for the two days prior to R #10 passing are as follows: [DATE] 19:34 96.0 % Oxygen via Nasal Cannula [DATE] 13:58 93.0 % Oxygen via Nasal Cannula [DATE] 04:03 94.0 % Room Air [DATE] 23:53 95.0 % Oxygen via Nasal Cannula [DATE] 19:54 95.0 % Oxygen via Nasal Cannula [DATE] 07:45 95.0 % Oxygen via Nasal Cannula Q. Record review of the Medication Administration Record (MAR) indicated the following: Ativan Tablet (Lorazepam) (used for anxiety) 0.5 mg give one tablet every 4 hours as needed for anxiety, start date was [DATE]. This medication was given a total of three times once on ,d+[DATE], ,d+[DATE] and ,d+[DATE]. There is no documentation of R #10 receiving this medication on [DATE]. Morphine Sulfate (used for pain) solution 20 mg, give 0.25 ml by mouth every 1 hour as needed for pain and SOB (shortness of breath) start date [DATE]. This medication was not given while resident was in the facility. U. On [DATE] at 11:29 am during interview, the Center Nursing Executive (CNE) stated that she (R #10) had called 911 days prior to [DATE]. He stated that he is not familiar with this resident because he was not working at this facility at that time. He stated that looking at the information that the facility had at that time (vitals) she didn't appear in any distress. He did wonder why no medication was given when it was already ordered for her, because she was on hospice. He stated that because this was occurring all day for her it would have been appropriate to give her the ordered, as needed medication. He said that she had morphine on order as needed, and Ativan on order as needed. Since she was anxious and stating she was short of breath morphine would have been more appropriate since that medication can help relax smooth muscles and she wouldn't have felt so short of breath. The CNE did find that Ativan was signed off in the narcotic book at 8:00 pm on [DATE] for R #10 but wasn't put on the MAR as actually being given so it wasn't clear. He also stated that if EMS comes out and they assess a resident as being medically stable they will not take them to the hospital, even if they want to go. EMS comes out and they can make a determination of whether they are appropriate to go out or not. He said that he disagrees with this but he has encountered this in the past. R. On [DATE] at 5:05 pm during an interview with the former Unit Manager (UM), she stated that she remembers checking on R #10 and her oxygen saturation wasn't low and she did not appear to be in any distress. She stated that R #10 did not tell her she was short of breath or having a hard time breathing and she did not have a conversation with her about it. When asked what R #10 was doing when she went into the room to assess/check on her and UM stated that she was lying in bed, resting. She did not appear to be in any distress or short of breath. She did call the son to ask that he call his mother to request that she stop calling 911. She stated that EMS came out at least once maybe twice. She stated that she didn't remember if the physician was ever called, but probably not because the resident had stable vitals. She did not give any medication to the resident on [DATE] but was not sure if the nurse on duty had or not. .

Based on record review and interview, the facility failed to develop an effective discharge plan for 1 (R #7) of 1 (R #7) resident reviewed for discharge planning (the process of transitioning a resident from one level of care to the next). The facility failed to involve the resident and the residents family in the discharge planning process and accurately identify the residents post discharge needs. This deficient practice likely resulted in R #7 staying at the facility longer than desired and needed, resulting in undue emotional distress (sadness, fear and/or worry). The findings are: A. Record review of R #7's face sheet revealed he was admitted to the facility on [DATE] and discharged on [DATE]. B. Record review of R #7's face sheet revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of R #7's physicians progress notes dated 12/30/21 00:00 (12:00 am) revealed This is a [AGE] year-old man who was admitted to [name of hospital] from an outside hospital for a right first metatarsal (bone in the foot just behind the big toe) [CONDITION(S)]. He had a right foot ulcer (open sore on the foot) as well as abscess (mass filled with pus caused due to infection) and [CONDITION(S)] (a serious bacterial infection of the skin) of the entire right foot. He received IV (IV stands for intravenous, which is a thin, plastic tube called a catheter that is put into a vein designed to be deliver medication directly into the bloodstream). and oral (taken by mouth) antibiotics (medication intended to treat and prevent bacterial infections). He underwent a right foot wound debridement (a procedure to remove debris-scattered pieces of waste or remains, infected or dead tissue from a wound) including bone. Cultures of the soft tissue and bone were positive for staph aureus (a germ people carry in their noses or on their skin), [MEDICATION(S)] (a yeast like fungus that causes fungal infections), and group B strep common bacteria that lives in the body and often carried in the intestines-vita organ that helps digest food and absorb nutrients and vitamins). His hospitalization was complicated by epistaxis (nosebleed) and [CONDITION(S)] (a condition in which there is a build up in the blood of bilirubin - a yellowish pigment that is made during the normal breakdown of red blood cells). He was discharged to [name of the facility] on 12/13/2021 for ongoing wound care with a wound VAC (a treatment vacuum assisted device that shrinks the size of the wound and draws the edges of the wound together making it easier for the body to repair the gap) to the site as well as IV antibiotic treatment. D. Record review of R #7's Post Admission Pt (Patient)/Family Conference notes dated 12/20/21 revealed Patient expectations for length of stay = 15-21 days, IDT (Interdisciplinary Team - group of health care professionals from different fields or departments who work in a coordinated fashion toward a common goal for the resident) determination for projected length of stay = 15-21 days and Additional Comments: This baseline, Person-Centered Care Plan is developed within 48 hours and is reviewed at the Post Admission Patient/Family Conference and given to the resident and/or resident representative and updated as indicated. Social services discussed discharge plan. E. On 03/15/22 at 11:05 am, during an interview, R #7 reported I was always confused and ignored while I was at [name of the facility]. R #7 reported that the staff never kept him informed of his care and when he would be discharging. R #7 reported one nurse said I would be going home after the IV antibiotics were done on January 18th (2022), another nurse told me I would be going home a couple of days after that, the other ones (staff) would poke their head in my room and tell me you are going home tomorrow and I would see them again the next day and they would say oh no you are not going home yet. R #7 reported that he did not participate in any discharge planning meetings even though he asked them every day about going home. R #7 reported I started feeling really depressed (feeling of sadness and loss of interest affecting normal activities) and anxious (feeling worried, uneasy and nervous), it just hit me all at once and I called my parents to come and pick me up (on 01/25/22), because no one (at the facility) was listening to me. R #7 reported that he still had a wound on the bottom of his right foot when he left the faciity on [DATE], but the staff did not provide him or his family with any information about the status of the wound and they only provided about 2 days worth of bandages for the wound so they (R #7 and his family) had to stop at the store on the way out of town for wound care supplies. F. On 03/15/22 at 11:26 am, during an interview, R #7's mother reported that she and other family members made several telephonic attempts on several occasions to reach the facility regarding R #7's discharge and no one ever returned their calls. She reported that the staff was aware that they live over 2.5 hrs away from the facility and that she needed to be involved in the discharge planning process as R #7 could not drive himself home even if he wanted to. She reported I was on the phone with him (R #7) all the time, because he wanted to come home and they would come into his (R#7's) room and he would tell them, I need to let my mom know when I'm going home so she can come pick me up. She reported that he (R #7) wanted to go home, because he was getting depressed and anxious and not sleeping well, because they (the staff) always ignored him when he asked about his progress and when he would be able to go home. She reported he (R #7) would call me and cry and cry and say I want to go home. They caused him emotional distress, he does not deserve that. It's like they wanted to keep him, but they did not want to take care of him. She reported the day we finally just drove there (to the facility) to pick him (R#7) up (on 01/25/22), we let them (the staff) know right away that we were there to pick him up and they (the staff) just let us just sit there in his room for more than 3 hrs. She reported I went up to the nurses station and the male nurse just kept on working like I was not even there and even walked off and left me standing there and the CNA's (Certified Nursing Assistants) kept telling me wait for the nurse, wait for the Social Worker and we kept waiting and no one came so I finally said we need to get home before dark so we are leaving. She reported they told me that he (R #7) can't take the wound vac home and I told them, we don't have electricity where we live so we don't want to take it. She reported the male nurse finally came in to the room and took the bandage off the wound on the bottom of R #7's right foot, applied cream to the wound and put another bandage on the wound and gave them no information about the wound or instruction on what they should do care wise with the wound at home. She reported they made us wait for hours and they still sent us away with no discharge orders and only a couple of supplies for the wound. We had to stop at [name of store] on the way home and buy $130 worth of supplies (for wound care). She reported my son (R #7) is [AGE] years old, but he is still like a child in some ways, because of his learning disability. His mind is still very young. G. Record review of R #7's care plan revealed the following Goal created by Social Services and initiated on 12/14/21: [First name of R #7] will have an ongoing discharge plan that provides for a safe and effective discharge. H. Record review of the facility policy titled Discharge Planning Process revision date 02/01/19 revealed Weekly, and Interprofessional Utilization Management (UM - helps ensure that patients have the proper care and the required services without overusing resources) and Discharge Planning Meeting will be conducted to continue evaluation of discharge potential. I. Record review of R #7's [name of facility] - Short Term Patient notes (also known as UM discharge planning meeting notes) revealed the following: 12/28/21 Keep another week - wound vac needs update and Continues to have IV (Intravenous, which is a thin, plastic tube called a catheter that is put into a vein designed to be deliver medication directly into the bloodstream) antibiotics medication (intended to treat and prevent bacterial infections) and wound vac (a treatment vacuum assisted device that shrinks the size of the wound and draws the edges of the wound together making it easier for the body to repair the gap). Keep until IV are completed. Pt (patient) was d/c (discharged ) off therapy on 12/27/21. 01/04/22 On IV anti (antibiotics) until 01/18/21 (year should be listed as 22). 01/05/22 Spoke with patient, gave nursing wound sheet to fill out. 01/17/22 Wrong form submitted (for wound vac order) new forms obtained given to nursing. Told pt (patient) center is working on wound vac. J. Record review of R #7's electronic medical record revealed no weekly discharge planning meeting notes for the weeks of 12/13/21, 12/20/21, 01/10/22 and 01/24/22. K. Record review of R #7's nursing progress notes dated 01/25/22 18:45 (6:45 pm) revealed Pt (patient) called his mother and told her he was being discharged from facility. Pt's mother came to facility and was noticeably upset stating she had been trying to get a hold of somebody because she had no information on pt's dc (discharge). Writer stated to pt's mother that the dc planning is still on going and that dc is pending approval of wound vac to be taken home. Mother stated she wanted to take pt home d/t (due to) pt having completed IV ab (antibiotics). Pt and pts mother were notified that if pt left facility today it would be considered AMA (Against Medical Advice). Family stated understanding and decided to take pt home. Social services and pt's Nurse notified. Wound vac was taken off pt and a dressing applied to right foot wound. L. On 03/17/22 at 1:30 pm, during an interview, the SSD confirmed there were no discharge planning meeting notes on file for R #7 for the weeks of 12/13/21, 12/20/21, 01/10/22 and 01/24/22. The SSD reported that the only documented discharge planning meeting that included R #7 and/or his family was held on 12/20/21 at 14:06 (2:06 pm), in which the SSD met in-person with only R #7. The SSD reported I don't write down every interaction that I have with residents regarding discharge planning, because I have these conversations with them (residents) all of the time and I remember speaking to him (R #7) at least twice maybe three or four times about discharge planning. I probably did give him different dates of when he could leave (discharge from the facility), but not every interaction is documented. The SSD reported that they (she & R #7) did not discuss the specific transportation needs R #7 would have upon discharge or the need to involve other family members in the discharge planning process. SSD reported that the length of stay when a resident admits to facility just depends on what is going on with the resident. The SSD reported In this case (R #7's), the wound vac that we needed to order for him was holding up the discharge. Regarding R #7 discharging AMA on 01/25/22, SSD confirmed that he was documented as leaving AMA because he left prior to the wound vac being delivered and she confirmed that R #7 was not provided any discharge information. The SSD reported that she was unaware that R #7 did not have electricity in his home, which is needed to operate a wound vac and that R #7 or the nursing staff should have told her that there was no electricity in R #7's home.

Record review of an intake for complaint survey #NM revealed that the family had concerns about their family member [R #135] oxygen saturation being too low on 06/05/21. His oxygen saturation was checked and it was 48% [the amount of oxygen traveling through your body] The nurse was notified of this but told the family that if residents oxygen was at 48% he would be dead. No further action was taken. On 08/11/21 at 9:30 am during an interview with Certified Nursing Assistant [CNA] #7, she stated that she worked on 06/05/21 and checked the residents vitals during her morning rounds. She stated that residents oxygen level was 48%. She then checked it on a different oximeter [monitors blood oxygen saturation] and got the same reading of 48%. She notified the nurse, but was not sure of the time when she notified her. The nurse came down to assess the resident and told the CNA to keep an eye on him. The nurse never notified the physician of the low oxygen reading. On 08/12/21 at 12:00 pm during an interview with RN (Registered Nurse) #3, she confirmed that she did not notify the physician. Resident passed away on 06/05/21 at 13:47 [1:47 pm]. On 08/11/21 at 2:30 pm, during an interview with the resident's family member, he stated that resident's left arm was swollen and there were concerns that it could be a blood clot. He stated that he had spoken with the Physician on 06/04/21 about it and the physician was aware of the arm and forgot to submit an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/05/21 the family inquired about the Venous Doppler test with the nurse on duty [06/05/21]. The nurse was not aware of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R #135 was admitted to the facility on [DATE]. During the Physician exam on 06/04/21, Physician noted redness and swelling in R #135's arm and wrote in her progress notes that she was going to order doppler to rule out DVT [deep veing [CONDITION(S)]]. This order was never submitted. On the morning of 06/05/21 the CNA working the hall was doing morning rounds/vitals. R #135's O2 (Oxygen) Saturation (amount of oxygen in the blood) for resident was 48% x 2 (on 2 different oximeters). CNA went and got the nurse. Nurse concluded that O2 sat was wrong due to the resident was still alert. No further action was taken. At this time, R #135's family during window visit on morning of 06/05/21 informed nurse of swelling and redness in resident's arm and concern about a possible blood clot, however, nurse failed to assess. Physician was not notified of change in condition. Resident passed away on 06/05/21 at 13:47 [1:47 pm]. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being called on 09/01/21 at 4:05 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 09/01/21 at 8:04 pm. Implementation of the POR was verified onsite [09/02/21]. Based on the Plan of Removal, the interventions included: Plan of Removal: o Licensed Nurses assessed current residents residing in the center on 09/01/21 to determine presence of a medical change in condition. Identified issues were reported to MD [Medical Doctor] for further direction and medical orders. o Registered Nurses reviewed current residents progress notes on 09/01/21 to determine presence of a medical change in condition with steps taken to provide care related to identified medical need. Identified changes of medical condition not reported to MD will be reported and medical orders followed. o The Center Nurse Executive re-educated current licensed staff regarding policy for resident change in condition. The licensed nurse is to document the change of condition in the medical record, document notification to MD along with treatment plan/orders received, ensure medical orders are implemented, and notify the resident and family of the change in condition and treatment plan. The licensed nurse must also continue to monitor the medical plan put into place for improvement vs. decline. If a decline is noted an assessment will be documented in the medical record and the MD will be notified for additional orders, and the resident and family will be notified of the new treatment plan. The Center Nurse Executive/designee will begin education 09/01/2021 through 09/03/21, any licensed staff member on leave of absence (FMLA) Family Medical Leave Act, vacation, or PRN [as needed] staff will be re-educated prior to returning to duty. New hires will be educated on the change in condition policy during orientation. o The Center Nurse Executive/designee will review resident progress notes, orders and nursing dashboard during morning clinical meetings to determine if residents noted with a change in condition identified have been reported to MD with treatment plan/orders noted in the medical record. The Center Nurse Executive will complete a weekly audit to show changes in condition have been reviewed with MD notification completed and plan/orders are followed. o The Center Nurse Executive/designee will make rounds with nursing staff to determine if they are aware of a resident change in condition that has not been reported or documented in the medical record. The Center Nurse Executive/designee will complete random nursing rounds 5 x (times) weekly for 2 weeks, then 3 x times weekly ongoing. o The MD in question is no longer employed by [name of] Medical Group. o The Center Nurse Executive/designee will educate Nursing staff on actions to take when a change in condition is assessed by the MD. The licensed nurse will review the medical record for any new orders, and attempt to have face to face conversations regarding MD treatment plans/orders. Should the licensed nurse not see and/or speak with the MD after resident assessment, or the licensed nurse does not see new orders when a change of condition is identified, the licensed nurse will call the MD to verify the treatment plan/orders. The education will begin on 09/01/21 through 09/03/21, any licensed staff member on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires will be educated on the change in condition policy during orientation. o The Center Nurse Executive/designee will complete a random audit after MD visit to ensure a resident with a change in condition has plan/orders in place. The Center Nurse Executive/ designee will complete an audit after MD visits to the center 2 x weekly to verify orders are communicated and implemented timely. o The Center Executive Director will review the plan of removal during the Ad Hoc [as needed]QAPI [Quality Assurance and Performance Improvement] meeting for approval and additional recommendation. The Center Executive Director will also oversee the QAPI team who will review the outcome of the audits presented by the Center Nurse Executive/designee for tracking, trending and further recommendations. The QAPI team will determine the length of audits to ensure compliance with the plan. Scope and Severity was reduced from the level J to a level G. IJ removed at 12:09 pm on 09/02/21. Based on record review and interview the facility failed to provide quality of care by: 1. Staff not notifying the physician when they identified extremely low oxygen level readings using different oximeters [an instrument for measuring the proportion of oxygenated hemoglobin in the blood] on the morning of 06/05/21 for R #135 that was also refusing to wear his Bi-PAP [[NAME] Positive Airway Pressure [CONDITION(S)] is a method of breathing support] equipment. 2. The physician failing to enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #135 was observed with a red/purple swollen arm during her evaluation on 06/04/21 causing a delay in treatment. 3. The nurse on duty did not notify the physician of the potential blood clot in resident's arm after the family asked the nurse about having a test done to rule out the blood clot. These deficient practices could likely have contributed to the resident's death. The findings are: A. Record review of the face sheet for R #135 indicated that the resident was admitted on [DATE] and was discharged [passed away] on 06/05/21. The resident was admitted with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the hospital discharge paperwork dated 06/03/21, indicated that R #135 had orders to wear a Bi-PAP [Bilevel Positive Airway Pressure [CONDITION(S)] is a method of breathing support] 3 to 4 hours at night and 2 to 3 hours during the day along with continuous oxygen throughout the day, to be kept above 90%. IPAP 15 EPAP 6 [Settings on [CONDITION(S)]: IPAP - Inspiratory Positive Airway Pressure is higher and supports a breath as it is taken in]. The expiratory positive airway pressure [EPAP - Expiratory Positive Airway Pressure is a lower pressure that allows you to comfortably breathe out]. Titrate saturation [continuously measure and adjust] to: Greater than 88%. FiO2 35% [Fraction of inspired O2 (%)] Adult preferred device Full Face Mask [covers the entire face]. C. Record review of the facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Post Tx:[treatment] Evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds. The Bi-PAP orders were as follows: Pressure IPAP 15 and EPAP 6. Oxygen Liter Flow (for bleed in): 35%. Apply at HS [bedtime] and remove in AM [morning]. Interface type: Full face mask, fill humidifier with sterile or distilled [free of microorganisms] water. D. On 08/11/21 at 9:30 am during an interview with Certified Nursing Assistant [CNA] #7, she stated that she was working the 6:00 am to 2:00 pm shift on 06/05/21. When she went in to get vitals for R #135, he did not have his oxygen on or his Bi-PAP on. She stated that when she checked his oxygen it was 48%. [Oxygen level should be in the 90's]. She stated that she thought it was the machine [oximeter] and went and got another one and tried again, and it was the same reading of 48%. She stated that R #135's arm was full of fluid and she thought it might be that. She notified RN (Registered Nurse) #3 and the nurse checked it as well. She stated that the nurse did not feel that the reading was right and that if his oxygen was at 48%, he would likely be dead and since he was coherent, she didn't think the reading was right. The nurse told the CNA to keep an eye on him. She asked if she should try to put on his Bi-Pap on and the nurse stated yes. CNA #7 tried, but the resident declined. She did put his oxygen on him. She stated that the family had been there that morning and they were asking a bunch questions. She stated that she assisted R #135 with eating at breakfast and lunch. He wasn't really eating much and wasn't really talking during the meal. She stated that after lunch she started her rounds before the end of her shift which was at 2 pm. R #135 was the last room during rounds and when she checked on him he needed to be changed. She stated that when she changed him, his poop was really strong and she suspected C-Diff [Clostridioides difficile is a germ (bacterium) that causes severe diarrhea and [CONDITION(S)] (an inflammation of the colon] so she put his brief back on and told him she was going to get the nurse. When she came back to R# 135's room, she went ahead and started changing him. She turned him on his side and when she rolled him back over he was drooling. She stated that he was unresponsive and breathing weird. She stated that it looked like he was choking on air. She stated that his legs and arms were swollen. She left to go get the nurse again and they both went back to R #135's room and that is when he took his last breath. R #135 was pronounced at 13:47 [1:47 pm]. R #135 was a do not resuscitate [DNR], so life saving measures were not initiated. E. On 08/11/21 at 2:30 pm, during an interview with R #135's family member, he stated that R #135 was admitted to the facility on [DATE] at night. He stated that when he came to visit R #135 the next day, he met the physician. He stated that he asked the physician several questions, one being if he was wearing his Bi-Pap machine, the physician told him that it wasn't documented whether he was or wasn't so he wasn't given an answer. He asked about his arm, because it was very swollen and the physician stated that it looked like it could be a blood clot and would have it checked out. On 06/05/21, the family went back to the facility to visit R #135. He stated that CNA #7 came in to the room and checked R #135's vitals and his oxygen was 48%. He stated that the CNA went and got RN #3 and the nurse told them that if his oxygen was 48%, he would be dead. He stated that they [CNA and nurse] did check his oxygen level several times with an oximeter using different fingers, but the CNA and nurse did not share the oxygen level reading with him. He stated that he could tell his father [R #135] was off and something was wrong with him. He was sort of out of it and one of his arms was swollen and purple. R #135 appeared discolored to him, maybe kind of yellow. He stated that R #135 was talking about the paint on the door and delivering pizzas. He stated that this was not normal and wasn't his baseline [normal for that person]. He said that he felt like neglect from the facility killed him [R #135]. F. On 08/12/21 at 12:00 pm, during an interview with RN #3, she stated that she remembers the family was at the window doing a visit the morning of 06/05/21. She stated that there was a lot of family and they were asking a bunch of questions. They were concerned about R #135 having a blood clot in his arm. She had not been told about the blood clot concerns or that there were any orders. RN #3 stated that she did check R #135's oxygen level that morning and it was low, but she doesn't remember what it was. She stated that because the resident was coherent [awake and aware] and talking she went off of her assessment and not what the oxygen machine was indicating even though it was checked a couple of times with two different oximeters. She stated that the O2 reading of 48% was not matching her assessment of the resident. She remembers that he wasn't wearing his Bi-PAP machine as ordered and that was verbally stated by other staff; and the family wanted her to force it on him. She informed the family that restraining him or forcing him was not how the facility handled these situations. She stated that she never got a chance to look at his arm. She stated that she had two halls that day and was giving medications and care to both halls. She stated that staffing has been an issue and it does have a part to play in residents getting their needs met. She stated that she did observe him a couple of times throughout the morning but didn't feel like her assessment of the resident warranted her calling the physician. G. On 08/12/21 at 1:36 pm, during an interview with the Center Nursing Executive [CNE], she stated that she was in the building on 06/05/21. She stated that she was aware that CNA #7 was concerned about R #135's oxygen level being low and wasn't sure the reading was right. She stated that R #135's fingers were cold and that was causing it [the oximeter] to not pick up the oxygen level reading. She remembers that his oxygen was low, but couldn't remember how low it was. The CNE stated that the family wanted to force the [CONDITION(S)] machine on R #135, but they weren't going to force him if he didn't want to wear it. When asked if a resident was refusing medications, if they would notify the physician she stated Yes, we would notify the physician. When asked if refusing to wear oxygen or a Bi-PAP machine was any different from refusing medications she stated No, it's no different and she would expect that the physician be called. She confirmed that the she did not see a note or indication that the physician was called on 06/05/21 regarding R #135's refusal to use the [CONDITION(S)] machine. When asked whether or not she was aware of the concerns about R #135 having a blood clot in his arm, she stated she wasn't aware. She confirmed that in the History and Physical (H and P) progress note 06/04/21 she did see where it noted a concern about a blood clot in his arm and the plan was to order the Venous Doppler to rule out a blood clot. The CNE stated that she did see this in the H and P note. H. Record review of the History and Physical progress note dated 06/04/21. .Patient is being seen today for admission. Pt's [patient] family was visiting from his window. Patient seemed very pleased. Patient had significant left arm [CONDITION(S)] [swelling caused by excess fluid in the body tissue] which he states he was told was due to IV infiltration [liquid from the IV is not going into the vein but going into surrounding tissue] Patient reports feeling well and has no complaints today. Patient is voiding [going to the bathroom] normally, eating and sleeping well, and without pain. Per nursing staff, no new issues to report. Patient denies any lightheadedness, dizziness, headaches, fevers or chills, shortness of breath, cough, chest pain or palpitations [rapis, strong, irregular heart beat] abdominal pain or discomfort, nausea or vomiting, problems with urination or bowel movements, acute pain or any other abnormalities at this time . In the PLAN [what action the physician was going to take] it revealed the following: [CONDITION(S)] in left upper extremity [LUE]. Patient notes he was told this was due to infiltration of the IV but the swelling goes all the way up to the proximal [indicating a point of attachment] arm. Need to rule out DVT [Deep Vein [CONDITION(S)]] .Left upper extremity Venous Doppler . I. On 08/17/21 at 8:09 am, during an interview with the CNE, she stated that the physician did see R #135 on 06/04/21. She stated that the physician told her that she did have concerns about a blood clot in R #135's arm and did want to do a Venous Doppler. The CNE confirmed this information with the physician after it was brought to her attention on 08/17/21. CNE stated that when she spoke with the physician about the Venous Doppler for R #135, the physician told her that she forgot to submit the order on [06/04/21] and placed the order for the Venous Doppler the next day [06/05/21] not realizing that R #135 had already passed. The CNE stated that the physician should have put the order in immediately, so it could have been done. J. Record review of the Physician/Advanced Practice Provider [APP] Notification Policy revised on 06/01/21 indicated the following: Upon identification at [sic] a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations, and collect pertinent patient information such as age, diagnoses, prior vital signs, labs, recent changed in medications, previous incidents of a similar nature, code status etc. and report to Physician/Advanced Practice Provider [APP]. If unable to contact Attending Physician/APP, the Medical Director will be contacted. K. On 09/01/21 at 11:58 am, during an interview with Physician #1, when asked if a resident who had an O2 [Oxygen Saturation] reading twice on two different oximeters that was 48%; what her expectation would be from the staff, she stated that the physician/on-call physician should have been notified. She stated that even if the nurse assessed the resident, the physician should be notified. When asked if a person could be conscious and awake with an 02 stat of 48% she stated if they [resident] had been dealing with issues like [CONDITION(S)] [ Chronic Obstructive Pulmonary Disease is a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs] and their body is already used to compensating [the body learning to tolerate and continue to function with obstructed airflow] with low oxygen levels, then yes, they might be awake and talking. It all depends on the person. A healthy person who wasn't compensating due to lung issues probably would not be awake and talking.

This is a repeat deficiency from a Recertification survey completed on 09/23/20. Based on record review and interview, the facility failed to ensure that 1 (R #335) of 1 (R #335) sampled resident reviewed for Pressure Ulcers (PU) [wound(s) involving the skin and at some times underlying fat, muscle and bone caused primarily by excess pressure to the body area affected] received the necessary treatment and services to prevent wound development, wound worsening, and promote healing by not conducting timely, consistent skin and pressure ulcer wound assessments and treatment and by delaying in obtaining physician orders for wound care. This deficient practice resulted in R #335 being admitted to a hospital care facility with [CONDITION(S)] [a serious medical condition resulting from the presence of harmful microorganisms (microscopic organism which can be either bacteria, or fungi) or in the blood or other tissues and the body's response to their presence], which was found to be due to his deteriorating necrotic [having dead tissue in the wound] sacral/coccyx [area of the body, low back, just below the spinal column] wound. The findings are: A. Record review of the facility's policy titled, Skin Integrity Management, revised 06/01/21 revealed the following: Perform skin inspection on admission .and weekly. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. B. Record review of R #335's Admission Record revealed an [AGE] year-old male, admitted on [DATE], indicating he had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] #335's hardware was removed from his tibia due to being infected with [CONDITION(S)] (infection of the bone)], Peripheral Vascular Disease [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs (arms or legs)], Diabetes [a group of diseases that result in too much sugar in the blood], [CONDITION(S)] [a condition having involuntary tremors (shakiness), slowness of movement and stiff muscles], hypertension [having a high blood pressure], and dementia [a group of thinking and social symptoms that interferes with daily functioning]. He was admitted from another nursing home facility in the state, where he was on hospice care [which focuses on the quality of life for people who are experiencing an advanced, life-limiting illness]. C. Record review of R #335's Physician Orders dated 02/25/21, revealed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of the transfer documents a Wound Evaluation dated 02/18/21, from R #335's previous nursing home facility, indicated a Pressure ulcer - Stage 2 [the skin has broken down, which forms an ulcer, which would be tender and painful to the touch] to the coccyx, which measured 7.43 by 5.45 cm [centimeter]. R #335 had additional Stage 2 wounds on his right and left legs. E. Record review of R #335, Physician order summary dated 02/25/21 - 03/19/21, regarding the PU topical [skin] care of the sacral/coccyx wound revealed: 1. On 03/02/21 (this order was written five days after admission), Wound(s): pressure injury to coccyx, sacrum and posterior thighs, abrasion to left scapula, surgical wound to LLE (left lower extremity), skin tear to LLE. Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), 2. On 03/10/21 (this order was written twelve (12) days after admission), Wound(s): pressure injury to coccyx, sacrum and posterior thighs, surgical wound to LLE, skin tear to LLE. Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable. 3. On 03/16/21 (this order was written nineteen (19) days after admission), Wound care coccyx/sacrum/bilateral buttocks: Cleanse with normal saline [a salt solution], pat dry, apply [MEDICATION(S)] [a wound care product], and cover with sacral foam [a dressing that absorbs and retains the drainage, maintaining a moist wound environment]. 4. On 03/16/21, an Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . for Pressure ulcer. F. Record review of the nursing progress notes, revealed the sacral wound was not noted until day three at the facility, the notes are as follows 1. On 02/25/21 at 6:20 pm, .pt [patient] was very fatigued and did not want to cooperate .Integumentary System [the skin and its parts] reviewed Skin Check completed: The following New skin injury/wound(s) were identified: Discoloration(s): Description: bilat [bilateral, both sides] LLE [left lower extremity, left leg] Skin Tear(s): Description: bilat [both sides] gluteal [the division which separates buttocks] fold OTHER Wound(s): Description: open wound to upper mid back. Note did not identify that any wound care treatment was provided. 2. On 02/25/21 at 7:34 pm, a note from a different nurse, revealed, Skin check performed, pt has open sore to upper mid back, skin tears to bilat [both] buttocks [rear end/[NAME]] discoloration to bilat LE [lower extremities, legs]. Note did not identify that any wound care treatment was provided. 3. On 02/26/21 at 7:45 pm, A new pressure wound Stage 3 present on admission Location: Left Calf (Lateral) was assessed today. Note did not identify that any wound care treatment was provided. 4. On 02/26/21 at 9:26 pm, Pt has open sore to upper mid back, skin tears to bilat gluteal fold, pt did not want to cooperate with skin upon admission, skin was reassessed and pt has long open wound on L [left] later [lateral, towards the side of the body, not the middle] LE. Note did not identify that any wound care treatment was provided. 5. On 02/28/21 at 5:58 pm, Wound to LLE and sacrum [triangular bone in lower back, just above the coccyx, as the sacral and coccyx areas are adjacent to each other they are often labeled as one or the other or as both {sacral/coccyx}] in nursing documentation. Note did not identify that any wound care treatment was provided. 6. On 02/28/21 at 9:58 am, Integumentary [skin] System reviewed Skin Check completed: The following New skin injury/wound(s) were identified: Pressure(s): Description: sacrum stage 3 [involve the loss of all the skin layers, potentially extending into the fatty tissue layer] . bil [bilateral] thigh dti [deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [CONDITION(S)] have the appearance of a deep bruise]. Note did not identify that any wound care treatment was provided. G. On 09/01/21 at 1:00 pm, during an interview, Licensed Practical Nurse #1 confirmed that she was the nurse who admitted R #335 to the facility. She stated that when he arrived to their facility he was uncooperative, combative, and yelling at the nursing staff. She stated that the nursing staff were unable to position him to his side the day of admission, in order to get a good view of his buttock area. She stated that she was only able to view his upper shoulder area to his mid-back, I could not see anything from his waist down. She stated that the wound care assessment was attempted on the next day, due to the resident's behavioral issues. She stated that the facility does not have a current wound care nurse nor has there been a wound care nurse for a long time. She stated that it was up to the licensed nurse on duty for that hall to provide wound care to the residents'. LPN #1 stated that due to R #335's behavioral issues, the nurses attempted to do their wound care treatments when either the Physical Therapist or Occupational Therapist was working with the resident. She stated even then, it was very difficult to provide care to the resident. LPN #1 revealed, that there was a Corporate Nurse Practitioner, who will come into the facility on ce a week to recommend or guide nurses on wound care for their resident's. The Corporate Nurse Practitioner did not see R #335 until 03/12/21, fourteen (14) days after the resident was transferred. In regards to residents getting bathed, LPN #1 stated that the CNAs will notify the nurse, if they were to see any skin issues. As this wound was not noted. When asked about resident's behaviors coming from a previous facility, LPN #1 stated that the transferring facility does not normally mention to the on-coming facility, if a resident was having behavior problems at their facility. She said that usually we find out if the resident has behavioral issues, once they arrived at their facility. H. Record review of the Weekly Bath and Skin Report, [a document that allows for documentation of skin problems when the resident was bathed by a Certified Nursing Assistant (CNA) which was a different document titled Skin and Wound Evaluations, which are completed by a licensed nurse] dated 03/10/21, did not indicate any breakdown of skin on the resident's coccyx area. I. Record review of nurse progress notes on 02/28/21 at 9:58 am revealed, The following skin injury/wound(s) were previously identified and were evaluated as follows: Other(s): Description: scapula [shoulder blade] pressure injury sacrum/coccyx. open area measures 12 by 10 [cm.] with varying depths within the wound. Deepest point 0.5 surrounding skin, purple non-blanching [discoloration with a purple tint and does not become pale when the blood vessels are compressed] dti, [these [CONDITION(S)] have the appearance of a deep bruise]. [This was the first time any measurements or assessment of wound other than location was noted in any of the nursing documentation]. Lt [left] thigh [measured] a 1 by 10 cm, rt [right] thigh [measured] 6 by 1 cm. Summary of any additional findings: skin concerns to coccyx and thighs treated. dressing remains in place cdi [clean, dry, intact] resident tolerated procedure. J. Record review of the facility's Admission/Transfer/Discharge document revealed R #335 was discharged to a hospital on 03/19/21. K. On 08/16/21 at 11:10 am, during an interview, Registered Nurse (RN) #1, She revealed that she had recalled the resident, that the resident was not cooperative, but could be finessed [approach in a delicate manner] into cooperation with treatment. L. Record review of R #335's Skin and Wound Evaluations [which are documented by a licensed nurse] were completed for the coccyx wound, during the course of R #335's admission at the facility, were as follows: 1. On 03/01/21 at 2:31 pm, A new pressure wound Stage 3 [a pressure wound that involves loss of all layers of the skin and may also involve loss of some of the fat layer under it] present on admission, Location: Coccyx was assessed today. Measurements were 9.8 cm. by 9.9 cm. with a 100 % granulation [beefy red tissue that was a sign of healing] filled wound bed. 2. On 03/09/21 at 3:10 pm, A stable pressure wound Stage 3 present on admission, Location: Coccyx was assessed today. Measurements were 13.4 by 15.6 cm. with 90% granulation [red bumpy tissue which is new collagen and blood vessels to fill the wound space and eventually transforms into scar tissue] and 10% epithelialization [new skin] and no signs of infection. 3. On 03/12/21 at 10:54 am, A deteriorating [worsening] pressure wound Stage 3 present on admission, Location: Coccyx was assessed today. Measuring 12.5 cm. by 16.7 cm. with 100% epithelialization [this would indicate that the wound was now completely covered by new skin]. M. Record review of R #335's care plan dated 02/25/21, revealed only the following regarding PU prevention and treatment, the nutritional goal was as follows: On 03/05/21 [last name of R #335] was at nutritional risk related to disease state a/e/b [as evidenced by] [her list of diagnoses] and multiple pressure wound areas. N. Record review of R #335's hospital notes dated from 03/19/21 through 03/30/21, revealed the following: 1. On 03/19/21, a CT (Computed Tomography, which can identify sites of infection) revealed the following results: Sacral decub (bedsore) ulcer with findings suspicious for [CONDITION(S)] of the lower sacrum/coccyx. 2. On 03/20/21 at 7:38 am, [Patient] here with AMS [altered mental status] and severe [CONDITION(S)] presumably from a [CONDITION(S)] [urinary track infection] vs [versus] a sacral pressure ulcer vs PNA [pneumonia, a lung infection] vs hx [history] of an ankle OM [[CONDITION(S)], the bone infection related to tibial hardware removal]. 3. On 03/30/21 at 10:19 am, [after ruling out other potential diagnoses] it was determined the resident had the following: Severe [CONDITION(S)] primarily due to soft tissue [skin, fat, muscle] lumbar infection [low spine area, next to the sacral area] with dehydration [a dangerous loss of body fluid] component. [Name of R #335] has a large necrotic (having dead tissue cells) sacral wound, it was determined that he was not a surgical candidate to remove the dead tissue. R #335 was discharged from the acute care facility to a nursing home facility to receive hospice care.

Based on record review and interview the facility failed to prevent skin breakdown that led to pressure ulcers (PU) (Injury to the skin and its underlying tissue due to prolonged pressure) for 1 (R #96) of 1 (R #96) resident looked at for pressure injury/ulcers and skin breakdown. This deficient practice contributed to R #96 having multiple pressure ulcers requiring wound treatment that creates pain and can contribute to the decline that R #96 is already experiencing. The findings are: A. Record review of the facesheet indicated that R #96 was admitted initially on 06/21/20. R #96 has a [DIAGNOSES REDACTED]. interfere with your daily life), Perhiperal Vascular Disease, (refers to any disease or disorder of the circulatory system outside of the brain and heart) and Stage III Kidney Disease (kidneys become damaged, inhibiting their ability to filter waste from the blood). (this list is not all inclusive) B. Record review of the progress notes dated 07/28/20 indicated the following, around 12:00 pm, Certified Nursing Assistant (CNA) asked pt (patient) at door if it was ok for CNA to step into pt's room and pick up lunch tray. Pt said, Yes. As CNA entered room, picked lunch tray up and turned around to walk out of room, pt stepped into pt's (sic) face swung with closed fist and hit CNA in right jaw. Pt then grabbed CNA's scrub top at her chest, scratching CNA on chest. Staff member walked by and noticed incident and was able to convince pt to let go of CNA. Pt was noted agitated and verbally and physically aggressive towards staff. Pt continued to focus on same CNA calling her skinny [***] and threatening to slap the[***]out of her. Staff attempted to talk to pt and calm pt down, to no avail . C. Record review of the nursing progress notes dated 07/30/20, resident readmitted to (name of facility) from recent aggressive behaviors. D. Record review of the nursing progress notes indicated that R #96 was readmitted to this facility on 08/20/20 from (name of facility). E. Record review of the nursing progress notes dated 08/22/20 indicated the following, spoke to provider (name of provider) regarding resident minimal intake, somnolence (a state of strong desire for sleep, or sleeping for unusually long periods), need for more assistance with Activities of Daily Living (ADL), recent medication change, and transfer/return from (name of facility) also provided as report to provider. Provider stated she would look at resident for possible medication adjustments and possible reason for decline. F. Record review of skin assessment note dated 08/26/20 indicated the following skin check was performed. The following new skin injury/wound was identified: Pressure Area: Location: Left foot (DTI) deep tissue injury (injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body and are not stage able at this time). G. Record review did not reveal any new interventions based upon the new DTI to left foot on 08/26/20. H. Record review of the progress notes dated 08/28/20 indicated the following, pt lethargic. I. Record review of the progress notes dated 09/1/20 indicated the following, pt has declined a lot, did not eat dinner, drowsy, doe (sic) not get out of bed. need help to feed and (sic) drink. pt (sic) is sleeping throughout the night. favors (sic) head to left side. J. Record review of a eInteract Change in Condition Note dated 09/15/20, indicated that a change in condition had been noted. The symptoms include: Skin wound or ulcer 09/15/2020 to the coccyx (tailbone). K. Record review of the nursing progress notes dated 09/18/20 indicated the following: R #96 seen for wound to coccyx. R #96 found sleeping on her back, rouses but doesn't answer questions. R #96 has new onset unstageable ulcer (full thickness skin or tissue loss with unknown depth. Full thickness tissue loss is when the actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) to coccyx and onto right buttock. Area of loose skin over buttock was debrided (remove damage tissue) by Certified Nurse Practitioner (CNP). Center area of thick dark yellow slough is firmly adhered and not able to be debrided at this time. Wound area measures 5.2 cm x 2.9 cm x unknown. Edges are clean, no signs/symptoms (s/s) infection noted. R #96 also found to have unstageable wounds to bilateral heels. Left heel has a close serous (contains or relates to both blood and the liquid part of blood (serum)) blister area of 4 cm x 4.5 cm x unk. Right heel has a stable eschar (is composed of necrotic granulation tissue, muscle, fat, tendon or skin) of 4.5 cm x 5.5 cm x unknown. Rsd (Resident) tolerates care to feet without complaint during this care. R #96 has frequent behaviors of refusing care, hitting, cursing at staff. When not alert, R #96 is very somnolent and sleeps in her bed. She refuses to be moved at times when in bed. New treatment (tx) orders in place. L. Record review of the physician orders [REDACTED]. (floated heels are when the mid/forefoot is raised and the heel is no longer in contact with the ground). Document any refusals of care in NN (nursing notes). M. Record review of the care plan indicated that a care plan item for Assist resident in turning and reposition every 2 hrs was initiated on 09/21/20, and another intervention for off load/float heels while in bed with _____ (left blank) was initiated on 09/23/20. N. On 09/23/20 at 1:50 pm, during an observation of R #96, she was sitting in her wheelchair with the bed table in front her with her lunch plate. She had her fork in her hand and it was clinking on her plate due to a tremor she has in her hands. She had eaten very little of her meal. O. On 09/23/20 at 2:09 pm, during an interview with Certified Nursing Assistant (CNA) #10, he stated that he remembers R #96 from when she was on a different unit. She could walk and talk no problem, she would go and visit other residents. She went out to the hospital or some place and when she came back she no longer walks and doesn't talk much, she sleeps all the time and needs assistance from staff. She doesn't eat much, but will take a shake. They try to assist her with eating and sometimes it helps and sometimes it doesn't, they assist her with turning. She is totally different person than she was before. He agreed that she does have a tremor in her hand. CNA #10 stated that he thinks she was over medicated at the place she was prior to coming back here. P. On 09/23/20 at 2:15 pm, during an interview with CNA #11 she stated that R #96 has been on this 200 unit for about 3 or 4 weeks now. She is aware that after she came back to the facility there was a drastic change. She is also aware that she has some pressure ulcers that happened recently. She stated that she can feed herself a little bit. They get her up for meals but then lay her back down. She is pretty dependent on staff. Q. On 09/23/20 at 2:22 pm, during an interview with CNA #12, working on this hall seven months and R #96 recently transferred to this hall. She is totally dependent with care. She will feed herself sometimes and then other times she won't. U. An observation was made on 09/23/20 at 2:30 pm, revealed R #96 in bed without heel protectors/boots and heels were on a pillow but not floated. R. On 09/23/20 at 2:36 pm, during an interview with the Center Nurse Executive (CNE), she stated that R #96 came to them as a skilled resident than transitioned to long term care (LTC). The CNE stated that her behaviors began to escalate and became unmanageable, so they sent her out to (name of psychaitric facility). When she returned to the facility she wasn't like herself at all. She went from functional to not functional. When she first got back none of her meds were changed, when she transitioned over to LTC her medical provider changed. That is when the CNP started to adjust her medications around 09/03/20. The PU's were just found a few days ago. When asked if anything was in place for prevention of the ulcers like heel protectors, the CNE stated, She thought there was, but does not see anything in place or ordered. S. On 09/23/20 at 3:18 pm, during an interview with Licensed Professional Nurse (LPN), she stated that R #96 has bad behaviors. She was sent out and when she came back she was very sedated (calm) She would no longer get out of bed and became incontinent (unable to control bladder functioning) She needs help with eating and to be re-positioned/turned, and toileting or brief change. She stated that she had heel protectors on 500 hall not sure where they are now. As she is being weaned off of medications and seeing how she responds; being in bed so much, it is possible for the PU's have developed. LPN stated that she thinks that the CNA's know to prop up her heels, but if they are moving too fast, or they are a new CNA, they might overlook doing it.

Based on interview and record review, the facility failed to identify and remove as a potentially hazardous item, a mattress overlay, to keep a resident free from avoidable accidents for 1 (R #275) of 1 (R #275) resident reviewed for a fall. This deficient practice likely resulted in R #275 falling from bed with a head injury resulting in his being transferred to a hospital for care. The findings are: A. Record review of facility Admission Record revealed R #275 was admitted on [DATE] (no time noted) with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (a disorder or disease of the brain resulting in varied symptoms that often include lack of coordination, weakness and disordered thinking ) .Secondary . Cerebral Infarction (often called a, stroke is a result of a lack of oxygen to part of the brain causing that brain tissue to die often with subsequent, physical, mental and/or emotional dysfunctions). B. Record review of nursing progress notes revealed the following: 1. On 06/25/20 at 3:54 pm, the first note was documented and revealed, .Mental Status: Alert. Pt. (patient) is oriented to Person (knows who he is and can recognize significant others) .Left lower extremity contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Right lower extremity contracture .bilateral foot drop (inability to raise the front of the foot due to weakness or paralysis) Pt. has left arm extremity weakness. Pt. has right arm extremity weakness. Pt. has left leg extremity weakness. Pt. has right leg extremity weakness Bed Rail evaluation completed. No Bed Rail(s) to be used No GAP (space) was found BETWEEN HEAD OR FOOT BOARD & MATTRESS Patient observed in bed without bed rails in the up position or other rail devices. Results: Resident is not able to move upper or lower extremities and therefore bed rails are not indicated. 2. On 06/26/20 at 12:49 am, Patient continues to fidget in bed, pull on his PEG (percutaneous endoscopic gastrostomy, (a feeding tube through the skin and into the stomach) tube and foley (Foley, a tube placed into bladder to drain urine). 3. On 06/26/20 at 7:24 am, Today, rsd (resident) appears AxOx1 (alert and oriented to himself but not to where he is or the date and time). C. Record review of facility, Event Summary Report revealed, on 06/26/20 at 8:45 pm for R #275, Patient was found on the floor lying on his right side facing towards his bed. Mattress [MEDICATION NAME] (an overlay or pad, often made of down or foam or blown up with air and placed on top of mattress, often to make it comfortable) also on floor with patient . Patient assessed and was found to have a laceration (cut) to the right side of his head from his ear going towards his temporal (scull bones on sides of head) area. Neuro (neurological) check (assessment of the patient's level of awareness and interaction with the environment) was done to find pupils non responsive (a signal of injury and damage to the brain or eye) which is not baseline (normal) for patient. Patient was screaming out in pain. EMS (Emergency medical services) was called and patient sent to (name of acute care hospital) ED (Emergency Department) .Cognitive/behavior factors prior to fall: Agitated, Confused, Poor safety awareness, Restless .Root cause/conclusion: mattress [MEDICATION NAME] came off bed and patient slid off bed with it .Corrective Actions: sent to ed (ED) for eval (evaluation) and treat (treatment), [MEDICATION NAME] removed. D. Record review of hospital emergency providers progress note dated 06/27/20 at 3:48 am, revealed, R #275 had a laceration of the right ear that required sutures (stitches), that he had, A large anterior (front) pneumomediastinum (air in the center of the chest outside of the lungs). This resident was eventually discharged to a different nursing facility. E. On 09/23/20 at 10:50 am, during interview with the Center Nurse Executive, when queried about if the [MEDICATION NAME]/overlay the resident was using was appropriate for the mattress he was on, she revealed, that they do not use the type of [MEDICATION NAME] that was on the mattress in the facility, that it was a type that is made of plastic and inflated with air, that the resident was brought in (by hospital transport) with the [MEDICATION NAME] and put on the mattress with it by the ambulance service that had transported the resident to the facility on his admission, the day before he fell . She stated that she does not have a policy/protocol for what [MEDICATION NAME] are appropriate for use in the facility .that her investigation of the incident had shown that the residents' assigned nurse was not aware that the [MEDICATION NAME] was on the mattress, and that the wound care nurse was aware, and did not remove it and therefore received a reprimand. F. On 09/25/20 at approximately 4:45 pm during telephone interview with the facility Administrator she revealed, that they do have a formulary of products that are allowed to be used in the facility such as mattress overlays and that type of overlay ([MEDICATION NAME] used for R #275) would not have been utilized if the formulary was followed.

The facility failed to ensure that accident hazards were minimized on the locked Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) unit, by failing to place Wet Floor signs where the floor had recently been mopped and failed to ensure cleaning chemicals were locked and secured in the housekeeping carts while left unattended. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of K being identified on 02/20/18. The facility was notified on 02/20/18 at 9:35 am. The facility took corrective action by providing an acceptable Plan of Removal on 02/20/18 at 11:00 am. Based on the Plan of Removal, interventions included: 1. On 02/20/18 at 10:15 am, all EVS (Environmental Services) carts and chemicals were secure, locks were checked and repairs made as needed. 2. Current housekeeping staff currently working were immediately in-serviced in both Spanish and English regarding chemical safety and incident/accident hazards with wet floors. Housekeeping staff on all shifts will be in-serviced prior to their next working shift. 3. Current staff will be in-serviced on safe chemical storage and incident/accident hazards by 02/23/18. 4. EVS Supervisor has implemented twice daily EVS cart audits which will continue indefinitely. Based on the Plan of Removal, the IJ was lifted on 02/20/18 at 11:30 am. This resulted in the scope and severity being reduced from level K to level E. Based on observation, record review, and interview the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 14 (R #s 5, 25, 26, 37, 53, 54, 57, 63, 69, 70, 82, 111, 212 and 214) of 14 (R #s 5, 25, 26, 37, 53, 54, 57, 63, 69, 70, 82, 111, 212 and 214) residents reviewed for accidents as evidenced by: failing to place Wet Floor signs on areas that had recently been mopped, leaving EVS carts unattended and cleaning chemicals unlocked and unsecured, and failing to ensure a residents mattress were the correct size for the bed frame. These deficient practices are likely to result in significant resident injury, through avoidable slip-and-fall accidents, ingesting chemicals, and possible entrapment. The findings are: Findings related to Housekeeping: A. On 02/19/18 around 9:40 am, during observation on the locked Dementia Unit, Housekeeper #1 was seen sweeping and moping the floor in the dining room. No Wet Floor signs were observed and residents (R #s 5, 25, 26, 37, 53, 54, 57, 63, 69, 70, 82, 111, 212 and 214) were present at the time. B. On 02/19/18 at 10:23 am, during observation on the locked Dementia Unit, the EVS cart was left unattended and unlocked. The top section of the cart could be opened revealing several bottles of chemicals in clear plastic bottles and a container of comet were present and accessible. C. On 02/19/18 at 1:48 pm, during observation on the locked Dementia Unit, Housekeeper #1 was seen mopping the right side of the hall between the dining room and the nurses station. No Wet Floor signs were observed and residents (R #s 5, 25, 26, 37, 53, 54, 57, 63, 69, 70, 82, 111, 212 and 214) were present at the time. Housekeeper #1 had Wet Floor signs on the EVS cart. D. On 02/19/18 at 2:34 pm, during an interview with Licensed Practical Nurse (LPN) #2, he stated the following residents were able to ambulate independently or with a walker: R #s 5, 25, 53, 54, 57, 63, 69, 82, 111, 212, and 214. E. On 02/19/18 at 2:37 pm, during interview the Housekeeping Director confirmed staff is expected to put Wet Floor signs down before they mop and cleaning chemicals should be locked when not in use. F. On 02/19/18 at 4:14 pm, during interview Housekeeper #1 confirmed he did not place Wet Floor signs when he mopped the floors on the Dementia Unit. Housekeeper #1 was asked if left the cart unattended, he stated I might have, I walked away to use the restroom. Housekeeper #1 also confirmed he did not lock the EVS cart stating, The carts don't really lock, I guess it's broken. G. On 02/20/18 at 7:33 am, during observation on the locked Dementia Unit an EVS cart was unattended and unlocked with cleaning chemicals accessible. Housekeeper #2 was seen walking out of the janitors closet several minutes later. H. On 02/20/19 at 7:35 am, during interview Housekeeper #2 attempted to lock the EVS cart without success, stating that one side cannot be locked because the lock was broken. She stated that it has been that way since she started working at the facility, about a year ago. I. On 02/20/18 at 8:16 am, during a second interview the Housekeeping Director stated that staff are supposed to check the locks on the cart everyday. The Housekeeping Director stated that they should report any problems with the carts to him immediately, stating They dropped the ball by not notifying me. J. On 02/20/18 at 8:44 am, during an interview the Dementia Programs Director (DPD) stated that R #s 53, 26, 82, 63, 37, 69 and 70 wander on the unit and R #s 63 and 26 will sometimes go through resident's drawers and grab items from the dining room. K. On 02/20/18 at 8:45 am, the Housekeeping Director provided a hand written list stating what chemicals and items are on the housekeeping carts, Clorox healthcare, satin shine, comet cleanser, breakdown odor digester, oxivir-disinfectant (A one-step disinfectant cleaner), putty knife, scissors, and toilet brush. He stated the items in the EVS carts are the same. L. Record review of the Stocking a Cart policy and procedure dated 6/2016, revealed top shelf Must be locked up when not in use. Review of the Cleaning policies, revealed Use 'Wet Floor' sign. Findings related to R #26: M. Record review of R #26's Admission Record revealed she has a [DIAGNOSES REDACTED]. N. On 02/20/18 at 2:43 pm, during observation of R #26's bed, she had bilateral (both sides) quarter side rails, a standard size mattress on a wide bed frame. There was a gap between the mattress and the footboard of about 4 inches and the right side rail was in the up position with about 6 inches between the mattress and rail. O. On 02/21/18 at 1:50 pm, during observation of R #26's bed, both quarter side rails were down, however when raised there was still a 6 inch gap between mattress and rail and a 4 inch gap between the mattress and footboard. P. Record review of R #26's Medical Record did not show a physicians order for the use of [REDACTED]. Q. On 02/21/18 at 2:26 pm, during interview with the Maintenance Director, he stated that he tries to make rounds on the dementia unit once a week. He stated he looks in the rooms to make sure everything is working. The Maintenance Director stated that on the locked unit, each resident has a widening frame on the bed to allow a 42 inch mattress. He stated that he checks for any gaps between the bed and frame by doing visuals. He stated Most of the time I do a visual, I don't lift the side rails up I can just peak if it is. R. On 02/21/18 at 3:22 pm, during an interview with the DPD, she stated that she makes rounds in residents' rooms twice a day. She stated that she was not aware of the gap between R #26's mattress, bed rail, and footboard. The DPD stated that maintenance checks for gaps. S. On 02/21/18 at 3:31 pm, during interview the Administrator stated that R #26's bed was Too narrow by 3-4 inches. The Administrator confirmed that the gap between the side rail, mattress, and footboard is not appropriate. T. On 02/22/18 at 3:33 pm, during interview the Administrator in Training confirmed R #26 does not have physician orders [REDACTED]. U. Record review of the Bed Safety Policy dated 11/28/16, revealed Center nursing and Maintenance will conduct an annual inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. The Bed Safety Audit will be used to conduct the inspection. When bed rails and mattresses's are used and purchased separately from the bed frame, the center must ensure that the bed rails, mattress, and bed frame are compatible. If a bed rail is used: use the Bed Safety Action Grid to assess the patient/resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the patient or resident representative and obtain informed consent prior to installation using the Consent for Use of Bed Rails form, maintain consent form in the patient's medical record. If the bed rails is not needed as an enabler or patient did not request the bed rail, secure the bed rail to the bed.

Based on record review and interview, the facility failed to consistently provide care and services to prevent the development of avoidable pressure ulcers (PUs), for 2 (R #s 5 and 7) of 12 (R #s 1-12) residents that were reviewed for pressure ulcers either in-house acquired or residents that were admitted to the facility as having a pressure ulcer. The residents were identified on 11/22/17 by the Clinical Nurse Executive (CNE) as being treated for [REDACTED]. 1. R #5 was identified on admission (10/03/17) to an acute care hospital as having a PU, not noted by the facility. R #5 was then readmitted (10/07/17) to the facility and again the PU was not identified until 16 (sixteen) days later (10/24/17). 2. R #7 developed skin breakdown 7 (seven) days after admission (10/28/17) to the facility (11/04/17). This skin breakdown ultimately resulted in the resident being transferred to a local hospital for PU treatment. The deficient facility practices of not assessing, and treating skin impairments in a timely manner resulted in harm to the residents. The findings are: Findings for R #5: A. Record review of a medical records from a local hospital where R #5 was admitted on [DATE], indicate the following: 1. The history and physical (H & P) dated 10/03/17 revealed the following Diagnoses: [REDACTED]. 2. Record review of the RN (registered nurse) Wound Svcs (services) Progress Note Form dated 10/05/17, revealed the following: 10/5 RNWC (RN Wound Clinician) in to assess skin, pt (patient) unable to assist with turning, minimally responsive verbally, floor RN at bedside, verbal report given to (name of provider), orders obtained for q 2 hr (every 2 hours) turns, sacral (a large, triangular bone at the base of the spine) and heel [MEDICATION NAME] foam dressings (Soft, flexible and highly absorbent bandage), and to float heels. Deep tissue injury to right heel, skin intact, dark purple, non-blanching, dressed with heel [MEDICATION NAME] foam. Moisture friction shearing to coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column ) is open, moist, pink, blanching, uneven borders, no s/s (signs and symptoms) of infection, dressed with [MEDICATION NAME] foam . 3. The Wound assessment dated [DATE] revealed the following: a. Wound Assessment of the Midline Sacrum Moisture/Friction area measured 1 x 1x 0.1 cm (centimeter). b. Pressure Injury Assessment of the right heel, measured 1.5 x 1.5 x 0 cm. B. Record review of the medical records from the facility indicate the following: 1. The Admission Minimum Data Set ((MDS) dated [DATE] (R #5 was admitted to the facility on [DATE]) revealed under Section M Skin Conditions that R #5 did not have any skin conditions indicated at that time. 2. The Initial Nursing assessment dated [DATE] (the day R #5 was readmitted to the facility from the hospital) indicate under the Integumentary (the skin and its appendages acting to protect the body from various kinds of damage) section, there were no skin impairments present. 3. Record review of the Skin Checks dated 10/09/17 and 10/16/17 indicated no skin injury or wounds identified. 4. Record review of the RMS (Risk Management System) Event Summary Reports dated 10/24/17 and 11/10/17 respectively, revealed the following: a. The RMS Event Summary Report dated 10/24/17, indicated the following: PU - New in-house acquired, deep tissue injury to the heel; Braden score (a scale used for predicting pressure sore risk, Severe Risk: Total score < 10, High Risk: Total score 10 - 12, Moderate Risk: Total score 13-14 and Mild risk: Total score 15 - 18) at admission (08/31/17) was at 13, the most recent Braden score was 15 (10/24/17). Weekly skin checks were documented, the last skin check documented was on 10/23/17. Interventions were in place. The conclusion was that the PU was avoidable . b. The RMS Event Summary Report dated 11/10/17, indicated the following: PU - New in-house acquired, stage II to coccyx .Interventions in place did not prevent pressure ulcer from forming. The conclusion was that the PU was avoidable . C. On 11/21/17 at 3:15 pm, during interview, the CNE stated that she realized the facility did not have a good system-wide wound care program, so the facility conducted a skin sweep the first of (MONTH) (YEAR). After the skin sweep was conducted, the CNE put into place wound care action plans. The CNE confirmed that during the skin sweep, R #5 was not in the facility as she had been sent to a local hospital. When R #5 returned from the hospital on [DATE], the nurses failed to assess the wounds as they should have, in spite of having a wound care action plan in place. The CNE confirmed that R #5's wounds had been discovered on 10/24/17 and 11/10/17 respectively. D. On 11/28/17 at 9:00 am, during an interview with the CNE, a request was made for the facility's skin sweep results that were conducted 10/01/17 to 10/05/17. At 10:50 am, the CNE stated that she was having trouble locating the skin sweep results. By the end of the day (11/28/17), the facility's skin sweep results could not be located. Findings for R #7: E. Record review of R #7's medical records who was admitted to the hospital on [DATE] indicate the following: 1. R #7 has [DIAGNOSES REDACTED]. 2. Skin Check note dated 10/29/2017, indicated no skin impairment. 3. The physician progress notes [REDACTED].morbidly obese man with poorly controlled diabetes mellitus , on high doses of insulin (a hormone released by the pancreas gland), who has been declining .within the past 1-2 weeks. He said that the became extremely weak. He was not able to move and ambulate (walk; move about). He also reports that his legs started swelling, and he developed worsening pain in his knees .he has history of gout .was treated with [MEDICATION NAME] (medication to treat gout), but now cannot take the medication because of worsening kidney function .he has difficult time participating in physical therapy because of worsening pain in his bilateral legs. 4. Skin Check note dated 11/04/17, indicated a dark purple area to (the) right buttock with scab approx. (approximately) 2 cm (in length) X (by) 2 cm (width). 5. Record review of the RMS (Risk Management System) Event Summary Report dated 11/07/17, revealed the following: a. PU - New in-house acquired, Skin check performed and a wound to the left and right buttock noted. Wound to left buttock is 2.5 x 2.5 x sf (superficial) with 100% eschar (a collection of dead tissue within the wound bed) and light drainage noted. Wound to right buttock is 1 x 2.5 x sf with 100% eschar and light drainage noted .; Braden score was 20, the most recent Braden score was 16 11/07/17. Weekly skin checks were documented, the last skin check documented was on 11/04/17. Interventions were in place. The conclusion was that the PU was avoidable .Resident does not take active role in own health, upon interviewing resident stated that he thought he had a skin issue going on but did not want to bother taking care of it . 6. Progress Note dated 11/08/17, revealed the following: IDT (Interdisciplinary Team) review of change in skin condition. New skin condition noted to bilateral buttocks. Unstageable (Ulcers covered with slough (wet) or eschar (dry) are by definition unstageable. The base of the ulcer needs to be visible in order to properly stage the ulcer) areas x 2. Rsd (resident) skin clear on admission, utilizes hoyer lift (a mechanical lift that transfers resident from bed to wheelchair, and from wheelchair to bed) for transfers .Interview with staff finds that resident will frequently refuse to lay down when he is up in the chair. Rsd is obese man and requires assist from staff, does not participate in care and appears to be passive in regards to care . F. physician progress notes [REDACTED].alerted by the nurse .concerned that his decubital ulcer (also known as a pressure ulcer, pressure sore, or bedsore) to the left buttock is getting worse. He has black eschar, which was stable eschar. No (sic) he has odor coming from his wound. And the area surrounding the wound is angrier red. Patient is complaining of worsening pain to his left buttock. G. physician progress notes [REDACTED].send the patient to the ER (emergency room ) .to evaluate for infected decubital ulcer .