Every finding on record at Beloit Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R10, R13, and R12) reviewed for supervision. R10 was found smoking in his room. R10 was deemed to be an elopement risk on admission but deemed to be safe to smoke unsupervised. R13 was found smoking in her room. R13 was observed smoking in an undesignated smoking area, and the smoking areas was unkept. R12 was observed eating food that was not in accordance with her physician ordered diet. Findings: The facility policy titled, Resident Smoking, last revised 3/1/25, states in part. Guideline: It is the guideline of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area (or alike) sign may be posted and well visible. 2. Safety measure for the designated smoking area will include, but not limited to: a. Protection from weather conditions (i.e. covered) b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible metal containers with self-closing covers into which ashtrays can be emptied. d. Accessible fire extinguisher. 6. Residents who desire to smoke will be further evaluated, using the Smoking Evaluation, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 9. If a resident who smokes experiences any decline in condition or cognition, he/she will be reevaluated for ability to smoke independently and/or to evaluate whether any additional safety measures are indicated. 12. A resident does not have the right to put others at risk within or on grounds of the facility and the right to smoke may be revoked immediately. Example 1 R10 was admitted to the facility on [DATE]. R10 has a Brief Interview of Mental Status (BIMS) of 11, indicating R10 has moderate cognitive impairment. R10's diagnoses include in part. malignant neoplasm of esophagus, malnutrition, cachexia, epilepsy, and history of alcohol abuse. R10's care plan states in part. Focus: The resident is an elopement risk/wanderer. Interventions: Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The resident's triggers for wandering/eloping are (specify). The resident's behavior is de-escalated by (specify). Of Note: There are no specific triggers or ways to de-escalate R1's wandering listed on the plan of care. Focus: [Name] is a smoker. Interventions: Instruct resident about the facility policy on smoking/smokeless tobacco: locations, times, safety concerns. The resident is UNSUPERVISED while smoking and/or using smokeless tobacco, initiated 6/3/26, revised 6/18/26. Of Note: R1's smoking evaluation completed on 6/3/26 indicates R10 requires supervision for smoking. R3's smoking assessments dated 11/8/24 states in part. Smoking Safety Interaction: 2. Which of the following products does resident use? Tobacco. 3. Does the resident display any of the following? Follows the facility's policy on location and times of smoking. Care planning: Tobacco Use. Interventions/Tasks: Conduct Smoking Safety Evaluation on admission and PRN. Educate Resident/Responsible Party on the facility's tobacco/smoking policy(s). If a smoking facility, orient Resident to smoking times and procedures. Clinical Suggestions: Nothing marked. R10's smoking evaluation dated 6/3/26 states in part. admission Smoking Evaluation: Does the resident smoke? Yes Does the resident have cognitive loss? Yes g. Can residents light own cigarette? Yes i. Does resident need facility to store lighter and cigarettes? No j. Plan of care is used to assure resident is safe while smoking? Yes l. Is the resident a supervised or unsupervised smoker? Supervised R10's elopement risk evaluation completed 6/3/26 states in part. admission Elopement Risk Evaluation, score of 13 indicating the resident is at risk for elopement. Of Note: R10 was deemed to be a wander risk on admission and in need of supervision with smoking. Smoking re-evaluation completed and R10 at that time deemed not needing supervision with smoking although R10 remained an elopement risk. R10's smoking evaluation dated 6/10/26 states in part. Smoking Evaluation: Does the resident have cognitive loss? Yes 6. Can residents light own cigarette? Yes 8. Does resident need facility to store lighter and cigarettes? No 9. Plan of care is used to assure resident is safe while smoking? Yes 10. Is the resident a supervised or unsupervised smoker? Unsupervised Nurses Note dated 6/14/26 states in part. Note Text: Writer was walking by res (resident) room, is [sic] door was open, he was sitting in his w/c (wheelchair) in full view from door, holding a cigarette that had just been light [sic]. Entered the room and took cigarette from res, destroyed by flushing, res repeatedly saying, I'm sorry, I'm sorry, writer informed res that smoking inside was not allowed, due to his smoking in his room, his cigarette and lighter were confiscated without protest, informed res that he could continue to smoke but he would need to get his cigarettes and lighter from nursing staff. Nurses Note dated 6/15/26 states, Note Text: Res found holding a single cigarette, pack of cigarettes confiscated, explained to res that smoking was a violation of WI (Wisconsin) law and because he was found with a lit cigarette in his room, he violated facility trust about have [sic] his smoking materials. Again explained to res that he could still smoke, he would just need to request his smoking materials from any staff member. On 7/8/26 at 11:35 AM, Surveyor interviewed LPN4 (Licensed Practical Nurse). Surveyor asked LPN4 if she remember an incident with R10. LPN4 stated that R10 had been caught smoking in his room by the NOC (night) shift nurse. LPN4 states that when she came into the facility in the morning for her shift the night nurse reported to her that R10 had a lit cigarette in his room that she took from him. Surveyor asked LPN4 if she is aware if any changes were made in regard to R10's care plan following this incident. LPN4 states that she is unsure what changes were made but is aware that after this R10's smoking materials were kept in the nurses' cart. On 7/8/26 at 11:54 AM, Surveyor interviewed DON. Surveyor asked DON who completed admission evaluation and care plan for R10. DON states that the admit nurse will complete the evaluations and care plan within 48 hours of admission. Surveyor asked DON if the SW completes any of the care plan or evaluations. DON states that the SW is able to complete smoking evaluations and update the care plan. Surveyor asked DON if a resident is at risk for elopement should they be unsupervised with smoking. DON states that if residents are an elopement risk they should be supervised with smoking. Surveyor reviewed smoking and elopement risk assessments with DON. DON states R10 should have remained a supervised smoker since he was at risk for elopement. Surveyor asked DON about R10 smoking in the facility. DON states that R10 did not have a lit cigarette that she was only aware of R10 holding a cigarette not that it was lit. On 7/8/26 at 12:30 PM, Surveyor interviewed LPN1. Surveyor asked LPN1 if a resident who is an elopement risk should be supervised with smoking. LPN1 stated, if a resident is an elopement risk should not be an unsupervised smoker. On 7/8/26 at 12:40 PM, DON approached Surveyor stating, I reviewed the note from 6/15/26 regarding R10 smoking in his room. We were not aware that R10 had a lit cigarette in his room. We were under the impression it was not lit but reviewing the note it says different. We didn't do anything following this incident due to not being aware. We were not aware of the note. On 7/9/26 at 8:36 AM, Surveyor received a return call from RN3. Surveyor asked RN3 if she could talk about incident with R10 smoking in his room. RN states that she walked by R10's room, his door was open and I looked over and saw R10 with a lit cigarette. RN3 states she removed R10's smoking materials from his room and placed them in the medication cart. Following this incident R10 was again caught with a cigarette but this time it was not lit. RN3 states that she again took cigarettes from R10 and believes that R10's family was bringing smoking materials into R10. Surveyor asked if R10 was a supervised or unsupervised smoker. RN3 states R10 was an unsupervised smoker so up until being caught with the lit cigarette he was able to keep his smoking materials on his person. Surveyor asked RN3 if a resident is an elopement risk should they be a supervised smoker. RN3 states, if a resident is an elopement risk they should be a supervised smoker. Example 2: R13 was admitted on [DATE] with a nicotine dependence. R13's Minimum Data Set (MDS) dated [DATE] indicated R13's BIMS is a 10 out of 15 indicating moderate cognitive impairment. On 4/3/26, R13's Smoking evaluation indicated R13 has a cognitive loss, R13 smokes morning, afternoon and evening. Safety section indicates R13 can light her own cigarette. R13 has been educated on the smoking procedure and is marked as being unsupervised. On 5/8/26 at 4:07 AM, R13's progress note states in part: Received message from charge nurse related to son calling facility. Writer walked into room and upon entering and resident was smoking a cigattete [sic]. Resident then put the cigarette out in the sink. VS (vital signs) WNL (within normal limits) and communicating appropriately. Resident appears to be at baseline cognition. (R13) says she is feeling fine. Will follow up with on call nurse (name) related to cigarette smoking and charge nurse aware will continue to closely monitor. On 5/8/26, R13's smoking evaluation indicated R13 needs the facility to store lighter and cigarettes and is marked as being unsupervised. Additional comments, state in part Resident is aware of the facility smoking procedures and is able to safely smoke unsupervised in the designated smoking area. The facility is to store resident lighter and cigarette in nursing cart. On 5/8/26 at 2:07 PM, R13's Progress note states in part: Son was called about last night's incident. He will be giving (the) nurse the cigarette's when he buys them for her. On 7/8/26 at 1:57 PM, Surveyor interviewed LPN5 (Licensed Practical Nurse) regarding R13 and smoking in her room. LPN5 indicated he walked into R12's room and she was smoking. LPN5 indicated R13 put it out in her Pepsi, and he went and got the other nurse and removed her lighter. LPN5 indicated he is not aware of any other resident smoking in their room. LPN5 indicated if they are supervised, you're to stay with them and they cannot have their items. LPN5 indicated R13 was independent and its care planned. On 7/8/26 at 1:03 PM, Surveyor interviewed Administrator regarding R13. Administrator indicated R13 should not have been smoking in her room. Administrator indicated they reviewed all residents who smoke in house, started education with staff and residents, held a Quality assurance meeting, completed new smoking evaluations and has residents sign smoking contracts. Example 3 The Wisconsin Department of Health Services, Smoking in Wisconsin Nursing Homes, dated 9/2017, states in part: .Designated Outdoor smoking areas. Facilities that allow smoking in a designated outdoor smoking area should ensure that each designated outdoor smoking area is located in an area adjacent to the facility that is easily accessed and protected from the weather (e.g., covered, wall or fence on one side if there are winds typically from one direction, etc.,) The area or areas must also protect nonsmokers from the potential hazards of second-hand smoke. The Life safety code (NFPA 101, 2012 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied must be readily available . On 7/8/26 at 1:40 PM, Surveyor observed R13 outside smoking in an undesignated smoking area, while sitting under the shade of a tree. R13 has a pack of cigarettes in her lap and was actively smoking a cigarette. The area where R13 was smoking had no ash receptacle or way to put out cigarette butts. There were nine cigarette butts in a cement plantar, with a sign that says no smoking near a bench, and multiple butts scattered on the ground around where R13 was smoking. On 7/8/26 at 1:45 PM, Visitor approached Surveyor and indicated that R13 came over to this area due to not having shade at the smoking area. Visitor indicated there are cigarette butts all along the ground. On 7/8/26 At 1:53 PM, Surveyor interviewed ADON (Assistant Director of Nursing). Surveyor had ADON observed the area where R13 was smoking. ADON indicated cigarette butts should not be in the planters or on the ground. ADON indicated residents should not be smoking in that area. Example 4 R12 was admitted to the facility on [DATE] and has diagnoses that include dysphagia. R12's physician's orders, dated 6/29/26, call for a mechanical soft diet with ground meats. On 7/8/26 at 12:20 PM, Surveyor observed R12 at the nurse's station. A group of friends who do not reside in the facility walked up to the nurse's station and asked if they could take R12 somewhere inside the facility to eat. The friends had multiple bags of takeout food. LPN 4 (Licensed Practical Nurse) pointed to a nearby lounge. The friends then took R12 to that room. Surveyor followed a few moments later and observed the friends of R12 with sub sandwiches and bags of potato chips. A sub sandwich and bag of potato chips were in front of R12. Surveyor immediately notified DON B (Director of Nursing) at 12:25 PM. DON B then promptly went into the room and took the sub sandwich and potato chips and stated to Surveyor that R12's POA did not want her eating that food and it is dangerous to her due to her dysphagia. DON B confirmed the sandwich was a sub sandwich with deli meat on it. DON B indicated at this time that she would expect staff to be aware of food being brought in and knowing if it would be appropriate for that particular resident. On 7/8/26 at 12:40 PM, Surveyor interviewed CNA4 (Certified Nursing Assistant) who stated that she had seen the friends walk in with the food and take R12 to the lounge. On 7/8/26 at 12:42 PM, Surveyor interviewed LPN4 who stated that she had directed the friends to the lounge but was not aware that they had food with them. On 7/8/26 at 12:50 PM, Surveyor interviewed FSD (Food Service Director) who stated that the bread on a sub sandwich and potato chips would not be appropriate on a mechanical soft diet. FSD also indicated that deli meat would not be appropriate for someone who required ground meats.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 59 residents who reside at the facility. Surveyor observed staff in the kitchen not wearing hair restraints. Cook E touched ready to eat food with contaminated gloves. CNA M did not wash or sanitize her hands after assisting one resident and before assisting another resident with their meal. Evidenced by: The facility policy, Food Safety Requirements, dated 10/2022.states, in part;.1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process including the following.f. Employee hygienic practices.7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.a. Staff shall wash hands according to facility procedures. b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.d. Dietary staff must wear hair restraints to prevent hair from contacting food.h. Gloves will be worn when directly touching ready-to-eat foods and when serving residents who are transmission-based precautions. Example 1 On 1/28/26 at 2:00 PM, Surveyor observed staff in the kitchen without wearing a hairnet. On 1/28/26 at 2:30PM, Dietary Manager D (DM) indicated any time staff are in the kitchen staff should wear hair restraints. DM D indicated understanding of the above concern. Example 2 Facility policy, titled Hand Hygiene, reviewed 3/27/25, includes: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub R68 admitted to the facility on [DATE]. R49 admitted to the facility on [DATE]. R33 admitted to the facility on [DATE]. On 1/27/2026 at 12:55 PM Surveyor observed CNA M (Certified Nursing Assistant) clean R49 glasses and assisted him getting his fork in his hand. CNA M then went to the other side of the table and assisted R68 by using his fork to push food on his plate and then placing it in his hand. CNA M then went over to R49 again and handed him his cup. CNA M walked to the next table where she peeled the clear covering off of R33's cake. Surveyor observed CNA M shaking hands and dance with a kitchen staff member. Then Surveyor observed CNA M remove R68's soiled neck napkin. It is important to note CNA M did not wash or sanitize her hands after assisting one resident and before assisting another resident with their meal. On 1/27/2026 at 1:07 PM CNA M indicated she should have washed her hands after assisting R49 clean his glasses and before assisting R68 with his meal. Then CNA M indicated she should have washed her hands or sanitized them after she assisted R68 with his fork and before assisting R49 by placing his drink in his hand and then again before assisting R33 with opening his cake. On 1/29/2026 at 10:05 AM NHA A (Nursing Home Administrator), DON B (Director of Nursing), and ADON C (Assistant Director of Nursing) indicated CNA M should wash or sanitize hands before doing anything with the food and in between residents when assisting in dining room. Example 3 On 1/27/26 at 12:33 PM, Surveyor observed [NAME] E in the dining room preparing meal plates. While wearing gloves, [NAME] E grabbed the waistband of [NAME] E's pants and pulled the pants up. [NAME] E then grabbed a tortilla with that same gloved hand and made a fajita. Surveyor asked [NAME] E about infection control when plating meals. [NAME] E stated I need to make sure to wear proper hair net, ensure utensils are not mixed, let other staff handle meal tickets to keep gloves from being contaminated. Surveyor asked if gloves are contaminated if they touch staff clothing. [NAME] E stated yes. On 1/29/26 at 10:10 AM, Surveyor interviewed Food Services Director (FSD) D and asked about gloves and infection control with meal preparation. FSD D stated that if anything other than food is touched, need to change gloves. Tongs should be used for touching ready to eat foods. FSD D stated that [NAME] E told FSD D what occurred and stated it is not ok to touch clothing and then touch food. On 1/29/26 at 10:16 AM, Surveyor interviewed Assistant Director of Nursing/Infection Preventionist (ADON/IP) C and asked if gloves are contaminated after touching staff clothing. ADON/IP C stated yes and stated that staff cannot touch ready to eat food with gloved hands after gloves have touched staff clothing.

Based on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the potential to affect all 59 residents who reside at the facility.Garbage was found outside the dumpsters at the facility. Evidenced by:The facility policy, Disposal of Garbage and Refuse, revised on 3/2025.states, in part.The facility shall properly dispose of kitchen garbage and refuse.8. Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster.On 1/27/26 at 9:44 AM, during the initial walk through of the kitchen, Surveyor observed garbage on the ground next to the facility dumpsters. Surveyor observed cardboard, food wrappers, and used gloves on the ground. Dietary Manager D (DM) indicated garbage should not be left on the ground. DM D indicated everyone is responsible for picking up garbage.On 1/28/26 at 1:10 PM, Nursing Home Administrator A (NHA) indicated garbage should be picked up and put in the dumpster. NHA A indicated understanding of the above concern.The facility failed to ensure garbage and refuse was disposed of properly.

Based on interview, and record review, the facility did not ensure 1 of 4 residents (R12) received the necessary services for acceptable nutrition.R12 triggered for significant weight change with a weight loss of 7.4% in the last thirty days. The Registered Dietician recommended a scheduled snack of choice at HS (bedtime) on 1/20/26. The order was not started until 1/28/26.Evidenced by:The facility policy, Nutritional Management, revised on 4/2024, states, in part;.The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.A systematic approach is used to optimize each resident's nutritional status:.c. Developing and consistently implementing pertinent approaches.R12 was admitted to the facility on [DATE] with a diagnoses including cancer, bipolar disorder, and panic disorder.R12's most recent care plan, states, in part;.The resident has nutritional problems or potential nutritional problems r/t cancer and recent hospitalization 11/25/25.The resident will maintain adequate nutritional status as evidenced by no significant weight changes, no s/sx (signs/symptoms) of malnutrition and consuming at least 50% of at least 3 meals daily through review date.Registered Dietician to evaluate and make diet change recommendations PRN (as needed).R12's progress notes state, in part;.11/25/25 135.2lbs.Goal is for weight maintenance.R12's progress notes state, in part;.1/20/26.Resident triggers for a significant weight change of a loss of 7.4% in the last 30 days.125.2lbs.Goal is for weight maintenance. Resident is on a regular diet. PO (by mouth) avg 50-100% (average 50 to 100 percent) of meals. Recommend scheduled snack of choice @ HS (at bedtime) to help make sure calorie needs are met. Registered Dietician to continue monitoring and will f/u (follow up) as needed.R12's current orders, state, in part;.to have an HS snack of choice, a sandwich, cottage cheese, yogurt, or peanut butter crackers at bedtime for weight loss.start date: 1/28/26. (Of note: this order was recommended on 1/20/26 and was not entered until 8 days later)On 1/28/26 at 12:41PM, Nursing Home Administrator A (NHA) indicated R12's recommendations from the Registered Dietician did not start until 1/28/26. NHA A indicated the order should have been started sooner and they are working on correcting the concern.The facility failed to ensure all residents receive the necessary services for acceptable nutrition.

Based on interview and record review, the facility did not ensure Physician progress notes were maintained in a physical chart or Electronic Health Record (EHR) for 1 of 3 supplemental residents reviewed (R61).R61 reported that they would like to schedule an appointment with their doctor; Surveyor was unable to locate documentation of physician visits in their physical chart or EHR.Evidenced by:The facility's policy titled Physician Visits and Physician Delegation last reviewed on 10/16/24 states in part .1. The Licensed Nurse, Medical Records, or Facility Designee should: .f. Remind the physician to date and sign all orders and write a progress note.h. Ensure a progress note is present to reflect the date and time of the physician visit, an indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit.2. The Physician should: .d. Date, write and sign a progress note for each visit. R61 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left sided weakness following a stroke), type 2 diabetes mellitus, depression, and hypertension (high blood pressure).R61's most recent MDS (Minimum Data Set) dated 1/27/26 states that R61 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R61 is cognitively intact.On 1/28/26 at 1:30 PM, Surveyors met with residents for the group meeting. R61 reported to Surveyors that they have been trying to schedule an appointment with their PCP (Primary Care Physician) and that they haven't had an appointment in a while.On 1/28/26 at 3:00 PM, Surveyor reviewed R61's physical chart and EHR. Surveyor was unable to locate any documentation indicating that R61's PCP (primary care physician) or their delegate had seen them.On 1/28/26 at 4:00 PM, Surveyor interviewed Receptionist I, who is responsible for medical records and scheduling appointments. Surveyor asked Receptionist I what the process is when a resident wants to make an appointment with their doctor, Receptionist I states that the nurse will communicate the request and then they will schedule the appointment. Surveyor asked Receptionist I if they were aware that R61 would like to see their PCP, Receptionist I stated that they were unaware of the request and that R61's PCP comes to the facility on Fridays. Surveyor asked Receptionist I when the last time R61 saw their PCP, Receptionist I stated they were unsure and would have to get back to Surveyor.On 1/28/26 at 4:05 PM, Surveyor asked DON B (Director of Nursing) for documentation of R61's PCP visits.On 1/28/26 at 4:47 PM, Surveyor interviewed DON B. DON B provided Surveyor with a visit note dated 6/4/25 and reported that this is the documentation they received regarding R61's last visit. Surveyor asked DON B how often residents should be seen by their PCP, DON B stated every 30 days for the first 90 days and then at least every 60 days thereafter. Surveyor asked DON B if R61 should be seen more regularly, DON B stated yes.On 1/29/26 at 7:58 AM, DON B reported that R61's PCP will be faxing their notes to the facility. Surveyor asked DON B what their process is for obtaining Physician visit notes, DON B stated that some providers document in their EHR. Surveyor asked DON B if it is the facility's responsibility to obtain the visit notes, DON B stated yes. Surveyor asked DON B if the visit notes are not in the medical record, is the medical record complete, DON B stated no.

Based on observation, interview, and record review the facility did not ensure each resident receives food prepared in a form designed to meet individual needs for 1 of 4 Residents (R40 ) reviewed for nutrition.R40 has an order for ground meat and received general texture meats.Evidenced by:The facility's Therapeutic Diet Orders policy, dated 3/26/25, states, in part: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. Definitions: Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic Diet is a diet ordered by a physician.as part of treatment for a disease or clinical condition. Explanation and Compliance Guidelines: .2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual [NAME] as determined by the resident's assessment. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescibed.R40 admitted to the facility on [DATE] with diagnoses that include: encephalopathy (brain dysfunction that causes altered mental states such as confusion, personality changes, and cognitive impairment); Adult failure to thrive (a syndrome characterized by unintentional weight loss, malnutrition, dehydration, cognitive decline, and reduced physical functionality); unspecified dementia (cognitive decline without a specific identified cause).R40's Physician Orders include: Regular diet Mechanical Soft - Ground Meat texture.start date 1/2/26.On 1/27/26 at 12:35 PM, Surveyor observed R40 in dining room with plate of 2 chicken fajitas (chicken cut in thick strips placed inside a soft shell tortilla), rice, beans, and cake. R40 was eating independently, with no teeth, occasionally spitting out bites of food onto R40's plate.On 1/28/26 at 12:33 PM, Surveyor observed R40 in dining room. BOM G (Business office Manager) placed plate with turkey (cut into cubes) in gravy over a slice of bread, mashed potatoes and sliced carrots in front of R40. Surveyor observed meal ticket next to R40's place. Meal ticket stated, in part: Texture: Mechanical Ground.Entree: 1 each Ground open faced turkey sandwich. CNA H (Certified Nursing Assistant) was seated at table across from R40. Surveyor asked CNA H about ground meat. CNA H stated it would be ground up, but not pureed. Surveyor asked if the meat on R40's plate was ground. CNA H stated it doesn't appear ground; I will check.On 1/28/26 at 12:34 PM, Surveyor asked BOM G about responsibility in the dining room. BOM G stated to serve the right meal to the right person. Surveyor asked how you would know if it is the right meal. BOM G stated, get it from the cook; they know.On 1/28/26 at 12:35 PM, CNA H stated that the cook told CNA H that the meat was considered ground as it is soft.On 1/28/26 at 12:43 PM, Surveyor asked [NAME] F about turkey for a ground diet. [NAME] F stated I put it in the Robot Coupe (food processor) and blend it just a little bit. Surveyor asked what size the turkey ends up to be, [NAME] F stated it kind of looks mashed.On 1/28/26 at 12:44 PM, Surveyor asked FSM D (Food Services Manager) if the turkey on R40's plate was ground. FSM D stated, no, it is diced. Surveyor asked if diced was an appropriate texture for R40. FSM D stated no. FSM D stated the turkey comes to the facility diced; it needs to be ground in the food processor to a taco meat consistency. Surveyor asked FSM D to define taco meat consistency. FSM D stated it would be the size of rice.On 1/28/26 at 2:49 PM, Surveyor asked NHA A (Nursing Home Administrator) about mechanically altered diets. NHA A stated that staff are expected to follow the proper diet and should serve foods according to physician orders.

Based on interview and record review, the facility did not implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for residents; and did not ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect all 1 of 3 sampled residents (R44) RR J (R44's Resident Representative and Power of Attorney (POA)) and RR K voiced concerns of having signed an arbitration agreement while filling out admission paperwork and not fully understanding what she had signed. RR K indicated the arbitration agreement was not explained to her fully and she would not have wanted to sign that if she knew she was signing away constitutional rights to use the judicial system to resolve disputes with the facility. Evidenced by:Facility policy, titled Binding Arbitration Agreement, dated 12/1/24, includes: The facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility. Arbitration is a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments. binding arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final can be enforced by a court and can only be appealed on very narrow grounds. Judicial proceeding is any action by a judge formally before the court including trials, hearings, petitions, or other matters. when explaining the arbitration agreement the facility shall explicitly inform the resident or his representative of his or her right not to sign the agreement as a condition of admission . Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. ensure a resident or his or her representative acknowledges that he or she understands the agreement. the agreement must: provide for the selection of a neutral arbitrator agreed upon by both parties. provide for selection of a venue that is convenient to both parties. explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission. the agreement must not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials.R44 admitted to the facility on [DATE] with diagnoses, including cerebral infarction, type 2 diabetes mellitus, and unspecified dementia. R44's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/13/26, indicates R44's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15.On 1/27/26 at 11:34 AM RR K (Resident Representative) indicated she had concerns that R44's admission packet contained a signed arbitration agreement that was not explained at the time of it being signed.On 1/28/26 at 12:16 PM RR/POA J indicated she was unaware if she signed an arbitration agreement with the facility at the time of admission and she was not sure what the word arbitration means. Surveyor opened R44's admission packet and reviewed with RR/POA J over the phone, including the date and time the arbitration agreement was signed. Surveyor explained the agreement is that if a dispute arises RR/POA J would use the facility's appointed third party to resolve dispute and that RR/POA J would not use the judicial system to resolve disputes with the facility. RR/POA J indicated she would have never signed that if she knew what she was agreeing to.Facility's admission welcome packet includes a body with 114 pages. 8 of these pages is an arbitration agreement. A signature line exists on page 12 of the 114 pages.R44's Arbitration Agreement, signed and dated 12/9/25, includes: Please read this arbitration agreement carefully. You have the right to, and the facility recommends you ask any questions you have and consult with an attorney, family, or friends before choosing to sign and accept the terms and conditions of this arbitration agreement. Execution of this agreement by the resident is not a condition of admission to or required to continue receiving care at the facility, in other words, the resident has the right not to sign this agreement and still be admitted to or continue receiving care at the facility. It is understood by the facility and R44 that any legal dispute, controversy, demand, or claim, unless specifically excluded below that arises out of or relates to the Resident admission Agreement or any service or health care provided by the Facility to the Resident shall be resolved exclusively by the binding arbitration and not by a lawsuit or resort to judicial process except to the extent applicable law provide for judicial review of arbitration proceedings or judicial enforcement of arbitration awards. Rescission of Agreement: The Resident also understands that he/she has the right to seek legal counsel concerning this agreement and this agreement may be rescinded by written notice to the facility from the Resident within 30 days of the Resident's signature below. If not rescinded within 30 days, this agreement shall remain in effect for all care and services subsequently rendered by the facility, even if such care and services are rendered following the Resident's discharge and readmission to the facility.On 1/28/26 at 1:41 PM RCC L (Resident Care Coordinator) indicated if a resident signs an arbitration agreement that it means they and the facility will settle disputes in the county circuit court system. RRC L also indicated there is no time frame for rescinding the agreement and once it is signed it is in effect. Surveyor and RCC L reviewed the agreement noting the 30-day rescission period. Surveyor and RCC L reviewed the agreement noting the dispute would be settled without using the judicial system. RCC L indicated she did not completely understand what the arbitration agreement was for.On 1/28/26 at 2:10 PM NHA A (Nursing Home Administrator) indicated residents and/or their representatives are presented with an arbitration agreement to sign or decline by RCC L during the admission process. NHA A indicated an arbitration agreement is a contract between the facility and resident ensuring residents can't sue the company. NHA A indicated residents have 30 days to rescind the agreement. Surveyor shared her interview with RCC L with NHA A. NHA A indicated RCC L should be able to explain arbitration agreements and should know the time limits associated with the agreement. NHA A indicated she would educate RCC L about arbitration agreements again. Surveyor informed NHA A that RR/POA J wished to not be in a binding arbitration agreement with the facility. NHA A indicated she would discuss this with the Corporation to see if they would approve her to rescind after the 30 days.

Based on record review and interviews, the facility did not include accurate potential financial liability to residents whose Medicare coverage was ending when issuing the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 3 of 3 residents reviewed (R43, R54, and R72).R43 was receiving Medicare A benefits. R43 was not provided accurate potential financial liability when the SNFABN was issued.R54 was receiving Medicare A benefits. R54 was not provided accurate potential financial liability when the SNFABN was issued.R72 was receiving Medicare A benefits. R72 was not provided accurate potential financial liability when the SNFABN was issued.Evidenced by:The facility's policy titled Policy and Procedure: Advanced Beneficiary Notice dated 2/1/22 states in part .2. When determined that services are no longer necessary a. Social Services or Social Services back up i. The social services representative will issue Room and Board ABNs per policy and upload this information into [facility's computer system] under the miscellaneous tab.c. Business office Manager i. Will provide updated room rate and therapy rate sheets to be issued with the ABN.Example 1R43's Medicare coverage ended on 1/9/26. R43 was not provided with accurate potential financial liability when their SNF ABN form was issued. Example 2R54's Medicare coverage ended on 9/20/25. R54 was not provided with accurate potential financial liability when their SNF ABN form was issued.Example 3R72's Medicare coverage ended on 11/7/25. R72 was not provided with accurate potential financial liability when their SNF ABN form was issued.On 1/29/26 at 8:05 AM, Surveyor interviewed BOM G (Business Office Manager). Surveyor asked BOM G what the process is for SNFABNs, BOM G stated that social services takes care of them. Surveyor asked how residents or representatives are made aware of the room rates and therapy rates when Medicare coverage ends, BOM G states that they mail out room rates to families, but it doesn't have their names on it. Surveyor asked BOM G if the SNFABNs should have the room and therapy rates issued with it, BOM G stated that they were not aware of that needing to be done. Surveyor asked BOM G how would residents or families know that information, BOM G stated that they tell them verbally. Surveyor asked BOM G if there was any documentation to support that, BOM G stated no. Surveyor directed BOM G to the SNFABN form where it states estimated cost- see attached, BOM G stated that they were unaware of that.On 1/29/26 at 8:13 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if they would expect the SNFABN form to contain the cost of room and therapy, NHA A stated yes and that they would expect documentation in the resident's chart if a paper copy were not provided.

Based on interview and record review, the facility did not promptly notify and consult with a physician when a resident missed their medications for 1 of 1 resident's (R2) reviewed for medication administration. R2's physician was not notified when R2 did not receive antipsychotic medication over several days. This is evidenced by: The facility's policy titled Notification of Changes, dated 10/24/23, includes the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family or legal representative when there is a change requiring such notification. The facility's policy titled Medication Error Reporting and Counseling Procedure, dated 12/12/23, includes the following: Notifying the Provider(s): The facility will inform the primary or prescribing physician(s) of the medication error in a timely manner and document notification in the medical record. This communication will help ensure that appropriate corrective measures can be taken, and future medication orders can be adjusted, if necessary. R2 admitted to the facility on [DATE] with a diagnosis of schizophrenia. R2's physician orders include the following: Seroquel oral tablet 25 mg give 1 tablet by mouth one time a day related to Schizophrenia Start date 11/21/24 8:00 AM. Seroquel oral tablet 25 mg give 1 tablet by mouth one time a day related to Schizophrenia Start date 11/21/24 12:00 PM Seroquel oral tablet 25 mg give 2 tablets by mouth one time a day related to Schizophrenia Start date 11/21/24 4:00 PM R2's nurse progress notes include the following: 12/21/24 at 5:29 PM Seroquel oral tablet 25 MG . none in cart on order. 12/22/24 at 5:28 PM Seroquel oral tablet 25 MG .on order 12/23/24 at 5:35 PM Seroquel oral tablet 25 MG .on order 12/24/24 at 5:24 PM Seroquel oral tablet 25 MG .on order 12/25/24 at 10:23 AM Seroquel oral tablet 25 MG .waiting for delivery 12/25/24 at 12:27 PM Seroquel oral tablet 25 MG .waiting on delivery 12/25/24 at 4:15 PM Seroquel oral tablet 25 MG .on order 12/26/24 at 4:46 PM Seroquel oral tablet 25 MG . (no documentation) 12/27/24 at 6:53 PM Seroquel oral tablet 25 MG . on order 12/29/24 at 11:16 AM Seroquel oral tablet 25 MG . (no documentation) 12/29/24 at 4:14 PM Seroquel oral tablet 25 MG .awaiting delivery of medication 12/30/24 at 8:37 PM Seroquel oral tablet 25 MG . not in cart Of note, there is no documentation of the physician being notified that R2 did not have his prescribed Seroquel for these days. On 4/29/25 at 3:10 PM, Surveyor asked LPN G (Licensed Practical Nurse) to show surveyor what medications are in the facility's contingency medication supply. LPN G showed surveyor the facility's contingency supply contained Seroquel 25 mg. LPN G stated the contingency supply is usually 8 to 10 pills of the medication. On 4/29/25 at 11:40 AM, Surveyor interviewed RN D (Registered Nurse) regarding administering medications. RN D indicated if a resident does not have a medication, the nursing staff is supposed to look in the facility's contingency medication supply and pull the medication from there to give to the resident. RN D also stated the staff is supposed to call pharmacy and ask to have the medication delivered and to notify the physician. RN D indicated this should all be documented in the resident's medical record. Surveyor asked what the facility would do if a resident did not get the medication delivered and now it was the second day, and the resident still does not have the medication. RN D indicated the facility would call the pharmacy and have the medication stat delivered which means the medication should be there within 4 hours. Surveyor asked what the process would be if a resident did not have a medication on the third day. RN D indicated she has never had it get that far before. On 4/29/25 at 11:50 AM, Surveyor interviewed LPN E regarding administering medications. LPN E indicated on day one of a resident not having medication, the facility should look in the contingency medication supply and call pharmacy to order it. LPN E indicated the physician should also be notified. On day two of a resident not having medication, LPN E stated she would notify DON B (Director of Nursing). On day three of a resident not having a medication, LPN E indicated she would ask the provider for a substitute. On day four, LPN E indicated she would call the physician and do an assessment. LPN E indicated it is unacceptable for a resident to be without medication for four days. On 4/29/25 at 2:08 PM, Surveyor interviewed ADON/WN C (Assistant Director of Nursing/Wound Nurse) regarding medication administration. ADON/WN C indicated on day one of a resident not having medication, the staff should look in the contingency medication supply, call the physician and call pharmacy to have the medication stat delivered. Day two, the staff should notify the physician, call pharmacy and notify their supervisor. ADON/WN indicated there should not be a day three. On 4/29/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) regarding medication administration. DON B indicated if a resident does not have medication, on day one, the facility should check in the contingency medication supply, call pharmacy, and call the provider. On day two, the staff should call again. On day three, staff should call the physician, and the facility would have to call the head of pharmacy because there is a problem. On day four, the staff should do the same thing, call the pharmacy, and call the physician. DON B indicated an assessment needs to be done daily based on the missed medication. DON B indicated all of this should be documented in the resident's medical record. DON B stated missed medications is a medication error and a risk management should be completed. Surveyor notified DON B that surveyor was unable to locate any documentation of a completed assessment for the missed medication, the pharmacy being notified, or the physician being notified of the missed Seroquel for R2 for the dates of 12/21/24 through 12/30/24. DON B did not provide surveyor with any documentation regarding R2's missed Seroquel for those dates.

Based on interview and record review the facility did not ensure based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents/choice for 1 of 2 residents (R1) reviewed for non-pressure wounds. R1 had dates his wound care was not signed out in the TAR (Treatment Administration Record). R1 returned from the hospital and did not have a full assessment completed for his non-pressure wounds. This is evidenced by: The Facilities Policy and Procedure entitled Wound Treatment Management dated 2/14/23 documents in part: .Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders .7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound . R1 is a long-term resident of the facility. R1 has the following diagnoses: metabolic encephalopathy, type 2 diabetes mellitus, cellulitis of RLE (right lower extremity) (infection of leg), open wound to RLE, open wound to LLE (left lower extremity), open wound to right foot, PVD (peripheral vascular disease- circulatory condition where narrowed blood vessels reduce blood flow to the limbs), and CHF (congestive heart failure- condition where the heart muscle is weakened and can't pump enough blood to meet the body's needs, leading to buildup of fluid in the lungs and other body parts). R1's TAR has the following documented: January 2025- blank box on 1/2/25. February 2025- 2/24/25 has 4 documented. According to key on TAR 4 is other/see nurse's notes. March 2025- blank box on 3/21/25. R1' Progress Notes do not include a nurses note for 2/24/25 as to why R1's wound care was not completed. R1 was hospitalized [DATE]-[DATE]. Upon R1's return to the facility on [DATE] there was not a full assessment of R1's wounds. R1's Admission/Readmission/Routine Head to Toe Evaluation dated 1/23/25 documents the following: .Skin integrity .Site #42 LLE (left lower extremity) (front) bilateral lower extremity unna boot, multiple open areas. Site #41 RLE (right lower extremity) Bilateral lower extremity unna boot, multiple open areas. Is worse looking than left leg. Bilateral feet 3+ pitting edema . On 4/30/25 at 11:40 AM, Surveyor interviewed RN D (Registered Nurse) regarding signing out treatments on the TAR. RN D indicated if the TAR is blank, the treatment was not completed. RN D indicated if there is a number 4 on the TAR, that means there should be a progress note made in the resident's chart on why the treatment was not completed. On 4/30/25 at 11:50 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding signing out treatments on the TAR. LPN E indicated if the TAR is blank, the treatment was not completed. LPN E indicated a number 4 on the TAR means there should be a progress note regarding the treatment. On 4/30/25 at 12:00 PM, Surveyor interviewed RN F regarding signing out treatments on the TAR. RN F indicated if it is not documented then it was not done and a number 4 on the TAR would indicate there is a progress note related to the treatment. On 4/30/25 at 2:08 PM, Surveyor interviewed ADON/WN C (Assistant Director of Nursing/Wound Nurse) regarding signing out treatments on the TAR. ADON/WN C indicated a 4 would mean there is a progress note about the treatment and if the TAR is blank, it means the treatment was not completed. ADON/WN C indicated treatments should be completed and signed out. On 4/30/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) regarding signing out treatments on the TAR. DON B indicated if a nurse charts a 4 on the TAR, then the nurse would make a progress note about the treatment. DON B indicated if the TAR is blank, then the treatment was not completed. DON B indicated all treatments should be completed or a note made for why it was not completed. DON B stated she expects treatments to completed. On 4/30/25 at 3:51 PM, Surveyor interviewed ADON/WN C. Surveyor asked ADON/WN C if there should have been a full assessment of R1's wounds to BLE's (bilateral lower extremities) upon return from the hospital on 1/23/25, ADON/WN C stated, yes there should have been. On 4/30/25 at 5:10 PM, Surveyor interviewed DON B. Surveyor asked DON B if she would have expected there to have been a full assessment of R1's wound to BLE's upon return from the hospital, DON B stated yes.

Based on interview and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 3 residents (R2) reviewed for pressure injuries. The facility did not complete wound care as ordered for R2. This is evidenced by: The facility's policy titled Wound Treatment Management, dated 2/14/23, includes: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Treatments will be documented on the Treatment Administration Record or in the electronic health record. R2 admitted to the facility on [DATE] and discharged on [DATE]. R2's Treatment Administration Record (TAR) for December 2024 includes the following: Sacrum wound; Cleanse with Vashe wound cleanser (a solution used for cleaning wounds) or equivalent, apply skin prep to peri-wound, apply hydrofera blue classic (a type of wound dressing that provides antibacterial protection) to wound bed, cover with ABD (absorbent gauze pad) and secure with mediflex tape (a type of tape to secure dressings) daily. Start date 12/5/24. Discontinued dated 12/18/24. R2's TAR indicates 12/15/24 and 12/16/24 are blank. Sacrum wound; Cleanse with Vashe wound cleanser (a solution used for cleaning wounds) or equivalent, apply skin prep to peri-wound, apply hydrofera blue classic (a type of wound dressing that provides antibacterial protection) to wound bed, cover with foam dressing twice daily. Start 12/19/24 Discontinued 1/8/25. R2's TAR indicates 12/19/24 and 12/25/24 are blank. R2's TAR indicates there is no documentation of the wound care being completed a second time from 12/19/24 through 12/31/24. B/L (bilateral, both) ischial tuberosities (the part of the pelvis that supports your weight when you're seated): Cleanse with Vashe wound cleanser or equivalent, apply skin prep to peri-wound, lightly pack with hydrofera blue classic, cover with hydralock (super absorbent dressing) 4 x 4, then abd pad, and secure with medi-flex tape once daily. Use betadine swabs to macerated wound edges every day and evening shift for wound care. Start Date 12/11/24 1500 (3:00 PM). Discontinued 12/18/24 1513 (3:13 PM). R2's TAR indicates 12/15/24 and 12/16/24 are blank. R2's TAR indicates 12/14/25 is blank. B/L (bilateral, both) ischial tuberosities (the part of the pelvis that supports your weight when you're seated): Cleanse with Vashe wound cleanser or equivalent, apply skin prep to peri-wound, lightly pack with hydrofera blue classic, cover with hydralock (super absorbent dressing) 4 x 4, secure with foam dressings. Use betadine swabs to macerated wound edges every day and evening shift for wound care. Start dated 12/19/24 0700 (7:00 AM). Discontinued 1/8/25 1216 (12:16 PM). R2's TAR indicates 12/19/24 and 12/25/24 day shifts are blank. R2's TAR indicates 12/22/24 and 12/25/24 evening shifts are blank. R2's TAR for January 2025 includes the following: B/L ischial tuberosities: Cleanse with Vashe wound cleanser or equivalent, apply skin prep to peri-wound, lightly pack with hydrofera blue classic, cover with hydralock 4 x 4 secure with foam dressing Use betadine swabs to macerated wound edges every day and evening shift for wound care Start 12/19/24 Discontinue 1/8/25. R2's TAR indicates 1/5/25 is blank for day shift. R2's TAR indicates 1/2/25 is blank for evening shift. Cleanse B/L ischial tuberosity wounds and sacrum with vashe or equivalent wound cleanser, protect peri wound with skin prep, lightly pack with Ca alginate and cover with Hydralock dressing then ABD, Secure with mepilex tape once daily and as needed if dressing soiled or loose every day shift for wound care Start date 1/23/25. Discontinued 3/25/25. R2's TAR indicates 1/28/25 and 1/30/25 are blank. Sacrum wound; Cleanse with Vashe wound cleanser (a solution used for cleaning wounds) or equivalent, apply skin prep to peri-wound, apply hydrofera blue classic (a type of wound dressing that provides antibacterial protection) to wound bed, cover with foam dressing twice daily. Start 12/19/24 Discontinued 1/8/25. R2's TAR indicates 1/5/25 is blank. R2's TAR indicates there is no documentation of the wound care being completed a second time from 1/1/25 through 1/7/25. Sacrum: Cleanse with vashe or equivalent wound cleanser, protect peri wound with skin prep and apply foam dressing daily and as needed every day shift for wound care Start 1/20/25. Discontinue 1/15/25. R2's TAR indicates 1/12/25 through 1/15/25 is blank. On 4/30/25 at 11:40 AM, Surveyor interviewed RN D (Registered Nurse) regarding signing out treatments on the Treatment Administration Record (TAR). RN D indicated if the TAR is blank, the treatment was not completed. RN D indicated if there is a number 4 on the TAR, that means there should be a progress note made in the resident's chart on why the treatment was not completed. On 4/30/25 at 11:50 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding signing out treatments on the TAR. LPN E indicated if the TAR is blank, the treatment was not completed. LPN E indicated a number 4 on the TAR means there should be a progress note regarding the treatment. On 4/30/25 at 12:00 PM, Surveyor interviewed RN F (Registered Nurse) regarding signing out treatments on the TAR. RN F indicated if it is not documented then it was not done and a number 4 on the TAR would indicate there is a progress note related to the treatment. On 4/30/25 at 2:08 PM, Surveyor interviewed ADON/WN C (Assistant Director of Nursing/Wound Nurse) regarding signing out treatments on the TAR. ADON/WN C indicated a 4 would mean there is a progress note about the treatment and if the TAR is blank, it means the treatment was not completed. ADON/WN C indicated treatments should be completed and signed out. On 4/30/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) regarding signing out treatments on the TAR. DON B indicated if a nurse charts a 4 on the TAR, then the nurse would make a progress note about the treatment. DON B indicated if the TAR is blank, then the treatment was not completed. DON B indicated all treatments should be completed or a note made for why it was not completed. DON B stated she expects treatments to completed. Of note, R2's treatment to his sacrum was not documented as completed 26 times between December 2024 and January 2025. R2's treatment to his bilateral tuberosity wounds was not documented as completed 11 times between December 2024 and January 2025.

Based on interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident's (R2) reviewed for smoking/vaping. The facility failed to re-assess and update R2's care plan for safety after being observed vaping in the facility. This is evidenced by: The facility's policy titled Resident Smoking, dated 7/10/25, includes the following: It is the guideline of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Smoking is prohibited in all areas except the designated smoking area. Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include but are not limited to: Use of e-cigarettes in designated smoking areas only. A safe smoking assessment will be completed on all residents using e-cigarettes. Any resident who is deemed safe to smoke .will be allowed to smoke in designated smoking areas . A Risk vs. Benefit Evaluation may be conducted by facility staff if a resident is exercising rights that may cause risk or harm to themselves. A resident does not have the right to put others at risk within or on grounds of the facility and the right to smoke may be revoked immediately. If a resident or family does not abide by the smoking policy or care plan .the plan of care may be revised to include additional safety measures and may include a Smoking Contract. R2's Smoking evaluation dated 12/30/24 includes the following: Does resident need facility to store lighter and cigarettes? No Plan of care is used to assure resident is safe while smoking? Yes Is the resident a supervised or unsupervised smoke? Unsupervised R2's comprehensive care plan printed on 4/29/25 includes the following: Focus: The resident is a smoker. Interventions: Instruct resident about the facility policy on smoking: locations, times, safety concerns. The resident can smoke unsupervised. The resident's smoking supplies are stored on his person. R2's nurse progress notes include the following: 1/11/25 1:20 PM . pt (R2) up in w/c vaping . Of note, this was in the facility when R2 was speaking to the nurse about wound treatments. 1/13/25 1:54 PM .when this writer entered room and noted pt (R2) vaping, this writer attempted to educate pt that he is not to be vaping in room. Pt shrugged his shoulders with a smile on his face and then took a long drag on the vape. Of note, R2 did not have a new smoking assessment completed and did not have his care plan updated after the 2 incidents of non-compliance when vaping in the facility. On 4/30/25 at 3:00 PM, Surveyor interviewed ADON/WN C (Assistant Director of Nursing/Wound Nurse) regarding R2's vaping. Surveyor asked ADONWN C if R2 should have had a new smoking assessment, care plan review, or IDT (Intradisciplinary Team) meeting/progress note regarding his non-compliance with the facility's smoking policy. ADON/WN C indicated something should have been done but was not. On 4/30/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) regarding R2's vaping. DON B indicated vaping was treated the same as smoking and all vaping should be done outside in the designated smoking areas. DON B indicated a new smoking assessment should have been completed and R2 should have turned in his vape supplies but did not.

Based on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 1 resident's (R2) reviewed for medications. The facility did not ensure R2 was provided his Seroquel (Antipsychotic medications) for several days. This is evidenced by: The facility policy titled Medication Error Reporting and Counseling Procedure, dated 12/12/23, includes the following: Medication errors .should be reviewed for the potential of a negative outcome. When a medication error occurs, the licensed nurse/employee needs to be able to report the error .to Nursing Management. The facility should consider reporting the error to their contracted pharmacy provider for any desired information or needed follow-up. A prompt assessment of the resident(s) involved to be completed to determine harm or the potential risks to the resident. Three general guidelines in determining whether a medication error is significant or not: resident condition, drug category and frequency of error. The facility will inform the primary or prescribing physician(s) of the medication error in a timely manner and document notification in the medical record. This communication will help ensure that appropriate corrective measures can be taken, and future medication orders can be adjusted, if necessary. R2 admitted to the facility on [DATE] with a diagnosis of schizophrenia. R2's physician orders include the following: Seroquel oral tablet 25 mg give 1 tablet by mouth one time a day related to Schizophrenia Start date 11/21/24 8:00 AM. Seroquel oral tablet 25 mg give 1 tablet by mouth one time a day related to Schizophrenia Start date 11/21/24 12:00 PM Seroquel oral tablet 25 mg give 2 tablets by mouth one time a day related to Schizophrenia Start date 11/21/24 4:00 PM R2's nurse progress notes include the following: 12/21/24 at 5:29 PM Seroquel oral tablet 25 MG . none in cart on order. 12/22/24 at 5:28 PM Seroquel oral tablet 25 MG .on order 12/23/24 at 5:35 PM Seroquel oral tablet 25 MG .on order 12/24/24 at 5:24 PM Seroquel oral tablet 25 MG .on order 12/25/24 at 10:23 AM Seroquel oral tablet 25 MG .waiting for delivery 12/25/24 at 12:27 PM Seroquel oral tablet 25 MG .waiting on delivery 12/25/24 at 4:15 PM Seroquel oral tablet 25 MG .on order 12/26/24 at 4:46 PM Seroquel oral tablet 25 MG . (no documentation) 12/27/24 at 6:53 PM Seroquel oral tablet 25 MG . on order 12/29/24 at 11:16 AM Seroquel oral tablet 25 MG . (no documentation) 12/29/24 at 4:14 PM Seroquel oral tablet 25 MG .awaiting delivery of medication 12/30/24 at 8:37 PM Seroquel oral tablet 25 MG . not in cart On 4/29/25 at 3:10 PM, Surveyor asked LPN G (Licensed Practical Nurse) to show surveyor what medications are in the facility's contingency medication supply. LPN G showed surveyor the facility's contingency supply contained Seroquel 25 mg. LPN G stated the contingency supply is usually 8 to 10 pills of the medication. On 4/29/25 at 11:40 AM, Surveyor interviewed RN D (Registered Nurse) regarding administering medications. RN D indicated if a resident does not have a medication, the nursing staff is supposed to look in the facility's contingency medication supply and pull the medication from there to give to the resident. RN D also stated the staff is supposed to call pharmacy and ask to have the medication delivered and to notify the physician. RN D indicated this should all be documented in the resident's medical record. Surveyor asked what the facility would do if a resident did not get the medication delivered and now it was the second day, and the resident still does not have the medication. RN D indicated the facility would call the pharmacy and have the medication stat delivered which means the medication should be there within 4 hours. Surveyor asked what the process would be if a resident did not have a medication on the third day. RN D indicated she has never had it get that far before. On 4/29/25 at 11:50 AM, Surveyor interviewed LPN E regarding administering medications. LPN E indicated on day one of a resident not having medication, the facility should look in the contingency medication supply and call pharmacy to order it. LPN E indicated the physician should also be notified. On day two of a resident not having medication, LPN E stated she would notify DON B (Director of Nursing). On day three of a resident not having a medication, LPN E indicated she would ask the provider for a substitute. On day four, LPN E indicated she would call the physician and do an assessment. LPN E indicated it is unacceptable for a resident to be without medication for four days. On 4/29/25 at 2:08 PM, Surveyor interviewed ADON/WN C (Assistant Director of Nursing/Wound Nurse) regarding medication administration. ADON/WN C indicated on day one of a resident not having medication, the staff should look in the contingency medication supply, call the physician and call pharmacy to have the medication stat delivered. Day two, the staff should notify the physician, call pharmacy and notify their supervisor. ADON/WN C indicated there should not be a day three. On 4/29/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) regarding medication administration. DON B indicated if a resident does not have medication, on day one, the facility should check in the contingency medication supply, call pharmacy, and call the provider. On day two, the staff should call again. On day three, staff should call the physician, and the facility would have to call the head of pharmacy because there is a problem. On day four, the staff should do the same thing, call the pharmacy, and call the physician. DON B indicated an assessment needs to be done daily based on the missed medication. DON B indicated all of this should be documented in the resident's medical record. DON B stated missed medications is a medication error and a risk management should be completed. Surveyor notified DON B that surveyor was unable to locate any documentation of a completed assessment for the missed medication, the pharmacy being notified, or the physician being notified of the missed Seroquel for R2 for the dates of 12/21/24 through 12/30/24. DON B did not provide surveyor with any documentation regarding R2's missed Seroquel for those dates.

Based on interview and record review, the facility did not ensure that residents were free of any significant medication errors for 1 of 1 resident (R57) reviewed for significant medication errors. R57 did not receive scheduled insulin at 8:00AM on 7/24/24 and did not have blood glucose monitoring in place. R57 was hospitalized on the evening of 7/24/24 with acute hyperglycemia (a medical emergency that occurs when blood sugar levels are extremely high) requiring treatment with insulin drip (administration of insulin through intravenous line.) Evidenced by: Facility policy entitled Medication Administration, dated 05/2024, states in part: Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice . 20. Sign MAR (Medication Administration Record) after administered . R57 admitted to the facility on [DATE] with diagnoses that include, in part: Type 2 Diabetes Mellitus without complications (a condition that occurs when the body doesn't produce enough insulin or can't use insulin properly, resulting in high blood sugar levels.) Of note, R57 was admitted from the hospital after being treated for hyperglycemia. R57's MDS (Minimum Data Set) dated 8/7/24 indicates that R57 has a BIMS (Brief Interview of Mental Status) of 15, indicating R57 is cognitively intact. R57's physician orders dated 7/23/24, state in part: insulin glargine (Lantus) 20 units subcutaneous once a day (in the morning). It is important to note there were no physician orders for monitoring blood glucose levels. R57's MAR (Medication Administration Record) for July 2024 shows: 7/24/24 8:00 AM--Medication not administered. Important to note: R57's TAR (Treatment Administration Record) for July 2024 shows no record of blood glucose monitoring on 7/23/24 or 7/24/24. R57's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress Note dated 7/24/24 8:00PM states, in part: .resident yelled out for help, writer went to resident's room. Resident stated he did not feel well. Resident diaphoretic (sweating), shaking, cold to touch, BP (blood pressure) low. Glucometer (device to test blood sugar level) reads HI (reading beyond the level which the machine can report). R57's Nephrology Consult Note dated 7/25/24, states, in part: .sent back to the ED (emergency department), where his BS (blood sugar) was noted to be in the 900's. Was started on an insulin drip. R57's hospital discharge summary dated 7/27/24, states, in part: Discharge Diagnosis: acute hyperglycemia . On 09/10/24 at 8:03 AM, Surveyor interviewed R57, who indicated being hospitalized after admission to facility due to blood sugar issues. On 09/12/24 at 8:26 AM, Surveyor interviewed LPN O (Licensed Practical Nurse) and asked what interventions would be expected for a new admission with a diagnosis of diabetes. LPN O stated accu checks (blood glucose checks / monitoring), insulin or oral meds as needed, parameters, glucagon gel or injection, diet. Surveyor asked what the process would be if there were no blood glucose checks ordered for a new admission. LPN O stated call the physician and double check to ensure it wasn't missed. Surveyor asked if medications are signed for on the MAR when they are administered. LPN O said yes. On 9/12/24 at 9:19 AM, Surveyor reviewed the July 2024 MAR with LPN O and asked if the Lantus ordered for R57 at 8:00AM on 7/24/24 was given. LPN O stated no, it isn't signed out. On 9/12/24 at 8:37 AM, Surveyor interviewed LPN E and asked if blood glucose checks / monitoring would be expected for a new admission with diagnosis of diabetes. LPN E stated yes. Surveyor asked what the process would be if there were no blood glucose checks ordered. LPN E stated check with the doctor. Surveyor asked if medications are signed for on the MAR when they are administered. LPN E stated yes. On 09/12/24 at 9:33 AM, Surveyor interviewed DON B (Director of Nursing) and asked if staff is expected to follow physician orders. DON B stated yes. Surveyor asked if nurses should be signing out meds at the time they are given. DON B stated yes. Surveyor asked if a medication is not signed out on the MAR has it been administered. DON B stated no. Surveyor reviewed July 2024 MAR with DON B and asked if the Lantus had been administered on 7/24/24. DON B said no, that was not given. Surveyor asked if DON B would expect Lantus to be administered if ordered? DON B stated yes. Surveyor asked DON B if blood glucose checks would be expected to be ordered and checked for a resident on Lantus? DON B stated yes, if there is no order, ask the doctor for orders. Surveyor asked DON B is it possible that if R57 had received his Lantus at 8am that the hospitalization would have been avoided. DON B stated yes. On 9/12/24 at 3:18 PM, Surveyor interviewed NP N (Nurse Practitioner) and asked would you expect the facility to administer medications as orders? NP N stated yes. Reviewed MAR indicating that R57 had not received his insulin on 7/24/24 and asked if NP N would expect the facility to have administered this insulin? NP N stated yes. Surveyor asked NP N is it possible that if the facility had administered his AM insulin, his blood sugar would not have been registering high. NP N stated it is not a yes or no, potentially. Surveyor asked NP N if administration of the Lantus may have prevented the need for the insulin drip. NP N stated yes, it is possible. Surveyor asked NP N if the facility had been monitoring blood glucose checks on a regular basis if the need for hospitalization may have been prevented. NP N stated yes. Surveyor asked if NP N would expect that the facility would inquire about doing blood glucose monitoring if R57 was admitted without orders and was on Lantus. NP N stated yes.

Based on interview and record review, the facility did not ensure they followed their Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 6 sampled residents (R16 and R34) and 1 supplemental resident (R612) reviewed for antibiotic stewardship. R16 is being cited at severity level 3 (actual harm). R34 and R612 are being cited at severity level 2 (potential for more than minimal harm). The facility did not follow Standards of Practice for Antibiotic Stewardship: R16 has a history of antibiotic resistance and was prescribed antibiotics without meeting criteria. R16 was prescribed antibiotics for five events between March 26, 2024 and July 5, 2024, for asymptomatic bacteremia (presence of bacteria that does not cause symptoms thus not requiring antibiotic treatment). The facility did not thoroughly review R16's urine culture and sensitivities, and therefore, did not recognize R16 had developed resistance to a prescribed antibiotic. R34 was prescribed an antibiotic for Urinary Tract Infection (UTI) twice in the month of July without meeting criteria. R612 was prescribed and received an antibiotic for Acute Kidney Injury (AKI). R612 did not meet criteria for the prescribed antibiotic. Evidenced by: The facility policy titled Antibiotic Stewardship Program with a date of 12/23/22, states in part: It is the policy of this facility to implement and Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use . ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections. iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. vi. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized . Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . According to National Institutes of Health (NIH), Asymptomatic bacteriuria is very common in clinical practice and its incidence increases with age .most patients with asymptomatic bacteriuria will never develop symptomatic urinary tract infections and will have no adverse consequences from asymptomatic bacteriuria . most patients will not benefit from treatment (www.ncbi.nlm.nih.gov). The facility form titled Infection Report Form is used for the facility's infection control program. The Infection Report Form identifies criteria that must be present to meet surveillance criteria for an infection. Example 1 R16 was admitted to the facility on [DATE]. R16's medical diagnoses list does not indicate any diagnoses related to UTI or Multidrug-Resistant Organism (MDRO). R16's admission Minimum Data Set (MDS) assessment dated [DATE] states in part, Section I Active Diagnoses Infections does not have a check mark for I1700. Multidrug-Resistant Organism (MDRO), I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS). This indicates R16 does not have an MDRO and does not currently have a UTI and has not had a UTI in the previous 30 days. Event 1 R16's 3/22/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Methicillin-Resistant Staphylococcus aureus (MRSA) isolated. 30,000 cfu/ml Mixed flora (multiple species present). Resistant to Oxacillin, Penicillin G, and Tetracycline (antibiotics). R16's 3/21/24 Infection Report Form (facility form used for antibiotic stewardship) does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states Resident returned from appt (appointment) - order for UA (urinalysis)/microalbum, creatinine. Asymptomatic bacteremia [sic] (presence of bacteria that does not cause symptoms). Of note, the follow up section indicates the urinalysis was obtained as a routine lab from a consulting provider. R16's March 2024 Medication Administration Record (MAR) indicates R16 received 4 doses of Bactrim DS oral tablet 800-160 for asymptomatic bacteremia. Event 2 R16's 4/4/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Enterococcus faecalis isolated. Resistant to Gentamicin and Tetracycline. 30,000 cfu/ml Methicillin-Resistant Staphylococcus aureus isolated. Of note, this is the same bacteria as the previous event. Resistant to Oxacillin, Penicillin G, and Tetracycline. R16's 3/26/24 Infection Report Form, in section two of UTI criteria, has marked At least 105 cfu/ml or no more than 2 species of microorganisms in a voided urine sample. Of note, section one of the UTI criteria has no marks, indicating R16 does not meet criteria. R16's 4/5/24 physician order states, Bactrim DS 800-160 give one tablet by mouth two times a day for UTI until 4/11/24. R16's April 2024 MAR indicates R16 received 12 doses of Bactrim DS 800-160 for asymptomatic bacteremia. R16's 4/24/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Enterococcus faecalis isolated. Resistant to Gentamicin and Tetracycline. 20,000 cfu/ml Methicillin-Resistant Staphylococcus aureus isolated. Resistant to Oxacillin, Penicillin G, and Tetracycline. Of note, these are both the same bacteria as the previous event. Event 3 R16's 4/24/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states, switched to this after report next to Nitrofurantoin (antibiotic) 100 mg po (by mouth) BID (twice a day), indicating the Amoxicillin (antibiotic) order was discontinued and changed to Nitrofurantoin. R16's 4/25/24 physician order states Amoxicillin 500 MG give 1 tablet by mouth four times a day for UTI. R16's physician order on 4/29/24 states Nitrofurantoin Macrocrystal oral capsule 100 MG give one capsule by mouth two times a day for UTI for 14 days. R16's April 2024 and May 2024 MAR indicates R16 received 13 doses of Amoxicillin 500 MG and 27 doses of Nitrofurantoin 100 MG. R16 received antibiotics for a total of 18 days. Of note this is the 3rd time R16 was treated and had asymptomatic bacteremia. A 5/2/24 Urology note states in part; Recent MRSA (Methicillin Resistant Staph Aureus and Enterococcus UTI known to be a MRSA carrier-probably the MRSA is could be [sic] primary source in the bladder or could be secondary and seeding from somewhere else staff [sic] is known to do that. Event 4 R16's 6/4/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Proteus mirabilis isolated. Resistant to Ampicillin, Gentamicin, Nitrofurantoin, Tetracycline, and Trimethoprim/Sulfa (is also known as Bactrim DS). Of note, R16 is now resistant to Bactrim DS and Nitrofurantoin. R16's 6/5/24 Infection Report Form, in section two of UTI criteria, has marked At least 105 cfu/ml or no more than 2 species of microorganisms in a voided urine sample. Of note, section one of the UTI criteria has no marks, indicating R16 does not meet criteria. In the follow up section the report states Asymptomatic Bacteremia [sic]. R16's 6/5/24 physician order states Keflex Oral Capsule 500 MG (antibiotic) give 500 mg by mouth four times a day for UTI for 5 days. R16's June 2024 MAR indicates R16 received 20 doses of Keflex. Event 5 R16's 7/2/24 Urine Culture and Sensitivity Report states, in part: >100,000 cfu/ml Proteus mirabilis isolated. Of note, this is the same bacteria as the previous event. Resistant to Ampicillin, Gentamicin, Nitrofurantoin, Tetracycline, and Trimethoprim/Sulfa. R16's 7/2/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R16 has no symptoms of UTI. Of note, R16 does not meet criteria. In the follow up section the report states Asymptomatic Bacteremia [sic]. R16's 7/2/24 physician order states Nitrofurantoin 100 MG give 1 capsule by mouth two times a day for UTI for 10 days. Of note, R16's previous culture and sensitivity noted R16 was resistant to Nitrofurantoin. R16's 7/5/24 physician order states Cipro oral tablet 500 MG (broad spectrum antibiotic) give 1 tablet by mouth two times a day for UTI for 10 days. R16's July 2024 MAR indicates R16 received 6 doses of Nitrofurantoin and 20 doses of Cipro. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B indicated R16 has had no symptoms for these five events. Surveyor asked DON B if R16's asymptomatic bacteriuria should be treated. DON B indicated if a resident is asymptomatic, not showing signs of UTI, the facility should not treat. DON B indicated she expects antibiotic stewardship to be followed. Surveyor asked DON B if the prescribing physicians have been educated on antibiotic stewardship for R16's asymptomatic bacteriuria. DON B could not present evidence that the facility has educated the physicians regarding treating asymptomatic bacteremia. Example 2 R34 was admitted to the facility on [DATE] with diagnoses that include neuromuscular dysfunction of bladder (bladder muscles are not functioning properly, causing problems with urination) and paraplegia (affects the ability to move or feel the lower half of the body). R34's 7/11/24 Urine Culture and Sensitivity Report states >100,000 cfu/ml Mixed flora (multiple species present). Suggest appropriate recollection if clinically indicated. Of note, mixed flora is indicative of a contaminated urine sample. R34's 7/11/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R34 has no symptoms of UTI. Of note, R34 does not meet criteria. R34's 7/11/24 physician order states Cefpodoxime Proxetil oral tablet 200 MG (antibiotic) give 1 tablet by mouth every 12 hours for 10 days for UTI. R34's July 2024 MAR indicates R34 received 5 doses of Cefpodoxime Proxetil 200 MG. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B indicated the facility did not obtain a recollection of urine for R34 per the recommendations of the 7/11/24 Urine Culture and Sensitivity Report. Example 3 R612 was admitted to the facility on [DATE] with diagnoses that include benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate). R612's 6/29/24 Urine Culture and Sensitivity Report states 70,000 cfu/ml Mixed flora (multiple species present). R612's 6/27/24 Infection Report Form does not have any criteria marked under the UTI section, indicating R612 has no symptoms of UTI. In the follow up section, the report indicates the antibiotic ordered was for an acute kidney injury. Of note, R612 does not meet criteria. R612's 6/29/24 physician order states Macrobid Oral Capsule 100 MG (antibiotic) give 1 capsule by mouth two times a day for UTI for 5 days. R612's June 2024 and July 2024 MARs indicate R612 received Macrobid for 4 days (8 doses). On 7/2/24, after R612 received 4 days of Macrobid, physician discontinued the order. Nurses progress notes dated 7/2/24 at 14:19 (2:19PM) states in part Dr. (Doctor's name) responded back to the UA (Urinalysis) stating that it does not appear that R612 has a UTI .you may discontinue this medication. On 9/12/24 at 8:33AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she oversees and participates in the infection prevention program. DON B agreed R612 did not meet criteria for an antibiotic and should not have received the antibiotic. The facility treated R16's asymptomatic bacteriuria five times. R16 now has resistance to Nitrofurantoin. R34 and R612 received treatment for UTIs that did not meet criteria. DON B indicated the facility did not follow antibiotic stewardship.

Based on observation, interview, and record review, the facility did not ensure each resident received meals at their desired time in accordance with resident needs, preferences, or requests. This has the potential to affect all 58 residents residing at the facility. Residents (R8, R41, and R35) voiced concern regarding meals being served over an hour after the scheduled time. Surveyors observed meals being served 1-1.5 hours after the scheduled mealtimes. Evidenced by: The facility policy, Frequency of Meals, dated, 7/17, states, in part: .The following mealtimes have been established by our facility for residents, Breakfast 7:45AM, Lunch 11:45AM, Dinner 4:45PM . Example 1: R8 was admitted to the facility on [DATE]. R8's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/14/24 indicated R8 has a BIMS (Brief Interview for Mental Status) score of 13 indicating R8 is cognitively intact. R8 is own person. On 9/10/24 at 8:28AM, R8 indicated meals are often served over an hour after the scheduled mealtimes. R8 indicated today they didn't get lunch until after 1:00PM in the dining room. R8 indicated there has been times that supper doesn't come until 6:00PM or later. R8 indicated she will order snacks and get them sent to the facility; these snacks help hold her over because meals are often delivered so late. R8 indicated she was raised on a farm and her personal preference is to have breakfast before 8am, lunch at noon, and supper at 5pm. R8 indicated she always eats her meals in the dining room. R8 indicated staff know the meals are often late. Example 2: R41 was admitted to the facility on [DATE]. R41's most recent MDS (Minimum Data Set) with a target date of 6/12/24, indicates R41 has a BIMS (Brief Interview for Mental Status) score of 12, indicating R41 has a mild cognitive impairment. On 9/10/24 at 4:12PM, R41 indicated meals are always served late. R41 stated, It bothers me .it bothers everyone. R41 indicated R41 eats meals in the dining room and meals are often served an hour or more after the scheduled meal times. Example 3: R35 was admitted to the facility on [DATE]. R35's most recent MDS (Minimum Data Set) with a target date of 7/25/24, indicates R35 has a BIMS (Brief Interview for Mental Status) score of 11, indicating R35 has a mild cognitive impairment. On 9/10/24 at 8:28AM, Surveyor observed R35 receive breakfast tray in his room. On 9/11/24 at 8:33AM, Surveyor interviewed R35 who indicated that about 3 - 4 times a week his breakfast tray is late. R35 indicated that he eats slower due to his Parkinson's. R35 stated because the meals are served late when lunch comes, I will not want to eat again because the meals will be too close together. Example 4: On 9/9/24, Surveyor observed lunch being served in dining room at 1:00PM. On 9/10/24, Surveyor observed breakfast being served at 9:00AM in dining room. Surveyor observed the following posting of mealtimes: Breakfast 7:45AM, Lunch 11:45PM, Dinner 4:45PM in dining room. On 9/12/24 at 9:49AM, NSD W (Nutrition Services Director) indicated he has been working on building his team in the kitchen. NSD W indicated he had multiple new staff start for a couple weeks and then quit. NSD W indicated he knows the meals have been served late and this is due to call ins and one of the cooks is still getting down the routine. NSD W indicated he would expect meals to be served during the scheduled mealtimes.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 58 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for five fiscal year quarters, dated 4/1/23 - 6/30/24, for inadequate weekend staffing. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 3 2024 (April 1 - June 30), ran on 9/4/24 indicates the following: Metric: Excessively Low Weekend Staffing, Result: Triggered, Definition: Triggered = (equals) Submitted Weekend Staffing data is excessively low. PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year Quarter 2 2024 (January 1 - March 31), ran on 9/4/24 indicates the following: Metric: Excessively Low Weekend Staffing, Result: Triggered, Definition: Triggered = Submitted Weekend Staffing data is excessively low. PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year Quarter 1 2024 (October 1 - December 31), ran on 9/4/24 indicates the following: Metric: Excessively Low Weekend Staffing, Result: Triggered, Definition: Triggered = Submitted Weekend Staffing data is excessively low. PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year Quarter 4 2023 (July 1 - September 30), ran on 9/4/24 indicates the following: Metric: Excessively Low Weekend Staffing, Result: Triggered, Definition: Triggered = Submitted Weekend Staffing data is excessively low. PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year Quarter 3 2023 (April 1 - June 30), ran on 9/4/24 indicates the following: Metric: Excessively Low Weekend Staffing, Result: Triggered, Definition: Triggered = Submitted Weekend Staffing data is excessively low. The facility's Facility assessment dated [DATE] states in part: .This facility assessment will be used to inform staffing decisions to ensure that there are a sufficient number of staff . consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population . consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to its resident population . The facility's Facility Assessment indicates Nurse Aide Hours per Resident Day (HRD) as 1.686 HRD, Nurse Aide Case Mix Hours per Resident Day as 2.291 HRD, and Nurse Aide Adjusted Hours per Resident Day as 1.656 HRD. On 9/10/24, Surveyor reviewed the facility's Daily Nurse Staffing Forms which indicated the following: On 1/6/24, the Certified Nursing Assistant (CNA) hours compute to 1.60 HRD. On 6/30/24, the CNA hours compute to 1.53 HRD. On 6/29/24, the CNA hours compute to 1.55 HRD. On 6/16/24, the CNA hours compute to 1.46 HRD. On 6/15/24, the CNA hours compute to 1.39 HRD. On 6/9/24, the CNA hours compute to 1.64 HRD. On 6/2/24, the CNA hours compute to 1.39 HRD. On 7/6/24, the CNA hours compute to 1.46 HRD. On 9/11/24 at 2:04 PM, Surveyor interviewed Scheduler E, who stated that she staffed according to census. Scheduler E was unsure about the facility assessment. Scheduler E stated they have no staffing concerns right now. Surveyor reviewed with Scheduler E the PBJ Staffing Data Report. Scheduler E stated that she did not understand how they could be triggering for low staffing. On 9/11/24 at 2:45 PM, Surveyor interviewed MDS Coordinator M (Minimum Data Set), who stated that the hours in the facility assessment are historical. MDS Coordinator M indicated that the facility assessment case mix hours would be used if there was higher acuity. MDS Coordinator M stated that the facility assessment staffing hours were sent to corporate who reviewed and approved the HRD for CNAs. On 9/11/24 at 2:50 PM, Surveyor interviewed DON B (Director of Nursing), who stated that the facility assessment had baseline hours for staffing that could be adjusted up or down based on acuity. Surveyor reviewed with DON B the PBJ Staffing Report. DON B indicated that June was a tough month for weekend staffing but that they always have a department head in the building on the weekends to help pass trays and answer call lights. DON B stated that these manager hours are not reflected in the PBJ staffing numbers.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19. This has the potential to affect the census of 58 residents (R). The facility infection prevention and control policies have not been updated annually. The facility did not ensure contact tracing and testing was completed accurately and timely during a COVID outbreak. Surveyor observed cares for R35 with breaches in infection control technique. Evidenced by: The facility policy titled Infection Prevention and Control Program dated 5/16/23, states, in part: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per acted national standards and guidelines . All staff are responsible for following all policies and procedures related to the program . A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards . The RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections . Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic residents with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . If healthcare-associated transmission is suspected or identified, the facility may consider expanded testing of HCP (Health Care Personnel) and residents as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. If and expanded testing (e.g., affected unit as opposed to the entire facility) approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days . Annual Review: a. The facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures based upon the facility assessment which includes any facility and community risk. b. Following review, the infection and prevention control program will be updated as necessary. Example 1: The following is a list of facility policies with their last review dates: -Infection Prevention and Control Program 5/16/23 -Infection Outbreak Response and Investigation 5/16/23 -Influenza Vaccination 8/30/23 -Pneumococcal Vaccine (Series) 8/30/23 -Legionella Surveillance no date -COVID-19 Vaccination 5/16/23 -Hand Hygiene 10/23 -Antibiotic Stewardship Program 12/23/22 On 9/11/23 at 2:57PM, Surveyor interviewed DON B (Director of Nursing) and ADON/IP C (Assistant Director of Nursing/Infection Preventionist). ADON C indicated she is the infection preventionist. DON B indicated she oversees the infection prevention and control program. DON B indicated policies should be reviewed annually. DON B indicated these policies listed have not been reviewed annually. Example 2: The facility had a COVID-19 outbreak in March 2024. The facility provided Surveyor with an outbreak folder containing documentation related to the outbreak. A document titled 3/5/24 COVID outbreak summarizing the facility COVID outbreak states: 1. 3/5/24 R613 began to have a change in condition with a cough and increased shortness of breath. Provider phoned and gave order to send patient to [Town Name] ER (emergency room ). 2. 3/5/24 Around 10 pm nurse called to check on status of patient. ER explained the patient was being admitted for fluid overload and was COVID positive. 3. 3/6/24 Outbreak status initiated in facility and signage posted to notify visitors and outside providers. Housekeeping increasing sanitation of common areas. [Medical Director Name] the facility medical director notified. 4. R614 came to the nurses station early AM requesting her temperature be taken. Temperature taken and elevated at that time. R614 was then tested for COVID with positive results. COVID hallway opened and R614 placed on isolation. PCP (Primary Care Provider) phoned to notify. Contact tracing completed with R614. 5. R614 reported she had possibly exposed 4 other residents. The first resident being previously positive R613, whom she was seated by during tornado warning. She also reported possibly exposing R28, R618 and R13. All three of exposed residents COVID tested and negative at this time. 6. [County Name] county health department phoned and updated, and line list sent. 7. 3/8/24 PM shift R28 reported having a new cough and requested to be testing [sic] again for COVID with positive results. R28 placed on contact droplet isolation. R28 denies being within 6 ft (feet) of any peers for more than 15 minutes without a mask on. 8. 3/9/24 The other 2 exposed residents tested for COVID. R618 and R13 both testing negative for COVID. 9. 3/11/24 staff member DON B (Director of Nursing) tested positive for COVID and has not been in the facility without a mask on. Symptoms began 3/8/24 in the evening. R618 and R13 tested again for COVID with negative results. [County Name] health department RN (Registered Nurse) [Nurse Name] phoned and updated of newly positive staff member as well as resident. All residents updated of COVID status and residents contacted [sic] notified. 10. 3/12/21 R616 having increased abdominal girth along with lower extremity edema. Patient sent to ED (Emergency Department) and admitted COVID positive. R616 returned from hospital and readmitted to facility. Resident placed on COVID hall on isolation. 11. 3/13/24 Line list updated and sent to [County Name] Health department. [County Name] health department phoned and updated. All residents and resident contacts updated of ongoing COVID status. 12. 3/14/24 R617 went to ER 3/13/24 and tested positive for COVID. She returned 3/14/24 and was placed on COVID isolation in room. [County Name] Health department updated, and this nurse spoke to nurse [Nurse Name] related to ongoing outbreak. Line list updated and sent to [County Name] health department. 13. 3/15/24 Handwashing audits completed in all departments. Housekeeping continues to increase sanitation to high trafficked areas. All residents notified and resident contacts notified of ongoing COVID outbreak. 14. 3/18/24 R47 had an emesis and was tested for COVID and positive. Patient was moved to COVID hall and placed on isolation precautions. PCP and family updated. Roommate R8 tested and negative at this time. 15. 3/19/24 contact tracing initiated for R47, and table mates tested for COVID. R9 noted to be positive for COVID. Patient moved to COVID hall and placed on isolation precautions. PCP updated as well as family. R619 tested as was a tablemate and negative at this time. All residents in facility updated of ongoing COVID outbreak as well as resident contacts. R18 reported generalized malaise. Resident tested for COVID and positive. Roommate [sic] R43 tested and negative for COVID per contact tracing protocol. 16. 3/21/24 Per contact tracing protocol R8 re-tested for COVID and positive at this time. R8 was moved to COVID hall and placed on isolation precautions. PCP (Primary Care Provider), Family as well as residents in building updated on continue [sic] COVID outbreak. Ongoing enhanced cleaning of highly traffics [sic] area ongoing for 2 weeks post last positive patient. 17. COVID outbreak officially closed 4/1/24. Please see line list for dates. [County Name] updated. On 9/11/24 at 2:57PM, Surveyor interviewed DON B and ADON C. Surveyor asked why contact tracing had not been completed for R613, the first resident with COVID. ADON C indicated R613 never leaves her room and eats in her room. Of note, there was a tornado drill where R613 exposed a minimum of one other resident, R614. Surveyor asked if contact tracing had been completed for R616 after testing positive for COVID. DON B and ADON C indicated since they had not added contact tracing to the summary, they did not complete contact tracing for her. They indicated she always stays in her room. Surveyor presented a nurse progress note dated 3/8/24 at 13:56 (1:56PM) that states pt (patient) up in w/c (wheelchair) and to the MDR (Main Dining Room) for meals, pleasant and cooperative so far this shift and has no c/o (complaints of). DON B indicated contact tracing should have been completed for R616 if she was eating her meals in the main dining room. Of note, contact tracing was not completed for R613 and R614. R47 tested positive on 3/18/24 after having an emesis. R47's nurse progress note dated 3/18/24 at 22:40 (10:40PM) states, in part, Writer informed by CNA (Certified Nursing Assistant) that resident has large emisis [sic] of undigested food . Resident has had a slight cough this weekend, Rapid COVID test done showing Positive results . On 9/12/24 at 8:40AM, Surveyor interviewed DON B. Surveyor asked if the facility should have waited until Monday 3/18/24 to test R47 for COVID as she was showing signs and symptoms over the weekend. DON B indicated she would have expected the facility to test R47 sooner and should not have waited until Monday if she was showing signs over the weekend. The COVID outbreak folder also contained testing documentation completed during the outbreak. On 3/6/24, R614 indicated she possibly exposed three other residents, R28, R618, and R13. R28 was tested on [DATE] and positive. R618 and R13 were tested on [DATE] and 3/11/24. On 9/12/24 at 8:40AM, Surveyor interviewed DON B. Surveyor asked if testing was completed per the facility policy and standard of practice for R28, R618, and R13 as these residents should have been tested on [DATE]. DON B agreed R28, R618, and R13 should have been tested on [DATE] and were not. On 3/18/24, R8 was exposed. R8 was tested on [DATE] with negative results and again on 3/21/24 with positive results. On 9/12/24 at 8:40AM, Surveyor interviewed DON B. Surveyor asked if testing was completed per the facility policy and standard of practice for R8 as she should have been tested on [DATE]. DON B agreed R8 should have been tested on [DATE] and was not. On 3/18/24, R619 and R43 were exposed to a positive resident. R619 and R43 were tested on [DATE], 3/22/24, and 3/24/24. On 9/12/24 at 8:40AM, Surveyor interviewed DON B. Surveyor asked if testing was completed per the facility policy and standard of practice for R619 and R43 as testing should have been completed on 3/19/24, 3/21/24, and 3/23/24. DON B agreed testing should have been completed on 3/19/24, 3/21/24, and 3/23/24 and was not. R12, R26, R41, and R14 were tested on [DATE], 3/24/24, and 3/27/24. On 9/12/24 at 8:40AM, Surveyor interviewed DON B. Surveyor asked if testing was completed per the facility policy and standard of practice for R12, R26, R41, and R14 as they should have been tested on [DATE], 3/23/24, and 3/25/24. DON B agreed testing should have been completed on 3/21/24, 3/23/24, and 3/25/24 and was not. The facility did not review policies and procedures within the required time frame of annually. The facility did not contact trace for two residents, R613 and R614. The facility did not test for COVID timely for 11 residents, R8, R12, R13, R14, R26, R28, R41, R43, R47, R618, and R619. 39849 Example 3: R35 was admitted to the facility on [DATE]. On 9/12/24 at 10:18AM, Surveyor observed CNA DD (Certified Nursing Assistant) and CNA R assist R35 in getting washed up. CNA R took clean washcloths to the sink, wet the washcloths under the running water and set each washcloth on the edge of the sink while she wet the next one. CNA R then used these washcloths to wash R35's upper body and for peri-care with the brief change. During cares CNA R obtained a container of zinc oxide from a shelf in R35's room. CNA R then took her gloved hand and placed it into the container of zinc oxide and applied it to R35's buttock. CNA R then placed the same gloved hand back into the container of zinc oxide and applied it to bilateral groin areas. After cares were completed, Surveyor interviewed CNA R. During this interview CNA R indicated the sink could be considered contaminated and that she should not have set the washcloths on the edge of the sink prior to using them for cares. CNA R indicated she has not been trained not to use a gloved hand to remove the zinc oxide from the container. CNA R indicated that after applying the zinc oxide to R35's buttock she should not have used the same gloved hand to obtain more zinc oxide from the container and she should not have applied to the groin area with that same gloved hand after she had applied to his buttock. On 9/12/24 at 11:53AM, Surveyor interviewed DON B (Director of Nursing) and reviewed the above observation. During the interview, DON B indicated that the washcloths should not have been set on the sink, they should be wet and then go straight to the resident for use. DON B indicated the CNA should not have reinserted her gloved hand into the container of zinc oxide, should put the zinc oxide in a cup using a plastic spoon, and should not use a gloved hand directly in the container. DON B indicated that the CNA should have either applied the zinc oxide from front to back or should have changed gloves between application to buttock and groin area.

Based on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 sampled Residents (R35, R52, & R15) and 1 of 1 supplemental (R49). R35 and R49's floor in their room had not been cleaned and had visible dirt on the floor. R15's room was not homelike with visible repairs needed. R52 voiced concern that R52 is unable to use closet in bedroom because of roommate thinking R52 is stealing clothes. R52 voiced concern that her dresser is broken as well. R52 indicated she has to keep all of her clothes and items in boxes in R52's room. Surveyor observed R52 to have boxes stacked up in her room. This is evidenced by: Facility Policy entitled 'Routine Cleaning and Disinfection,' dated 8/2022, states in part: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.Policy explanation and compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms and at the time of discharge . Example 1 Facility cleaning schedule sheets dated 9/9/24 indicates Needlepoint, Birchway, and Chapelway Halls were not cleaned by housekeeping. On 9/10/24 at 8:04 AM, Surveyor was going down Needlepoint Hallway observing the environment and rooms. Two Surveyors observed R35 and R49's rooms to have an unclean floor, more than half of the room appeared unclean with visible dirt on the floor. Surveyor took a wet paper towel and wiped an area on the floor that appeared to be unclean and was able visible remove dirt off the floor in both R35 and R49's room. On 9/10/24 at 8:06 AM, Surveyor interviewed Housekeeper J (HSK) regarding the floors. HSK J indicated he's only at the facility on Tuesdays, Wednesdays, and Fridays to clean the floors. Surveyor asked HSK J who would clean the floors when he's not there, HSK J replied to no one deep cleans the floors when he's not there, but Housekeepers are to mop and sweep each room every day. HSK J indicated he cleans R49's floors really good on Fridays. HSK J indicated that R35 and R49's floors were not cleaned. On 9/10/24 at 9:34 AM, Surveyor interviewed R35 regarding his floor. R35 indicated his floor has been unclean for a little while and was unable to say how long the floor was dirty. On 9/10/24 at 12:22 PM, Surveyor interviewed HSK K regarding cleaning. HSK K indicated she cleans the sink, the toilet, and the bathroom, then removes the trash before she sweeps and mops on her assigned side. HSK K who was currently in R49's room indicated this unit was not her assigned unit or side. HSK K indicated she was just called down to clean the floor for the 3rd time as R49 has a habit of peeing on the floor. HSK K indicated the other housekeepers work every other day and the person normally down here on the other days up and quit on Friday. Surveyor asked HSK K who the housekeeping manager is and HSK K indicated it is NHA A (Nursing Home Administrator) currently. On 9/10/24 at 12:37 PM, Surveyor interviewed NHA A regarding observations on Needlepoint Hall. NHA A indicated that the usual housekeeper quit on Friday. NHA A indicated that no one cleaned down Needlepoint yesterday (9/9/24) due to a miscommunication with staff. NHA A indicated that the CNA's did take trash out of the rooms, but no one swept or mopped the floors yesterday. 44552 Example 2 R52 was admitted to the facility on [DATE] with a diagnoses including parkinsonism, asthma, diabetes, respiratory failure, depression, anxiety disorder, and insomnia. R52 most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/6/24, indicates R52 has a Brief Interview for Mental Status (BIMS) score of 13 indicating R52 is cognitively intact. R52 is own person. On 9/9/24 at 4:25 PM, R52 indicated R52 is unable to use her closet. R52 indicated her dresser is broken so she has to keep clothes and personal items in boxes. Surveyor observed boxes to be lined up against wall in R52's room. R52 indicated she has reported these concerns to staff. On 9/12/24 at 9:34 AM, MD Q (Maintenance Director) indicated staff are able to report maintenance issues through their computer system. MD Q indicated he was not aware of R52's concern with her dresser and closet. MD Q indicated he would expect staff to report maintenance issues through reporting system so he can track and prioritize projects. MD Q indicated he would go talk to R52 now and fix her dresser. On 9/12/24 at 12:14 PM, SW D (Social Worker) indicated she would follow up with R52 regarding her closet and dresser and ensure someone assists her with unpacking boxes. SW D indicated she would expect residents to have a dresser and an area to have personal items. 50285 Example 3 R15 was admitted to the facility on [DATE] with diagnoses that include Major Depressive Disorder, unspecified dementia, muscle wasting and atrophy, and anxiety disorder unspecified. R15's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R15 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates he has severe cognitive impairment. On 9/10/24 at 10:28 AM, Surveyor observed the condition of R15's room and noted that the trim was pulling away from the wall by the sink, a large area of peeling paint and drywall near the foot of the bed, multiple brown scuff marks on the wall next to the bed, and a large blackish stain on the overhead ceiling tile. On 9/10/24 at 11:40 AM, Surveyor interviewed R15's Power of Attorney (POA) and RR U (Resident Representative). RR U stated that overall, the facility could do a better job with the cleaning and maintenance of the building. RR U commented that the trim in R15's room was coming loose, and the drywall was disintegrating. RR U stated that the room had been in this state of disrepair for months. RR U said that she had come in to visit R15 and noticed drops of urine on the floor that she had cleaned up herself. On 9/11/24 at 7:43 AM, Surveyor interviewed Maintenance Q, who stated that he was aware of the condition of R15's room, and that the repairs were on his priority list. Maintenance Q stated that the black stain on the ceiling tile was not mold, but was condensation sweat from the black pipe that was above the ceiling, and that he had ordered new ceiling tiles. Surveyor asked Maintenance Q if R15's room would be considered a homelike environment, and Maintenance Q said no, it was not a homelike environment. On 9/12/24 at 10:16 AM, Surveyor interviewed NHA A (Nursing Home Administrator), who stated that next year the facility would be getting new flooring and when they do that, they will also fix the peeling wallpaper and paint. Surveyor asked NHA A if the scuff marks, crumbling wall, and peeling paint in R15's room would be considered a homelike environment, and NHA A stated no, that is not a homelike environment.

Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 4 of 24 total sampled Residents (R48, R38, R15 & R16). R48 did not receive her showers twice a week every week. R38 did not receive the appropriate oral hygiene care recommended by the dentist. R15 did not receive oral hygiene daily R16's nails were visibly long and staff did not assist R16 in trimming them. Evidenced by: Facility policy entitled 'Oral care,' dated 8/22, states in part: Policy: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque- associated oral diseases. Equipment and supplies. soft- bristle tooth brush, toothpaste; tongue depressor; penlight; mouthwash (optional); dental floss; emesis basin; glass of cool water; face towel; gloves. Policy explanation and compliance guidelines: .4. Apply toothpaste to brush. Holding brush over emesis basin, poor small amount of water over toothpaste. 5. Resident may assist with brushing if able. 6. Hold toothbrush at 45-degree angle to gum line. be sure that bristles rest against and penetrate under gum line. Brush inner and outer surfaces of upper and lower teeth by brushing from gum to crown of each tooth.13. Allow resident to floss and assist as needed. Floss between all teeth. Hold floss against tooth while moving it up and down sides of teeth and under gum line. Avoid flossing if Resident has a tendency to bleed . Facility policy entitled 'Activities of Daily Living (ADLs),' dated 10/24/22, states in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. bathing, dressing, grooming and oral care; 2. transfer and ambulation; 3. toileting; 4. eating to include meals and snacks; and 5. using speech, language, or other functional communication system. Policy explanation and compliance guidelines: .3. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. Example 1 R38 was readmitted on [DATE] with diagnosis that include parkinsonism and unspecified dementia. R38's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R38 has a Brief Interview of Mental Status (BIMS) of 6 out of 15 indicating that R38 is severely cognitively impaired. Section B indicates R38 has clear speech is understood by others and usually understands others. Section GG indicates R38 requires set up assist with oral hygiene. Section L indicates no oral/dental concerns marked. R38's Care plan indicates assist resident with brushing teeth/dentures, oral care (4/19/23). R38's CNA care guide provided to Surveyor on 9/11/24 indicates set up with oral care. R38's Oral hygiene documentation for the last 30 days shows R38 only received oral hygiene care once a day instead of twice per day on the following dates: 8/16/24, 8/20/24. 8/21/24, 8/25/24, 8/29/24 ,9/1/24, 9/3/24 and 9/4/24. R38's Health Drive Dental visit signed on 8/26/24, states in part: Exam date 8/24/2024 . Teeth .soft plaque/food debris buildup: heavy.Action required by nursing home staff. Continue daily oral care: brush along gumline in a circular motion; assist patient with brushing and flossing twice daily; morning and evening; patient cannot brush for themselves, please brush and floss patient's teeth twice daily. On 9/9/24 at 2:43 PM, Surveyor interviewed R38 regarding her cares. R38 stated they hurt while showing Surveyor her mouth and teeth. Surveyor asked R38 and her husband if R38 has seen a dentist? R38 replied I would like to go. Surveyor observed R38's teeth to have a gray discoloration, and slightly pink/red along gum line near her teeth. On 9/10/24 at 5:54 PM, Surveyor interviewed DON B (Director of Nursing) regarding R38's oral cares. DON B indicated that based on the health drive information she should have flossing on her care plan. Surveyor asked DON B to look at R38's care plan to see if assisting with brushing and flossing twice daily was on there, DON B indicated it's not on there and should be. On 9/11/24 at 9:03 AM, Surveyor interviewed CNA L (Certified Nursing Assistant) regarding R38's oral care. CNA L indicated that she sets her up by putting tooth paste on her tooth brush, and she (R38) brushes her teeth. Surveyor asked CNA L if she offers to floss R38's teeth or if R38 flosses her own teeth, CNA L indicated they don't have any floss sticks or floss, she has never seen floss in a nursing home. R38's dental care is not being provided per recommendations of the dentist. Example 2 R48 was admitted on [DATE] with diagnosis that include critical illness myopathy (weakness or fatigue of muscles), Acute respiratory distress syndrome, Morbid (sever) obesity, asthma, and acute respiratory failure with hypoxia (low oxygen). R48's Minimum Data Set (MDS) dated [DATE] indicates R48's Brief Interview of Mental Status (BIMS) is a 15 out of 15, indicating R48 is cognitively intact. R48's Care plan states in part: Bathing/showering: The resident requires by staff [sic] with bathing/showering (12/28/23). R48's CNA care guide indicates Showers are on Thursday AM shift and Tuesday PM shift. On 9/9/24 at 12:08 PM Surveyor interviewed R48 regarding choices. R48 indicated she doesn't really get a choice regarding her showers. R48 indicated she receives a shower when staff can do it. R48 indicated she's supposed to get a shower two times a week Tuesday and Thursday but would like them every other day. R48 states I feel gross going from Thursday to Tuesday without a shower. R48's Shower documentation shows she did not get her scheduled showers on Tuesdays and Thursdays on the following dates: 7/2/24, 7/16/24, 7/18/24, 7/23/24, 7/25/24, 8/6/24, 8/13/24, or 9/5/24. On 9/10/24 at 5:30 PM, Surveyor interviewed DON B (Director of Nursing) regarding showers for R48 and oral hygiene for R38. DON B indicated she would expect R48 to receive her showers on Tuesdays and Thursdays as scheduled and extra if needed. DON B indicated that she would expect R38's dental recommendation to be added to the care plan and staff to follow the recommendations. 50285 Example 3 R15 was admitted to the facility on [DATE] with diagnoses that include Major Depressive Disorder, unspecified dementia, muscle wasting and atrophy, and anxiety disorder unspecified. R15's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R15 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates he has severe cognitive impairment. R15's Functional Ability, Section GG of the MDS states in Section 6 sub-part B: Oral hygiene: Partial to moderate assist . R15's Care Plan states in part: Focus dated 11/9/22: Self-care deficit related to activity intolerance, cognitive deficits, decreased mobility, disease process, fatigue, generalized weakness. Intervention dated 11/9/22: Oral care requires staff assist with oral cares .Focus dated 5/8/23: ADL (Activities of Daily Living) Function requires staff intervention to complete ADLs. Intervention dated 5/8/23: Dependent with oral care . R15's record did not have evidence to show R15 receives oral care daily. Surveyor reviewed POC (Point of Care) history, which indicated R15 as Independent with oral care three times, Set up assistance three times, and N/A (not applicable) 28 times. On 9/10/24 at 11:40 AM, Surveyor interviewed R15's Power of Attorney (POA) and RR U (Resident Representative), who voiced concerns that the facility could do a better job assisting R15 with oral cares. RR U stated that R15 is completely dependent on staff assistance for brushing his teeth, and that he recently had to have several teeth extracted. On 9/11/24 at 8:35 AM, Surveyor interviewed CNA R (Certified Nursing Assistance), who stated that R15 was fully dependent on staff for assistance with brushing his teeth. CNA R stated that R15 gets his teeth brushed every day. Surveyor asked CNA R where oral hygiene was documented. CNA R indicated that they chart in Point Click Care (PCC) in the POC (point of care) charting. CNA R did not know why the POC charting would indicate that R15 was independent, or why N/A had been marked. On 9/11/24 at 8:45 AM, Surveyor interviewed CNA F who stated that she attempted to assist R15 with brushing his teeth, but that sometimes he refuses. CNA F indicated that charting is completed in the POC screen of PCC, and that sometimes staff members chart N/A when a resident refuses assistance. On 9/11/24 at 2:50 PM, Surveyor interviewed DON B (Director of Nursing) regarding oral hygiene and documentation. DON B indicated that staff should not be documenting N/A, but should be documenting Resident Refused, which would be more accurate. 36253 Example 4 On 9/9/24 at 11:16 AM, Surveyor observed R16 in his room. His fingernails were visibly long and yellowing. There was visible dirt under many of his fingernails. When asked if he likes his fingernails long or if he would like them to cut, R16 stated that he wanted them cut but did not have a pair of fingernail clippers and staff are usually busy. R16's hands were visibly shaking when he held his hands out. When asked if he could trim his own fingernails, R16 said, I don't know. On 9/11/24 at 1:18 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) who stated that she noticed R16's nails were long a few days ago and that they should be cut but because staff typically get behind doing certain cares and tasks, fingernails often get forgotten. On 9/11/24 at 1:21 PM, RN G (Registered Nurse) stated that she was unsure if R16 could trim his own nails, but that she would get it done. RN G stated that they were long and needed to be cut.

Based on interview and record review, the facility did not immediately consult with a resident's physician when there was a need to alter treatment for 1 of 7 residents (R63) that resulted in actual harmy, and 1 of 7 residents (R61) that had potential for minimal harm. The facility did not consult with R63's Medical Doctor (MD) per Physician Orders and as her condition changed resulting in actual harm when R63 was hospitalized and aggressive diuresis. Evidenced by: Facility policy, entitled Notifications of Change, date implemented 12/2022, states in part .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . the facility must inform the resident, consult with the residence physician and or notify the resident's family member or legal representative when there is a change requiring such notification: circumstances requiring notification include: significant change in the resident's physical, mental or psychosocial condition . circumstances that require a need to alter treatment . it's for our discharge of the resident from the facility . Example 1: R63 was admitted to the facility on [DATE] with diagnoses including asthma, Chronic Obstructive Pulmonary Disease (COPD), acute and chronic respiratory failure, dependence on supplemental oxygen, Nonrheumatic aortic valve stenosis (narrowing of a valve between the left lower chamber of heart and a major blood vessel/aorta), and Heart Failure with preserved ejection fraction (a type of heart failure that affects the left side of the heart, especially the lower chamber called the left ventricle. It occurs when the left ventricle is stiff and cannot relax and fill with blood properly. This causes high pressure inside the heart and reduces the blood flow to the rest of the body.) R63's Hospital Discharge Summary and Discharge Instructions, dated 4/5/23, include, in part: . Heart Failure Care: Weigh yourself daily. Call your physician for any weight gain of more than 2 lbs (pounds) in 24-hour period or 5lbs in one week. Take your weight record to your doctors on your follow up . Notify your physician of any of the following and/or seek attention immediately if develop: . swelling in your legs, feet, or ankles, increased shortness of breath with activity or SOB (shortness of breath) at night while lying flat, weight gain of 2lbs in 24-hour period or 5lbs in one week, nausea, feeling more tired or weaker than usual . Go to the emergency room or call 911 if you have new or increased chest pain or moderate to severe shortness of breath to the point that you cannot speak, weakness, or numbness of extremity, not able to speak or have difficulty finding words, change in vision, or confusion. R63's Physician Orders, for 4/5/23-4/30/23, include in part: daily weight every day shift for CHF (Congestive Heart Failure) . call physician for any weight gain more than 2 lbs in 24 hours . (It is important to note this does not include 5lbs weight gain in one week as the discharge instructions stated.) R63's Medical Record included the following: R63's Nurses Note, dated 4/5/2023, includes: .Resident admitted to facility per stretcher via ambulance. Resident is alert and oriented. States she is here for strengthening . ambulates with assist of one and a walker. Resident walked to the toilet, SOB (Shortness of breath) noted on rest and exertion. Resident is oriented to room and controls . able to make needs known . All cares complete per care plan. No signs or symptoms of distress noted. R63's weight, 4/5/23, 310.0 Lbs. R63's Heart Failure Clinic (HFC) Note, dated 4/13/23, includes in part: If weight gain is 3 or more pounds in one day or 5 pounds in one week, call Heart Failure Clinic .Check swelling in your feet, legs, abdomen - call HFC if you notice increase in swelling . Are you experiencing SOB? Call HFC if you notice worsening shortness of breath with activity or shortness of breath when you are lying down . If you are having trouble breathing while sitting or at rest, go to ER or call 911. If you notice tiredness, weakness, lightheadedness, call HFC. R63's Nurse Note, dated 4/13/23, includes: . returned from medical appt . was seen by Cardiology. R63's weight, 4/13/23, 311.2 Lbs. R63's Nurse Note, dated 4/14/23, includes: .writer called R63's MD (Medical Doctor) regarding critical lab value of Carbon Dioxide level 44 . left message with clinical staff . awaiting return call. (It is important to note the facility did not provide evidence of a return call by R63's MD to consult about critical lab values.) R63's weight, 4/14/23, No weight recorded. (It is important to note the facility did not provide evidence of R63's weight being recorded for this date.) R63's weight, 4/15/23, 309.9 Lbs. R63's weight, 4/16/23, 310.4 Lbs. R63's Nurse Notes, dated 4/16/23, include: .alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain oxygen saturation level greater than 90% . becomes SOB and easily fatigued with physical activity. Breath sounds diminished throughout bilateral lungs. No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. No increased edema noted to bilateral lower extremities . has a fluid filled blister to top of left foot . R63's Nurse Note, dated 4/17/23 includes: Resident with 4+ edema in her feet and lower legs. States I wish I could get rid of this fluid, but does not want to elevate her feet while in bed and is not compliant with her fluid restriction. Reported that when she got up to the bathroom a few minutes ago her left foot was wet and she believed it was weeping. No weeping noted by this writer at this time . Writer received call from R63's MD office. Writer informed MD . fluid filled blister, elevated Carbon Dioxide level, noncompliance . staff to continue to educate and encourage. R63's weight, 4/17/23, 311.6 Lbs. R63's weight, 4/18/23, 311.8 Lbs. R63's weight, 4/19/23, 313.8 Lbs. (Note this is a 2lb weight gain in 24 hrs with no MD notification). R63's Nurse Notes, 4/19/23, includes: . alert with baseline mentation . uses oxygen continuous at 4 L/minute via nasal canula to maintain oxygen saturation level greater than 90% during the day hours and 5 L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout bilateral lungs . No cough or congestion . lacks motivation to participate in cares . spends day in room lying in bed or sitting in chair watching tv. R63's Consultation Report, dated 4/19/23, includes: change Lasix to after lunch, please avoid processed meat and canned foods . (The facility did not provide evidence of R63's weights being reviewed or her increased edema being addressed with the MD.) R63's Nurse Notes, 4/20/23, includes: . alert with baseline mentation . uses oxygen continuous at 4 L/minute via nasal canula to maintain oxygen saturation level greater than 90% during the day hours and 5 L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout bilateral lungs . No cough or congestion . lacks motivation to participate in cares . spends day in room lying in bed or sitting in chair watching tv. R63's weight, 4/20/23, 315.0 Lbs. (It is important to note this weight gain of 5 Lbs. since 4/15/23. The facility failed to consult with R63's MD regarding this weight increase.) R63's Nurse Notes, 4/21/23, include: The patient is alert and oriented x 3. She is cooperative with nursing interventions and consumes meals in her room per her choice. She is on a fluid restriction and is non-compliant drinking extra fluids in her room. BMP (Basic Metabolic Panel - a blood test for metabolism) completed this am and faxed to clinic; awaiting response. VS taken; BP 140/68, resp 20, pulse 88, temp 97.6. R63's weight, 4/21/23, 317.0 Lbs. (It is important to note R63's weight has increased by 2 Lbs. in 24 hours and 7 pounds since 4/15/23 and the facility did not provide evidence of notifying R63's MD regarding this weight increase.) R63's weight, 4/22/23, 319.4 Lbs. (It is important to note R63's weight increase of 2 additional pounds in 24 hours and 9 Lbs. in one week with no evidence R63's MD was consulted with regarding this.) R63's weight, 4/23/23, 320.8 Lbs. (It is important to note R63's weight continues to go up. The facility provided no evidence of MD notification.) R63's weight, 4/24/23, 319.8 Lbs. R63's Nurse Notes, dated 4/24/23, include: . alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain . greater than 90% during day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. Increased edema to bilateral lower extremities and bilateral upper extremities . (it is important to note the increase in edema to R63's lower and upper extremities.) R63's weight, 4/25/23, 320.8 Lbs. R63's Nurse Notes, dated 4/25/23, include: . alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain . greater than 90% during day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . spends day in room lying in bed or sitting on chair watching tv. Increased edema to bilateral lower extremities and bilateral upper extremities .Today's BMP results received. Results faxed to heart failure clinic per MD instructions along with today's weight. (It is important to note the facility did not provide evidence of R63's heart failure clinic or MD consulting with facility regarding R63's increased edema, increased weight, or lack of motivation.) R63's Nurse Notes, dated 4/26/23, include: Patient is alert with baseline mentation . uses oxygen continuous at 4L/minute via nasal canula to maintain oxygen saturation greater than 90% during the day hours and 5L at night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . Increased edema to bilateral lower and upper extremities . MD updated with today's CBC (complete blood count- blood test) results. R63's weight, 4/26/23, 321.8 Lbs. R63's Nurse Note, 4/27/23, includes: Patient currently out of building on her way to cardiologist appointment. Pt alert with baseline mentation. Pt uses O2 continuous @ 4L/min via NC to maintain POX > 90% during day hours and 5L t night . becomes SOB and easily fatigued with physical activity . becomes SOB when lying flat. Breath sounds diminished throughout . No cough or congestion . lacks motivation to assist with cares . Increased edema to bilateral lower and upper extremities . Resident admitted to hospital from cardiologist doctor appointment admitted for fluid overload. History: Writer spoke with R63's daughter, on 4/27/23, patient has had a weight gain of 0.5 Lbs. per day, increased edema in lower bilateral extremities, and increased shortness of breath. Today's weight is 319.0 Lbs . Telephone encounter by Cardiologist: on 4/24/23 spoke with facility RN to increase furosemide to 40 mg twice daily. BMP and see me on 4/27/23 R63's Cardiology Follow Up Note, dated 4/27/23, includes: The patients daughter who works in the emergency room called a few days ago complaining of a 10 pound plus weight gain. I doubled her furosemide dose to 40mg twice daily. This has not made a difference. She has gained about 15 pounds since discharge from the hospital (4/5/23). The patient also admits to worsening shortness of breath and orthopnea. She has conversational dyspnea. Assessment: The patient is grossly volume overloaded. She is not doing well on an increased dose of oral loop diuretic therapy. She will need inpatient management for aggressive diuresis. Extremities: Gross bilateral lower extremity pitting edema . Weight 322Lbs. R63's Hospital Summary, dated 5/14/23, includes: admission 4/27/23 .discharged [DATE] with diagnoses of COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure) Exacerbation and was found to be in Atrial Fibrillation with RVR (rapid ventricular rate). She spent a couple weeks in the hospital and was on Lasix drip . IV Lasix 5cc through continuous infusion . On 6/14/23 at 3:14 PM, during an interview, RN Y (Registered Nurse) indicated when R63's weight gain reached 5 Lbs. in one week the nurse on the unit should have consulted the Heart Failure Clinic and/or R63's MD. RN Y also indicated staff should have called and consulted R63's physician regarding her increased edema. On 6/14/23 at 4:55 PM, ADON C indicated R63's daughter called the Cardiologist regarding R63's weight gain, lack of motivation, and worsening edema on 4/24/23. ADON C indicated the facility should not have relied on R63's daughter to contact R63's MD and should have kept the HFC and R63's MD apprised of her changing condition and should have followed MD orders of when to update. ADON C indicated the facility should have updated R63's MD on her changing condition. On 6/15/23 at 9:29 AM, NHA A, DON B, and ADON C indicated R63 was non-complaint with her fluid restrictions, elevating her lower extremities, and wearing her compression stockings. NHA A, DON B, and ADON C indicated the nurse on the unit should have consulted with R63's MD with her weight gain of 5 Lbs. in one week and her increase in edema when it was noted. Of note, there is no evidence the facility provided risks and benefits to R63 regarding following fluid restriction and elevation of lower extremities. The facility failed to notify the HFC and MD of R63's weight gain per physician's orders. R63 was hospitalized and required intravenous diuretic therapy. 38725 R1's physician was not updated when resident had a change of condition. This example is at a level 2 potential for harm/isolated. Example 2 R61's Nurse's Notes document the following: 12/9/2022 21:29 (9:29 PM) Note Text: Res (Resident) sleeping very soundly at start of shift. vitals and bgm (blood glucose monitoring) taken and res did not wake. Res was on room air o2 (oxygen) was at 76 (%). O2 applied at 2l (liters) via NC (nasal cannula) O2 came up to 85 (%). O2 bumped up to 3liters. o2 in 90s. Res awake and was told these findings also res had periods of apnea. This writer explained to res it would be wise ro keep o2 while in bed. Res agreed as well as husband on the phone. Res in stable condition, all cares complete per care plan. No s/s (signs and symptoms) of distress noted. [SIC] On 6/14/23 at 11:40 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H when a resident has a change in their oxygen level, when should the Provider be updated; LPN H stated, at the time it happens. Surveyor asked LPN H how she would inform the Provider of a change in oxygen level, LPN H said call, it is a change of condition. On 6/14/23 at 2:36 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B should a Provider be updated if the residents' oxygen level changes, DON B stated yes. Surveyor asked DON B when would you expect staff to inform a provider of a change in a residents' oxygen level, DON B said they should have updated the on call Physician and sent an update to the Primary Care Provider. It is important to note that there was no documentation in R61's medical record that a provider was ever made aware of this change in her oxygen level.

Based on record review and interview, the facility did not offer and/or administer the influenza immunization to each resident, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and immunization for 1 of 6 (R64) residents reviewed for immunizations that resulted in actual harm, and 2 of 6 residents (R34 and R27) reviewed for immunizations that resulted in the potential for harm. R64 consented to have the influenza immunization upon admission to the facility. R64 did not receive the immunization and then contracted Influenza A which resulted in a complex hospitalization . Evidenced by: The facility's policy titled Influenza Vaccination dated 12/2022, states in part: Policy: it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. Policy Explanation and Compliance Guidelines: .7. Individuals receiving the influenza vaccine< or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record .9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . According to the Center for Disease Control and Prevention (CDC) article titled Flu Vaccine Provided Substantial Protection This Season dated 2/22/23, This year's flu vaccine reduced the risk of influenza A-related hospitalization among adults by nearly half according to the CDC Flu vaccine effectiveness against circulating influenza A (H1N1) viruses was 56% .Adults [AGE] years and older were 35% less likely to have flu-related hospitalization . Example 1: R64 was readmitted to the facility on [DATE] with diagnoses that include: Parkinson's Disease, Type 2 Diabetes Mellitus, asthma, history of COVID-19, and congestive heart failure. R64's Minimum Data Set (MDS) dated [DATE] states that R64 has a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating that R64 is cognitively intact. On 10/3/22, the facility's former ADON (Assistant Director of Nursing) obtained verbal consent from R64 to receive the influenza vaccine and co-signed the Vaccine Administration Record (VAR) - Informed Consent for Vaccination form. It is important to note that the back of the form that typically includes the vaccine specific information, date given, and signature of the person administering the vaccine is missing on R64's form. On 10/4/22, the facility held a flu clinic to administer the influenza vaccine. The facility's ADON kept track of resident's vaccinations on a resident roster. That roster indicates that R64 received the influenza vaccination. R64's Wisconsin Immunization Registry (WIR) states that R64 received the influenza vaccine on 2/8/23. (Of note, this was after R64 contracted Influenza A and was hospitalized .) The facility's nurse's notes state the following: 12/4/22 at 10:55 AM: Resident requesting PRN (as needed) geri-tussin for non-productive cough .faxes sent to communicate all concerns. 12/4/22 at 7:30 PM: R64 stated that she didn't feel great. T-97.4, P-84, R18, O2 sat (oxygen saturation) 97% on room air. Noted an occasional dry cough. She also stated that she could not taste. Episodes of flushed face .Lungs clear with occasional expiratory wheezes. COVID rapid test completed, results negative . 12/5/22 at 10:51 AM: .Resident c/o (complained of) increased congestion and cough. COVID test negative. SPO2 96% on room air. Call placed to MD regarding symptoms . 12/5/22 at 9:23 PM: New orders obtained for labs and STAT chest x-ray. Orders to send to ER (emergency room ) for eval (evaluation) if symptoms worsen or at resident request. Resident had PRN acetaminophen, remains afebrile. Resident continues to c/o (complain of) malaise but denies increased symptoms. Slept intermittently throughout the shift. Non- productive cough noted. Refused to go to the ER for eval, wanting to wait here for chest x-ray. 12/5/22 at 9:44 PM: Technician arrived at facility for chest x-ray. 12/6/22 at 7:11 AM: Chest x-ray results negative and sent to [MD] for review. Requesting orders for flu testing . 12/6/22 at 9:54 AM: Writer called [MD] office requesting to test and treat for the flu, awaiting response. 12/6/22 at 2:21 PM: New orders for COVID PCR, Influenza A/B and RSV swab. Swab taken to [hospital] for processing . 12/6/22 at 11:05 PM: Resident alert and cooperative. Resident lying in bed and appears lethargic. Audible wheezing heard at bedside. Temp. 96.7, b/p (blood pressure) 151/77, HR (Heart rate) 72 PsO2[sic] 90-94%, R (respirations) 18 and resident reports S.O.B (shortness of breath), wheezing, diminished lung sounds not [sic] to right upper lobe. Resident able to cough and clear some congestion. Resident agreed at this time to be seen in the ER and was sent to [hospital] for eval and treat. Call placed to ER for an update and resident was found positive for the flu and admitted . Hospital H&P (History and Physical) dated 12/12/22 states in part: . presented with SOB, wheeze, and chest discomfort on 12/6/22. Initially diagnosed with exacerbation of asthma. Influenza A positive in ED (Emergency Department). Started on Tamiflu (anti-viral) and Solu-Medrol (steroid) and azithromycin (antibiotic). On presentation, mild elevation of troponin thought secondary to demand ischemia from dyspnea. On presentation patient was afebrile, normotensive, normal heart rate, normal O2 sat, no leukocytosis . On 12/8/22, patient noted to be hypoxic and lethargic- ABG (Arterial Blood Gas) with hypoxemia, started on supplemental O2, CXR (Chest x-ray) with new perihilar infiltrates (suggestive of pneumonia) . Patient required increasing O2 supplementation and then placed on BiPAP with no significant improvement- transferred to ICU (Intensive Care Unit) for continued monitoring. Patient was intubated on 12/9/22, at approximately 3:00 AM after intubation, patient went into VT (Ventricular Tachycardia/irregular rapid heartbeat that leads to cardiac arrest if not corrected) arrest, achieved ROSC (Return of Spontaneous Circulation) within 2 minutes. Sputum and blood cultures taken on 12/8/22 have grown MSSA (Methicillin Sensitive Staph aureus- a type of bacteria). Antibiotics changed to Cefazolin on 12/9/22 . R64 remained on the ventilator until 12/18/22 and was finally discharged from the hospital on 12/29/22. On 6/14/23 at 10:20 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the facility's process is when a resident consents to receiving the influenza vaccine, DON B stated that the resident should get it. Surveyor asked DON B how the nurse is made aware of the consent, DON B stated that the consent should be in the admission packet, they get the consent signed, and then they place an order for the influenza vaccine. DON B also reported that last year, the facility had the pharmacy come into the facility on [DATE], for vaccination administration. Surveyor asked DON B to explain why R64 did not receive the vaccine, DON B stated that she thought that R64 had received it and that she would have to get back to this Surveyor. Surveyor asked DON B if she was aware or recognized that R64 did not receive the vaccine, DON B stated no. It is important to note that the facility was also unaware that the pharmacy (from Illinois) did not submit the vaccination records to WIR. On 6/14/23 at 11:06 AM, DON B reported to Surveyor that R64 approached the former ADON Z asking for the vaccine and that his tracking sheet indicates that she received the vaccination. On 6/14/23 at 11:09 AM, Surveyor interviewed former ADON Z. Surveyor asked ADON Z if he administered the influenza vaccination to R64, ADON Z stated that R64 returned from an appointment after the pharmacy's flu clinic was over, so he administered the vaccination to R64. Surveyor asked ADON Z where he documented the administration of the vaccine, ADON Z stated that he thought he wrote it on the back of one of the forms. Surveyor asked ADON Z if he documented it in the nurse's notes, ADON Z stated probably not. On 6/14/23 at 11:15 AM, Surveyor called the pharmacy that held the flu clinic at the facility. Surveyor spoke with PT AA (Pharmacy Tech). Surveyor asked PT AA if they have any documentation of R64 receiving the influenza vaccination, PT AA stated that she couldn't see anywhere that R64 received it from them and that they didn't have any forms scanned into their system. On 6/14/23 at 11:35 AM, Surveyor interviewed R64. Surveyor asked R64 if ADON Z had given her the influenza vaccination, R64 stated that she had asked for it several times, but they just kept putting her off. R64 stated that she never received the influenza vaccination while at the facility. On 6/14/23 at 12:15 PM, Surveyor met with ADON C. Surveyor asked ADON C if they were able to find the back side of the form or if they had received any documentation from the pharmacy, ADON C reported that the pharmacy didn't have anything, and that ADON Z had given it after they had left, so they wouldn't have the form anyway. The facility was unable to provide any documentation showing that R64 received the influenza vaccination. R64 states she did not receive the vaccine prior to contracting Influenza A. R64 contracted Influenza A which resulted in being placed on a ventilator, and subsequently having a cardiac arrest. R64's hospitalization lasted 23 days. 41788 R34 did not have the influenza immunization offered and no declination and risks and benefits were documented. R27 did not have the influenza immunization offered and no declination and risks and benefits were documented. These examples rise to a level 2 potential for harm/isolated. This is evidenced by: The facility policy entitled, Infection Prevention and Control Program, dated 5/16/23, states, in part. 7. Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time . c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse the immunizations. e. Documentation will reflect the education provided and details regarding whether the resident received the immunizations . Example 2 R34 was admitted to the facility on [DATE], and has diagnoses that include: Acute and Chronic Respiratory Failure with Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), sarcoidosis of lung (growth of tiny collections of inflammatory cells in the lungs causing dry coughing, shortness of breath, wheezing, and chest pain), asthma (a condition in which airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and pneumonia. There is no documentation that R34 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined for 2022. Example 3 R27 was admitted to the facility on [DATE] and has diagnoses that include: systemic lupus erythematosus (an inflammatory disease caused when the immune system attacks its own tissues, affecting the joints, skin, kidneys, blood cells, brain, heart, and lungs), heart failure, and cardiomyopathy (an acquired or hereditary disease of the heart muscle making it hard for the heart to deliver blood to the body). There is no documentation that R27 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined. On 6/15/23 at 9:26 AM, Surveyor interviewed DON B (Director of Nursing) and asked if R34 was offered the influenza immunization in 2022. DON B indicated there was no documentation that R34 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined for 2022. Surveyor asked DON B if there should be documentation in R34's medical record and DON B indicated yes. Surveyor asked DON B when R27 was admitted to the facility and DON B indicated 8/14/19. Surveyor asked DON B if R27 had been offered the influenza immunization and DON B indicated she would have hoped so. Surveyor asked DON B if R27 was provided education on the risks and benefits of the influenza immunization or that the immunization was offered, received, or declined. DON B indicated no. Surveyor asked DON B how often the influenza immunization should be offered to residents and DON B indicated yearly. Surveyor asked DON B if there should be documentation in R27's medical record regarding the influenza immunization and DON B indicated yes and there is not.

Based on interview and record review, the facility did not ensure Residents maintained acceptable parameters of nutritional and hydration status for 1 of 3 Residents (R2) reviewed for nutritional status. R2's nutritional and fluid intakes were not monitored to ensure he was meeting his estimated daily nutritional and fluid needs, resulting in 2 hospitalization s for dehydration. This is evidenced by: Facility policy titled Nutrition and Hydration Guideline dated 10/3/22, states in part, Purpose: The intent of this requirement is that the resident maintains, to the extent possible, acceptable parameters for nutritional and hydration status through: Providing nutritional and hydration care and services consistent with the nutritional comprehensive assessment. Recognizing, evaluating, and addressing the needs of every resident, including but not limited to, those at risk or already impaired nutrition and hydration .Process: Accurately and consistently assess a resident's nutritional status on admission and as needed thereafter: Identify a resident at nutritional risk and address risk factors for impaired nutritional status .Obtain weights upon admission, weekly x 4, monthly .Identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident's needs, choices, preferences, goals, and current professional standards of practice, to maintain acceptable parameters of nutritional status. Notify the physician as appropriate in evaluating and managing causes of the resident's nutritional risk and impaired nutritional status. Identify and apply relevant approaches to maintain acceptable parameters of nutritional status, including fluids .Offer sufficient fluid intake to maintain proper hydration and health. Facility policy titled Notification of Change Guideline dated 10/3/22 states in part, .Requirements for notification of resident, the resident's representative, and their physician: A significant change in the resident's physical, mental, or psychosocial status. A significant change includes deterioration in health, mental, or psycho-social status . R2 was admitted to the facility on [DATE] with diagnoses that include right hip fracture with repair, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting the left side, Major Depressive Disorder, and hypertension. R2's Admission Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating that R2 is severely cognitively impaired. R2 requires extensive 2 person assist for bed mobility and is independent with eating, requiring setup help only. R2's Physician Orders state: Daily weight upon admission x 3 days, then weekly x 4 weeks, then monthly. R2 also had an order dated 11/3/22 for Ensure Clear with meals, changed to Ensure Regular with meals on 11/10/22. There is no documentation showing that R2 received the Ensure or how much he consumed. R2's weights were documented as follows: 11/2/22: 147.2 lbs. (pounds). 11/7/22: 156 lbs. 11/18/22: 130.2 lbs. 11/19/22: 131.3 lbs. 11/20/22: 130.0 lbs. 11/21/22: 129.6 lbs. 11/28/22: 129.0 lbs. It is important to note that the facility did not complete daily weights for the first 3 days after admission (11/3 and 11/4), nor did they obtain a re-weigh when documentation showed that R2 had gained 9 lbs. Based on the documented weights, R2 had lost 26 lbs. from 11/7/22 to 11/18/22. Additionally, facility staff only entered the weights from 11/2/22 and 11/18/22 into the Electronic Health Record (EHR), the others were documented on the paper Medication Administration Record (MAR). There is no documentation indicating that the Physician was updated on R2's significant weight loss. R2's meal intake documentation is as follows: 11/2: RU (Resident Unavailable) 11/3: no documentation 11/4: 2 (51-75%), 1 (26-50%), no documentation for supper 11/5: no documentation 11/6: no documentation 11/7: no documentation 11/8: 3 (76-100%), 3, no documentation for supper 11/9: RR (Resident Refused), RR, 2 11/10: RR, 2, no documentation for supper 11/11: 0 (0-25%), 0, 0 (R2 tested positive for Covid-19) 11/12: 0, 2, no documentation for supper 11/13: 0, 0, 0 11/14: 3, 0, 0 11/15: 2, 2, no documentation for supper 11/16: 3, RU, RU (hospital) 11/17: in hospital 11/18: no documentation- R2 returned from the hospital at 4:15 PM 11/19: 0, 0, RR 11/20: 0, RR, 0 11/21: 0, 1, RU 11/22: 0, 3, 0 11/23: 3, no documentation for lunch, 0 11/24: 0, RR, no documentation for supper 11/25: 0, 1, 0 11/26: 0, 0, 0 11/27: 0, RR, RR 11/28: 0, 0, 1 11/29: 2, 1, no documentation for supper 11/30: RR, 1, RR R2's fluid intake (in milliliters) documentation (by shift) is as follows: 11/2: AM: NA (Not applicable) PM: RU (Resident unavailable) NOC: no documentation 11/3: AM: no documentation PM: no documentation NOC: 0 11/4: AM: 300 PM: no documentation NOC: no documentation 11/5: AM: 120 PM: no documentation NOC: 0 11/6: AM: no documentation PM: 120 NOC: NA (Not Applicable) 11/7: AM: no documentation PM: no documentation NOC: NA 11/8: AM: 480 PM: no documentation NOC: 120 11/9: AM: 240 PM: no documentation NOC: 120 11/10: AM: 120 PM: no documentation NOC: 120 11/11: AM: 50 PM: 250 NOC: no documentation (R2 tested positive for Covid-19) 11/12: AM: 600 PM: 240 NOC: 0 11/13: AM:240 PM: 240 NOC: 240 11/14: AM:600 PM: 120 NOC: 150 11/15: AM: 360 PM: no documentation NOC: 200 11/16: AM:240 PM: RU NOC:120 11/17: in hospital 11/18: AM: no documentation PM: no documentation NOC: RU 11/19: AM:120 PM:0 NOC: 200 11/20: AM:480 PM:0 NOC: no documentation 11/21: AM: 120 PM:240 NOC: 0 11/22: AM: 600 PM: 480 NOC: 0 11/23: AM: 240 PM: 360 NOC: NA 11/24: AM: 500 PM: no documentation NOC: 0 11/25: AM: 480 PM: 720 NOC: no documentation 11/26: AM: 480 PM: 480 NOC: 200 11/27: AM: 240 PM: 240 NOC: 200 11/28: AM: 120 PM: 120 NOC: 200 11/29: AM: 240 PM: 120 NOC: 0 11/30: AM: 200 PM: 120 NOC: 120 Surveyor reviewed the Nurse's Notes, and there is no documentation stating that the Physician was updated regarding R2's poor appetite or poor fluid intake. Facility staff did not total daily intakes to ensure that R2 was receiving an adequate amount of fluids. On 11/11/22, R2 was positive for Covid-19. On 11/16/22, R2 had an unwitnessed fall and was sent to the emergency department. The hospital's History and Physical (H&P) states in part, On exam, frail elderly male with right sided weakness and expressive aphasia, dry mucous membrane noted. Patient admitted for UTI (Urinary Tract Infection) and AKI (Acute Kidney Injury) in setting of dehydration and recent COVID-19 infection. Plan: continue gentle hydration . Abnormal lab values include Sodium 147 (H), BUN (Blood Urea Nitrogen) 32 (H). R2 received IV (Intravenous) fluids. R2's Discharge MDS dated [DATE] states that R2 now requires supervision - oversight, encouragement or cueing with eating. R2 returned to the facility on [DATE]. Facility did not complete a dehydration assessment on R2. R2's Nutrition Risk Care Plan dated 11/27/22 states in part, At nutritional risk r/t (related to): Consumes <75%, weight loss - down 17 lbs. x 2 weeks. Goal: Weight will remain stable 130 lbs., Resident will be free of dehydration AEB (As Evidenced By) good skin turgor, labs, etc., Resident will meet 75-100% est (estimated) needs. Interventions: Provide diet as ordered .honor food preferences .supplements as ordered: TID (Three Times a Day) Ensure, monitor weights: as ordered, monitor for signs of dehydration. R2's Nutritional assessment dated [DATE] states in part, .Needs staff to cut up food- indicated on meal ticket. Usually requires supervision- at times may need assistance. Est. needs: 1700-2070 kcal/day, 1480-1780 ml/day. Est. needs increased d/t (due to) low BMI (Body Mass Index) and R (Right) hip fx (fracture) with surgical site .No new recommendations at this time. Reweight requested . It is important to note that the facility's Registered Dietician (RD) did not see R2 until R2 had been at the facility for 25 days. R2 went from being independent with set-up to now needing staff to cut up food, requiring staff supervision, and needing assist at times. R2's Quarterly MDS dated [DATE] states that R2 now requires extensive 1 person physical assist for bed mobility, eating, and toilet use. On 12/2/22, R2 went to see his Primary Care Physician (PCP) due to making suicidal remarks and the facility's request to increase his mirtazapine (anti-depressant.) R2 was found to be hypotensive (low blood pressure) with blood pressure readings of 60/40 and 80/52. Clinic notes state that R2 was ill-appearing and pale. The Physician discussed options with family, fluids were started, and R2 was sent to the ED (Emergency Department) and was subsequently admitted to the hospital for 5 days with the diagnoses of dehydration, elevated lactic acid level, hypotension, and failure to thrive. Abnormal lab values include Hemoglobin 8.4 (L), Lactic Acid 3.9 (H), Cortisol 31.0 (H), Creatinine 1.3 (H), and Albumin 3.3 (L). (Albumin test measures the amount of protein in the clear liquid portion of the blood. Low albumin levels can be a sign of malnutrition.) On 12/13/22 at 1:52 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J how often residents are weighed? CNA J stated that everyone gets weighed on the 1st of the month, but new admissions are weighed 3 days straight. Surveyor asked CNA J what they do with the weights after they have obtained them? CNA J stated that they give them to the nurse, and they put them in the computer. On 12/13/22 at 1:55 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). Surveyor asked LPN I what do the nurses do with the weights when the CNAs give them to them? LPN I stated that they put them in the computer or on the MAR. Surveyor asked LPN I, how are the nurses alerted to weight loss in a resident? LPN I stated by looking at it and that the computer also updates them when there is weight loss. Surveyor asked LPN I what steps she takes after noticing or being alerted to a weight loss? LPN I stated that they inform the dietician, the doctor, and the family. Surveyor asked LPN I where they would document this communication? LPN I stated in the nurse's notes. On 12/13/22 at 2:40 PM, Surveyor interviewed DON B (Director of Nursing) and ADON F (Assistant Director of Nursing.) Surveyor asked DON B what the facility's policy is for weighing new admissions? DON B stated that they are weighed on admission and then depending on the MD (Medical Doctor) orders. Surveyor asked DON B what her expectations were when a nurse notices a weight loss or gain? DON B stated that she would expect the nurse to let her and ADON F know, and he will update the dietician. Surveyor asked DON B if the MD should be updated; DON B stated yes. Surveyor asked DON B if she would expect that communication to be documented; DON B stated yes. Surveyor asked DON B if by reviewing the documentation, she could tell if the MD was updated on R2's weight loss; DON B stated no. Surveyor asked DON B if she would expect that the RD (Registered Dietician) see R2 before 11/27/22? DON B stated yes, he should have been seen when he was newly admitted . Surveyor asked DON B who is responsible for totaling daily fluid intakes? DON B stated that it is usually dietary. Surveyor asked DON B who reviews the intake totals? DON B stated that before it was dietary, but she is unsure at this time. Surveyor asked DON B if she expected the CNAs to document every day and shift; DON B stated yes. Surveyor asked DON B if staff were aware of R2's poor appetite, would she expect that R2 be weighed more frequently; DON B stated yes. Surveyor asked ADON F if at any point he updated the MD regarding R2's weight loss? ADON F stated he receives and reviews the dietary notes and then sends them to the MD. Surveyor asked ADON F if at any point during the 9 days from when the weight loss was documented, until the RD saw R2 was the MD updated? ADON F stated that he was not sure. On 12/14/22 at 8:25 AM, Surveyor interviewed RN G (Registered Nurse (MD office)). Surveyor asked RN G if they had received any updates from the facility regarding R2's poor appetite and decreased fluid intake? RN G reviewed the clinic documentation and reported that they received faxes on: 11/2 regarding admission paperwork, 11/9 requesting to change Ensure from clear to regular, 11/15 requesting an order for Mucinex and to schedule oxycodone, and 11/18 request orders for an antibiotic for UTI. RN G stated that they also received a call on 12/1 to request an increase to mirtazapine. Surveyor asked RN G if the clinic/MD was made aware the R2 had a 17-pound weight loss? RN G stated that they were not made aware of that. RN G reported to Surveyor that the MD required R2 to come into the clinic to be assessed before increasing his mirtazapine, and then was sent to the hospital for hypotension and dehydration on 12/2/22. On 12/14/22 at 9:35 AM, Surveyor interviewed RD H. Surveyor asked RD H what her timeline is for seeing new admissions? RD H stated 14 days. Surveyor asked RD H if R2 was seen within 14 days of admission? RD H stated no and that she must have been late with that one. Surveyor asked RD H if the facility updated her regarding R2's 17-pound weight loss; RD H stated no, but that she noticed it in the computer and sent an email to the ADON and DON requesting a reweigh. Surveyor asked RD H if a reweigh was completed? RD H stated that she was unsure because some are documented on paper and others are in the EHR (Electronic Health Record.) Surveyor asked RD H if she reviews daily fluid intakes? RD H stated no. Surveyor asked RD H if R2 was meeting his daily fluid intake needs? RD H stated no. Surveyor asked RD H if she knew how much of R2's Ensure he was consuming daily? RD H stated no. Surveyor asked RD H if the dietary staff was documenting how much Ensure is consumed? RD H stated no, nursing should be documenting that. On 12/14/22 at 10:04 AM, Surveyor interviewed DON B. Surveyor asked DON B how they know if a resident is receiving the Ensure if no one is documenting on it? DON B stated that it should be documented on the MAR. DON B reviewed R2's MAR and stated that it's not on there. Surveyor asked DON B how does the nurse know if the Ensure has been given? DON B stated that they would have to check with staff. Surveyor asked DON B if she would expect that to be documented; DON B stated yes. Surveyor asked DON B if they currently have a process to track how much Ensure is being consumed and therefore tracking the calories from the Ensure? DON B stated no. Surveyor asked DON B if they have a Dehydration assessment for R2; DON B stated no. R2 had weight loss due to a decline in fluid and nutritional intake, staff were not monitoring R2's weights or intakes to ensure he was meeting his estimated daily needs. R2 went from being independent to supervision to needing assist of 1 with eating within 28 days of being admitted . R2 became ill with Covid-19 which increased his daily nutritional and fluid requirement while ill. R2 was not assessed for dehydration at any time during his stay by the facility and was hospitalized two times with dehydration. R2 did not return to the facility after his 12/2/22 hospitalization .

Based on observation, interview and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 1 of 4 residents sampled for pressure injuries (Resident 6). R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had a care planned intervention for an air mattress, the facility removed the air mattress without evidence of reassessing R6's risk for developing a PI before removal. R6 developed a PI after the air mattress was removed. The facility failed to assess the area after skin impairment was noted on 8/7/22 and to ensure R6 was turned and repositioned per R6's individualized care plan. R6 was not provided with risk and benefits of not repositioning. R6 developed an infected stage IV PI. The failure of the facility to prevent the development of a PI for an at-risk resident, failure to follow R6's care plan interventions to prevent a PI and monitor R6's skin integrity resulted in R6 developing a Stage 4 PI, which became infected requiring antibiotic therapy. This created a situation of Immediate Jeopardy, which began on 9/1/22 when R6 was found with an unstageable PI which developed into a Stage 4 PI and became infected. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) was formally notified on 10/17/22 at 12:00 PM that an Immediate Jeopardy situation existed. The immediate jeopardy was removed on 10/17/22. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy titled, Prevention of Pressure Ulcers/Injuries, revised 7/2017, includes, in part, the following: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 4. Inspect the skin daily when performing or assisting with personal care or ADLs (Activities of Daily Living). b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); e. Reposition resident as indicated on the care plan. Prevention: Moisture: 1. Keep the skin clean and free of exposure to urine and fecal matter. Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. R6 was admitted to the facility on [DATE]. R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 has a history of Stage 3 pressure injury on her right buttock in 3/2021 which did heal. R6's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/16/22 states R6 has moderate cognitive impairment, needs extensive assistance of one person for bed mobility, needs extensive assistance of two persons to transfer, needs extensive assistance of two persons for toilet use, and extensive assistance of one person for personal hygiene. In addition, The MDS indicated R6 is frequently incontinent of urine, is at risk for pressure injuries, did not have any unhealed pressure injuries, and needed a pressure reducing device for chair and bed. It is important to note that R6's MDS did not indicate R6 needed a turning and repositioning program. R6's Braden Risk Assessment Scale includes, in part, the following: 2/10/21 - R6's Braden Score was 17 - at minimal risk for skin breakdown 3/2/22 - R6's Braden Score was 17 - at minimal risk for skin breakdown 5/10/22 - R6's Braden Score was 15 - at minimal risk for skin breakdown R6's Skin Grid - Pressure/[CONDITION(S)] Ulcer/Other, dated 3/6/21, includes, in part, the following: Stage 2 right buttock, right gluteal fold. 3/30/21, healed. R6's ADL (Activities for Daily Living)/Mobility Care Plan, most recent update 5/16/22, includes, in part, the following: Problem: Potential or Actual ADL/Mobility deficit, poor oral hygiene, oral infection r/t (related to): arthritis, cognitive impairment, generalized weakness, easily fatigued, decreased ability to understand others.12/10/21, 2 A (assist) SUL (stand up lift). R6's Skin Integrity Assessment, Prevention and Treatment Care Plan, most recent update 5/16/22, includes, in part, the following: Assessment/Problem: Braden Risk Assessment Score: At Risk (15 - 19): Frequent turning, maximal remobilization, protect heels, manage moisture, nutrition, friction and sheer, pressure-reduction support surface if bed or chair-bound, bladder incontinence, chronic leg [CONDITION(S)], Alzheimer, Dementia. Interventions include, in part, the following: Use lift sheet to move resident, keep skin clean, dry, and free of body wastes, perspiration and wound drainage, inspect the skin for s/s (signs/symptoms) of breakdown, encourage ambulation and mobility as tolerated, specialty mattress 3/16/21 air mattress, 3/16/21 vicar cushion in w/c (wheelchair). R6's Documentation Survey Report with Intervention/Task: Turned and Repositioned August 2022, documentation is blank on 42 shifts, September 2022, documentation is blank on 38 shifts and October 1 - 13, documentation is blank on 8 shifts. In addition, August 2022, has 7 shifts that indicate turning and repositioning was not applicable. There is no evidence that R6 was turned for these 96 shifts that there was no documentation. R6's Skin Check, dated, 8/7/22, includes, in part, the following: Findings: See Skin Grid - Pressure/Stasis Ulcer/Other, Front OK, back: Comments: I put cream on the area. Locate skin impairment site(s) with a Letter from the key: upper inner right buttock area is marked. Of note the skin check indicates there is an area of skin impairment on 8/7/22 there is no evidence this area is assessed or documented on by a registered nurse (RN). R6's Skin Check, dated 8/24/22, includes, in part, the following: the form is signed by a CNA (Certified Nursing Assistant) and an LPN (Licensed Practical Nurse). There is no documentation on the skin sheet for either R6's front or back and there are no areas of skin impairment documented. Nursing Progress notes dated 8/15/22, 07:53 (AM), (Physician's Name) updated via physicians answering service of residents COVID 19 positive results on rapid antigen testing. Nursing Progress notes dated 8/19/22, no time, . resident is COVID + (positive)/ remains on isolation/vitals WNL's (within normal limits). Of note R6 had a change of condition positive COVID-19 increasing the need for facility staff to provide aggressive PI prevention including frequent repositioning and turning to prevent PI development. R6's Skin Check, dated 9/1/22, includes, in part, the following: Findings: See Skin Grid - Pressure/Stasis Ulcer/Other, Comments: today noted new area sacrum wound, redness, yellow. R6's Skin Grid - Pressure/[CONDITION(S)] Ulcer/Other, dated 9/1/22, includes, in part, the following: Site Unstageable, Pressure. Dimension: Length: 5 (centimeters), Width 5 (centimeters), Depth: (centimeters). Drainage: Yellow. Color: S (serosanguineous). Amount of drainage: Mod (moderate). It is important to know there is a picture of a body with an x over the coccyx, indicating the area of the PI. R6's Accident/Incident Report, dated 9/1/22, includes, in part, the following: Describe Injury and Exactly What Occurred: CNA reported while performing cares that resident had an open area to coccyx writer assessed - sacrum open wound. Immediate action taken to prevent further incidents: air mattress in place, cushion in place w/c (wheelchair), reposition in chair and bed. Only up 1 meal a day if resident allows. Dietician referral. Message sent to R6's physician, 9/1/22, 12:36 PM, include, in part, the following: Other Reason: CNA found open area/pressure ulcer on coccyx. Requesting an order to cleanse with half strength Dakin's solution, pat dry, add Santyl and cover with border gauze daily. They have started to use an air mattress; the wound is 5 x 2.5 and looks deep, the wound team will follow weekly. R6's physician's fax reply 9/1/22, 1:22 PM, Agree. Nursing Progress notes dated 9/1/22, 13:20 (1:20 PM), Resident noted to have open area to coccyx, writer called PCP (primary care physician) (Physician's Name) and new order received treatment daily, air mattress in place and wound team to assess weekly. Resident encouraged to lay down between meals to take pressure off buttock, will continue to monitor Of note, the air mattress was not restarted until after R6's PI was discovered. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 9/1/22, coccyx cleanse (with) 1/2 Dakin's, pat dry apply Santyl, f/b (followed by) bordered gauze daily. R6's Nursing Progress notes dated 9/4/22, 11:07 (AM), Dressing intact to coccyx. No increased warmth or redness to surrounding skin. No c/o (complaints of) pain. Pt (patient) receives wound care daily in the evening. Pt has spent most of shift up in w/c (wheelchair) despite staff encouragement to lay down to help relieve pressure off coccyx. R6's Nursing Progress notes dated 9/5/22, 18:07 (6:07 PM), Resident alert, pleasant and cooperative. No complaints of pain or discomfort. Took all medications and tolerated well. Treatment to coccyx completed. Moderate amount of yellowish drainage noted, no swelling, peri wound appears red, no odor noted. No other concerns at this time, will continue to monitor. R6's Nursing Progress Notes dated 9/6/22, 13:41 (1:41 PM), Resident up in w/c per usual and is being seen by (Physician's Name) wound care of sacrum and is encouraged to lay down and only up for one meal a day. Resident agreed. No pain noted. Will continue to monitor. Treatment order changed to sacrum. R6's Skin Grid - Pressure/[CONDITION(S)] Ulcer/Other, dated 9/6/22, includes, in part, the following: Site: Sacrum, Pressure Stage 4. Dimensions: Length 2.22 (centimeters), Width 1.89 (centimeters), 1.30 (centimeters). Drainage: Mod/Serous (moderate/serosanguineous), Amount of drainage: moderate. R6's wound rounds documentation, signed by the wound care physician, dated 9/6/22 states in part; Undermining 12-12 o'clock: 1.4 cm R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse 1/2 Dakin's f/b (followed by) Santyl f/b calcium alginate f/b bordered gauze daily and prn. R6's Nursing Progress Notes dated 9/7/22, 17:08 (5:08 PM), . remains on bed rest r/t (related to) wound on the bottom. R6's Nursing Progress Notes dated 9/11/22, 12:45 (PM), . Remains on bed rest r/t open wound. Offloading as much as possible. Tolerating well. No complaints of pain or discomfort. Able to make needs known. No other concerns at this time. R6's Nursing Progress Notes dated 9/12/22, 11:28 (AM), Pt alert. Pt on bed rest secondary to sacrum wound. At meals well. No c/o pain noted. Pt repositioned side to side by staff Q 2 hrs. (hours) and prn. Will continue to monitor. R6's wound rounds documentation, signed by the wound care physician, dated 9/13/22, Stage 4, Length 2.64 (centimeters), Width 2.20 (centimeters), Depth 2.0 (centimeters). Color of drainage: serous. Color: Y (yellow). 9/13/22: Undermining 4-3 o'clock: 4.7 cm R6's Nursing Progress Note, dated 9/14/22, 20:53 (8:52 PM), . Est (estimated) needs increased due to increased d/t (due to) new coccyx PI. At risk for unintended wt. (weight) d/t dementia, malntr (malnutrition) dx (diagnosis). New open pressure area to coccyx noted 9/1. MD (Medical Doctor) order received by nursing for treatment daily, air mattress in place, and wound team to assess weekly. Resident encouraged to lay down between meals to take pressure off buttock. Repositioned q (every) 2 hours. Nutr (nutrition) dx: increased kcal (calorie) and pro (protein) needs r/t increased demands of healing new coccyx PI. Interventions: recommend new order for QD (every day) 30 ml (milliliters) Prostat or equivalent . Nursing updated via Dietary Recommendation form to obtain MD order. R6's wound rounds documentation, signed by the wound care physician, dated 9/20/22, Stage 4, Length 3.0 (centimeters), Width 2.3 (centimeters), Depth 1.5 (centimeters). Color of drainage: 20% eschar, gray drng (drainage). Color: P (Pink). Tunnelling/Undermining Depth: 10 to 12, 1.0 (centimeter) R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Prealbumin 9/21 and 10/12/22. R6's Nursing Progress Notes dated 9/20/22, 12:05 (PM), Discussed resident's wound with DON (Director of Nursing) and nursing. Rec (recommend) to increase Proheal 30 mls to BID (twice a day) to aid in wound healing. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R6's Nursing Progress Notes dated 9/25/22, 18:17 (6:17 PM), . resident has no c/o pain or discomfort at this time. Wound vac still in place and working, . R6's Nursing Progress Notes dated 9/26/22, 13:45 (1:45 PM), Resident up in chair for lunch and then laid back down to off load d/t sacrum wound. Wound changed because of leakage, large amount of drainage in canister, resident repositioned q (every) 2 hours and prn (as needed). R6's wound rounds documentation, signed by the wound care physician, dated 9/27/22, Stage 4, Length 3.03 (centimeters), Width 2.36 (centimeters), Depth 1.4 (centimeters). Color of drainage: 75% gran (granulation) 25% slough. Color: P/Y (pink/yellow). Tunnelling/Undermining Depth: 10 to 12. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Cleanse with normal saline. 2. Skin prep peri wound. 3. Collagen in wound bed. 4. Pack undermining lightly with silver alginate. 5. Cover with border dressing. 6. Change daily and prn. R6's Nursing Progress Notes dated 10/4/22, 06:37 (AM), Residents wound vac not functioning around 2300 (11:00 PM) Call placed to ADON (Assistant Director of Nursing) at the time and this nurse was instructed to pack wound with saline gauze after cleaning and cover with ABD (abdominal) pad and cover with bordered gauze until morning when he gets to facility. R6's wound rounds documentation, signed by the wound care physician, dated 10/5/22, Stage 4, Length 4.2 (centimeters), Width 3 (centimeters), Depth 0.2 (centimeters). Color of drainage: serous. Color: R (red). Odor: F (foul). Tunneling/Undermining: 4 cm. R6's Wound Culture, dated 10/5/22, indicated moderate Escherichia coli isolated, few proteus mirabilis isolated. R6's Nursing Progress Notes dated 10/5/22, 12:59 (PM), New orders received for [MEDICATION(S)] today for wound infection. To be given IV (intravenous), if unable to access an IV may give IM (intramuscular). IV #24 angio inserted into her left for (sic) arm. Blood noted and the line flushed well. Transferred to (Name of Hospital) for blood draw and wound culture completed. R6's Nursing Progress Notes dated 10/6/22, 13:58 (1:58 PM), . antibiotics x (times) 2 for sacrum wound no adverse reactions noted. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. D/C wound vac. 3. Culture wound. 5. [MEDICATION(S)] 100 mg PO (orally) bid x 14 days. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Send stat. wound infection. Peripheral IV site, may use pass 72 hours as long as intact. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. D/C IV [MEDICATION(S)]/ D/C IV site. 3. [MEDICATION(S)] 1- tab (tablet) po BID x 15 days. Irrigate wound (with) 1/2 strength Dakin's. R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Protect periwound with skin prep. 3. Apply [MEDICATION(S)] Blue or Derma Blue (cut to size) to wound bed. 4. Cover with Bordered Gauze. 5. Change daily and prn. R6's Nursing Progress Notes dated 10/7/22, 13:56 (1:56 PM), . continue antibiotic related to wound, writer spoke with (Physician's Name) regarding labs and culture results from wound, new order received for [MEDICATION(S)] (double strength) and to discontinue IV site and IV medication. R6's Nursing Progress Notes dated 10/9/22, 09:47 (AM), . Pt remains on ABT (antibiotic)/wound infection without adverse reaction. Treatment done to sacrum wound, slough present to wound bed. Wound edges intact. R6's Nursing Progress Notes dated 10/10/22, 11:21 (AM), . Pt remains on ABT/wound infection without adverse reaction. Dressing to sacrum done and resident tolerated well. Moderate amount of brownish/sanguineous drainage noted. 10/14/22, 00:10(12:10 AM), Resident remains on ABT therapy r/t wound care. On 10/14/22, 9:50 AM, Surveyor observed R6 lying on her back in bed, head of the bed was up approximately 45 degrees, R6's heels were directly on the mattress. R6's bed had an air mattress on it, which was appropriately inflated. On 10/14/22, 11:00 AM Surveyor interviewed LPN K (Licensed Practical Nurse). LPN K stated R6 did not have an air mattress when her coccyx PI was found. LPN K did not know when or why R6's original air mattress was removed or what type of mattress was provided to R6. LPN K stated a new air mattress and new chair cushion were provided to R6 on 9/1/22. LPN K stated R6 is incontinent of bowel and bladder and does not like to be off her back/bottom. LPN K stated R6 was educated on being off her bottom, however R6 is forgetful. On 10/14/22, 12:30 PM Surveyor interviewed DON B (Director of Nursing). DON B stated R6 should have a turning and repositioning program, should be turned and repositioned and R6's care plan should have been updated to reflect her mattress had been changed. Surveyor requested from DON B the date when R6's air mattress was removed, and evidence of what mattress was put on. No evidence was provided to Surveyor. On 10/14/22 at 12:45 PM Surveyor interviewed CNA L (Certifed Nursing Assistant). CNA L stated she was caring for R6 on 9/1/22 and found R6 had redness on her bottom. CNA L stated she reported this to the nurse. CNA L stated R6 did not like to lay down. CNA L stated R6's air mattress was removed a couple of months ago, during the summer of 2022, she could not remember an exact date and a standard mattress was applied to R6's bed. On 10/14/22, 12:55 PM Surveyor observed R6 lying on her back, head of the bed was up approximately 45 degrees. R6's heels were directly on the mattress. R6 was eating lunch. On 10/14/22 at 2:15 PM Surveyor observed R6 lying slightly on her right side. R6's heels were directly on the mattress. On 10/14/22 at 2:45 PM Surveyor observed R6's wound care with ADON J (Assistant Director of Nursing) and LPN H. R6 was turned to her left side, R6's wound dressing was soiled. R6's dressing was removed and R6's bedding was changed. R6's wound was pink, granulation tissue with 20% slough in the wound bed and 80% granulation with undermining. R6 asked LPN K are you going to lift my heels, they have been digging in and they hurt. R6's heels were pink, intact and blanchable. R6's dressing was applied. R6's heels were left directly on the mattress. On 10/14/22 at 3:00 PM Surveyor interviewed ADON J. Surveyor asked ADON J if R6's heels should be floated. ADON J stated R6's heels should be floated as heel wounds are the number one issue with wounds and floating heels is the Standard of Practice. On 10/14/22 at 3:35 PM Surveyor and LPN K observed R6's heels. R6's heels were directly on the mattress. LPN K stated R6's heels should be floated. R6 stated I don't want my heels grinding in anymore. LPN K put a pillow under R6's heel to float R6's heels. R6 stated that feels a lot better. On 10/14/22 at 6:18 PM Surveyor interviewed DON B (Director of Nursing). DON B stated that R6's heels should be floated and R6 should be turned on a regular basis to help prevent R6's PI from worsening. R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's air mattress was removed without evidence of assessing R6's risk for redeveloping a PI. R6 ws not turned and repositioned per her plan of care. R6 developed a Stage IV infected PI. The facilities failure to ensure pressure injury prevention devices were in place, and care plan interventions were followed resulted in R6 developing an infected stage IV PI, this created a finding of immediate jeopardy beginning on 9/1/22. The facility removed the jeopardy on 10/17/22 when the following was completed: 1. Ad Hoc QA (Quality Assurance) meeting held to educate the entire leadership team on our plan and follow up. 2. All licensed and unlicensed personnel were educated on the facility policy for treatment and prevention of pressure injuries including interventions: Ensuring the HOB (head of bed) is not elevated greater than 30 degrees, ensuring heels are offloaded and ensuring that turning and repositioning is done per the resident's plan of care. 3. A skin sweep was conducted on all residents in the facility to identify any new areas of skin impairment. 4. Braden evaluations were completed on all residents in the facility to determine their risk for pressure injury development. 5. The care plans and care delivery guides of any resident that was determined to be at risk were updated to ensure proper interventions and devices are in place. 6. The facility will ensure that resident's risk for pressure injury development will be assessed per the skin impairment prevention policy on admission/readmission, quarterly, annually and with any significant change of condition. Licensed staff were educated on the skin impairment prevention policy for completing Braden assessments and implementation of interventions, all education will be completed with licensed staff currently in the building and all other licensed staff will be educated prior to his/her next scheduled shift. 7. The facility will ensure that any resident having been identified at moderate risk or below has interventions and proper devices in place and is care planned properly.

Based on observation, interviews, and record review, the facility did not ensure that 1 of 13 residents (R7) reviewed received food that accommodated the resident's allergies. R7, who is allergic to fish, received fish for lunch. The Cook, who cooked and plated the food admitted that he did not use the dietary cards due to being in a rush. The CNA (Certified Nursing Assistant) who served the food indicated that she did not take the cover off of the food to view it before leaving it with R7 and was unaware of the allergy. The AD (Activity Director) was unaware of R7's food allergy until R7 made her aware of it. The facility's failure to provide food that accommodated the resident's fish allergy created a finding of Immediate Jeopardy (IJ) that began on 1/23/20. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the IJ on 1/23/20 at 5:00 PM. The IJ was removed on 1/23/20. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its plan of correction. This is evidenced by: R7 was admitted to the facility, on 10/4/19, with [DIAGNOSES REDACTED]. R7's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 1/9/20, indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Section G indicates R7 requires setup help only to meet his needs in eating. R7's Physician Orders, 1/1/2020-1/31/2020, include, in part: . allergies- fish derived products, onions, mushroom extract complex, mushroom, aspirin . R7's Admission Nutrition Assessment, dated 10/15/19, includes, in part: Food Allergies: onions, mushrooms, fish . R7's Nutrition Risk Care Plan, reviewed 1/9/20, with a goal date of 4/20, does not include an entry related to R7's allergies. (It is important to note R7's Comprehensive Care Plan does not indicate R7 is allergic to fish, onions, mushrooms, or aspirin.) R7's Meal Cards for 1/23/20, include, in part: breakfast- allergy: fish, mushroom, onion . lunch- allergy: fish, mushroom, onion . DO NOT SERVE: Tuna Melt supper- allergy: fish, mushroom, onion . On 1/23/20, between 1:10 PM - 1:50 PM, Survey Team observed the dining process in main dining room and down the hallways. In Main Dining Room, Surveyor observed DM D (Dietary Manager) give instructions to DA T (Dietary Aide) to pass out salads to all residents who wanted one. DA T stated, I don't know diets or who can have what. I don't really want to do this. I am not trained on who gets what here. DM D replied to DA T, Just ask them. Outside of the kitchen door, in hallway, Surveyor observed AA S (Activity Assistant) bring a tray back to the kitchen indicating the resident wants tuna melt, not what was on the plate. DM D called out in a loud stern voice, This is why we take orders. AA S stated to Surveyor, This is embarrassing. I have been here 9 years. AA S also indicated the hallway that the meals are being passed on did not have any desserts on the trays. DM D brought out a tray of desserts and told AA S to give them to all who want one. Surveyor observed DM D going table-to-table asking residents what they wanted to eat. DM D was telling Cook O orders and Cook O was plating orders. During an interview, Cook O indicated he was unsure who the plates were for, he was just fulfilling orders that staff, including DM D, were telling him. (It is important to note resident Meal Cards were not passed out with meal or used by Cook O in the main dining room and were not accessible for DA T. They remained in a stack on hot cart for the duration of this meal.) On 1/23/20 at 1:13 PM, Surveyor observed CNA U set R7's meal on a bedside table and leave R7's room. R7 took cover off his meal and called out, Hey. I am allergic to fish, mushrooms, and onions. I can't eat this. I am allergic to fish and onions and mushrooms. You have to take this back. I can't eat this. AD V entered the room. R7 explained to her he was not able to eat the meal provided to him due to his allergies. AD V looked at R7's Meal Card and took plate from his room. AD V returned with a different meal for R7. On 1/23/20 at 1:25 PM, during an interview, R7 indicated he sent the first plate back because it contained fish and he is allergic to fish. R7 stated he did not eat it, because he knows what would happen to him. R7 stated, I swell up when I eat fish. Then I have to go to hospital for a bunch of injections. On 1/23/20 at 1:49 PM, during an interview, DM D indicated that Cook O is supposed to look at cards before plating food, but he was rushed and they did not use Meal Cards this noon meal. DM D indicated that she did not use resident Meal Cards at noon meal, because she just knows what they can have and can't have. DM D indicated that DA T would not know the residents' allergies, diets, and preferences by memory and he should have had access to resident Meal Cards, while he was passing out salads to residents. DM D indicated that Volunteer Q, who passed beverages in the main dining room, does not know residents' preferences, diets, and allergies by memory and should have access to the resident Meal Cards when passing drinks out. DM D indicated this practice of not using Meal Cards is dangerous. On 1/23/20 at 4:20 PM, during an interview, CNA U indicated that she was unaware R7 was allergic to fish or that it was on the menu for that day. CNA U also indicated she did not remove the cover off of R7's meal before exiting the room. On 1/23/20 at 4:25 PM, during an interview, AD V indicated R7 was calling from his room and she went in. AD V indicated R7 told her he was allergic to fish, she looked at his Meal Card that was with meal, and looked at the plate and saw fish. Then AD V took the plate to kitchen and brought him a new one without fish. On 1/23/20 at 6:18 PM, during an interview, R7 indicated he was thankful he looked before biting into the sandwich he was given, because it would have been an emergency situation. R7 stated he swells way up when he eats fish and then has to go to the hospital for injections. On 1/28/20 at 3:00 PM, during a phone interview, DON B indicated there were 10 residents residing in the home with food allergies and out of those 10, 2 of them were cognitively impaired. The facility's failure to provide food that accommodated R7's fish allergy created a finding of Immediate Jeopardy. The Food Allergy Research and Education (FARE) notes, in part: Finned fish can cause severe and potentially life threatening allergic reactions (such as [MEDICATION NAME]). Allergic reactions can be unpredictable, and even very small amounts of fish can cause one. https://www.foodallergy.org/common-allergens/fish-allergy The facility removed the jeopardy, on 1/23/20, when it had initiated and/or completed the following: 1. The Dietary Manager will audit the electronic dietary Kardex (CNA care plan) and put watermark allergy across the ticket for each resident who has a known dietary allergies. 2. Allergies will be called out to plater before plate is dished, effective with supper meal and ongoing. 3. Dietician and Dietary Manager will educate staff on the importance of reading the information on the tickets and assembling the meal accurately to the ticket. 4. Dietician and Dietary Manager will educate new staff on the importance of reading the information on the tickets and assembling the meal accurately to the ticket. 5. All trays will be checked by a person other than the person assembling the tray prior to the trays leaving the kitchen. 6. The Dietary Manager will audit 10 percent of trays for 1 breakfast, 1 lunch, and 1 supper meal per week for three months and report results to Quality Assurance Performance Improvement committee. If 100 percent accurate, then will discontinue audit. 7. Nursing will include asking about known food allergies in admission assessments. 8. The dietician will audit the medical record for food allergies and match to electronic dietary Kardex monthly for three months. 9. For residents eating in the dining room, meal tickets will be placed at the table, order written on ticket, ticket used for plating, and left at table when meal is served.

Based on interview, and record review, the facility failed to prevent abuse or the likelihood of abuse for 1 of 6 residents (R2) reviewed for abuse out of a total sample of 13. R2 was touched by R3 in her vaginal area without her consent. R3 had begun showing signs of inappropriate behaviors with staff in the preceding four days. No one assessed the risk that R3 might pose to residents and R3's care plan was not updated until 1/20/20, three days after the incident. R2 was trembling and hysterical after the incident and feels uncomfortable now when she sees R3. This is evidenced by: Facility Policy entitled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, revised (MONTH) (YEAR), states, in part: .The Center prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc. The Center has designed and implemented processes, which strive to ensure the prevention and reporting of resident abuse, neglect, mistreatment, and/or misappropriation of property.Definitions: The Center acknowledges the following definitions: .Willful - Willful means the individual intended the action itself that they knew or should have known could cause physical harm, pain or mental anguish. Even though a resident may have cognitive impairment, they still could commit a willful act. However, there are instances when a resident's willful intent cannot be determined. In those cases, a resident-to-resident altercation should be reviewed . Abuse willful infliction of injury, unreasonable confinement, intimidation resulting in physical harm or pain or mental anguish, punishment with resulting physical harm or pain or mental anguish.The following definitions are not intended as all-inclusive but has examples to assist in the immediate identification and reporting of abuse and/or neglect . Sexual Abuse includes, but is not limited to, humiliation, harassment, coercion or assault . Per CMS (Centers of Medicare and Medicaid), Sexual abuse is defined at §483.5 as non-consensual sexual contact of any type with a resident. R2 is a [AGE] year old female, admitted on [DATE], with [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set), dated 10/26/19, indicates that R2 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating R2 is cognitively intact. R2 is able to ambulate independently. R3 is an [AGE] year old male admitted , on 12/2/2019, with [DIAGNOSES REDACTED]. R3's MDS, dated [DATE], indicates that R3 has a BIMS of an 11 out of 15, indicating moderate cognitive impairment and that R3 requires 2 person physical assist with transfers. R3's Stop & Watch Early Warning Tool, dated 12/30/19 at 9:00 AM, signed by TD F (Therapy Director) indicates the following: Seems different than usual, sexually inappropriate with all 3 therapy staff. This is not normal behavior with therapy staff and all 3 reported at different times. Form indicates this was reported to ADON C (Assistant Director of Nursing). On 12/30/19 at 11:23 AM, R3's Occupational Therapy (OT) Note, states, in part: .Today pt (patient) was making inappropriate comments about therapists breasts and what he wanted to do with them. Pt needed max (maximum) redirection to task . On 12/30/19 at 4:57 PM, R3's Speech Language Pathologist (SLP) Note states, in part: .Unfortunately pt was making sexual comments to Writer. SLP informed pt that he needs to speak to his caregivers like he would talk to his sister or his mother (attempting to convey the concept of non-sexual topics). Pt continued to make comments that were disrespectful and after a second re-direction and he still continued, SLP had to end session early because of behaviors. SLP discussed this with therapy team including DOR (Director of Rehab) . On 12/30/19, (no time), TD F's written statement regarding R3 states: Resident making sexually inappropriate comments to all 3 therapy staff members (PT (Physical Therapist)/OT (Occupational Therapist)/ST (Speech Therapist)). This is not reported as normal behavior. ADON (Assistant Director of Nursing) (ADON C's name) notified in AM at morning meeting. Nurse notified and report that no report from CNA (Certified Nursing Assistant) staff at this time. This Writer concerned of medical change to be causing this. Nurse to follow up. Social Worker (SW K) notified of the behaviors and will follow up with resident. Stop & Watch form filled out and provided to ADON. R3's Nurses Note, dated 12/30/19 at 8:00 PM, indicates no inappropriate comments. (No further Nursing Notes indicated for monitoring R3 for inappropriate comments) R3's Incident Report, dated 1/17/20 at 6:28 PM, filled out by LPN J (Licensed Practical Nurse), states, in part: .This nurse was notified that a resident reported that (R3) had touched her in an inappropriate way while she was sitting in the dining room. This nurse was at the nursing station when the incident took place. Resident was removed from dining room immediately.When this nurse asked resident what happened in the dining room, his response was I heard that it was snowing outside so I wheeled to the dining room to look out of the window. This nurse asked resident if he did anything that he should not have done while in the dining room. Resident response was What are you talking about? this nurse replied with Did you touch any one while you were in the dining room? Resident replied No, I didn't do anything. This nurse then replied with Another resident is saying that she was touched in an inappropriate way by you. The resident replied No, I wouldn't touch anyone, I said Hi to a few people and that was it. Residents separated immediately. Resident placed one on one. Police were called . (Please note that R3 refused to sign a Witness Investigation Statement, on 1/17/20 at 4:00 PM, which says verbatim what R3's Incident Report says.) R2's Incident Report, dated 1/17/20 at 6:29 PM, filled out by LPN I, states, in part: Resident approached nurse in the hall at med cart crying and shaking repeating That man touched me. Writer asked what happened. Who touched her and was she hurt? Resident said she was unsure who the old man was. She took Writer to the MDR (main dining room) to point the resident out she was talking about.Resident stated while in the MDR playing games on her phone the resident in question put his hand on her leg, her legs where (SIC) crossed, then put his hand between her legs. States when she said No! he wheeled away in his wheelchair. States she came to get Writer immediately. Immediate action taken: .Writer immediately took resident out of the MDR and to the nursing station where she called ADON. Writer called 911 to report incident and request an officer come to facility. Skin check done, no physical marks noted. DON (Director of Nursing) notified along with (Physician Name) whom was on call for (Physician Name). Resident did not want Writer to contact any family regarding matter. When resident came to nursing station following resident, Writer escorted him to the other side of the building. Resident was placed on 1-1 (one-on-one) supervision . On 1/17/20, R2's Witness Investigation Statement, signed by R2, states: I was sitting at my table on my phone, the man put his hand on my lap. My legs were closed but he put his hand further to my crotch. I, said no he then wheeled away. I then went and got my nurse (LPN I) right away. On 1/17/20, LPN I's Witness Investigation Statement, signed by LPN I on 1/17/20, states: Resident came to med cart where I was doing med pass down the hall crying. Resident stated a man touched her while in the dining room. I asked her who, she took me to the MDR to point him out. Writer took resident to nursing station, called ADON for instructions. 911 called to report incident and request officers to come. Resident (R3) came to nursing station where Resident (R2) was. Writer took him immediately to other side of building. Resident placed on 1-1 supervision. (Physician Name) on call for (Physician Name) notified. DON updated, RN (Registered Nurse) supervisor starting reportable, awaiting police arrival. On 1/17/20, R3's Nurses Notes, dated 1/17/20 (no time), states: Another resident stated that resident touched her in an inappropriate manner while she was in the dining room at 1545 (3:45 PM). Residents were separated immediately and this resident (R3) was immediately placed (with) one on one supervision. Police were called. This nurse questioned resident about incident & resident stated that he did not know what this nurse was talking about & stated that he went to the MDR to see the snow. He became angry as this nurse questioned him & denied touching another resident. Police arrived & questioned both residents. Investigation will continue. Resident has continued on one on one since incident. DON notified. MD (Medical Doctor) notified. Resident's son notified with permission of resident. Incident report completed staff to continue to monitor. (Signed by LPN J) On 1/17/20 at 4:40 PM, R2's Nurses Note states, in part: Resident reported another resident touched her inappropriately while in the MDR states resident placed hand on legs then between legs at her vagina. Resident told him No then he wheeled away. Writer called ADON to report, 911 called officer to come. (Physician Name) on call notified. Skin check done no concerns. Resident with Writer for comfort. Other resident placed on 1-1 supervision. Resident does not want any family called at this time awaiting police arrival. On 1/17/20 at 6:20 PM, R2's Nurses Note states: (City name) police arrived at facility. Officer questioning resident, Resident refused to have Writer present stated, I'm ok to do this. (Please note there is no further documentation or Nurses Notes indicating staff are monitoring or following up with R2 after the incident on 1/17/20.) R3's Individual Care Plan Conference form, dated 1/20/20, indicates R3's son, SW, DON and ADON met indicating that R3 has had a significant change and R3's son has never seen R3 have this type of behavior, although he has been different since his stroke. R3's Mood and Behavior Symptom Assessment Care Plan, dated 1/20/20, indicates resident touched another resident's vagina, Goal: resident will not repeat this behavior, will exhibit social appropriate behaviors; Goal Date: 4/20/20; Interventions: 1:1 while awake and 15 minute checks while sleeping. (Please note R3's care plan was updated 3 days after the incident and there are no other interventions, goals or assessments indicated for R3 on this Mood/Behavior Care Plan.) On 1/23/20, Surveyor received a copy of facility's time line of events for R2 and R3's incident on 1/17/20, which is as follows: 1/17/20 (no time) - incident reported by (R2) to (LPN I) that a male resident touched her inappropriately. While she was talking to (LPN I) R2 said resident had started following her to the door. (LPN I) sent the resident to his room. Male resident was immediately put on a 1:1 watch for safety. (R2) was notified that male resident is now on 1:1 watch and she is to notify staff if she feels uncomfortable at any time. She was asked if she wanted staff to inform her family. She stated she would call her dad. Immediately the following people were notified of the incident: State, DON, ADON, Social Services Director (SSD), Administrator and Physician notified. Male resident's son was notified of the incident. 1/18/2020 to current date - (no time) Male resident kept on 1:1 with staff. No problems or negative interactions with any residents or staff. 1/20/2020 - (no time) continued investigation. Care plan with SSD, DON and son of male resident. Explained the situation. He has never seen this behavior before. He has noticed differences in his dad's behavior since his stroke. It was decided that an alternative placement would be sought for his dad that will be able to better handle his needs. 1/21/2020 - (no time) DON and SSD met with (R2) to discuss that it was reported that a female resident asked her to point out the resident that this occurred with the previous day after dinner. (sic) She said she did not see him. The male resident was sitting across the room, (R2) has poor distance eye site. (R2) admitted to us (DON and SSD) that it made her very uncomfortable to be asked by the female resident in front of everyone. The DON and I walked (R2) into the dining room. As soon as she looked in the door, she pointed out the male resident. It was the one she had identified when it happened. It was again explained to (R2) that the male resident is 1:1 with a staff member. She said she felt safe. (R2) maintained her usual activities of going to [MEDICAL TREATMENT], eating in the dining room and attending facility activities that interest her. 1/22/2020 -(no time) Administrator and SSD met with the male resident (R3). He stated he doesn't remember doing anything wrong, but he is very sorry this is happening. We explained that while his actions may be related to his stroke, we need to ensure the safety of all residents. His son had previously explained we would be looking at alternate placement, but we reiterated this. We also stated he would be 1:1 supervision until he can be moved to another placement. He stated he understood. (Please note the facility time line provided to Surveyor, on 1/23/20, has no signature and does not indicate who wrote the timeline.) On 1/23/20 at 11:10AM, Surveyor interviewed LPN I regarding R2 and R3's incident on 1/17/20. LPN I indicated R2 was sitting in the dining room, playing on her phone at a table, in the back of the dining room. LPN I indicated that she was going in and out of the dining room passing medications when R2 came out of the dining room Hysterical, and couldn't get her breath. LPN I indicated that R2 kept saying the old man touched me. LPN I indicated that R2 was yelling and upset at this time. LPN I indicated that she didn't know what R2 meant for sure so she had her take a seat to catch her breath. LPN I indicated that R2 said to her, I have [MEDICAL CONDITION], a man touched me, I don't know him and I haven't seen him before. LPN I indicated that R2 pointed to R3. LPN I indicated that R2 couldn't get her breath and that R2 was Terrified. LPN I indicated that they got her safe by having her sit with LPN I as she called the DON. LPN I indicated that once R2 said he (R3) touched her, she didn't ask any more questions due to wanting to call the police and management right away and wanted R2 to feel safe. LPN I indicated that when R3 came out of the dining room he came to the nurses station on the side that R2 resides on and glared at R2. LPN I indicated that she told R3 not to come back to this side and wheeled him to the other side. LPN I indicated that she has never seen R3, not even one time at the nurses' station. LPN I indicated that R3 was looking right at R2 and R3 had no reason to be on that side, as activities were going on in the dining room. LPN I indicated that she is unaware of any other incidents occurring with R3. LPN I indicated that LPN J was told of the incident, who was R3's nurse at the time. LPN I indicated that LPN J pulled a person for one-on-one with R3. LPN I indicated she is unable to say if it did or did not happen. LPN I indicated she had to call the police twice, once they arrived she went with R2 and the male police officer to the lounge to ensure R2 was okay. LPN I indicated that R2 has anxiety and, during the incident, R2 could barely speak which is very unlike her. LPN I believes something happened. LPN I has never taken care of R3, has only seen him in a wheelchair. LPN I indicated that R2 walks with a walker and is unsteady and that R2 has vision and hearing impairments. On 1/23/20 at 11:36 AM, Surveyor interviewed LPN J regarding the incident. LPN J indicated that around approximately 4 PM, LPN J had been down the hall passing medications. LPN J indicated that a nurse had told her the incident already occurred and that they already removed him (R3) and had him on 1:1. LPN J indicated that LPN I told her that R2 said R3 touched her knee and moved his hand up and R2 said top twice and he left, and then the police had been called. Calls were placed to the physicians, DON and RN L put him on 1:1 at all times. LPN J indicated that R3 is not aware of the incident and that he gets confused at times and R3's stories don't match. LPN J indicated she asked R3 what happened in the dining room and that R3 told her he was going to the dining room to see if it's snowing and someone wheeled him back. LPN J indicated that R3 told the police he was in the dining room for dinner and was drinking coffee when it wasn't dinner time. LPN J indicated that R3 is not inappropriate with staff and that all he usually asks is if staff is married and gives staff looks, but has not touched any staff, to her knowledge. LPN J indicated R3 is not verbally inappropriate to staff to her knowledge, R3 just asks staff if they are married. LPN J indicated that she knows that R2 feels uncomfortable now. LPN J indicated she is unsure what staff is doing for R2, as she has not been her nurse. LPN J indicated that R3 is on 1:1's. On 1/23/20 at 12:00 PM, Surveyor interviewed TD F regarding R3. TD F indicated she has not seen inappropriate behaviors, but her staff have verbalized it and reported it to TD F that R3 had been verbally inappropriate to her staff. TD F indicated to talk to OT G and PT H for more information. On 1/23/20 at 12:01 PM, Surveyor interviewed LPN M regarding R3. LPN M indicated R3 is not inappropriate with her, as he knows she's his nurse. LPN M indicated R3 has been inappropriate with a CNA and it's been reported to the supervisor. LPN M indicated that Surveyor should talk with CNA E. LPN M indicated she is unsure when it was reported to the supervisor, but it was reported. LPN M indicated staff are to be arm's length from R3 and to let their nurse know if R3 is inappropriate with them. LPN M indicated she is only aware of the one incident with R2 that occurred, and has no knowledge of any other incidents with residents. On 1/23/20 at 1:00 PM, Surveyor interviewed LPN M regarding her previous statement. LPN M, at this time, indicated she did not know anything about the situation with CNA [NAME] until last week. LPN M indicated she heard through the grapevine CNA [NAME] had reported it to her (LPN M), and that management already knew, so she (LPN M) didn't report it. LPN M indicated CNA [NAME] never reported R3's behaviors to her. LPN M indicated to Surveyor she just spoke to DON B regarding this. On 1/23/20 at 12:10 PM, Surveyor interviewed RN L regarding the incident between R3 and R2. RN L indicated that LPN I came to her saying that R2 was crying and R3 was placed on 1:1. RN L indicated she got statements from interviewable residents. RN L indicated R2 was upset and normally is not upset. RN L indicated she updated both MDs, DON, NHA and families were notified. RN L indicated R3 is 1:1 which makes R2 feel safe and R2 is seeing the in-house psychiatrist. RN L indicated she is not aware of any staff inappropriateness or other resident incidents. On 1/23/20 at 12:15 PM, Surveyor interviewed OT G and PT H regarding R3. OT G indicated R3 was verbally inappropriate with her by asking if he can touch or play with her breasts. OT G indicated she would redirect him and then he would re-ask if he could play with OT G's breasts. PT H indicated that she witnessed R3 saying this to OT [NAME] OT G indicated she completed therapy with R3 and would try to redirect him and reported R3's verbal inappropriateness and that R3 did not try to physically touch her. OT G and PT H indicated they have both heard of other incidents, but have not witnessed R3 being inappropriate with others besides OT [NAME] OT G indicated she didn't think he would physically touch anyone, as it wasn't normal for R3 and that it was a one time thing that occurred with therapy approximately a month ago and did not have any real warning signs, it just happened. On 1/23/20 at 12:25 PM, Surveyor interviewed CNA [NAME] regarding R3. CNA [NAME] indicated R3 is usually pretty good, but kind of grumpy and uncooperative. CNA [NAME] indicated Approximately three weeks ago on a Thursday she was assisting R3 with his cares. CNA [NAME] indicated R3 was in the bathroom getting washed up and he had put his head on CNA E's breasts. CNA [NAME] indicated she told R3 he can't be doing that and then he tried to touch CNA E's breasts multiple times. CNA [NAME] indicated while she was washing R3's back, R3 grabbed CNA E's private area (vaginal area). CNA [NAME] indicated she told R3 it was inappropriate and not allowed and R3 replied, Oh, you know you like that. CNA [NAME] indicated she told R3 he can't be doing that. CNA [NAME] indicated R3 apologized to her and hasn't tried anything since then. CNA [NAME] indicated she is unaware of any other incidents with staff, but did hear about the situation with R2. CNA [NAME] indicated she reported his inappropriateness with her to the nurse on duty, LPN M. CNA [NAME] indicated R3 has been 1:1 since the incident with R2 and that 2 staff are required with cares since the incident with R2. CNA [NAME] indicated the DON, SW and ADON met with her regarding what happened. CNA [NAME] indicated R3 had no behaviors leading up to the incident and she had gotten R3 up today (1/23/20) without any incident. (Please note that this would make an additional incident of inappropriateness for R3 involving staff since 12/30/19, prior to the 1/17/20 incident.) On 1/23/20 at 12:50 PM, DON B indicated to Surveyor that she found out about CNA [NAME] yesterday. On 1/23/20 at 12:55 PM, Surveyor interviewed CNA [NAME] regarding R3. CNA [NAME] indicated she told LPN M the day it happened and the DON was told last week and had talked to her, she thinks on Monday (1/20/20).CNA [NAME] again indicated she can't remember the exact date, but it was about three weeks ago, on a Thursday, that the incident with R3 and herself occurred. On 1/23/20 at 1:30 PM, Surveyor interviewed TD F regarding the therapy incident with R3. TD F indicated she reported it in morning meeting and only had one incident at that time, but by the end of that day, I had all three reports. TD F indicated she gave a Stop & Watch Tool to the ADON on 12/30/19. TD F indicated she also approached the SW and the nurse on the hall at that time (unable to say who it was) to report R3 being sexually inappropriate verbally. TD F indicated that the nurse was to follow up and that nursing was taking care of it. TD F indicated they monitored for it a couple days in therapy and nothing else was reported. TD F indicated she reprinted therapy notes and the Stop & Watch Tool on the day the incident with R2 occurred. On 1/23/20 at 1:40 PM, Surveyor interviewed ADON C regarding the therapy incident, between R2 and R3. ADON C indicated she is aware that therapy brought up R3 being verbally sexual to one of the therapists and filled out a Stop & Watch form. ADON C thought R3 was sick and asked nurse if medical issues or any verbally inappropriate behaviors and nothing was indicated. ADON C indicated there was nothing else to her knowledge reported for inappropriate behaviors with R3. ADON C indicated she was aware of the incident with CNA E, after the incident between R3 and R2 occurred. ADON C indicated CNA [NAME] and LPN M both knew about the incident regarding CNA [NAME] being inappropriately touched, approximately a month ago. ADON C indicated CNA [NAME] told her she told the nurse, but didn't make a big deal out of it. ADON C indicated she told CNA [NAME] that they need to know about it. ADON C indicated CNA [NAME] should have told administration right away. ADON C thinks that CNA [NAME] probably did tell LPN M, but LPN M didn't report it to management. ADON C indicated no knowledge of any further inappropriate incidents since the incident between R3 and R2. ADON C indicated R2 see's a psychiatrist and had been, even prior to the incident with R3. ADON C indicated CNA [NAME] and LPN M have not had 1:1 coaching/education yet, but education has been started with staff related to reporting inappropriate touches. ADON C indicated R2 has [DIAGNOSES REDACTED]. ADON C indicated she noticed R2 had a [DIAGNOSES REDACTED]. On 1/23/20 at 2:10 PM, Surveyor interviewed SW K regarding the incident. SW K indicated that on Friday (17th) she got a call that R3 had an incident with R2; that R3 had put his hand on her and moved it towards her vagina at approximately 4 or 5 PM and that R3 was put on 1:1. SW K indicated R2 went to LPN I and reported it. SW K indicated R2 is able to walk with a walker and R3 uses a wheelchair. SW K indicated R2 was able to identify R3 right away. SW K indicated this was not the first inappropriate behavior incident. SW K indicated, a few weeks ago, TD F mentioned that on one day, R3 made inappropriate comments to staff, it was out of nowhere. Surveyor asked SW K about the Stop and Watch Tool written on 12/30/19, from therapy. SW K indicated they did not receive anything until yesterday (1/22/20) or the day before (1/21/20). SW K indicated that no further incidents were reported other than 3 therapy staff in one day. SW K agreed R3's care plan was not updated until 1/20/20. SW K is unable to tell Surveyor about R2's [MEDICAL CONDITION]. SW K indicated she did not know about R2's [MEDICAL CONDITION] other than she was told R2 was assaulted prior to coming to the facility and it did not happen here. SW K indicated she did not do R2's Mood/Behavior Care Plan. SW K indicated R2 saw the psychologist this week on Monday (1/20/20). SW K indicated staff have not changed or updated R2's care plan yet. On 1/23/20 at 2:20 PM, Surveyor interviewed DON B regarding the incident. DON B indicated she just saw the Stop and Watch Tool, from 12/30/19, the other day. DON B indicated the other day may have been yesterday (1/22/20). DON B indicated it had been put on the ADON C's desk. DON B indicated that she explained to TD F that a Stop and Watch Tool is to be brought to the staff's attention and not left on a desk. DON B indicated that R3's care plan should have been updated, after the therapy incident, to have cares in pairs. DON B indicated staff should have known about the therapy incident in order to keep an eye on R3. DON B then indicated that all R3 does is go to the dining room and then back to his room. (Please note that it's indicated that the incident with R3 having verbal inappropriateness with therapy staff was reported in the morning meeting and a Stop and Watch Tool was filled out on 12/30/19.) On 1/23/20 at 3:00 PM, NHA A indicated to Surveyor that the facility did not know about the other events until this week (1/20 - 1/23/20). (Please note that therapy staff and CNA's are indicating that management was told prior to this week (1/20/20 - 1/23/20).) On 1/23/20 at 3:15 PM, Surveyor interviewed R2 regarding the incident. R2 indicated his name is (R3's name). R2 indicated that R3 was talking to her, then he put his hand in her lap and proceeded to touch R2's vagina. R2 indicated she pushed his hand away and came out to (LPN I) right away. R2 indicated she has [MEDICAL CONDITION] and stated, When I was 19, I was raped, when Surveyor inquired about R2's [MEDICAL CONDITION] diagnosis. R2 indicated she felt more shocked, was shaky and started to cry because it sent her back to the incident when she was 19. R2 indicated the touching was most uncomfortable for her. R2 indicated she feels uncomfortable when she sees R3. R2 indicated she mostly feels safe only when she knows someone is with R3. R2 indicated she doesn't see well and that she usually doesn't see him. R2 stated to Surveyor, Someone told me a CNA was touched also, so it's not his first time. R2's Mood/Behavior Care Plan and CNA Care Plan, on 1/23/20, have no indication of being updated since the incident with R3 on 1/17/20. R3's CNA Care Plan, on 1/23/20, indicates one-on-one supervision and 15 minute checks while sleeping. No further interventions indicated to CNA's. On 1/23/20 at 5:10 PM, Surveyor requested Social Worker documentation for R2 regarding follow up from the incident with R3. SW K, at this time, indicated she has not documented in R2's chart, as all her follow up notes are currently on sticky notes. On 1/23/20 at 5:30 PM, Surveyor received notes from SW K for R2. SW K's notes state, in part: 1-20-2020 (no time) met privately with (R2) RE: (regarding) discussed how she was doing. If she needed any extra support. Discussed her seeing (Psychiatry Doctors Name) today. She agreed and signed release. Restated that the male resident is under 1:1 supervision. 1-21-2020 (no time) (DON B's name) and I met with (R2) discussed with incident in dining room where another female resident asked her to identify the male resident across the room. (R2) was unable to identify him at that time. (DON B) and I walked (R2) to the dining room. She immediately identified the male resident. (R2) stated it made her very uncomfortable to be asked to identify R3, by the female resident, in front of every one. I told her I would speak to the female resident. Again reassured (R2) that the male resident was on a 1:1. (R2) stated she felt safe. 1-22-2020 (no time) checked in with (R2) to see how she was doing. No concerns. She is attending meals and activities per her usual routine. 1-23-2020 (no time) Checked with (R2). She was tired from [MEDICAL TREATMENT]. I walked her to the dining room, no concerns. (Please note that none of these entries have times or indicated as late entries, which were written on 1/23/20, after Surveyor requested SW's documentation for R2.)

Based on observation, interview and record review in 1 of 1 outbreaks reviewed, the facility did not immediately implement aggressive infection control measures to prevent the spread of a gastroenteritis illness, which affected all 6 resident units in the facility and had the potential to affect all 94 residents. Specifically, the facility failed to: *Immediately quarantine affected residents / units *Maintain an accurate up to date line listing for both residents and staff *Exclude non - essential staff from entering affected units and rooms. *Discontinue floating staff from affected units to non - affected units if possible *Place signage outside affected residents' rooms *Implement contact precautions upon entering affected rooms and when in contact with symptomatic resident or have PPE (Personal Protective Equipment) readily available for staff outside affected resident rooms *Initiate appropriate cleaning practices *Practice appropriate hand washing techniques to use during an outbreak. *Initiate temporary care plans for those residents affected. The failure of the facility to immediately implement aggressive and appropriate infection control measures to limit the transmission of this outbreak created a situation of Immediate Jeopardy that began on 3/6/17. The NHA (Nursing Home Administrator) was notified of the Immediate Jeopardy on 3/8/17 at 10:20 AM. The finding of Immediate Jeopardy was removed on 3/7/17, but the citation continues at a scope/severity level of F as the facility continues education to staff. This is evidenced by: On 3/6/17 Surveyor spoke with DON (Director of Nursing) B. DON B stated for purposes of outbreaks the facility utilizes Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long - Term Care Facilities from the Wisconsin Division of Public Health Bureau of Communicable Diseases 10/20/09. DON B stated the facility also follows the CDC guidelines for infection control. These recommendations state, in part: Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to LTCFs (Long Term Care Facilities) including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and / or staff develop new onset of vomiting and / or diarrhea within one or two days B. Management of Residents and Staff 1. Immediate isolation of the resident and restricting access to affected areas is essential. 2. Confine symptomatic residents to their rooms until 48 hours after symptoms cease. Symptomatic residents should be cohorted . 3. Exclude non - essential staff from entering room. 5. Discontinuing floating staff from the affected unit to non - affected units, if possible . 8. If the outbreak continues, facility staff in consultation with their medical director should consider closing the unit / neighborhood or facility to new admissions . B. Management of Residents . 3. Clean and disinfect all equipment including, but not limited to: blood pressure cuffs, stethoscopes, electronic thermometers and transfer lifts before using for another resident . 5. Ensure health care providers managing a symptomatic resident's medical care are aware of their illness to determine if any changes to medical management are warranted . 7. Limit new admissions until the incidence of new cases has reached zero for at least 48 hours. If any new admissions are being considered, consult with the infection control practitioner and the facility medical advisor first . C. Management of Staff 1. Staff assignments a. Maintain the same staff to resident assignments, if possible. b. Limit staff from moving between affected and unaffected units. 2. Implement contact precautions: a. Wear personal protective equipment to include gloves, and gown (mask and goggles or face shield if vomitus present) upon entry to the room and when in contact with the symptomatic resident. b. Remove gloves, goggles or face shield, gown, mask and then perform hand hygiene immediately after removing all personal protective equipment and before contact with an unaffected resident in the same room or when exiting the resident's room (CDC (Centers for Disease Control) 2004). ii. Alcohol hand gels may be used if gloves or hands have not been visibly soiled. Given the variability in reported effectiveness of alcohol - based hand sanitizers in inactivating various norovirus strains, the CDC generally recommends washing with soap and water as the preferred method of hand hygiene. Use of alcohol hand gels after washing with soap and water or in a situation when such facilities are unavailable, may be helpful in outbreak settings. D. Management of Ill Staff . 2. During an outbreak, staff should exclude themselves from resident care / and or food service duties at the onset of symptoms including nausea, vomiting, abdominal pain, and / or diarrhea. Such exclusion shall remain in effect until the employee is asymptomatic and free of symptoms for 48 hours 5. A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and when they returned to work . E. Management of Environment . 3. CDC recommends that chlorine bleach should be applied to hard, non - porous environmental surfaces at a minimum concentration of 1000ppm (parts per million) . Appendix 1 Disinfection and Preparation of Chlorine Solutions . Ineffective disinfectants: Quaternary compounds . This meets the Wisconsin PHD (Public Health Department) definition of an outbreak, which the facility uses as their standard of practice. The facility identified the outbreak on 3/1/17 and should have immediately implemented aggressive infection control measures to prevent the spread of this illness. Facility documentation indicates the first resident became ill on 2/27/17. Ultimately, 17 residents and 8 staff became ill with signs and symptoms a of gastroenteritis illness, two of whom were diagnosed with [REDACTED]. Based on symptoms [MEDICATION NAME] was assumed for the remaining residents affected. Per the facility's line list of 3/7/17, residents and staff became ill as follows: 2/27/17 Chapelway: Resident 23 ill with nausea (N), vomiting (V), diarrhea (D) diagnosed with [REDACTED]. 3/1/17 Pine: Resident 21 (D) Lamplighter: Resident 12 (D) 1 Staff 3/2/17 Chapelway: Resident 24 (D) diagnosed with [REDACTED]. Chapelway: Resident 25 (N, V, D) Birch: Resident 32 (V) (D) 3 Staff 3/3/17 Chapelway: Resident 16 (D) Birch: Resident 33 (N, D) Birch: Resident 35 (D) 1 Staff 3/4/17 Chapelway: Resident 26 (N, D) Chapelway: Resident 27 (Not indicated) Birch: Resident 34 (N, V) Birch: Resident 36 (V, D) Birch: Resident 37 (N, V, D) 3/5/17 Chapelway: Resident 5 (V, D) Chapelway: Resident 28 (D) 2 Staff 3/6/17 Pine/White: Resident 22 (D) Needle: Resident 29 (N, V, D) 1 Staff 3/7/17 Needle: Resident 44 (N, V, D) Needle: Resident 31 (N, V, D) 1 Staff On 3/6/17 at 8:50 AM, Surveyor spoke with Deputy Director of Nurses/RN (Deputy Dir Nurs/RN) F to go over the roster matrix. Deputy Dir Nurs/RN F stated the the facility currently has an outbreak of norovirus. Surveyor asked Deputy Dir Nurs/RN F what is the expectation for staff for personal protective equipment (PPE) when staff enter the room of a resident on isolation. Deputy Dir Nurs/RN F stated that staff are to wear a gown, gloves, mask, and booties. Deputy Dir Nurs/RN F stated that the facility ran out of isolation carts over the weekend due to the high number of ill residents. Surveyor requested a copy of the current line listings for Needlepoint (Needle) and Birchwood (Birch) prior to touring down these halls. Surveyor reviewed the line lists and the room of each person that was indicated on isolation. Surveyor noted the following: On 3/6/17 at 9:42 AM, Surveyor began the tour on the Birchwood and Needlepoint Units. Surveyor observed the following: Example 1 Resident 34 was on the line list with symptoms (N, V) onset of 3/4/17. There was no isolation cart/station, no sign to see the nurse and no indication of the type of transmission based precautions or the recommended personal protective equipment (PPE) that was needed to enter the room. There was no PPE readily available outside of this room. Example 2 The following rooms with an isolation cart/station, but no sign to see the nurse and no indication of the type of transmission based precautions or the recommended PPE that was needed to enter the room. Resident 35, Resident 33 Example 3 On 3/6/17 at 9:45 AM, Resident 33 indicated to Surveyor who was walking by in the hallway that she needed assistance. Surveyor notified Unit Clerk HH as there were no Certified Nursing Assistants in view. Unit Clerk HH entered R33's room without any PPE, exited the room without washing her hands and returned to the nurses station. Example 4 On 3/7/1/7 at 1:30 PM, Surveyor spoke with Registered Nurse (RN) W. Surveyor asked RN W what halls she is working on today. RN W stated I'm all over the building. Surveyor asked you're working down all the halls today? RN W stated, Yes. Example 5 On 3/6/17 at 1:29 PM Surveyor interviewed CNA C working on the Lamplighter hall. Surveyor asked her if she had worked any other days during the Norovirus outbreak. CNA C stated she had worked the previous Thursday and Friday (March 2 & 3). Surveyor asked what unit she worked on and if she had gone onto any of the other units. CNA C explained that she worked on this same hall but also delivered brief products onto every unit on Friday. She stated that she did remember a nurse who ran down the hall after her to inform her that a resident was on isolation prior to entering a room. At 2:50 PM Surveyor confirmed with CNA C that she did go on every hall and into every resident's room Friday to deliver brief products. On 3/7/17 at 1:18 PM Surveyor asked her how she would identify if a resident was on isolation precautions, she stated that if a sign would be on the resident's door to see the nurse or an isolation cart would be placed just outside the door. Surveyor asked how she would know what to wear, she stated she would ask the nurse. Surveyor asked CNA C when she was observed washing her hands, she stated she did not recall but it was within the past year. She did verify that no one facility staff had observed her hand washing since the outbreak had started. On 3/6/17 at 2:15 PM Surveyor interviewed Labor Resource Manager (LRM) K and Director of Nursing (DON) B regarding supplies distribution during the Norovirus outbreak. LRM K identified that CNA C distributes residents' brief products but did not know her procedure. DON B stated she would expect that CNA C use the proper PPE (personal protective equipment) when entering resident rooms that were diagnosed with [REDACTED]. DON B agreed that going onto all the units and into all resident rooms is not a good practice during the outbreak even when proper infection control processes are followed. DON B went through each days schedule during the outbreak to show they had kept CNAs working only on one unit as much as possible (they only floated to cover a hall that would not otherwise have a staff). On 3/7/17 at 1:40 PM Surveyor interviewed CNA D. She stated that she would identify if a resident was on isolation precautions by an isolation bin outside the door or a sign to see the nurse. She stated that she would ask the nurse what PPE she should wear before entering the resident's room. If a resident required a mechanical lift CNA D stated she would wipe it down everywhere the resident touches with the wipes with the purple (sani wipes that do not state they kill norovirus) or green lids (hydrogen peroxide that states it does kill norovirus with a 3 minute contact time.) Surveyor asked CNA D how she wiped the lifts down and she stated she just wiped them off. Surveyor asked if she left the wipes on and she said no. Surveyor took a green lid wipe and wiped the surface of a table so it was saturated. After 2:05 minutes the surface of the table was completely dry. Example 6 On 3/6/2017 and 3/7/2017, Surveyor observed room [ROOM NUMBER] had no signage noting the resident residing in the room was infected by norovirus. On 3/8/17 at 9:00 A.M., Deputy Director of Nurses/RN (Deputy Dir Nurs/RN) F said all residents infected with norovirus should have a sign on the room door to see nurse before entering. Example 7 On 3/6/17 at 1:40 P.M., Surveyor observed CNA O in a resident's room marked as infected with norovirus. CNA O wore mask and gloves. CNA O was removing soiled linens from a resident's bed. CNA O held the soiled linens against the front of her uniform as she placed the soiled linens in a plastic bag. On 3/6/17 at 1:45 P.M. Surveyor spoke with CNA O. CNA O said since she wasn't touching the resident, she didn't think she had to wear full PPE. Example 8 On 3/7/17 at 7:40 A.M., Surveyor observed Licensed Practical Nurse (LPN) Q exit a resident room that was marked as infected with norovirus. LPN Q was wearing gloves and removed the gloves over the medication cart and the medication administration record book and used hand sanitizer on her hands. Example 9 On 3/7/17 at 7:45 A.M., Surveyor observed LPN Q enter a resident's room marked as infected with norovirus. LPN Q wore gloves. As LPN Q did a blood sugar check with a glucometer, LPN Q's legs touched the bed linens of the resident infected with the norovirus. As LPN Q exited the room, she removed one glove. She held the glucometer in her gloved hand and used a sani wipe purple lid (sani wipes that state on the label they do not kill norovirus) to wipe the glucometer. She wrapped the sani wipe around the glucometer and placed it in a clean cup. LPN Q removed the glove, placed it in the trash container on the medication cart, and used hand sanitizer on her hands. On 3/7/17 at 8:00 A.M., Surveyor spoke with LPN Q. LPN Q said she does not wear full PPE in the infected resident rooms because she is not handling resident waste. LPN Q said she can use the hand sanitizer three times before she has to wash her hands. Example 10 On 3/7/2017 at 10:20 A.M., Surveyor observed CNA P walk into a residents room [ROOM NUMBER], marked as infected with norovirus. She wore no PPE. She touched the residents bed linens, brush, comb and items on the bedside table and walked out of the room. CNA P walked to the nursing station and returned with a styrofoam cup. She entered a residents room [ROOM NUMBER], marked as infected with norovirus and gave him the cup. CNA P walked from the resident room. CNA P walked into resident room [ROOM NUMBER], which was marked as infected with norovirus. She donned gloves and emptied a resident commode CNA P did not use hand sanitizer after she removed the gloves. CNA P did not wear PPE, wash her hands or use hand sanitizer after she entered and exited rooms [ROOM NUMBERS]. On 3/7/17 at 1:15 P.M., CNA P said that she did not like to wear PPE because she got too warm with it on. CNA P said you should wear full PPE if the disease is airborne. On 3/7/17 at 1:30 P.M., Surveyor observed CNA O dragging on the floor a plastic bag that had ISOLATION printed on the outside. She was not wearing PPE. CNA O dragged the plastic bag into room [ROOM NUMBER], which was marked as infected with norovirus. CNA O picked up the resident's disposable plate, cup and cutlery and touched the bedside table. She put the plate, cup and utensils in the plastic bag. CNA O dragged the bag to room [ROOM NUMBER] and removed the plate, cup and utensils and deposited them in the bag. CNA O then dragged the bag to room [ROOM NUMBER] and did the same. CNA O dragged the bag to the shower room and tied the bag closed. During this process CNA O did not wear PPE or wash her hands. On 3/7/2017 at 1:45 P.M., Surveyor spoke with CNA O. CNA O said she was just picking up the residents' plates and trash, and she did not wear PPE because she did not touch any body fluids. Example 11 On 3/6/2017 at 2:00PM, Surveyor observed Certified Nursing Assistant (CNA) S come out of R22 room holding clear garbage in her hand with no gloves on, as she told another staff member R22 was on isolation due to having diarrhea all day. CNA S took garbage bag across the hall into Pine Tree shower room, used hand sanitizer, and then proceeded up to nurse's station where she made contact with counter of nurse's station. CNA S then proceeded down Pine Tree into R41's room, which is not an isolation room; CNA S touched the door and curtain in R41's room before washing hands in R41's sink located in the middle of R41's room. Example 12 On 3/06/2017 at 2:15PM Surveyor interviewed CNA BB and CNA CC regarding isolation. Both CNA BB and CNA CC indicated they would know that someone is on isolation by a cart/bin outside the room and a see nurse sign. Neither CNA BB nor CNA CC was aware of residents being sick without signage or bins/carts outside the room. CNA BB indicated she helped on different halls ways after the outbreak started. CNA CC also indicated she too helped with transfers on other hallways since the outbreak had started. CNA BB indicated that she would use hand gel prior to leaving and that she does not do hand washing prior to leaving an isolation room. Both CNA BB and CNA CC questioned Surveyor what they should do and how they would wash their hands in an isolation room when the sink is half way in each resident's room. When Surveyor asked CNA BB and CNA CC what their policy says, neither answered. CNA BB indicated there is no longer a sink in the shower room to wash their hands and CNA CC indicated that they no longer have isolation bins within rooms to place garbage or clothing in. Example 13 On 3/07/2017 at 7:20AM, Surveyor observed Registered Nurse (RN) T take R9's blood sugar. RN T took residents blood sugar then placed the glucometer on the over bed table without a barrier, RN T used hand gel as leaving room and placed glucometer on top of medication cart, at 7:29AM RN T placed glucometer back into medication cart without cleaning it. On 3/07/2017 at 7:48 am RN T gathered glucometer and supplies to head into R41's room. Surveyor stopped RN T as she got to R41's room and interviewed RN T regarding glucometer cleaning at 7:51AM. RN T indicated that she used gel off the wall to clean just the front of the machine. RN T indicated gel is not an effective way to clean the glucometer but its better than nothing. RN T indicated the facility wants nurses to use Sani-wipes (purple lid wipes). When asked if glucometer should be cleaned between residents, RN T did not answer and began looking for disinfecting wipes, which she did not have on her medication cart. RN T went and got a container of purple wipes and cleaned glucometer in front of surveyor. Example 14 On 3/7/2017 at 2:45PM, Director of Rehab (DOR) Z provided Surveyor with a list of residents seen in their rooms and in the therapy gym for 3/6 & 3/7. The information provided by DOR Z indicates that R35, who is in bed A and on isolation precautions for norovirus since 3/3/17; shows her roommate R42, was taken out of the isolation room and seen in the therapy gym by Physical Therapy on 3/6/17 and in the gym by Occupational therapy on 3/7/17. R42 had been seen by Physical therapy in the isolation room on 3/7/17 and by occupation therapy in isolation room on 3/6/17. R31, who is in bed B, was placed on isolation precautions due to norovirus on 3/7/17. Per therapy provided information R31's roommate R44 was seen in the therapy gym room. R44 was seen by Physical therapy on 3/6/17 and 3/7/17 in isolation room. R44 was seen by occupational therapy on 3/6/17 and 3/7/17 in therapy gym. On 03/07/17 at 1:35PM surveyor interviewed Occupational Therapist (OTR) Y regarding isolation. OTR Y indicated she would know a resident is on isolation by having a cart outside room and seeing a see nurse sign. OTR Y indicated there was no master list for who was on isolation precautions. OTR Y indicated she would use purple container wipes and did not specify how long items needed to be cleaned for. On 3/7/17 at 1:40PM surveyor interviewed Physical Therapy Assistant (PTA) FF regarding isolation. PTA FF indicated she would know a resident is on isolation precautions by a cart in front of room and magnet saying see nurse. On 3/7/17 at 1:42PM surveyor interviewed Physical Therapist (PT) GG regarding isolation. PT GG indicated she would know a residents on isolation due to see nurse sign and carts. PT GG indicated she was not aware residents on isolation did not have a bin or signage outside room. Example 15 On 3/7/17 at 1:19PM, Surveyor observed and interviewed House Keeping (HSK) EE. Observed HSK EE step into R22's room without personal protective equipment to grab garbage out of room and place garbage bag into housekeeping cart with same gloves on that was used to grab garbage out of room and bring into hallway. HSK EE indicated she would know a resident is on isolation precaution by an isolation cart outside door, and that she was not aware of residents being sick with norovirus and not having a sign or bin outside rooms. On 3/7/17 at 1:25PM, Surveyor observed HSK EE with isolation gear on touching items on housekeeping cart such as her keys, broom handle, and top of cart and cleaning wipe container while standing in R22's doorway of room after being in room already cleaning. Example 16 On 3/6/17 at 10:15 am Surveyor observed R22's room to have an isolation bin outside room but no signage to alert staff or visitors to see nurse. R21's room had signage stating to stop and see nurse but did not have an isolation bin outside room. The facility did not maintain and implement an Infection Control Program designed to prevent the development and transmission of infection. The facility's line list indicates the following progression of the outbreak throughout the building The facility failed to recognize an outbreak and implement aggressive measures to prevent the spread of infection and failed to educate staff regarding proper infection control measures to prevent the spread of infection. Facility staff did not use proper disinfectant to decrease the spread of infection and did not ensure all residents with infections were monitored on the facility's surveillance logs. The facitly removed the immediate jeopardy on 3/7/17 when they implimented the following: * Educated nursing staff regarding handwashing * Educated staff regarding use of PPE* Educated staff regarding proper wipes to use to kill norovirus* Educated staff regarding proper cleaning techniques for glucometers * Educated Occupational Therapy to check with DON B daily regarding residents on isolation status. Educated OT to not take residents to therapy if roommate is on isolation* Educated staff to ensure isolation signs and bins are in place for residents on isolation * Handling of linen and proper cleaning of lifts * Monitored all residents for signs and symptoms of norovirus with a special focus on Chapel hall. * Changes to the caring partner system have been put in place to assist with monitoring and compliance.

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure injuries received the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries/recurring pressure injuries from developing for 1 of 7 residents reviewed for treatment and prevention of pressure injuries (Resident 6). R6 (Resident 6) was admitted to the facility with multiple pressure injuries and was identified to be at risk for development. R6 started using a new electric wheelchair in October 2016 and developed a stage 3 pressure injury to his right lower lateral leg within less than 1 week. Occupational Therapy-Registered (OTR) Y made a modification to the right legrest of R6's electric wheelchair with foam tubing that covered the metal bracket on the legrest for pressure relief. This pressure injury became infected, requiring a course of antibiotics. The pressure injury healed 2/1/17. The facility did not do the following: 1. On 3/1/17 R6 developed two (2) new avoidable facility acquired pressure injuries to the same area as the previous facility acquired pressure injury caused by R6's electric wheelchair in 10/2016. The first pressure injury identified was to R6's right lateral lower leg (upper) measuring 5.0 x 1.0 centimeters (cm) identified as unstageable. The second pressure injury identified was to R6's right lateral lower leg (lower) measuring 2.5 x 2.5 x 0.1 identified as a stage 2 pressure injury. Based on observation and interview these pressure injuries are both unstageable. Deputy Dir Nurse/RN F stated the wheelchair was digging into R6's leg but did not take action to offload the pressure from R6's right lower lateral leg and did not immediately contact OT to evaluate R6 for pressure relief. 2. Document R6's facility acquired coccyx pressure injury as a stage 3 on 3/2/17 when it presented with slough. On 3/2/17 during an office visit with a Physician Assistant she noted the wound with more slough noted. The facility continued to document this pressure injury as a Stage 2 through 3/7/17. The presence of slough indicates the pressure injury is a stage 3. 3. On 3/8/17 Surveyor observed the incorrect treatment done to R6's coccyx. The updated 3/2/17 order from Physician Assistant (PA) DD was not updated on the TAR. The treatment is to be changed daily, but was not changed 3/3/17, 3/5/17, and 3/7/17 per PA DD's orders. 4. Skin Checks Daily not completed for the following dates: 11/1-11/3, 11/14, 11/21, 11/30, 12/27, 12/31, 1/21, 1/22, 1/24, 1/26-1/31/16. Note daily skin checks were documented as done during the month of February and on 3/1/17 the facility identified two (2) pressure injuries on R6's right lateral lower leg (1 unstageable and 1 stage 3 as of 3/2/17 when R6 was seen by PA DD.) 5. Skin Check Weekly on Bath Day not completed for the following dates: 12/27/16, 1/24/17, 1/31/17 6. On 3/7/17 R6 stated to Surveyor that he was not repositioned at all during night (Night shift 3/6 into 3/7). This is evidenced by: The facility policy entitled Wound Prevention and Treatment dated 7/2015 states as follows: The center strives to ensure that a resident entering the center without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates unavoidable skin breakdown. The center will consider all residents as at risk for skin impairment and will implement the following interventions to prevent the development of pressure ulcers: Reduce occurrence of pressure over bony prominence to minimize injury. Protect against the adverse effects of external mechanical forces (pressure, friction, shear). Increase the awareness of pressure ulcer prevention through educational programs. Staging of pressure injuries The following pressure injury staging system is consistent with the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP) . Pressure ulcers are staged using the system below:*Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . Note: The center acknowledges NPUAP, Wound, Ostomy and Continence Nurse (WOCN) recommendations; However, The center will comply with Medicare and Medicaid documentation requirements. Wound Prevention and Treatment Progression of wound healing will be documented by length, width and depth measurements. Nursing will remove the dressing, evaluate and document the condition of the wound. R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's Braden assessments on 10/10/16, 12/5/16 indicate a score of 17 which indicates R6 is at risk for pressure injury development. R6's Braden assessment on 3/1/17 indicates a score of 15 indicating R6 is at risk for pressure injury development. The facility's Braden risk score indications are as follows: At Risk: 15-18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. R6's annual Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) was completed with R6 scoring a 15 indicating he is cognitively intact. Section M0150 the MDS indicates R6 is at risk for developing pressure injuries. Section G0110, Activities of Daily Living (ADL's) indicates R6 requires 2 staff and extensive assist for bed mobility and requires 2 staff and is totally dependent for transfers. Care Area Assessment (CAA) worksheet states, He has a h/o (history of) chronic pressure injuries and current pressure injuries. Pressure reducing mattress and cushion. Staff assure that he is routinely changing position and assist appropriately and timely. See ongoing pink skin sheets. See TAR (Treatment Administration Record) for current treatments. See nutritional notes and CAA for information on their aspect for wound healing. R6's comprehensive care plan for Skin Integrity Assessment Prevention and Treatment Care Plan indicates the following areas of impairment: Right lateral lower leg: Facility acquired 10/10/16, Stage 2 (Note pressure injury was stage 3) Right lower leg lateral (upper wound): Facility acquired 3/1/17 - Stage 2 (Note pressure injury is unstageable) Right lower leg lateral (lower wound): Facility acquired 3/1/17 - Stage 2 (Note pressure injury is unstageable Coccyx: Facility acquired 12/12/16 - Stage 2 (Note pressure injury is a Stage 3). Goals: Will demonstrate healing without s/x (signs or symptoms) of infection, Will verbalize understanding re: Refusal of Care outcome, Will be cooperative with position changes, Will be free of pain. Intervention: Turn and reposition every 2 hours and PRN (as needed), Increased turning and repositioning r/t (related to) new pressure area 12/12/16, MA85 (mattress) ordered, encourage resident to stay out of wheelchair as much as possible to relieve pressure to coccyx, wound vac as ordered, Roho cushion in chair, encourage ambulation and mobility as tolerated ([MEDICAL CONDITION] - R6 does not ambulate), position body with pillows and/or other support devices. On 10/3/16 and 10/4/16 OTR Y evaluated R6 for safety of his new electric wheelchair and R6 began using the chair on 10/3/16. OTR Y note dated 10/4/16 states: OTR educated him on using power wc (wheelchair) only in facility and on grounds at this time. On 10/9/16 the facility noted via fax to the MD as follows: R6 has a 1.5 x 1.2cm open area on his right lateral aspect of lower leg. Area was obtain from wheelchair foot pedal pressure. Therapy to assess w/c for padding to prevent. Treatment request Allevyn q3d and PRN cleanse with NS. On 10/9/16 the facilty wrote a Nursing-Therapy Communication for: W/C Positioning foot rest padding pressure area from it. On 10/10/16 OTR Y indicated on caseload for therapy to address. R6's Telephone Order signed by the MD dated 10/10/16: Apply Allevyn to right lateral aspect of lower leg q3d and PRN after normal saline cleanse. On 10/12/16 OT note signed by OTR Y on 10/17/16 indicates evaluation for resident's function/posture and indicates the presence of a roho leg support. On 10/20/16 the facility noted via fax to MD Res has wound to R lower lateral leg filled with slough (note this indicates the pressure injury is a stage 3, not a stage 2), draining purulent tan drainage. Currently has Allevyn to wound q3d can we change order to apply [MEDICATION NAME] to slough, cover wound bed with calcium alginate, cover with [MEDICATION NAME] and wrap with kerlix change daily. *Periwound is red and swollen, concerned about infection. MD replied, Yes and indicated an order to start Keflex 500 mg TID x 7d. R6's Telephone Order signed by the MD dated 10/24/16: Apply [MEDICATION NAME] to slough, clover wound bed with calcium alginate cover with [MEDICATION NAME] and wrap with kerlix daily (PM). Keflex 500mg PO TID x 7 days. On 11/24/16 OTR Y documented a Treatment Encounter that states: Modification to wc right legrest to apply additional reinforcement to foram tubing that covers metal bracket on legrest for pressure relief. On 2/1/17 the facility documents this pressure injury to R6's right lower lateral leg as healed. On 3/1/17 the facility identified two (2) new pressure injuries to R6's right lateral lower leg, the same area as his prior pressure injury that was just healed on 2/1/17. The facility documented R6's pressure injuries on the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other as follows: All measurements are in centimeters. Right Leg Lower Lateral (Upper) pressure injury 3/1/17: 5.0 x 1.0 x 0 - Unstageable 3/8/17: 5.5 x 1.3 x 0.1 - Unstageable Right Leg Lower Lateral (Lower) pressure injury 3/1/17: 2.5 x 2.5 x 0.1 - Stage 2 3/8/17: 2.0 x 1.0 x 0.1 - Documented as Stage 2 (Pressure injury observed to be 100% necrotic, therefore is unstageable, per observation and interview with RN W noted below.) Coccyx Developed 12/12/16 - Most recent wound documentation 2/28/17: 2 x 1.5 x 0 - Stage 2 3/7/17: 2.0 x 1.4 x 0 - Stage 2 - Comments: No significant changes. Continue current tx (treatment). (Pressure injury observed to be a stage 3 with 50% slough, unable to see wound bed, per observation and interview with RN W noted below.) On 3/2/17 R6 went to an appointment with Physician Assistant (PA) DD. PA DD noted the following: Coccyx pressure injury is roughly the same, more slough noted. (Note, this indicates the coccyx pressure injury is a stage 3, not stage 2) The patient states he is not being rolled on to his side and this needs to happen in order for him to have a chance at healing. Patient should be rolled on one side for 2 hours, the other for 2 hours and then back on his back for 2 hours. He cannot spend all day laying on his back, an air mattress is not enough to prevent these from worsening. Surgical options, such as muscle flaps and skin grafing, are limited for R6 and local wound care is his best bet.The coccyx sore should be dressed with cellerate and [MEDICATION NAME]. The [MEDICATION NAME] dressings should be changed daily. R6 should return for follow up with MD on 3/21/17. The PA did not address the right lateral leg pressure injuries in her notes. On 3/6/17 Surveyor requested to Director of Nursing (DON) B to observe R6's upcoming wound treatments. On 3/6/17 at 12:56 PM, Surveyor spoke with R6. R6 was sitting in his electric wheelchair in his room, his right leg and lap was covered with an afghan and a gait belt was wrapped around his right lower leg over the afghan. Surveyor asked R6 about the gait belt. R6 stated he spends the majority of his time outside and the gait belt holds the afghan on his leg otherwise the afghan would just blow off from the wind. R6 likes the afghan and gait belt on his leg as it keeps him warm while spending time outside. On 3/6/17 at 2:55 PM, Surveyor observed R6 propelling by in his electric wheelchair to go outside. R6's right leg was covered with an afghan and a gait belt was wrapped around his right lower leg over the afghan. On 3/7/17 at 3:20 PM, Surveyor asked Deputy Dir Nurs/RN F to assist with R6 in order to observe R6's positioning in his electric wheelchair. Surveyor asked Deputy Dir Nurs/RN F if he would remove the blanket and gait belt with R6's permission so that R6's right leg would be visible. Surveyor observed the positioning of R6's right leg while R6 was seated in his electric wheelchair. Surveyor noted that R6's leg is externally rotated, slightly bent at the knee, and was in direct contact with the metal bar of the legrest and top of the foot caddy. The metal bar of the legrest and foot caddy was causing an indentation of 1 - 1 1/2 inches directly on the area of R6's lateral leg pressure injuries. R6's skin was notably red around the dressings from the excessive pressure exerted on his leg from the wheelchair. Deputy Dir Nurs/RN F observed R6's positioning and the pressure on his right leg from the electric wheelchair. Surveyor asked R6 if he was having any pain. R6 stated, no, he does not feel anything from the waist down and the only area he has pain is in his left arm where he has arthritis. Surveyor and Deputy Dir Nurs/RN F exited R6's room. Surveyor asked Deputy Dir Nurs/RN F what has been done since the pressure injuries were identified on 3/1/17 and if Therapy Department has been contacted. Deputy Dir Nurs/RN F stated after R6 got this new electric wheelchair last October he developed a pressure injury from the electric wheelchair. Therapy evaluated him and added some padding and tape to the wheelchair. The facility noted two (2) new pressure injuries re-developed in the same area (right lower leg lateral side) on 3/1/17. Surveyor asked Deputy Dir Nurs/RN F what has he done since 3/1/17 when he noted the pressure injuries. Deputy Dir Nurs/RN F stated he was going to be contacting the Therapy Department but has not yet done so. Deputy Dir Nurs/RN F stated the wheelchair is digging into R6's right lower lateral leg. Deputy Dir Nurs/RN F stated he called the clinic on 3/1/17 and set up an appointment for R6 to be seen by the PA for positioning for the new pressure injuries and he was hoping they would help with positioning, which the clinic did not. Deputy Dir Nurs/RN F stated he has been very disappointed in the clinic as well as with their wound documentation. Deputy Dir Nurs/RN F stated the clinic did nothing to address R6's positioning issue on 3/2/17 during his office visit and and PA DD has incorrectly staged some R6's pressure injuries. On 3/8/17 at 2:45 PM, Surveyor asked Deputy Dir Nurs/RN F on 3/1/17 when he made the appointment with the PA how did he inform the clinic of the purpose of the visit. Deputy Dir Nurs/RN F stated he verbally informed the clinic at the time he made the appointment. Deputy Dir Nurs/RN F did not submit any paperwork with R6 when he went to the 3/1/17 appointment stating the purpose of the appointment or about any concerns. On 3/8/17 at 10:08 AM, OTR Y documented an OT (Occupational Therapy) Initial Evaluation for R6: Reason for referral: Onset evaluation: 3/8/17 Clinical Reasoning: Due to new onset of 2 OA on RLE and need for modification to new w/c. PT did not have OA RLE prior (Note this is inaccurate). Patient is long-term care res (resident) of SNF (Skilled Nursing Facility) referred to skilled OT services for wc (wheelchair) positioning/modifications to existing power wc due to recent/new onset of OA developing on RLE. History of Illness: Pt is 78 y/o (year old) male long-term resident of SNF who has been referred to skilled OT after RN noted he began developing new pressure areas on RLE upper/lower lateral which may be related to positioning in power wc. Pt has had power wheelchair since 10/13/16 (Note this is inaccurate. OT documented R6 as using his electric wheelchair beginning 10/3/16). New OA noted on 3/1/17. Stage 2 RLE distal/lateral (Note this is inaccurate it is unstageable), unstageable RLE proximal/lateral. Pt has history of [MEDICAL CONDITION] and left AKA (Above the Knee Amputation) . On 3/8/17 at 11:56 AM, Occupational Therapy Registered (OTR) Y met with R6 and documented the following Treatment Encounter Note. OTR Y analyzed current wheelchair positioning and current modifications/adaptations that uphold pressure relief to determine additional measures that will effectively manage skin integrity/pressure relief. Team Collaboration/Communication: OTR Y spoke at length with RN manager (referring to Deputy Dir Nurs/RN F) regarding case. RN manager reports new pressure areas first noted on 3/1/17 along lateral proximal/distal RLE (Right Lower Extremity), possibly caused by prolonged contact with wheelchair. RN manager reports patient is non-compliant with turning/repo schedule and remains in wc (wheelchair) all day and also declines turning while in bed in PM. OTR Y also called and consulted with ATP regarding possible adaptations that may be appropriate and ATP recommending ROHO padding that can be cut/customized to fit wc. Response to Session Interventions: Pt (Patient) displays externally rotated RLE which does contact metal bar of legrest. He is developing pressure area along edge of top of foot caddy and may benefit from longer caddy or removal. OTR Y began search in DSSI catalog for equipment but will have to do further search with other companies as recommended equipment not available in DSSI. * Complexities/Barriers Impacting Session: High Risk of Amputation On 3/8/17 at 3:00 PM, Surveyor and RFOS observed Registered Nurse (RN) W and Registered Nurse (RN) X perform R6's five (5) wound treatments. Surveyor asked RN W how she would describe R6's right lateral leg ulcers. RN W stated the two lateral leg ulcers are both unstageable. RN W stated the upper ulcer is covered in slough, and she is unable to visualize the wound bed. RN W stated the right lower lateral leg is necrotic (black) with the peri wound intact. RFOS asked RN W if she knew what caused these pressure injuries to the right lateral leg. RN W stated There was a piece on the electric wheelchair that was rubbing. RN W stated that R6 can't feel this (rubbing) and doesn't know the skin is breaking down. R6 stated, I don't even feel it. R6 stated, If it wasn't for this crappy chair I wouldn't be in this mess. During the wound treatments, Surveyor asked RN W to describe R6's coccyx wound. RN W stated the wound bed has 50% slough and the periwound is red. RN W stated the coccyx is a Stage 3 pressure injury. Surveyor observed the dressing on R6's coccyx before RN W removed it for the dressing change. The dressing was dated 3/6/17. The current order for the coccyx wound states the wound treatment is to be done daily. R6's coccyx dressing was not changed on 3/3/17, 3/5/17, or 3/7/17 per PA DD's updated order on 3/2/17. This order was not updated on the TAR. Surveyor and RFOS observed RN W cleanse R6's coccyx with saline and apply a Allevyn dressing. RN W did not apply cellerate (collegen treatment) per the 3/2/17 order. On 3/8/17 at 4:45 PM, Deputy Dir Nurs/RN F stated to Surveyor that he contacted PA DD's office today regarding R6's right lateral leg pressure injuries since there was no information in the report from 3/2/17. Deputy Dir Nurs/RN F stated that PA DD added an addendum from R6's visit on 3/2/17 for R6's right lateral lower leg. The addendum is dated and electronically signed on 3/8/17 at 3:22 PM. Assessment and Plan: [DIAGNOSES REDACTED]. [AGE] year old male with a right lower leg ulcer that I am seeing for the first time today. R6 has little to offer on the history of this wound. The wound is covered with slough. I would like the wound to be dressed daily with Santyl to debride the wound bed and then covered with a [MEDICATION NAME] or similar foam dressing. Integumentary: Warm, Dry, please see previous note for pressure injury exam, linear, vertical wound of lateral right lower leg, 100% of the wound is covered in slough, drainage present but does not appear to be purulent, no odor, surrounding skin is intact and without [DIAGNOSES REDACTED]. On 3/9/17 at 1:05 PM, Surveyor spoke with OTR Y and Director of Rehab (DOR) Z. DOR Z stated yesterday, 3/8/17, we received a request form from Deputy Dir Nurs/RN F to screen R6 for wheelchair positioning and pressure relief for his lateral proximal/distal RLE. OTR Y stated based on where pressure injuries are developing additional modification to R6's chair is needed. OTR Y stated she called ATP (Assisted Technology Professionals) today for assistance in determining options for pressure relief. ATP is coming out next week to analyze pressure relief options for R6. OTR Y stated that because R6's right leg is externally rotated positioning has more complexities. OTR Y stated when she arrived to work today at 7:00 AM, R6's electric wheelchair was in the Occupational Therapy room. OTR Y stated she put a foam cradle on R6's (right) footrest first thing this morning and it appears to be helping and offloading pressure. OTR Y stated she checked back with R6 around Noon today and he is very happy with cradle. OTR Y stated she is still looking for other options that are not pre fabricated and may put down a Roho sheet as well. OTR Y stated when R6's electric wheelchair arrived in October 2016 they screened him for safety (on a quarterly basis) and normally if a chair is modified it has to be on caseload, but R6's chair was not on caseload. Surveyor asked OTR Y when she first heard of R6's wheelchair positioning issues. OTR Y stated, The first I heard of a pressure ulcer (injury) related to the wheelchair was yesterday (3/8/17). Despite the conversation and prompting with Deputy Dir Nurs/RN F on 3/7/17 at 3:20 PM and with RN W during the dressing changes on 3/8/17 at 3:00 PM, the facility did nothing to address and offload the source of the pressure to R6's right lateral leg while awaiting the therapy screen. No interventions were put into place until 3/9/17. Surveyor reviewed Skin Checks Daily on the Treatment Administration Record (TAR) and found they were not completed for the following dates: 11/1-11/3, 11/14, 11/21, 11/30, 12/27, 12/31, 1/21, 1/22, 1/24, 1/26-1/31/16 Surveyor reviewed Skin Check Weekly on Bath Day on the TAR and found they were not completed for the following dates: 12/27/16, 1/24/17, 1/31/17 On 3/7/17 R6 stated to Surveyor that he was not repositioned at all during night (Night shift 3/6 into 3/7). The facility did not have a system in place to track repositioning every 2 hours for R6 until 3/7/17 at 4:00 PM per the Director of Nursing (DON) B. On 3/9/17 at 2:00 PM, Surveyor and Surveyor spoke with Deputy Dir Nurs/RN F, DON B and Consultant II. Surveyor asked DON B if she expects staff to follow physician orders. DON B stated, Yes. Surveyor asked DON B if a resident has skin checks on the TAR do you expect staff to complete those skin checks on the TAR. DON B replied, Yes. Surveyor asked DON B if a wound has slough what stage would it be. DON B replied, Unstageable. Surveyor asked when they were aware of the pressure injuries on R6's right lower lateral leg and what they did. Deputy Dir Nurs/RN F stated he was aware of the pressure injury on 3/1/17 when a CNA alerted him while doing rounds. Deputy Dir Nurs/RN F stated he notified DON B and DON B called the MD. DON B stated they assessed R6, called the MD, called to make the appointment with the wound specialist, educated R6 regarding refusals (unrelated to inappropriately fitting wheelchair). Consultant II stated but R6 refuses interventions. Surveyor stated except what they did today (adding the cradle to the legrest), asked DON B if she has seen the pressure injuries and when. DON B stated she did see the pressure injuries, maybe 3/5/17. Surveyor asked DON B what she observed. DON B stated she saw slough in there but the padding looked good to her. Surveyor asked since 3/1/17 has the facility provided education to staff, identified any other residents at risk, and looked at residents with contractures for positioning. DON B replied, No. DON B stated the the ADONs or Deputy Dir Nurses are responsible for follow through. Consultant II stated I was aware he had a leg issue but I wasn't aware of the extent.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure injury does not develop a pressure injury and a resident having pressure injury receives necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing for 3 of 9 residents (Resident 11, Resident 8, Resident 5). Resident 11 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for PI development. The facility did not do the following to prevent Resident 11 from developing bilateral (right and left) heel Deep Tissue Injuries (DTIs), a type of PI: 1. Follow Physician recommendations regarding timing of wound care clinic visits. A follow up visit to the wound care clinic was scheduled 3 weeks late. On the day of Resident 11's appointment, the facility did not have resident 11 ready in time to be transported to the wound care clinic. Resident 11 missed his appointment on 9/13/16, which made his follow up 4 weeks late. 2. Ensure that Resident 11's dressings to bilateral heels were clean, dry and intact 3. (3 examples) Provide proper pressure relief to Resident 11's heels 4. Follow proper standards for infection control during dressing changes 5. Did not notify Resident 11's Medical Doctor (MD) when Resident 11's DTI's on his bilateral heels increased in size. 6. The facility did not follow Resident 11's Physician order [REDACTED].) for interventions, nor did the facility document refusals for the interventions, attempt other means of protecting Resident 11's heels when he refused, or notify the MD that Resident 11 was refusing these interventions. P.O.'s for interventions not being followed include: 1. No pressure to Rt (right) heel - Please use heel protectors 2. Continue to elevate BLE (bilateral lower extremities) Lt (Left) foot and toes swollen - dated 3/2/16 3. Night heel prevalon boot for protection 4. Diabetic foot check at bedtime dated 3/11/16 Resident 8 currently has a pressure ulcer to her inner thigh. This pressure ulcer is not addressed on Resident 8's comprehensive plan of care. Resident 5 was observed in his wheelchair beyond the physician prescribed length of time. This is evidence by The National Pressure Ulcer Advisory Panel (NPUAP): Prevention and treatment of [REDACTED]. Position the individual off area of suspected deep tissue injury with intact skin. If pressure over the area cannot be relieved by repositioning, select an appropriate support surface. Pressure reduces perfusion to injured tissue. Continued pressure on an existing pressure ulcer will delay healing and may cause additional deterioration. Repositioning for treating existing heel pressure ulcers, in part: Relieve pressure under the heels with Stage 1 or 2 pressure ulcers by placing legs on pillows to float heels off the bed or by using heel suspension device. Stage 3 and 4 pressure ulcers; place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer. Pressure on stage 3, 4 and unstageable heel pressure ulcers should be completely offloaded as much as possible. Elevation of the heel on a pillow is usually inadequate. The facility policy, Pressure Ulcer Prevention/Treatment, dated July 2015 states as follows: Policy: The center requires the use of the Braden Risk Assessment and Skin Integrity Assessment: Prevention and Treatment Care Plan. All residents will be assessed on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment, and Skin Integrity Assessment Prevention and Treatment Care Plan. The center recognizes it is difficult to describe a set of protocols that would fit every circumstance. However, Braden recommends the following: Mange moisture, Manage nutrition, Manage friction and shear, Manage other general care issues. Select appropriate interventions based on the following: Braden Risk Assessment score, Skin Integrity Assessment Prevention and Treatment Care Plan. At Risk (15-18) Frequent turning, maximal remobilization, reduce pressure to heels, manage moisture, nutrition and friction and shear, pressure-reduction support surface if bed or chair-bound Moderate Risk (13-14) Turning schedule use foam wedges for 30 degree lateral positioning, pressure-reduction support surface, maximal remobilization, reduce pressure to heels, manage moisture, nutrition and friction and shear High Risk (10-12) Increase frequency of turning, supplement with small shifts in body position, pressure reduction support surface, use foam wedges for 30 degree lateral positioning, maximal remobilization, reduce pressure to heels, manage moisture, nutrition and friction and shear The facility's Procedure Pressure Ulcer Prevention/Treatment 2. review assessments and identify individualized interventions using the Skin Integrity Assessment, Prevention and Treatment Care Plan Interventions may include, but are not limited to: a. Manage pressure: Use support surface on bed or wheelchair, use turning and repositioning, off load heel pressure Example 1 Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11's most recent Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score of 9, which indicates he has moderate cognitive impairment. The MDS indicates Resident 11 requires extensive assistance of 2 or more people for bed mobility, transfers, and personal hygiene. Resident 11 requires extensive assist of 1 person for locomotion. Resident 1's Braden Risk Assessments are as follows: 2/3/16: 16 (15-18 = minimal risk) - Minimal Risk 2/11/16: 12 (10-12 is high risk) - High Risk 4/7/16: 13 (13-14 = moderate risk) - Moderate Risk 7/22/16: 13 - Moderate Risk 8/1/16: 13 - Moderate Risk 9/6/16: 11 - High Risk Resident 11's Physician order [REDACTED]. 1. No pressure to Rt (right) heel - Please use heel protectors - dated 3/2/16 2. Continue to elevate BLE (bilateral lower extremities) Lt (Left) foot and toes swollen - dated 3/2/16. 3. Night heel prevalon boot for protection - dated 2/7/16 4. Diabetic foot check at bedtime - dated 3/11/16. Of note the facility was not following Physician order [REDACTED]. Resident 11's Resident Choice Plan of Care dated 3/2015 indicates resident chooses not to follow recommended plan of care with: Elevating heels, Avoid pressure to heels, avoid walking or self-propelling in wheelchair, elevating heels in bed, elevating legs by laying down 2 hours in AM and 2 hours in the PM . The facility was not documenting refusals to implement Physician Orders. See Example 6 below for detailed examples. Resident 11 developed a DTI on his right heel on 8/25/16 and a DTI on his left heel on 8/29/16. 1. Resident 11 was seen at the wound clinic on 8/4/16 for right leg ulcers. The Physician indicates, Follow up in 3 weeks, sooner if needed. Resident 11's three week follow up was due approximately 8/25/16. Resident 11 had an appointment at the wound clinic on 9/13/16, nearly 6 weeks later, which he missed due the facility not having him ready in time. His appointment was rescheduled to 9/20, nearly 7 weeks later. In Resident 11's After Visit Summary dated 9/20/16, the Physician indicates: Prevalon boots to the bilateral heels at all times. Heel ulcers are from pressure and friction/sheer. 2. On 9/13/16 at 12:40 PM, Surveyor observed Resident 11 in the dining room in his wheelchair eating lunch. Resident 11's heels were directly on the floor. Resident 11 was not wearing Prevalon boots or any type of heel protectors, per physician orders. Resident 11 had a dressing on both his right and left foot and ankles. Both dressings were soiled with copious drainage, particularly the dressing on his right heel. Surveyor observed Resident 11's right heel DTI to be uncovered and the dressing was worn through and saturated. Resident 11's PI on his right heel was visible while he sat eating lunch in the dining room. Of note, Resident 11 has a history of recurrent lower extremity [MEDICAL CONDITION], mostly on the right side, and a history of [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) in his right leg as recently as 2/3/16. On 9/13/16 at 12:55 PM, Surveyor spoke with LPN E (Licensed Practical Nurse). LPN E stated she was not aware the dressing was soiled. LPN E stated that Resident 11 has an appointment with the wound clinic today (9/13/16) at 2:30 PM. Surveyor asked LPN E if she was going to change his dressings before the appointment. LPN E stated his dressing changes are scheduled for the PM shift. Surveyor again asked LPN E if she was going to change Resident 11's dressing before his appointment. After pausing and thinking, LPN E stated she would change his dressings. 3. Surveyor observed Resident 11 sitting in his wheelchair with his feet (heels) directly on the floor at the following times: Occurrence 1: 9/13/16 at 9:40 - In the dining room (referenced above) heels were directly on the floor. Surveyor observed Resident 11's right heel DTI to be uncovered and the dressing was worn through and saturated. Occurrence 2: 9/13/16 at 1:10 PM - In Resident's room, heels directly on the floor Occurrence 3: 9/14/16 at 8:25 AM - Resident in wheelchair in dining room, heels directly on floor Throughout the facility's recertification survey from 9/13/16 - 9/19/16, Surveyor observed Resident 11's heels to be continually unprotected from pressure. Surveyor did not observe Resident 11 to ever be wearing Prevalon boots or have cushion, or any type of protection under his heels. Surveyor observed no prevalon boots in Resident 11's room. On 9/13/16 at 3:05 PM (full interview below) LPN E indicated that Resident 11 does not have or wear Prevalon boots. 4. On 9/13 at 2:05 PM, Surveyor observed LPN E complete the treatment to Resident 11's right and left foot. Registered Nurse (RN) C was also present to observe. LPN E did the following: LPN E placed two washcloths in the sink with water running over them for approximately 3-4 minutes. LPN E stated she put the washcloths in the sink so the water could warm up. LPN E then wrung on the washcloths, applied soap to the washcloths, and used them to cleanse Resident 11's right DTI that was open with copious amounts of drainage. LPN E left a bottle of wound cleanser and tube of Iodosorb cream lying directly on the floor with the cap off during and after the treatment. LPN E did not dispose of the Iodosorb. While observing the treatments to Resident 11's legs, Surveyor asked LPN E what caused the PIs. LPN E stated, I do know it's from pressure but he refuses to keep his feet up. On 9/13/16 at 2:05 PM, while observing the wound treatments, Surveyor asked RN C to describe the injury to Resident 11's right heel. RN C stated, The majority of the wound base is eschar, lateral and medial sloughing in the wound bed. Surveyor asked RN C if Resident 11 acquired the bilateral heel DTIs at the facility or if he was admitted with them. RN C stated Resident 11's bilateral heel DTI's are both facility acquired. RN C stated Resident 11 refuses to float heels, won't use foot pedals, is very resistant to care and has massive swelling in his right leg. The facility has not tried other measures such as a cushion under Resident 11's heels when he is up in his wheelchair, or changed his transfer status. The facility also does not document refusals, or notify the MD of refusals. On 9/13/16 at 3:00 PM, after LPN E was done with the wound treatments, RN C asked Surveyor how she (LPN E) did. Surveyor spoke with RN C. Surveyor asked ADON C if she saw LPN E place the washcloths directly in the sink before using them for wound care. RN C stated, Yes. Surveyor asked RN C if it is acceptable to place washcloths directly in a sink to wet them before using them for wound care. RN C stated, No, you're crossing dirty and clean. Surveyor asked RN C if it is acceptable to place wound cleanser and Iodosorb with the lid off directly on the floor. RN C stated, I would not put them on the floor due to infection control. On 9/13/16 at 3:05 PM, Surveyor spoke with LPN E. Surveyor asked LPN E if it is acceptable to place washcloths directly in the sink before using them for wound care. LPN E stated, No, because the sink could be dirty. Of note, Surveyor observed LPN E wash her hands at the sink multiple times prior to placing the washcloths in the same dirty sink. Surveyor asked LPN E if it is acceptable to place wound cleanser and Iodosorb with the lid off directly on the floor. RN C stated, it's not ok because you don't know what's on the floor. Surveyor asked LPN E what she did with the Iodosorb. LPN E stated, It's in his (Resident 11's) room but I should throw it out. Surveyor asked LPN E if Resident 11 is supposed to be wearing any type of protective boot. LPN E replied, He doesn't have boots. Surveyor asked LPN E if Resident 11 is supposed to be wearing boots. LPN E replied, No, he doesn't have boots. It is also important to note that Resident 11's ride to the wound clinic arrived while LPN E was doing the treatments. The ride did not wait so Resident 11 missed his appointment at the wound clinic. The appointment was rescheduled for over 1 week later, on 9/20/16. 5. The facility did not notify Resident 11's Medical Doctor (MD) on 9/7/16 and 9/14/16 when Resident 11's DTI's on his right and left heels increased in size. Resident 11's measurements for the right DTI: 8/25/16: 2.5 x 3.5 9/1/16: 3.5 x 3.4 *9/7/16: 4.0 x 4.5 x 0.2 - No MD notification *9/14/16: 4.5 x 6.5 x 0.2 - No MD notification Resident 11's measurements for the left DTI: 8/29/16: 5.0 x 5.0 *9/7/16: 8.0 x 11.0 x unknown - No MD notification 9/14/16: 6.0 x 7.0 x 0.1 The MD changed the treatment order on 9/10/16; however, there was no documentation that the MD was notified prior to 9/10/16. On 9/10/16 the MD changed the treatment order for the left heel. There was no documentation that the MD was notified on 9/14/16 when Resident 11's right DTI increased in size. On 9/19/16 at 2:55 PM, Surveyor spoke with ADON C. Surveyor asked ADON C if the MD should have been notified when the PIs increased in size. ADON C stated, The doctor should always be called when there's a change in condition. ADON C confirmed that there is no documentation that the MD was contacted on 9/7/16 or at any point prior to 9/10/16, and 9/14/16. 6. Resident 11's Physician order [REDACTED]. The facility was not following Physician order [REDACTED]. ~No pressure to Rt (right) heel - Please use heel protectors - dated 3/2/16 This intervention is on the TAR. The months of July, August and September contain documentation that this was not done on the following date and shift: 7/28: AM & PM 8/4 - PM 8/12: AM PM 8/16: PM 8/17: AM, PM 8/18: AM, PM 8/25: AM, PM 8/26: AM, PM 8/29: PM 8/30: PM 9/3: AM 9/10: AM, PM 9/13: AM There is no documentation of staff offering this intervention and Resident 11 refusing. The MD was also not notified of any refusals. ~Continue to elevate BLE (bilateral lower extremities) Lt (Left) foot and toes swollen - dated 3/2/16. This intervention is on the TAR and is completely blank (not signed out) for the months of July, August, and September. There is no documentation of staff offering this intervention and Resident 11 refusing. The MD was also not notified of any refusals. ~Night heel prevalon boot for protection - dated 2/7/16 This intervention is on the TAR and is completely blank (not signed out) for the months of July, August, and September. ~Diabetic foot check at bedtime - dated 3/11/16. The months of July and September contain documentation that this was not done on the following date and shift: 7/1, 7/2, 7/3, 7/4, 7/6, 7/7, 7/8, 7/9, 7/10, 7/12, 7/20, 7/21, 7/27, 7/28, 7/30, 7/31. For the month of August, this intervention is not on the TAR. This intervention is completely blank (not signed out for the month of September). On 9/19/16 at 1:55 PM, Surveyor spoke with Director of Nursing (DON) B. Surveyor asked DON B if physician's orders [REDACTED]. Surveyor asked DON B if a resident refuses an intervention that is a Physicians Order, what should staff do. DON B stated that all refusals should be documented and the resident should be reapproached. DON B stated having a different staff member reapproach is sometimes effective. DON B stated the nurse and the MD should be notified. DON B stated physician's orders [REDACTED]. Example 2 Resident 8's [DIAGNOSES REDACTED]. Resident 8 currently has an indwelling Foley urinary catheter. On admission, Resident 8 had excoriation to the buttock area. Resident 8 was identified as being at risk for pressure injuries and a comprehensive care plan entitled Skin Integrity Assessment Prevention and treatment Care Plan was initiated. =Resident 8's Nurses Notes state that on 8/1/16 a new skin issue developed to Resident 8's right inner thigh. Skin breakdown had occurred due to pressure from the Foley catheter strap. On 9/13/16 this area was noted to be 3.5 cm x 0.2 cm and improving. A review of Resident 8's Skin Integrity Assessment: Prevention and Treatment Care Plan address Resident 8's buttock skin issues, and the need to monitor Resident 8's right heel scab that had opened, but this comprehensive care plan does not address Resident 8's pressure injury to the inner thigh caused by the Foley catheter strap. On 9/15/16 at approximately 5:15 pm Surveyor spoke with ADON (Assistant Director of Nursing) D regarding several topics including Resident 8's skin issues. Surveyor asked ADON D if Resident 8's inner thigh pressure injury should be addressed on the care plan. ADON D confirmed this inner thigh pressure injury should be identified and care planned on Resident 8's comprehensive care plan. Example 3 Resident 5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 5's most recent Minimum Data Set (MDS) indicates he is at risk for developing pressure injuries. Resident 5 has a physician's orders [REDACTED]. On 9/15/16 at 8:40 am, Surveyor observed Resident 5 eating breakfast in the facility's main dining room. At 10:40 am, Surveyor observed Resident 5 in his room, sitting in his wheelchair. Resident 5 stated I'm not supposed to be in my chair this long. At 11:01, Surveyor was able to find a staff member to get Resident 5 back into his bed. On 9/15/16 at 1:15 pm, Surveyor interviewed Certified Nursing Assistant (CNA) AA. CNA AA stated she had gotten Resident 5 up that morning at 8:00 am. On 9/19/16 at 10:55 am, Surveyor interviewed Certified Nursing Assistant (CNA) Z. CNA Z stated she knows what specific care to give to residents based on the CNA Care Delivery Guide and pulled one out of her pocket. CNA Z also stated that if a resident needed to be in his or her wheelchair for no longer than 2 hours, she would find that information on the CNA Care Delivery Guide. On 9/19/16 at 4:15 pm, Surveyor interviewed Director of Nursing (DON) B. DON B agreed the CNA care delivery guide did not address Resident 5's need to be in his chair no longer than 2 hours. DON B also stated she was not sure what that physician's orders [REDACTED].

Based on interview and record review, in 2 of 3 total residents reviewed (Residents 2 and 14) the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Resident 2 was prescribed an antibiotic without meeting the criteria of a urinary tract infection. Resident 2's antibiotic use was then extended by 7 days. Resident 2 had a reaction to the antibiotic and was then placed on an antibiotic in which the isolated bacteria was found to be resistant to the antibiotic. The facility did not consult with Resident 2's physician concerning the resistant culture or question the indications for its use. Resident 2 was admitted to the hospital with [REDACTED]. Resident 14 has a previous history [MEDICATION NAME] UTI (Urinary Tract Infection), Resident 14 was treated [MEDICATION NAME] an UTI prior to culture results being obtained. Resident 14's urine culture indicated Resident 14 has [MEDICATION NAME] organism. This is evidence by: On 9/15/15 at 4:30 PM Surveyor interviewed Registered Nurse Consultant (RNC) X. Regarding the facility's policy for treating UTI's. RNC X stated the facility follows the McGeer's criteria for surveillance of infections. The Society for Healthcare Epidemiology of America (SHEA)/Center of Disease Control (CDC) Paper, dated October 2012, states .Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria .Table 5. For residents without an indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign and symptom sub criteria a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate b. Fever or leukocytosis (see Table 2) and at least 1 of the following localizing urinary tract sub criteria i. Acute costal vertebral angle pain or tenderness ii. Supra pubic pain iii. Gross hematuria iv. New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract sub criteria i. Supra pubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urgency v. New or marked increase in frequency 2. One of the following microbiologic sub criteria a. At least 10-5 cfu/mL of no more than 2 species of microorganisms in voided urine sample b. At least 10-2 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter B. For residents with an indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign or symptom sub criteria a. Fever, rigors, or new-onset [MEDICAL CONDITION], with no alternate site of infection b. either acute change in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED]. purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate 2. Urinary catheter specimen culture with at least 10-5 cfu/mL of any organism(s) The facility Policy titled Urinary Tract Infections [MEDICAL CONDITION] in part, dated 7/2015, Policy: The center recognizes many residents have chronic bacteriuria (presence of bacteria in the urine). The center follows researched literature that suggests treating only symptomatic UTIs. Symptomatic UTIs are based on the based on the following criteria. For Residents with an indwelling catheter (both criteria must be met.) 1. At least 1 of the following signs or symptom subcriteria a. Fever, rigors, or new onset [MEDICAL CONDITION], with no alternate site of infection. b. Either acute change in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED]. New onset suprapubic pain or costovertebral pain or tenderness. d. Purulent discharge from around the catheter or acute pain swelling or tenderness of the testes, epididymis, or prostate. 2. Urinary catheter specimen culture with at least 105 cfu/mL of any organism. Note: Urinary catheter specimen for culture should be collected following replacement of the catheter, if current catheter has been in place for greater than (>) 14 days. Follow up of UTIs: The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria. Bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy. Recurrent symptomatic UTIs in a catheterized or non-catheterized resident should lead the center to check whether perineal hygiene is performed consistently to remove fecal soiling. Recurrent UTIs in a catheterized resident should lead the center to look for possible impairment of free urine flow through the catheter, to re-evaluate the techniques being used for perineal hygiene and catheter care. Example 1 Resident 2 [DIAGNOSES REDACTED]. Resident 2's Urologist physician order, dated 5/1/15, Foley maintenance. May irrigate Foley as needed (PRN); use at least 50 - 75 Milliliters (ml). No Urinalysis (UA) unless fever greater (>) 100.5, gross hematuria or significant mental status changes. Nursing note dated 5/6/15 at 6:00 PM, Patient (Pt.) has complained of weakness and fatigue which is associated with Pt. loose stools, which is what Pt. has had for the day. Urine output within limits. Pt. has been slightly confused. Temperature 99.8 axillary. Pt ' s urine is cloudy/foul/with hematuria. Per telephone order from Urologist urine meets guidelines for UA and culture and sensitivity. Physician communication and progress note (SBAR) sent to primary physician. (It should be noted that these symptoms do not meet the criteria set out above by the physician, there was no fever >100.5, gross hematuria or significant mental status changes.) Resident 2's Urinalysis (UA) report, dated 5/6/15, indicates the following: On the bottom page of the UA results a hand written message: (Physician name) on-call Bactrim Double Strength (DS) 1 tablet times 1 week. Update Resident 2's urologist with results on 5/7/15. Physician telephone order, dated 5/6/15, Bactrim DS 1 tablet orally (PO) twice a day (BID). Update (Urologist name) related to new order and lab results on 5/7/15. Note: There is no written documentation in Resident 2's medical record indicating Resident 2's Urologist was updated as ordered on [DATE]. Nursing note dated 5/8/15 at 9:50 PM, Resident Foley functioning properly- output 1150 ml. Resident 2 back to old self joking with staff. No cognitive deficit. Resident 2's urine culture final report, dated 5/9/15, Greater than (>) 100,000 cfu/ml Escherichia coli isolated and 50,000 cfu/ml Proteus mirabilis isolated. Bactrim DS is sensitive to both organisms. [MEDICATION NAME] is resistant to the organism Proteus mirabilis. Nursing note dated 5/12/15 (no time), No urinary complications. Nursing note 5/13/15 at 12:04 AM, Foley flushed per resident request draining well without problem. Urine yellow. Temperature 97.5. Interdisciplinary team (IDT) note dated 5/14/15 at 3:00 PM, IDT met to review resident for new antibiotic related to UTI. Urologist updated (5/1/15) and received order to irrigate catheter as needed - notify temperature greater than 100.5 or gross hematuria. No hematuria or fever noted this day. Catheter leaks at times related to bladder spasms. Nursing note dated 5/13/15 at 10:30 AM, Catheter irrigated with 100 milliliters (ml) of normal saline. Urine cloudy before irrigation and after irrigation urine was clearer. Writer called (Urologist name) to request follow up UA and a new order for Vitamin C. (Note: There is no evidence of a return call from Resident 2's Urologist) Interdisciplinary team (IDT) note dated 5/14/15 (no time) IDT met to review Bactrim DS/UTI completed no signs or symptoms of UTI. Foley draining clear yellow urine. Afebrile (no temperature). Nursing note, dated 5/14/15 at 10:10 PM, On call Physician updated related to (r/t) Resident 2's urine being milky no order given for UA. Suggested to update Primary Physician due to this maybe a chronic condition r/t Foley Catheter. Resident 2 complaint of slight abdominal pain. Temperature 98.7. Urine output 800 centimeters. Fax sent to Primary Physician. Resident 2's Physician notification Physician via Facsimile fax, dated 5/14/15, Resident 2 complained of slight lower abdominal discomfort. Completed Bactrim DS on 5/13/15 related to (r/t) UTI. Temperature 98. Urine output 800 centimeters (cc) 5/14/15 PM shift. Urine appears to be very milky. (Physician name) updated requested that you be updated, believes this maybe a chronic condition r/t Foley (indwelling) catheter. Would you like to give any new orders? New orders, dated 5/15/15: Spoke with Nursing Home (NH) staff. He got 7 days of Bactrim DS finished 2 days ago. Order another week of Bactrim DS. (Note: Resident 2's primary Physician was notified related to Resident 2's urinary complaints. A second round of antibiotics was started without symptoms of a UTI) Nursing note, dated 5/15/15, at 1:25 PM, New Order received for Bactrim DS times 7 days. Update Medical Doctor (MD) if symptoms persist when antibiotics complete. Resident denies any discomfort. Physician order, dated 5/15/15, Bactrim DS 1 tablet PO BID times 7 days. Update MD if symptoms continue. (Note: this order was received from Resident 2's Primary Physician and not Resident 2's Urologist.) Nursing note, dated 5/16/15 at 11:10 PM, Resident 2 Foley draining urine milky yellow. No complaint of discomfort. Temperature 98.4. Nursing note, dated 5/17/15 at 6:00 PM, Resident 2 complained of nausea. Had small emesis 25 milliliter (ml) - 30 ml yellow bile. Complained of (C/O) dizziness and head feels funny. Resident 2 not tolerating antibiotic (ABT). Temperature 97.4. Called on call MD and got Bactrim discontinued (dc ' d) and ok to start [MEDICATION NAME]. (Note: Resident 2's urine culture report indicated Proteus was resistant to [MEDICATION NAME]. No evidence the on call physician was notified of the resistant ABT.) Physician telephone order, dated 5/17/15, Discontinue Bactrim DS due to C/O nausea and dizziness. Start [MEDICATION NAME] 100 mg 1 tablet orally times five days. Interdisciplinary note, dated 5/18/15, Interdisciplinary team (IDT) met to review Resident 2 secondary to a change in ABT for treatment (TX) of UTI. Resident has been tolerating new ABT [MEDICATION NAME]. The nursing note is signed by the Director of Nursing (DON), Education Director, and 2 Registered nurses (RN). (Note: There is no evidence the IDT team reviewed Resident 2 for no symptoms of a UTI or that the Urine culture was resistant to the ABT [MEDICATION NAME].) Nursing note, dated 5/19/15 at 2:00 PM, Primary Physician changed [MEDICATION NAME] to [MEDICATION NAME] (trade name [MEDICATION NAME]) in order to open the capsule and mix with ice cream. Resident 2's Medication Administration Record [REDACTED]. (Resident 2 received a total of 6 days or 12 doses of the [MEDICATION NAME].) Nursing note, dated 5/20/15 at 5:30 AM, Writer went to give medications to Resident 2. Resident 2 lethargic but responsive. Altered mental status. Staring up to ceiling. Vital signs (VS) blood pressure (BP) 111/65, Pulse 81, Respiration 16 and Temperature 100.4. At 5:40 AM, Call placed to on call MD new order to send to emergency room for evaluation. Nursing note, dated 5/20/15 at 11:05 AM, Hospital called to let writer (Nurse) know that would be brining Resident 2 back to the facility. At the emergency room laboratory test were done and Resident 2 was given an enema and had results. IDT note, dated 5/20/15 at 2:45 PM, Resident found staring at the ceiling. Resident was receiving [MEDICATION NAME] 100 mg for UTI, changed on 5/17/15. Resident 2 was previously on Bactrim DS but was unable to tolerate the medication. MD contacted this morning and order received to send to emergency room (ER). ER contacted facility that Resident 2 would be transported back to facility. Resident given enema at ER. (Note: The facility did not review the previous labs to identify Resident 1's antibiotic was resistant to the organism identified.) Hospital note in part, dated 5/20/15, Basic information: Chief complaint, Resident 2 reports some abdominal pain due to lack of Bowel movements over the course of 2 weeks. The facility staff reports the patient is more confused than normal. History of present illness: Resident 2 has an indwelling catheter. He is currently being treated for [REDACTED]. Review of symptoms: [MEDICAL CONDITION] symptoms: Negative except as documented in the history of present illness. Inpatient orders: CAT scan abdomen and pelvis; X-ray abdomen series with chest view. Completed: Complete blood count, complete metabolic panel, and enema. (Note: Resident 2 did not have a urine culture completed at the hospital on [DATE].) IDT note, dated 5/22/15 at 4:10 PM, Met to review Resident 2 d/t transport toER on [DATE]. Temperature with in normal limits (WNL) and not elevation of temperature thus far. Urine appearance - clearing and less milky. No further episodes of change in mental status. Nursing note dated 5/24/15 at 8:00 PM, Temperature 102.0 state abdominal pain is very tender upon palpation and when Foley was flushed. He has no appetite and is lethargic with very slow mentation. MD notified. Infection Surveillance Worksheet onset symptom dated 5/6/15, 100,000 gram negative Bacilli. Bactrim DS 1 tablet BID times 7 days. On 5/17/15 Discontinue Bactrim DS due to complaint of nausea and dizziness change to [MEDICATION NAME] 100 mg BID times 5 days. (Note the infection preventionist did not review the culture results with the change in antibiotic to ensure [MEDICATION NAME] was not resistant to the organisms growing.) On 5/18/15 Change [MEDICATION NAME] to [MEDICATION NAME] 100 mg BID. On 5/25/15 UTI [MEDICAL CONDITION] culture done in ER [MEDICATION NAME] 500 mg 1 tablet four times a day for 10 days. Hospital progress note dated 5/24/15 at 10:08 PM, History of present illness: The patient presents with fever. The onset is unknown. The course/duration of symptoms is constant. Associated symptoms: abdominal pain. Prior episodes, occasional and recent recurrent UTIs. Therapy today: None. Medical Decision Making: Differential Diagnosis: [REDACTED].) Plan: [MEDICATION NAME] (antibiotic) 500 mg capsule 4 times a day for 10 days. Discharge patient order at 11:59 PM. Nursing note dated 5/25/15 at 2:15 PM, Resident 2 back from hospital. Temperature 101.6. Resident difficult to arouse. New order received for [MEDICATION NAME] 500 mg 1 capsule 4 times a day for 10 days. Nursing note dated 5/25/15, at 4:10 AM, Went to check on Resident 2. Resident abdominal breathing, [MEDICAL CONDITION]- Pulse 113. Pulse oxygenation saturation between 89% and 90% on room air. Resident opens eyes and slow to respond. Eyes glassy. Nursing note dated 5/25/14 at 4:45 AM, on call Physician gave order to send to Hospital. 911 called to transport resident. Nursing note dated 5/25/15 at 1:35 PM, Called (Hospital Name) to check on Resident 2 status. Staff nurse reported that patient was admitted . Stated patient will wake up and talk a little, then go back to sleep. Patient currently not taking pills because of risk of aspiration. Patient on Intravenous (IV) antibiotics. Medical staff decreased pain patch to try to get him to wake up. Resident 2's hospital History and Physician (H&P) in part, dated 5/25/15, Assessment and Plan: Patient presents with: Bladder infection, Fever. UTI [MEDICAL CONDITION]: Started on Keflex recently treated with [MEDICATION NAME] earlier this month. Remains afebrile here, but white blood count (WBC) 17.8 (elevated). Continue [MEDICATION NAME] Intravenously (IV) daily. Foley changed in emergency room [DATE]. Resident 2's hospital admission H&P in part, dated 5/25/15, In papers supplied by the facility, 5/6/15 urine culture shows 2 organisms - Escherichia coli (E-coli) and Proteus. He was on [MEDICATION NAME], which Proteus is resistant to. [MEDICATION NAME] should work for both organisms. E-coli was [MEDICATION NAME] resistant. Resident 2 is staying awake for a few seconds at a time. Physical exam: General: Somnolent, no distress, apneic episodes. Admission Diagnoses: [REDACTED]. On 9/15/15 at 4:15 PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 2's UTIs and urine culture resistant to [MEDICATION NAME]. DON B stated the facility follows the McGeer's standard of practice for all UTIs. DON B stated the nurses are to inform the physicians no antibiotics are to be started prior to the return of the cultures to ensure the proper medication is being administered. DON B stated antibiotics should not be prolonged for another cycle unless the symptoms and the culture identify a reason. DON B stated she would expect the nursing staff to review the symptoms and the previous culture with the Physician when medications are changed or when there is an extension of the current dose of medication. DON stated she would have expected the nurses to inform the Physician of the resistance to the medication prior to start of any doses. DON B stated only symptomatic UTI should be treated and only after a positive culture has returned. DON B continued to state Resident 2 should not have been on the [MEDICATION NAME] due to the medication was resistant to the organism and the Physician was not notified of the resistance to the antibiotic. Example 2 On 9/15/15 at 4:30 PM Surveyor interviewed Registered Nurse Consultant (RNC) X. Regarding the facility's policy for treating UTI's. RNC X stated the facility follows the McGeer's criteria for surveillance of infections. The Society for Healthcare Epidemiology of America (SHEA)/Center of Disease Control (CDC) Paper, dated October 2012, states .Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria .Table 5. For residents without an indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign and symptom sub criteria a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate b. Fever or leukocytosis (see Table 2) and at least 1 of the following localizing urinary tract sub criteria i. Acute costal vertebral angle pain or tenderness ii. Supra pubic pain iii. Gross hematuria iv. New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract sub criteria i. Supra pubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urgency v. New or marked increase in frequency 2. One of the following microbiologic sub criteria a. At least 10-5 cfu/mL of no more than 2 species of microorganisms in voided urine sample b. At least 10-2 cfu/mL of any number of organisms in a specimen collected by in-and-out catheter B. For residents with an indwelling catheter (both criteria 1and 2 must be present) 1. At least 1 of the following sign or symptom sub criteria a. Fever, rigors, or new-onset [MEDICAL CONDITION], with no alternate site of infection b. either acute change in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED]. purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate 2. Urinary catheter specimen culture with at least 10-5 cfu/mL of any organism(s) Resident 14's [DIAGNOSES REDACTED]. Resident 14's medical record contains the following entries: Urine Culture dated 2/5/15 states in part; > 100,000 Escherichia Coli (E-coli) and > 100,000 Streptococcus viridian's; E-[MEDICATION NAME]. Nursing notes dated 7/11/15 state in part; Resident complained of frequency with urination, burning and pain. Ordered received to collect urinalysis (UA); Urine sent to lab; positive results for UTI received. On call medical doctor (MD) ordered Cipro. UA Results dated 7/11/15 state in part; Blood: negative, UA [MEDICATION NAME]: positive, UA Leukocyte: large; Bacteria 4+. Telephone order dated 7/11/15 states in part; collect urine for UA.[MEDICATION NAME] milligrams (mg) 1 tab twice daily (BID) times 7 days. Nursing notes dated 7/13/15 states in part; Interdisciplinary Team (IDT) met to review initiation [MEDICATION NAME] UTI culture and sensitivity pending. Of note, Resident 14 has a Foley catheter and has a history [MEDICATION NAME] UTI's. The facility initiated treatment for [REDACTED]. Treating infections prior to receiving the culture and sensitivity report can lead to inappropriate antibiotic treatment and development of potential multi drug resistant organisms. Urine culture report dated 7/13/15 states in part; > 100,000 Proteus Miralilis;[MEDICATION NAME]. Nursing notes dated 7/14/15 at 3:00 AM state in part; temperature 97.4 continues on antibiotic Foley catheter draining well. Nursing notes dated 7/16/15 at 9:00 PM state in part; temperature 98.1 continues on antibiotic for UTI. Nursing notes dated 7/18/15 state in part; temperature 98.9 continues on antibiotic for UTI. No complaints of burning noted. Nursing notes dated 7/18/15 at 9:30 PM state in part; last dose of antibiotic given on day shift. Nursing notes dated 7/19/15 at 2:00 PM state in part; complaining of having to void, feeling full and abdominal discomfort. Unable to flush catheter, catheter changed and dark orange urine draining right away. Nursing notes dated 7/20/15 at 9:00 PM complaining of pain and burning with urination. On call MD notified. UA order received. Results returned on call physician [MEDICATION NAME] 1 dose than notify primary care provider (PCP) in AM for further orders. Telephone order dated 7/20/15 states UA and culture if indicated give 1 dose [MEDICATION NAME] mg tonight get orders from PCP tomorrow. UA results dated 7/20/15 state in part; UA blood: negative; [MEDICATION NAME]: positive; leukocytes: moderate; bacteria 3+. Nursing Notes dated 7/21/15 at 9:00 PM state in part; order received from PCP [MEDICATION NAME] UTI. Temperature 98.6. Telephone order dated 7/21/15 states in part;[MEDICATION NAME] mg by mouth twice daily for 10 days. Nursing notes dated 7/22/15 at 2:00 PM state in part; IDT met to review initiation [MEDICATION NAME] order for UTI related to positive UA obtained on 7/20/15. Urine culture report dated 7/22/15 states in part; > 100,000 E-coli; Resistant to Cipro. Nursing notes dated 7/22/15 at 3:05 PM state in part; new order received for [MEDICATION NAME] 1 gram Intramuscular daily for 7 days. Telephone Order dated 7/22/15 states in part; [MEDICATION NAME] 1 gram Intramuscular daily for 7 days. Discontinue Cipro. physician progress notes [REDACTED]. Of note Resident 14 urine culture grew out >100,000 of E-coli bacteria resistant to Cipro. Resident 14 received 4 doses [MEDICATION NAME] to the culture results being obtained. Resident 14 has a history [MEDICATION NAME] UTI's. Initiation [MEDICATION NAME] to culture results increases Resident 14's potential for MDRO. On 9/15/15 at 4:30 PM Surveyor interviewed RNC X regarding the use of antibiotic therapy prior to culture reports. RNC X stated it is up to the physician if they want to treat an UA prior to culture report. Surveyor asked RNC X if she would expect nursing to speak with the physician regarding the UA and that the sensitivity report is not back including resident history [MEDICATION NAME]. RNC X stated she would expect the nursing staff to document in the medical record that they spoke to the physician regarding the resident history [MEDICATION NAME] and that the sensitivity report was not complete. The facility failed to review Resident 14's history [MEDICATION NAME] with the physician. Resident 14 was treated [MEDICATION NAME] to the culture and sensitivity report being returned. Resident 14 was being treated with an antibiotic which due to her resistant history could present adverse consequences including multi drug resistance.

Based on interview and record review, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 2 residents reviewed for wounds (Residents 10 and 22) and 2 of 14 residents reviewed for pain. Resident 10 is identified as at risk for the development of impaired skin integrity. Resident 10 was admitted to the facility without skin impairment. Resident 10 has a [DIAGNOSES REDACTED]. The facility failed to complete weekly diabetic foot checks and weekly assessments and did not make changes to the care plan when periodic assessments showed deterioration in the ulcer. Resident 10's [MEDICAL CONDITION] to the left great toe became infected and progressed from a dime sized ulceration to a necrotic dry gangrene with the potential for amputation. Resident 10 did not receive the necessary assessments for treatment and care of the diabetic ulcer based upon the current standard of practice. Interventions were not put into place to promote healing and prevent pressure to the left great toe. Resident 10 was also observed during the survey process to have a diabetic ulcer on the left metatarsal head (bottom of foot below the left great toe). The facility was not aware of this ulcerated area. Observations were made that Resident 10 did not have current interventions in place to prevent impaired skin integrity or to promote healing, to include observations of: no specialized mattress, medial aspect of toe lying against standardized mattress with no blanket cradle. The sheet and blanket were pulled tight against Resident 10's left great toe ulcer and the left foot was not offloaded off the mattress. Resident 10 received antibiotic treatment for [REDACTED]. Resident 10 faces a potential amputation of the left great toe. The facility failed to ensure that Resident 10 received proper treatment and care for the diabetic ulcer, which resulted in an infection of the ulcer which then progressed to dry gangrene. Resident 10 faces a potential amputation of the left great toe. This created an Immediate Jeopardy situation that began 9/13/14. The Nursing Home Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/5/15. The facility removed the Immediate Jeopardy on 2/5/15 but the citation continues at a scope/severity level of G(actual harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan and as evidenced by the following. Resident 22 was admitted to the facility on [DATE] after an extensive hospital stay in which he was treated for [REDACTED]. Resident 22 had a surgical procedure for T12, L1 and L2 Laminectomy for drainage of lumbar spinal [MEDICATION NAME] abscess. On 1/29/15 Resident 22's medical doctor assessed his back incision to find bandage intact small serosanguineous drainage at base of the incision. Resident 22's pain was assessed to be decreasing. Resident 22 was assessed to be afebrile and clinical picture improving. Resident 22 had pain uncontrolled by a narcotic medication and bloody saturated dressings. The facility did not complete a pain assessment or a skin assessment on Resident 22 during his stay at the facility. Resident 22 was hosptalized on [DATE] and received a transfusion of 2 unit of packed red cells. Resident 22 was diagnosed with [REDACTED]. Resident 22 had surgery to repair the bleeding artery. Resident 11 was observed to be in moderate to severe pain with movement and the facility did not ensure that the doctor was contacted and that the plan of care/treatment was updated to manage Resident 11's pain. Resident 11 had multiple episodes of moderate to severe pain that were not fully assessed or treated. Resident 9 reported severe pain on the night shift. Resident 9 stated she requested a pain pill on 2 separate occasions and she did not receive her pain medication. Resident 9 stated she was unable to sleep due to the pain and had to meditate to relieve the pain. This is evidenced by: Example 1 The National Pressure Ulcer Advisory Panel: Prevention and treatment of [REDACTED]. Avoid positioning the individual on an area of [DIAGNOSES REDACTED] whenever possible. [DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading. Repositioning and early mobilization: General repositioning for all individuals: 2. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a preventive strategy. Reposition frequency: 1. Consider the pressure redistribution support surface in use when determining the frequency of repositioning. 2. Determine repositioning frequency with the consideration to the individuals; repositioning techniques: 1. Reposition the individual in such a way that the pressure is relieved or redistributed General recommendation for mattress and bed support surfaces: Select a support surface that meets the individual's needs. Consider the individual's needs for pressure for redistribution based on the following factors: Level of immobility, need for shear reduction, size and weight, risk for development of new pressure ulcer, and number and severity and location of existing pressure ulcers. Examine the appropriateness and functionality of the support surface on every encounter with the individual. The facility's policy Wound Prevention and Treatment dated 10/2014 states in part; the facility will consider all residents at risk for skin impairment and will implement the following interventions: ? reduce occurrence of pressure over bony prominence to minimize injury ? protect against external forces (pressure, friction and shear) The facility recognizes that even the most vigilant nursing care may not prevent the development and/or worsening of pressure ulcers in some residents. In those cases, intensive efforts will be directed at the following: ? management of the risk factors ? providing preventative interventions ? providing treatment Procedure: progression of wound healing will be documented by length, width and depth measurements. Documentation will also include s/s of infection. Regardless of who is doing the wound treatment, nursing services will do weekly assessment. Wound Algorithm: upon admit all residents are at risk for skin impairment. Complete upon admission: skin assessment, care plan, Braden and weekly x's 4. Complete a skin assessment upon re-admission, Implement preventative treatment interventions - other skin impairments: monitor area of skin impairment weekly using the Skin Grid-Pressure/Venous In sufficiency Ulcer/other and daily using the Treatment Administration Record (TAR) until healed. Continue weekly skin assessment on the TAR. Review and revise the Skin Integrity care plan. The facility uses a Panacea mattress as their standard mattress. Information provided by the facility indicated the mattress may be appropriate through a stage II pressure ulcer for pressure redistribution. On 2/5/15, at 09:30 AM Surveyor interviewed Registered Nurse (RN) BB regarding the facility skin care policy. RN BB stated a Braden assessment is completed on admission then weekly times 4 weeks. RN BB stated that when the facility identifies a resident to be at risk for skin impairment the facility should put appropriate interventions in place to prevent skin impairment. RN BB stated the facility completes weekly diabetic foot checks and that all wounds are assessed on a weekly basis. RN BB stated the facility is not aware of ulceration to the plantar aspect of Resident 10's foot but she would expect the area to be assessed and the medical doctor and family to be updated. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's primary language is Spanish, Resident 10 understands very little English. Resident 10's admission Braden assessment, dated 4/29/14, indicates Resident 10 scored a 17 indicating Resident 10 was at minimal risk for impaired skin integrity. The facility's Braden risk score indications are as follows: At Minimal Risk: 15 -18, Moderate Risk: 13-14, Very High Risk: 9 or below. The Braden assessment was again completed on 5/4/14 with a score of 14 at moderate risk, 5/11/14 with a score of 14 at moderate risk and 5/18/14 with a score of 16 minimal risk. The next completed Braden was 10/23/14 with a score of 14 moderate risk. There are no further Braden assessments after this date. Resident 10's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/14, indicates A Brief Interview for Mental Status (BIMS) was completed with Resident 10 scoring a 13 indicating Resident 10 is cognitively intact. Section M0150 of the MDS indicates Resident 10 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 10 requires extensive assistance for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states in part; admitted with no noted pressure ulcers. He is at risk related to decreased mobility, above knee amputation, diabetes, incontinence and needing extensive assist. Skin is monitored with cares. Resident 10's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/14. Section M0150 of the MDS indicates Resident 10 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 10 requires extensive assistance for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states in part; has no pressure ulcers. He is at risk related to needing extensive assistance with bed mobility. There is no documentation of the [MEDICAL CONDITION] in this CAA. Resident 10's comprehensive care plan Skin Integrity dated, 1/5/15 states in part; Assessment/Problem at risk related to (r/t): maximal remobilization, protect heels, frequent turning, manage moisture, nutrition, friction and shear, diabetes, diabetic [MEDICAL CONDITION], necrotic left great toe. Interventions to this comprehensive care planned problem include: complete Braden scale upon admission and weekly times 4 weeks, quarterly and with change of condition. Protect elbows and heels if being exposed to friction, inspect skin for signs and symptoms (s/s) of breakdown, protect elbows and heels as indicated. Monitor wound weekly. Of note, this is a standard care plan with check boxes. There are no updates to Resident 10's care plan to individualize interventions to prevent skin impairment for Resident 10. Nursing notes dated 9/13/14 (no time) state in part, fidgeting in bed, restless and calling out. Resident scraped his left great toe on the wall while fidgeting in bed new orders received to clean with normal saline apply Band-Aid every day until healed. Nurse Practitioner notes dated 9/15/14 state in part; only complaint today is that his left foot hurts. Band-Aid with shadow drainage noted to right {sic} great toe (should be left as resident has a right above the knee amputation). Skin: has a sore on his left great toe. Treatment Administration Records dated 9/14 state in part skin check weekly the weekly checks were not documented for 9/10 and 9/17. Podiatry progress note dated 10/13/14 states in part; chief complaint: presents with complaint of lesion on medial aspect of left hallux {sic} about 2 weeks. The patient presents with ulcer. The location of the ulcer is on the left, on the hallux. The duration of the ulcer has lasted for 2 weeks. Ulcer is described as dime size. Severity of the ulcer is moderate, not draining or red. Exacerbating factor consist of poor circulation. Dermatologic exam: ulcer on left, medial hallux. Arterial pulses are 1+ (barely palpable). Lower extremity sensation at the level of the ankle, at the level of the foot and the level of the toes is absent, to light touch, to proprioception and to vibration, length 0.7 centimeters (cm), width 0.7 cm, black, necrotic top to the ulceration, unstageable. Plan: Begin Santyl ointment on the toes and a dry sterile dressing to be changed daily to the toe ulcer. On 10/14/14 the facility completes the first wound assessment of the left great toe. Wound Information: Type: Vascular; Classification: Diabetic; Source: facility acquired; Date identified:10/14/14. Wound Measurements: length 0.7, width 0.9, depth unknown. 10/20-10/23 Resident 10 was inpatient at hospital. On 10/30/14 the facility wound assessment of the left great toe notes: Wound Information: Type: Vascular; Classification: Diabetic; Source: facility acquired; Date identified: 10/14/14. Wound Measurements: length 1.3 cm width 1.5 cm, depth unknown the periwound is described as [DIAGNOSES REDACTED]. Of note, Resident 10 is inpatient at the hospital from 10/20 - 10/23. A Braden is completed on 10/23/14 however, there is no wound assessment on 10/23/14; the next assessment does not occur for 7 days. Treatment Administration Records dated 10/14 state in part; diabetic foot checks weekly. The weekly checks were not documented for 10/29. On 11/6/14 the facility wound assessment of the left great toe notes: Wound Information: Type: Vascular Classification: Diabetic, Source: facility acquired, Date identified: 10/14/14. Wound Measurements: length 1.6 cm width 2.3 cm, depth unknown the periwound is described as [DIAGNOSES REDACTED]. Of note, Resident 10 is inpatient at the hospital from 11/8 - 11/12. A Braden is not completed upon re-admission on 11/12/14. There are no further assessments of this wound until 2/3/15. The following occurs at hospital stay from 11/8 -11/12/14: Wound culture dated 11/8/14 states in part Moderate [MEDICATION NAME] and [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Podiatry progress note dated 11/10/14 states in part; there is an ulcer on the left, hallux the duration of the ulcer has lasted 6 weeks. The ulcer is described as quarter size. The severity is moderate. The patient has the toe area of eschar covered again, but the [DIAGNOSES REDACTED] is gone. There is an ulcer on the left, medial hallux length 1.8 centimeter (cm) width 0.9 cm depth 0.2 cm, black, necrotic top to the ulceration stage III, full thickness. Arterial pulses are 1+ (barely palpable). Lower extremity sensation at the level of the ankle, at the level of the foot ant the level of the toes is absent, to light touch, to proprioception and to vibration. Indication: necrotic tissue, wound black, dry necrotic, dressing applied: dry, 4X4's, Santyl ointment, secured with tape. Diagnosis: [REDACTED]. Podiatry progress note dated 11/11/14 states in part; culture of toe shows [MEDICATION NAME]. Wound care for the toe ulcer: please cleanse wound with wound cleanser; mix Santyl ointment and [MEDICATION NAME] ointment together in 1/1 mixture. Of note, podiatry saw Resident 10 as inpatient at hospital on this date. Progress note dated 11/11/14 states in part; postponed transfer to nursing home; [MEDICATION NAME] 500 milligrams (mg) by mouth every 12 hours. Podiatry progress note dated 11/12/14 states in part; problem list: [MEDICAL CONDITION] of the digit. Dermatologic Exam: Ulcer left media, hallux, still mildly swollen around the area and the area is slightly red, stage III, full thickness. Wound Care: please cleanse wound with wound cleanser; mix Santyl ointment and [MEDICATION NAME] ointment together in 1/1 mixture, apply mixture to wound bed daily, cover with [MEDICATION NAME], 2X2 gauze, kerlix roll and secure with tape. Change dressing daily until healed. Resident 10 returned from the hospital on [DATE]. There is no wound assessment completed upon Resident 10's return. Discharge instructions dated 11/12/14 state in part; [MEDICATION NAME] DS (antibiotic) 800mg-160mg 1 tablet 2 times a day for 14 days. Podiatry progress note dated 11/26/14 states in part; the ulcer is on the left medial hallux, length 4.0 cm, width 2.0 cm depth 0.2 cm stage III full thickness. Eschar is crossed hatched to allow for the Santyl ointment to be able to penetrate into the necrotic tissue. Course: worsening; follow- up in 2 weeks. Treatment Administration Records dated 11/14 state in part diabetic foot checks weekly. The weekly checks were not documented for 11/18 and 11/25/14. Resident 10 is inpatient at hospital from 12/8-12/9/14. There is no wound assessment upon return from the hospital. Treatment remains the same. Wound Culture Results: Source Abscess dated 12/15/14 [MEDICAL CONDITION] and [MEDICATION NAME] cloacae. Telephone Orders dated 12/15/14 state in part; assess for peripheral inserted central catheter (PICC) line insertion. [MEDICATION NAME] 1 gram intravenous (IV) times 14 days. Per RN BB the [MEDICATION NAME] is ordered for [DIAGNOSES REDACTED] and wound infection. Consultation Report dated 12/19/14 states in part; Wound evaluation, continue IV antibiotics for the next 2 weeks; [DIAGNOSES REDACTED]. Telephone order dated 12/19/14/ states cleanse wound with wound cleanser, apply Santyl ointment to wound bed daily cover with [MEDICATION NAME] 2X2 guaze, kerlix roll and secure with tape change daily until healed continue Intravenous antibiotics. Telephone order dated 12/20/14 states give today's 1000 mg dose of [MEDICATION NAME] than change order to [MEDICATION NAME] 1500 mg intravenous (IV) every 24 hours. Podiatry Progress note dated 12/20/14 states in part chronic arterial ulcer of left great toe, severity of ulcer is moderate the odor is better and the [DIAGNOSES REDACTED] in the area is less still has a little bit in the area but not as bad as it was. Continue IV antibiotics for the wound; IV antibiotics for 6 weeks or more due to circulatory status, not sure he would be able to heal; an amputation of the toe and may need something more proximal, but may not be able to tolerate that type of a surgical intervention. Course: worsening. Of note Resident 10 was inpatient at hospital from 12/22/-12/31/14. Hospital History and Physical 12/22/14 states in part; [DIAGNOSES REDACTED]. Blood Culture Results dated 12/22/14 indicate Staph coagulase negative isolated in one blood culture. Hospital discharge summary dated 12/31/14 states in part; health care associated pneumonia, secondary necrotic left toe, vascular surgery evaluated toe no obvious signs of infection. Follow up vascular surgery amputation pending. Treatment Administration Records dated 12/14 state in part diabetic foot checks weekly. The weekly checks were not documented for 12/9 and 12/16/14. Telephone orders dated 1/2/15 state in part; necrotic toe swab with [MEDICATION NAME] twice daily, leave open to air. Of note Resident 10 was inpatient 1/20 - 1/23/15. Interdisciplinary notes dated 1/21/15 state in part; unresponsive episode at clinic admitted to [MEDICAL CONDITIONS] bacteremia, and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) urine. Hospital discharge summary dated 1/23/15 states in part; Primary Diagnosis: [REDACTED]. Secondary Diagnosis: [REDACTED]. Of note, a physical exam at discharge states: additional <1cm black dry lesion on bottom of 1st metatarsal. Of note the facility was not aware of this area until Surveyor notified the facility of the ulcer to the metatarsal head. Resident 10 returned to the facility on [DATE]. There is no wound assessment completed on this date or until 2/3/15. On 2/3/15 the facility completes a wound assessment of the left great toe for the first time since 11/6/14. Wound Information: Type: Vascular Classification: Diabetic, Source: Present on admitted identified: 2/3/15. Wound Measurements: length 4.0 cm, width 2.5 cm, depth unknown, clinical stage: full thickness. Of note, this assessment states the wound is discovered on 2/3/15 and was present on admission as a full thickness vascular ulcer of the left great toe. This is the same toe that has been described in the above documentation since 9/13/14. On 2/3/15 at 8:00 AM Surveyor observed Resident 10 lying on left side, with blankets tightly around left foot. There was no foot cradle on the bed and Resident 10's left foot was lying against the mattress - left foot was not offloaded off the mattress. On 2/3/15 at 11:00 AM Surveyor observed Resident 10 lying on left side, with blankets tightly around left foot. There was no foot cradle on the bed and Resident 10's left foot was lying against the mattress - left foot was not offloaded off the mattress. On 2/3/15 at 1:30 PM Surveyor observed Resident 10 lying on left side, with blankets tightly around left foot. There was no foot cradle on the bed and Resident 10's left foot was lying against the mattress - left foot was not offloaded off the mattress. On 2/3/15 at 4:30 PM Surveyor observed Resident 10 lying on left side, with blankets tightly around left foot. There was no foot cradle on the bed and Resident 10's left foot was lying against the mattress - left foot was not offloaded off the mattress. On 2/4/15 at 7:45 AM Surveyor observed Resident 10 lying on left side, with blankets tightly around left foot. There was no foot cradle on the bed and Resident 10's left foot was lying against the mattress - left foot was not offloaded off the mattress. On 2/4/15 at 10:55 AM Surveyor observed care being provided for Resident 10. Certified Nursing Assistant (CNA) I removed Resident 10's gripper sock off the left foot. Surveyor observed the left great toe with a large black cap around the entire circumference of the foot. Surveyor also observed pea-sized black, necrotic area to the posterior aspect of the foot at the metatarsal head. There was no dressing to either the wound on the toe or to the posterior foot. CNA I placed the gripper sock on Resident 10's foot. Surveyor asked CNA I how long Resident 10 has had the ulceration to the foot and CNA I stated "A while". On 2/4/15 at 1:30 PM Surveyor asked Director of Nursing (DON) B regarding wound assessments. DON B stated he completes wound assessments in wound rounds weekly. DON B was only able to show wound documentation for Resident 10 for 10/14/14, 10/30/14 and 11/6/14 and 2/3/14. DON B stated Resident 10 has been in and out of the hospital so much that he did not believe there was documentation for December and he would check for documentation for January. DON B stated that wounds are assessed on a weekly basis. On 2/5/15 at 1:45 PM Surveyor observed Resident 10 lying on his right side with his great toe placed directly on the mattress. Resident 10's foot was not offloaded. Surveyor asked CNA EE if Resident 10's foot should be floated on a pillow. CNA EE asked Resident if she could place his foot on a pillow and Resident 10 allowed her to offload his foot on a pillow. CNA EE exited the room and asked Assistant Director of Nursing (ADON) C if Resident 10 should have his heels offloaded. ADON C stated he would have to check Resident 10's plan of care. ADON C did not report back to Surveyor . Resident 10's foot remained on the pillow. On 2/5/14 at 9:30 AM Surveyor interviewed RN BB regarding Resident 10's diabetic ulcer. Surveyor asked RN BB if the facility completes weekly foot checks for residents with diabetes. RN BB confirmed it is expected that the facility complete weekly foot checks. Surveyor asked RN BB if Resident 10 was identified as at risk for impaired skin integrity on admission per the MDS, CAA and Braden would it be expected that Resident 10 have interventions in place to prevent impaired skin integrity. RN BB stated that in light of Resident 10's risk factors it would be expected that items such as a foot cradle, offloading of foot, and air mattress be in place to prevent impaired skin integrity. On 2/5/15 at 11:00 AM RN BB stated to Surveyor that the facility did not have any further Braden or wound assessments "I'm sorry to say we dropped the ball." RN BB stated she measured Resident 10's wound to the metatarsal head and had updated the physician for wound treatment. RN BB stated there was no assessment or wound documentation for this wound. RN BB further stated the facility does not have a policy for diabetic foot checks and that in light of further skin impairment the facility would be placing Resident 10 on a specialized mattress. Telephone orders dated 2/5/15 state in part; Left great toe treatment wash with normal saline daily, pat dry. Paint with [MEDICATION NAME]. Cover with kerlix for protection. Place foot cradle on bed to protect toe, air mattress and float heel when in bed. On 2/9/14 at 9:30 AM Surveyor observed Resident 10 lying in bed on his back. Resident 10 had a dressing to the left foot, a foot cradle on his bed and was lying on an air mattress. On 2/9/15 Surveyor interviewed Interim DON D regarding Resident 10's interventions to prevent skin integrity. Interim DON D stated that she expected, based on Resident 10's Braden and MDS assessment and the knowledge that Resident 10 was determined to be at risk for skin impairment, that staff should have placed appropriate interventions in place to prevent skin impairment. Resident 10 was admitted to the facility with significant co-morbidities placing him at increased risk for skin impairment. The facility failed to implement a plan of care to prevent impaired skin integrity. Furthermore once, Resident 10 developed a skin impairment the facility failed to complete weekly assessments or monitor for worsening of the ulceration or implement interventions to prevent further skin impairment. Resident 10 developed an additional ulceration to the metatarsal head of the left foot and the facility was not aware of this ulceration until notified by Surveyor . Resident 10's diabetic ulcer of the left toe became infected and progressed to a dry gangrene. Resident 10 has a follow-up pending for potential amputation of this diabetic ulcer. Resident 10 developed a [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) infection, which can spread and become life-threatening because it is resistant to many common antibiotics. The resident was also at risk for an amputation of the foot or leg and the complications associated with this type of surgery. According to the article "Complications of [MEDICAL CONDITION] in Diabetic Foot Infections," "Patients with diabetes have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes." This article also notes that "Diabetic foot infections that are not appropriately treated because of delayed [DIAGNOSES REDACTED]." <http://www.medscape.com/viewarticle/ 0>. According to "Amputations - Complications," Complications associated with having an amputation include: ? heart complications - such as [MEDICAL CONDITION] ? blood clots (venous [MEDICAL CONDITION]) ? slow wound healing and wound infection ? pneumonia (infection of the lungs) ? stump and "phantom limb" pain ? psychological problems "The loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one. Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands." <http://www.nhs.uk/Conditions/Amputation/Pages/Complications.aspx> The failure to ensure that Resident 10 received appropriate care and treatment for [REDACTED]. The Immediate Jeopardy situation was determined to be removed on 2/5/15 when the facility began implementing the following: Completed a comprehensive wound and pain assessment on Resident 10, updated attending physician on Resident 10's current condition, Implemented new orders; including preventative skin breakdown measures, floating of heel, foot cradle and air mattress; educated nurses regarding wound care program; updated Resident 10's plan of care; all new admissions will have a skin assessment completed by two nurses; one which will be a Registered Nurse. The deficient practice continues at a scope/severity level of G (actual harm/isolated) as evidenced by the following: Example 2 The facility policy entitled Pain Management Revised 7/2012, states in part; pain refers to any type of physical pain or discomfort in any part of the body. Pain can be expressed through behaviors in both verbal and non-verbal residents. Additional expressions of pain that need to be included in an evaluation include: a. vocalization of pain: moaning/groaning/grunting; c. Facial expressions: grimaces, winces, wrinkled forehead. All residents are initially screened for pain upon admission, quarterly, with significant change in condition and any time it is suspected a resident is in pain. The facility promotes resident slef-report as the most reliable indicator of pain. Residents with cognitive impairment will be assessed for pain based on objective clinical assessments, use of "proxy" pain reporting, and behavioral characteristics. Purpose: reduce physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. Procedure: members of the interdisciplinary team (IDT) will advocate for resident comfort and find clinically appropriate, cost-effective ways of achieving it. 1. Complete the Pain Data Collection Assessment a. admission, re-admission, quarterly with significant change and any time the resident has a new type/location of pain. 7. Identify potential cause of pain. 8. Determine the appropriate interventions to manage pain include both pharmacological and non-pharmacological interventions. 13. Review and revise pain management care plan. 14. Provide staff training as need, on pain management interventions. 15. Evaluate and document the effectiveness of pain management. 16. Notify the provider if interventions are not effective in achieving resident comfort. 17. Reassess resident status as indicated 18. Screen residents for pain regularly. An evidence-based protocol entitled "Acute Pain Management in the Elderly" by the University of Iowa, written 6/2000, states in part: "...Guide for Monitoring Acute Pain...2. Assess and document characteristics, intensity, duration, and effects of pain using selected assessment tools...Assess pain at least every two to four hours around the clock and during rest, during activity, and through the nighttime when pain is often heightened...Once every eight hours may be appropriate if pain is mild or well-controlled...Ask about pain and observe non-verbal pain-related behaviors during transfers or patient care activities...In all patients, observe for nonverbal cues of pain (e.g. grimacing, guarding) and behavioral changes (e.g. new onset of confusion, agitation and/or withdrawal; sleep disruptions; changes in activity)...3. Document pain in a visible place that can be used by other health care professionals...Information to document include: date; time; pain intensity rating; quality such as sharp, dull, burning, etc.; location; onset and duration; comfort goal; [MEDICATION NAME] information (e.g. drug, dose, route, frequency); other pain interventions; vital signs and side effects...Guide for Pharmacological Management...Pharmacological management for mild to moderate pain should begin, unless contraindicated, with a nonopioid (NSAID (Non-Steroidal Anti-[MEDICAL CONDITION]) or

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 4 of 4 residents (Residents 5, 11, 16, and 18). Resident 5, whose [DIAGNOSES REDACTED]. When multiple pressure ulcers developed, Resident 5 did not receive appropriate care and treatment to promote healing and prevent additional pressure ulcers. The facility's failure to put preventive measures in place upon admission with Resident 5's history and risk and the lack of appropriate care plan interventions once the areas were identified by the podiatrist created a finding of immediate jeopardy. The immediate jeopardy began on 1/5/15 when the podiatrist identified 2 pressure ulcers and a bruised area and the facility did not implement interventions to prevent further skin breakdown. Administrator A was notified of the immediate jeopardy on 2/5/15 at 3:10 PM. The immediacy was removed on 2/5/15 and continues at as severity and scope of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan and as evidenced by the following. Resident 16 is assessed to be at risk for the development of a pressure ulcer (PU). Observations were made when Resident 16 did not have interventions in place to prevent pressure ulcers to include bilateral heels not floated. Resident 11 did not have measures put into place to prevent pressure ulcers (PU) and had a history of [REDACTED]. The facility did not ensure that Resident 18 was positioned in bed to minimize the risk of skin breakdown. This is evidenced by the following: Example 1 Resident 5 was admitted to the facility on [DATE] following hospitalization for osteo[DIAGNOSES REDACTED] of the fourth toe on the left foot resulting in amputation of the fourth toe (12/21/14). Resident 5 had previously had the left foot fifth toe and three toes on the right foot amputated. Resident 5's [DIAGNOSES REDACTED]. Resident 5 also has a non-healing wound on her left thigh. Resident 5 goes to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. Resident 5's History and Physical, printed on 12/24/14, indicates Resident 5 has significant [MEDICAL CONDITION] with diminished sensation to her feet. Extremities are warm, but there are no palpable pulses. Decreased sensation to light touch is noted bilaterally. Resident 5's admission skin assessment, dated 12/26/14, notes amputations on bilateral feet, incision near left knee, and various old scars. Despite the resident's history and diagnoses, Resident 5's Braden Scale for predicting Pressure Ulcer Risk was completed on 12/26/14 with a score of 16 indicating a minimum risk for developing pressure ulcers. Resident 5's care plan for skin integrity, dated 12/26/14, identifies the following interventions: protect elbows and heels as needed (no indication how to do this) and Inspect the skin for s/s (signs and symptoms) of breakdown. On 1/5/15 Resident 5 was seen at the clinic by the podiatrist. The "Report of Consultation" indicates: Reason for consultation: New ulcerations/post op Current orders: Santyl ointment to planter right foot ulceration, cover with pad to off load area, then dry dressing, change daily. Discontinue walking, may still transfer. Diagnosis: [REDACTED]. On 1/5/15 the facility obtained a telephone order from Resident 5's podiatrist for Santyl ointment to plantar right foot ulceration. Cover with pad to offload area then dry dressing. Change daily. There was no nursing documentation prior to this podiatry appointment to indicate that staff was aware of the right foot plantar ulcerations. There is no information other than the "Report of Consultation" and telephone order in Resident 5's medical record regarding the pressure ulcers until 1/7/15. The facility did not have the podiatry clinic notes for 1/5/15 until requested by Surveyor on 2/4/15. The podiatry clinic notes indicate an ulcer on the right plantar, forefoot, length 2 cm width 1.5 cm depth 0.1 cm, stage full thickness under the second metatarsal head. There is bruising of the heel of the left foot in the posterior lateral aspect of the heel. The right heel has a scabbed area in the same location. Wound Assessment: 1. Right plantar foot- there is fibrosis seen in the center of the wound, discharge moderate amount, [MEDICAL CONDITION] changes, course worsening. 2. Left posterior lateral heel- color black and blue, characteristics soft but intact skin. 3. Posterior right heel- characteristics scabbed. Plan: Will need to continue IV antibiotics for another four weeks. I have evaluated the new ulcerations and we will begin to take the pressure off the right foot ulceration. I have given Resident 5 pads to help do this for the right foot plantar ulceration. I do not want Resident 5 to walk on this but may transfer on the foot. I have instructed the staff to use Santyl ointment on the area. For the heel ulcerations she will need to use pillows under the heels or will need to use heel protection while in bed. The facility assessed Resident 5's pressure ulcers on 1/7/15: 1. Right plantar foot Type of wound: pressure Date identified: 1/7/15 Clinical stage: Stage 2 Tissue: 100% pink non-granulating. Size: length 2.5 cm, width 1.9 cm, depth 0. The assessment includes a picture of Resident 5's right planter foot. In the picture you can see brown tissue covering approximately 50% of the wound bed. 2. Left heel Type of wound: pressure Date identified: 1/7/15 Clinical stage: Suspected Deep-Tissue injury Tissue: [MEDICATION NAME] Tissue-intact skin Size: length 5 cm, width 4.5 cm, depth 0. -There was no assessment for the right heel scabbed area. Resident 5's care plan was updated on 1/7/15 to include a specialty air mattress. No other changes to the care plan were made. The facility did not obtain an air mattress until 1/21/15. On 1/14/15 Resident 5's wound assessments were: 1. Right plantar foot Clinical stage: Stage 2 Tissue: 100% pink non-granulating. Size: length 1.8 cm, width 1.4 cm, depth 0. 2. Left Heel Clinical stage: Suspected Deep-Tissue injury Tissue: [MEDICATION NAME] Tissue-intact skin 100% Size: length 5 cm, width 4.5 cm, depth 0. -There was no assessment for the right heel scabbed area. The facility did not have the clinic notes from Resident 5's podiatry appointment on 1/20/15 until requested by Surveyor on 2/4/14. The clinic notes indicate the ulcer on the right plantar forefoot length 1.7 cm, width 1.1 cm, depth 0.1 cm, stage full thickness. There is bruising of the heel on the left foot that is resolving. The right heel has a scabbed area in the same location. Wound Assessment: 1. Right plantar foot- fibrosis seen in the center of the wound, discharge moderate amount, [MEDICAL CONDITION] changes. Course worsening. 2. Left posterior lateral heel- color black and blue, characteristics soft but intact skin. 3. Right posterior heel-scabbed. Plan: I do not want her to walk on this, but may transfer on the foot. For the heel ulcerations she will need to use pillows under the heels or will need to use heel protection while in bed. On 1/20/15 the facility obtained a telephone order from Resident 5's podiatrist for-No walking, may transfer. On 1/21/15 the facility faxed Resident 5's physician requesting an order for [REDACTED]. On 1/21/15 check inflation of MA65 air mattress with bolsters every shift was added to Resident 5's treatment administration record. On 1/21/15 Resident 5's facility wound assessments were: 1. Right plantar foot Clinical stage: Stage 2 Tissue: 100% pink non-granulating. Size: length 1.9 cm, width 1.4 cm, depth 0. 2. Left Heel Clinical stage: Suspected Deep-Tissue injury Tissue: [MEDICATION NAME] Tissue-intact skin 100% Size: length 5 cm, width 4.5 cm, depth 0. -There was no assessment for the right heel scabbed area. On 1/27/15 Resident 5's facility wound assessments were: 1. Right plantar foot Clinical stage: Stage 2 Tissue: 100% pink non-granulating. Size: length 1.8 cm, width 1.3 cm, depth 0. 2. Left Heel Clinical stage: Suspected Deep-Tissue injury Tissue: [MEDICATION NAME] Tissue-intact skin 100% Size: length 6 cm, width 4.5 cm, depth 0. -There was no assessment for the right heel scabbed area. On 2/3/15, Resident 5 was seen by the podiatrist. The podiatry notes indicate the ulcer on the right plantar foot length 1.5 cm, width 1 cm, depth 0.1 cm stage full thickness. There is bruising of the heel on the left foot in the posterior lateral aspect of the heel that is resolving. After I have debrided the area, it appears healed underneath this. The right heel has a scabbed area in the same location and again this area appears healed. Wound Assessment: 1. Right plantar foot- fibrosis seen in the center of the wound, discharge moderate amount, [MEDICAL CONDITION] changes. Course improving. 2. Left posterior lateral heel- color black and blue, characteristics healed skin under the blister. 3. Right posterior heel-scabbed. Plan: I do not want her to walk on this, but may transfer on the foot (bold and underlined). For the heel ulcerations she will need to use pillows under the heels or will need to use heel protection while in bed. On 2/3/15 Resident 5's facility wound assessments were: Left Heel Clinical stage: Suspected Deep-Tissue injury Tissue: Granulation tissue-pale pink non-granulating 60% Size: length 2.5 cm, width 0.5 cm, depth 0.2 cm. On 2/4/15 Resident 5's facility wound assessments were: Right plantar foot Clinical stage: Stage 2 Tissue: 100% pink non-granulating. Size: length 1.8 cm, width 1 cm, depth 0. -There was no assessment for the right heel scabbed area. On 2/4/15, at 8:56 AM, Surveyor observed Resident 5 lying in bed. Resident 5 had an air mattress in place and a heel lift boot on her left foot and a pillow under the left foot however it did not elevate the boot off the mattress. The bottom of Resident 5's left foot was pressing against the foot board. Resident 5's right foot was directly on the mattress. On 2/4/15, at 9:53 AM, Surveyor observed Licensed Practical Nurse (LPN) G provide wound care for Resident 5. Upon entering the room Resident 5 was in bed, the left foot was resting directly on a pillow (not floated) and the right foot was directly on the bed. There was an adhesive foam pad with the wound open to air in the center on the right foot but no other dressings in place on Resident 5's feet. LPN G stated DON B had been in the room and removed the dressing earlier. LPN G moistened a 4X4 gauze pad with saline and dabbed the wound via the opening of the adhesive foam pad on the right plantar foot with the gauze. LPN G did not remove the foam pad on Resident 5's foot. LPN G then applied Santyl to the wound bed, covered with 4X4 gauze and wrapped with kerlix. LPN G did not change her gloves or wash her hands after cleaning the wound and prior to applying the clean dressing. Surveyor also noted a dark scabbed area on the right heel. There was no treatment done to this area. Surveyor then observed Resident 5's left heel. The Achilles area was black about 2 cm long by 0.5 cm wide. LPN G began placing Resident 5's gripper socks on, then stopped and asked Resident 5 if she would like the left heel area covered. Resident 5 relied yes. LPN G then covered the area with a dry dressing. LPN G put Resident 5's gripper socks on and left the room. LPN G did not float Resident 5's heels or reapply the heel lift boot to the left foot. Following the observation Surveyor interviewed LPN G. LPN G stated she should have washed her hands following cleaning the wound and before placing the clean dressing. LPN G also stated she thought the foam pad could be left on and she would contact the podiatrist for orders on changing the foam pad and Resident 5's physician for treatment orders for the other areas. On 2/4/15, at 10:14 AM, during the interview with LPN G, Surveyor observed Certified Nursing Assistant (CNA) H enter Resident 5's room. CNA H offered and put the heel lift boot on Resident 5's left foot. CNA H also offered to reposition Resident 5 in bed as her foot was touching the foot board but Resident 5 declined the repositioning. Surveyor interviewed Resident 5 who stated she has had the heel lift boot since a couple days after she was admitted . On 2/4/15, at 10:30 AM, Surveyor interviewed DON B. DON B stated he had gone to assess Resident 5's wounds and removed the dressings. DON B stated the podiatrist had scraped the scab off Resident 5's left heel and now the area is smaller. Surveyor asked DON B how many wounds does Resident 5 have and where. DON B stated there is the right plantar wound, left heel wound and a surgical wound on her left thigh. DON B did not note the right heel scab and when Surveyor asked he stated he was unaware of a scab on her right heel. DON B stated the left heel area appeared to be caused by Resident 5 pushing herself up in bed so DON B educated her on calling for help and instituted the heel lift boot and air mattress. DON B continued to state there should be a pillow under both feet to keep them floated off the mattress. On 2/4/15, at 11:25 AM, Surveyor interviewed Resident 5. Resident 5's had a heel lift boot on the left boot and it was floated on a pillow. Resident 5's right foot was directly on the mattress. Resident 5 again stated the facility placed the boot on her left foot after the open area was found. Resident 5 then stated DON B was just in the room and stated he was going to get another pillow to place under her right foot. Resident 5 stated the facility has never given her anything to float her right foot and when it gets sore she just hangs it off the edge of the bed. Resident 5 stated on the days she goes out to [MEDICAL TREATMENT] they do not always do the dressing change to her feet. On 2/4/15, at 12:42 PM, LPN G informed Surveyor that she obtained an order for [REDACTED].) On 2/5/14, Surveyor reviewed Resident 5's treatment administration records. The following dates in 2015 are blank, with no explanation why, for Santyl Ointment to plantar right foot ulceration: 1/14, 1/22, 1/23, 1/24, 1/29, 2/1, and 2/3. On 2/5/15, Surveyor reviewed the communication book for Resident 5 between the facility and the [MEDICAL TREATMENT] center. There is no indication in the communication book that Resident 5 has pressure ulcers on her feet and that they should be floated off the chair. On 2/5/15, at 8:42 AM, Surveyor interviewed DON B who stated he noted Resident 5's right heel pressure ulcer after Surveyor spoke with him about it. DON B stated he did not see the area when he had removed the dressing the previous day. DON B measured the right heel pressure ulcer as 1.2 cm by 1.5 cm. Resident 5's husband then put on her socks and put a surgical shoe on the right foot and a tennis shoe on the left foot and left for [MEDICAL TREATMENT]. Surveyor then continued the interview with DON B. DON B stated the right heel scab area is an unstageable pressure ulcer. DON B stated wounds should be assessed immediately when they are noted and that the nurse manager should be reviewing consultation reports when residents return from appointments. DON B stated all heels should be elevated in bed even if the resident has an air mattress, usually with a pillow and if a resident requires a heel lift boot it should be on the care plan. DON B again stated there had been no assessment by the facility of the right heel pressure ulcer prior to 2/5/15. The failure to provide needed care placed the resident at high risk for complications related to her diabetes. According to http://emedicine.medscape.com/article/ 2-overview#a0156 <http://emedicine.medscape.com/article/ 2-overview>, " 15% (of diabetics) develop a foot ulcer, and 12-24% of individuals with a foot ulcer require amputation. Indeed, diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. " (Diabetics account for 3% of the US population and for over half of all nontraumatic lower leg amputations.) Similarly, the American Family Physician notes, "The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus ... The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. " <http://www.aafp.org/afp/1998/0315/p1325.html>. Resident 5's recent amputation due to an infected ulcer and medical [DIAGNOSES REDACTED]. The facility was not proactive in the prevention of the pressure ulcers. When Resident 5 did develop pressure ulcers the facility was not aware of them and did not put measures in place to promote healing and prevent additional pressure ulcers even after they were identified by the podiatrist. The immediate jeopardy was removed on 2/5/15 when the facility took the following measures: -Completed a comprehensive wound assessment for Resident 5 -Resident 5's physician was notified of current condition and new treatment orders were obtained. -Resident 5's care plan was updated with pressure ulcer prevention interventions. -A skin assessment was completed on all residents. -Validated all preventative measures were in place for all resident. -Educated nurses working and all nurses prior to their next shift on preventative skin care. -Implemented all new residents will have a skin assessment completed by two nurses. -Ensured that all paperwork is obtained on all podiatry consults. Example 2 The American Medical Directors Association's (AMDA) "Pressure Ulcers in the Long-term Care Setting" (2008) states, in part, ..Step 7; Provide general support for the patient...Patients who have or are at risk for developing heel ulcers (e.g. postoperative hip or knee surgery patients) will require offloading or pressure-redistribution device (e.g., heel boot, heel elevator, heel lift, suspension boot, or device that 'floats' the heel) to relieve pressure on the heels." Resident 16's [DIAGNOSES REDACTED]. Resident 16 Care Area Assessment Summary (CAAS), dated 2/3/15, Triggered conditions: 5. Resident at risk for developing pressure ulcers as indicated by: Is this resident at risk for developing pressure ulcers? = Yes. Resident 16 comprehensive care plan titled Skin integrity, dated 1/22/15, in part Intervention Position calves on pillow to elevate heels off the bed. Resident 16's Certified Nursing Assistant (CNA) care delivery guide, undated, under the column titled: Skin interventions: This column is blank for Resident 16. Unmarked column indicates Monitor and report any bleeding secondary to anticoagulant. Ambulate with Four wheeled walker (FWW) 3 times a day with wheel chair follow with minimal assist. Resident 16 care delivery guide does not direct the CNAs to elevate Resident 16's heels. Resident 16's Braden risk assessment scale indicates Resident 16 has a Braden score of 16. Resident 16's Braden scale score indicates Resident 16 is at risk for skin breakdown. On 2/5/15, at 2:25 PM, Surveyor observed Resident 16 lying in bed. Resident 16 was fully clothed and was not covered with a sheet or blanket. Resident 16's bilateral heels were placed directly on the pillow, which was placed under Resident 16's calves. Resident 16's heels were not floated. On 2/9/15 at 10:15 AM Surveyor spoke with Interim Director of Nursing (IDON) D regarding Resident 16's heels. IDON D stated she would expect Resident 16's care plan to be followed and Resident 16's heels are to also be floated off of the pillow. IDON D stated the facility is going to obtain a device to ensure the heels will be floated instead of just relying on the pillows. Example 3 Resident 11's [DIAGNOSES REDACTED]. Resident 11's Care Area Assessment Summary (CAAS), dated 10/17/14, triggered conditions: 5. Resident at risk for developing pressure ulcers as indicated by: Is this resident at risk for developing pressure ulcers? = Yes. Resident 11's comprehensive care plan titled Skin integrity, dated 10/14, state in part Intervention blue boots on at all times, palm protectors bilateral hands. Resident 11's Certified Nursing Assistant (CNA) care delivery guide, undated, under the column titled: Skin interventions: state monitor skin to hand splint area, blue boot area. Resident 11's Braden risk assessment scale indicates Resident 11 was at a high risk for PU. On 2/3/15 at 9:30 AM Surveyor observed care being provided for Resident 11. Resident 11's leg was resting against the arm rest of her Broda chair with no barrier between the armrest and her chair. Surveyor asked Registered Nurse (RN) KK if Resident 11 she was concerned about the leg being up against the arm rest of the chair with no barrier in between RN KK moved Resident 11 leg and there was a blanchable area of [DIAGNOSES REDACTED]. RN KK placed the leg back against the arm rest and did not place a barrier between the arm rest and Resident 11's leg. On 2/3/15 at 2:55 PM Surveyor observed care being provided to Resident 11 by Certified Nursing Assistants (CNA) LL and CNA MM Resident 11 was not wearing blue boots or palm protectors. Surveyor asked CNA LL about the blue boots and palm protectors CNA LL stated they do not put them on anymore because the husband does not like them used. On 2/4/15 at 12:00 PM Surveyor observed Resident 11 being transferred from her broda chair to bed by CNA NN and CNA II. Resident 11 was not wearing her blue boots or her hand protectors. Surveyor asked CNA NN about the blue boots and palm protectors CNA NN stated they do not use anymore as husband does not want them to be used. On 2/9/15 at 12:45 PM Surveyor interviewed Interim DON D regarding pressure prevention interventions for Resident 11. DON D stated she would expect the staff to use the ordered and proper interventions to prevent skin breakdown. Example 4 Resident 18 was readmitted to facility on 10/24/14 with [DIAGNOSES REDACTED]. Resident 18 is currently receiving wound vac therapy (Negative Pressure Wound Therapy) for an ulcer on her coccyx. According to the MDS (Minimum Data Set) assessment dated [DATE], Resident 18, is at risk for pressure ulcer development. Resident 18's skin integrity care plan, dated 10/14, identifies Resident 18 as being at "very high risk" for alteration in skin integrity. On 2/5/15 at 9:48 AM and at 10:12 AM, Surveyor observed Resident 18 in bed lying on her back, with wound vac tubing positioned under her leg. On 2/5/15 at 10:15 AM Surveyor requested RN (Registered Nurse) M to check Resident 18. CNA (Certified Nursing Assistant) P assisted with repositioning Resident 18. When RN M and CNA P rolled Resident 18 over, Surveyor observed the tubing and clips for the wound vac device were directly under both of Resident 18's thighs and buttocks. The wound vac tubing is a firm, flexible plastic, approximately 0.5 inch diameter, and the clips are hard plastic about 1.5 inches in length, 1 inch wide and 0.5 inch thick. Resident 18 was lying on about 18 inches of tubing and 2 plastic clips, leaving a red imprint and indentation to Resident 18's right and left thigh and buttocks. On 2/5/15 At 10:45 AM Surveyor interviewed RN M, who stated that the resident should not have been left lying on the tubing and clip, which could cause further skin breakdown.

Based on observation, interview, and record review, the facility did not ensure that 2 of 5 sampled residents (Residents 11 and 15) with limitations in range of motion received the necessary care and treatment to maintain or improve function. Resident 11 had a decline in functional ROM (Range of Motion) of the upper and lower extremities and was noted to have bilateral arm, knee and hand contractures. Resident 11 has an order for [REDACTED]. Resident 15 had discharge therapy recommendations to participate in the Restorative Nursing Program on 1/9/15. Resident 15 did not have a Restorative Care Plan or Range of Motion (ROM) Care Plan and did not have documentation for Restorative Nursing services. This is evidenced by: Example 1 Resident 11 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 11's quarterly MDS (Minimum Data Set) Assessment of 1/14/15 shows a BIMS (Brief Interview for Mental Status) was unable to be completed due to Resident 11's severe cognitive impairment. Section G0400 of this MDS indicates Resident 11 has functional limitations on both sides of her upper and both sides of her lower extremities. This is a decline from her Annual Comprehensive MDS assessment dated [DATE]. Section G0400 of this MDS indicates Resident 11 had functional limitations on 1 side of her upper and lower extremities. Hand splints: Resident 11's Restorative plan for Splint or Brace dated 7/31/12 states in part; Resident will be able to tolerate application of splint to bilateral upper and lower extremities to prevent further contractures. Upper extremity: Wash hands and dry thoroughly, PROM check skin them apply palm protectors on am off night (hs). Place contracture gloves at hs. Lower Extremity: blue static stretch AFO boots on when up in broda chair on AM and PM. Check skin prior to application and upon removal of suspension boots. The restorative program was last reviewed on 10/8/14 and states Resident 11 was compliant with program, will continue program. Occupational Therapy (OT) Progress and Discharge Summary dated 10/17/14 states in part; caregiver reports tolerating splints daily. The use of splints prevents further contractures. Designed and implemented restorative program for staff carryover and positional splinting to prevent further contractures. Caregiver educated on daily PROM and splint application. Post discharge recommendations for staff follow through include daily application of cone splints ... Patient discharged with recommendations including ... positional splinting to maintain joint integrity and contractures. Resident 11's care plan dated 10/14 states in part; ADL/Mobility plan of care Problem: Potential or Actual ADL/Mobility deficit r/t contractures as evidenced by (e/b) loss of voluntary arm movement, functional limitation in ROM arm and leg. Interventions: PROM restorative aide only every day, functional ROM in addition with dressing, finger separator to left hand and cone splint to right hand remove at night. Resident 11's signed physician order [REDACTED]. On 2/3/15 at 9:35 AM Surveyor observed Resident 11's hand cone splint sitting on the bedside table. Surveyor asked Registered Nurse (RN) KK about the splints and RN KK stated that Resident 11 wears the splints on 4 hours then off hours and that it was probably her "off hours." On 2/3/15 at 2:55 PM Surveyor observed Resident 11's hand cone sitting on the bedside table. Surveyor asked Certified Nursing Assistant (CNA) LL regarding the hand splints CNA LL stated that Resident 11's husband does not want the staff to put the splints on her anymore. Surveyor asked CNA LL when Resident 11 last wore the hand splints CNA LL stated she has not used them for a long time several months. ON 2/4/15 at 12:00 PM Surveyor observed Resident 11's hand cone sitting on the bedside table. Surveyor asked CNA NN about the hand splint. CNA NN stated the staff does not put the hand splints on Resident 11 anymore because Resident 11's husband does not want the facility to use them. Surveyor asked CNA NN when Resident 11 last wore the splints and CNA NN stated it has been months. On 2/9/15 Surveyor interviewed CNA QQ regarding hand splints and PROM for Resident 11. CNA QQ stated that the CNA staff does not perform PROM that it is only performed by the Restorative CNA RR. CNA QQ stated that they do not put the splints on Resident 11 because the husband does not like them to be put on. CNA QQ stated the hand splints were discontinued we were told today in report that the splints were discontinued. Resident 11's Treatment Administration Record (TAR) for 1/15 states in part hand splints on for only 4 hours during day then 4 hours off, then on 4 hours during evening then off for rest of day. Despite the above statements indicating that the hand splints were not being used, the nurses signed off this treatment at least one time daily AM, PM and NOC (night) shift for the month of January 2015. Resident 11's Treatment Administration Record (TAR) for 2/15 states in part hand splints on for only 4 hours during day then 4 hours off, then on 4 hours during evening then off for rest of day. The nurses signed off this treatment at daily AM, PM and NOC (night) shift for the month of January 2015. On 2/9/15 Surveyor interviewed Occupational Therapist (OTR) FF regarding the splinting and PROM Resident 11. OTR FF stated that she provided education to the Restorative CNA RR regarding PROM and splinting in October. To OTR FF's knowledge Restorative CNA RR is the only staff member providing PROM to Resident 11. OTR FF stated that the therapy team picks up Resident 11 about every 6 months as Resident 11 has abnormal tone and needs adjustments to help prevent further contracture, aid in pain management and prevent skin integrity issues. OTR FF stated the hand splints were to be used with the goal of preventing skin impairment and reducing pain due to her severe contractures. OTR FF stated she is aware that Resident 11's husband does not like devices to be used for Resident 11 but she provided him with education on the importance of the hand splints use and he was in agreement in October. OTR FF stated the hand splints would benefit Resident 11 in regards to pain management and skin integrity. Historically staff has reported and social service has documented Resident 11's spouse not being in agreement with treatment plans that are beneficial for Resident 11 there was no evidence that the facility has educated Resident 11's spouse on the risk and benefits of treatment orders for Resident 11. A Telephone order dated 2/8/15 states order clarification states in part discontinue hand splints. On 2/9/15 at 1:50 PM Surveyor interviewed RN BB regarding the splinting and PROM program for Resident 11. RN BB stated that all the devices were discontinued since they were not being used and that Resident 11 will be re-evaluated by OT. Surveyor asked RN BB if Resident 11's spouse was provided with the risks and benefits of the use/discontinuation of the splints for Resident 11 and RN BB stated she was not certain. RN BB agreed that documentation was needed to demonstrate risk and benefits were discussed with Resident 11's spouse before discontinuing the use of the assistive devices. Passive range of motion (PROM): Occupational Therapy (OT) Progress and Discharge Summary dated 10/17/14 states in part; Caregiver educated on daily PROM and splint application. Post discharge recommendations for staff follow through include daily... PROM to prevent further contractures. Patient discharged with recommendations including daily PROM... Resident 11's care plan dated 10/14 states in part; ADL/Mobility plan of care Problem: Potential or Actual ADL/Mobility deficit r/t contractures as evidenced by (e/b) loss of voluntary arm movement, functional limitation in ROM arm and leg. Interventions: PROM restorative aide only every day, functional ROM in addition with dressing, finger separator to left hand and cone splint to right hand remove at night. Resident 11's PROM program dated 6/11/14 states PROM for 20 minutes 3x day. This program was last reviewed on 10/14/14 and states in part; resident is compliant with program, will continue. The physician orders, therapy recommendations and restorative orders for Resident 11 are conflicting. Staff completed a daily entry into the PROM however, the PROM is only provided by the Restorative CNA, the Restorative CNA is not scheduled on a daily basis. On 2/9/15 at 10:45 Surveyor interviewed RN O. RN O stated she was in charge of restorative nursing but has not been in charge of the program now. RN O is not certain who is in charge of the restorative program. Of note, the Restorative CNA was the only CNA allowed to perform PROM. Restorative CNA RR does not work on a daily basis thus PROM was not performed on a daily basis. An attempt was made by Surveyor to contact Restorative CNA RR to no avail. A Telephone order dated 2/8/15 states order clarification: CNAs are able to perform ROM techniques 1 time day. On 2/9/15 at 1:50 PM Surveyor interviewed RN BB regarding the splinting and PROM program for Resident 11. Surveyor asked RN BB if Resident 11 was receiving PROM per order. RN BB stated Resident 11 was not receiving PROM per order however an order was changed to allow the floor staff to provide PROM for Resident 11 once per day. RN BB stated she would expect that Resident 11 receive PROM per order. Cross Reference F309 Example 2 Resident 15 was admitted to the facility with the following Diagnoses: [REDACTED]. Resident 15's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident 15 had functional limitations range of motion (ROM) to both the upper and lower extremity on one side. Resident 15's Care Area Assessment Summary (CAAS), dated 10/2/14, Treatment and other factors that cause increased risk of pressure ulcer: Functional limitation in Range of Motion. Resident 15's most current care plan in the medical record includes an Activity of daily living (ADL)/Mobility pan of care, dated 10/14, Problem: Intracranial bleed, hemipalegic. Functional limitation in ROM: Arm. Interventions: Provide assistive device as needed for transfer: Hoyer. Provide assistive device as needed for ambulation: Broda. ROM with care daily. Resident 15's Physical Therapy end of care note in part, dated 1/9/15, Finalized restorative with recommendations for 2 person stand pivot transfer bed and wheelchair transfers. Recommend left lower extremity passive ROM and right lower extremity ROM once on 1st and 2nd shift, and wearing scheduled left boot 24 hour/day with skin checks once per shift. Resident 15 Therapy recommendations, dated 1/9/15, 1. Passive and/ or active range of motion (ROM): perform left lower extremities Passive ROM / right lower extremity Active ROM all joints, all planes 2 times a day by first and second shift. 2. Splint or Brace assistance: Left ankle foot orthosis (AFO) / heel protector boot on 4 hours with skin check once per shift. 3. Transfer status and Training: Stand pivot transfer with 2 person assist. On 2/9/15 Surveyor reviewed Resident 15's current care plans in Resident 15's medical record. Resident 15 medical record did not contain a restorative nursing or a ROM plan of care. On 2/9/15 at 9:40 AM Surveyor spoke with Certified Nursing Assistant (CNA) II regarding Resident 15's restorative program. CNA II stated the Kiosk (care tracker) tells the staff which restorative program the resident is on. CNA II stated Resident 15 is on a restorative program. CNA II stated her program is related to her boots and splints. CNA I stated Resident 15 is a 2 person pivot transfer. CNA II stated Resident 15 does not use a Hoyer lift to transfer. CNA II stated Resident 15 is to wear a boot to her left foot and a brace to her left arm. On 2/9/15 9:45 AM Surveyor spoke with Registered Nurse (RN) / Unit Manager (RN) S regarding the facility restorative program to include who places the program for the CNAs and which nurse writes the summary notes of how the program is working. RN S stated she did not know who does the restorative program or who is in charge of the summary notes. RN S asked RN O if she knew who was in charge of the Restorative program. RN O stated she did not know who was in charge of the restorative program. On 2/9/15 at 9:52 AM Surveyor spoke with RN UU regarding restorative program, who places the program for the CNAs and the Nurse that writes the summary of the program. RN UU stated RN O was in charge of the program. RN UU stated the Unit managers will be taking over the program. RN UU stated at the present time no one is in charge of the program or writing the restorative nursing summary. On 2/9/15 Surveyor requested from Register Nurse (RN) BB Resident 15's current ROM program and the restorative nursing monthly summaries for the ROM program. RN BB stated she would print the current program and the nursing notes from the computer. On 2/9/15 at 12:30 PM Surveyor spoke with Rehab Director J regarding the restorative program for Resident 15. Rehab Director J stated Resident 15 is on a restorative program for ROM, transfer and to wear a boot. Rehab Director J stated the therapist will fill out a Restorative communication form and provided the form to the nursing department. The nursing department then places the information in Care tracker and on the care plan for the CNAs to follow. Rehab Director J stated the therapist wrote a new plan on 1/9/15. Rehab Director J provided Surveyor with the written restorative program written on 1/9/15. Rehab Director J stated Resident 15 is to receive the restorative program provided by the therapist. On 2/9/14 at 12:48 PM, RN BB provided Surveyor with Resident 15's current ROM program. RN BB stated she was unable to locate Nursing notes for the ROM program for Resident 15. RN BB stated she would have expected to have nursing summaries for the restorative program. No further information was provided to Surveyor . Resident 15's ROM active program report: Program name: Transfer program: Program start date: 9/12/14. Frequency: Everyday (all shifts) Every 1 day shift 1, 2, 3. Program text: Resident will transfer to and from wheelchair and bed with 2 assist and a Hoyer. (It is important to note Resident 15's current ROM program is not listed on the current program list provided by RN BB.) On 2/9/15 at 1:24 PM Surveyor spoke with RN BB regarding Resident 15 restorative program dated 1/9/15. RN BB stated she would have expected the facility to start the program as written and update the care plans according to the new program. Resident 15 did not receive the restorative program per the recommendation. The facility did not have evidence Passive ROM and Active ROM was provided to Resident 15.

Based on record review and interview the facility did not ensure each resident received sufficient fluid intake to maintain proper hydration and health for 2 of 24 residents reviewed (Residents 23). Resident 23 did not take in enough fluids to maintain a healthy hydration level and the facility did not act on this. Resident 23 was sent to the hospital with poor hydration and high potassium. This is evidenced by the following: According to Medscape (www.medscape.com/view article/ 8 <http://www.medscape.com/view article/ 8>) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately... In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls.... Body weight proved to be the most responsive to changes in hydration.... Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. The facility's "Fluid Intake Monitoring" Policy, effective April 2010, states: When an order is received for "Encourage Fluids", "Fluid Watch", monitor "Intake" or if the Interdisciplinary team determines need the procedure below will be followed to prevent impaired hydration. 1. Calculate estimated fluid intake needs. 6. Provide a minimum of 6 ounces of fluid during medication pass at least three times a day. 9. Record amount of fluids with meals, between meals and with medication pass using CareTracker. Note: The Licensed Nurse will record in the medical record the resident's response to interventions and causal factors for not accepting fluid intake per Care Plan goal. The facility's "Hydration" Policy, revised October 2014, states: 1. Calculate fluid requirements for all resident using the Nutrition Risk Data Collection and Assessment form upon Admission, significant change in condition, as deemed necessary by the resident clinical condition. 2. Identify causes and/or risk factors for dehydration which may include: -Fluid loss and increased fluid needs (e.g. diarrhea, vomiting) -Fluid restriction -Diuretic medication 3. Monitor for physical signs of dehydration: -Dry skin -Dry mucous membranes -Fever -Concentrated urine 12. Inform Interdisciplinary Team of Hydration issues 13. Develop individualized interventions to reduce/prevent risk of dehydration Example 1 Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 23's admission physician orders [REDACTED]. -[MEDICATION NAME] 40 mg every morning (a diuretic for [MEDICAL CONDITION]) -Potassium Chloride 20 meq (milliequivalent) twice a day -[MEDICATION NAME] 50 mg daily (helps eliminate unneeded water and sodium but reduces the loss of potassium) On 1/7/15 Resident 23 was sent to the emergency room for chest pain and was diagnosed with [REDACTED]. -Sodium 141 mmol/L (millimoles/liter) -Potassium 4 mmol/L -BUN (Blood Urea Nitrogen) 6 mg/dL (milligrams/deciliter) -Creatinine 0.82 mg/dL Resident 23 returned to the facility on [DATE]. On 1/8/15 Resident 23 had laboratory testing again with the following results: -Sodium 143 mmol/L -Potassium 4.1 mmol/L -BUN 9 mg/dL -Creatinine 0.89 mg/dL On 1/8/15, Resident 23's physician ordered a repeat Complete Blood Count (CBC) test done 1/12/15. There is no evidence this was completed. Resident 23's "Nutrition Risk Data Collection and Assessment" was completed on 1/9/15 by Dietician N. The assessment indicates Resident 23's estimated fluids needed to meet her needs are 1843-2211 cc (cubic centimeters) per day. Recommend Mighty Shakes three times a day with meals for nutritional support, related to weight loss. Plan to monitor intakes. On 1/12/15, an order was received to decrease Resident 23's [MEDICATION NAME] to 20 mg daily as Resident 23 was refusing the medication due to going to the bathroom all the time. Resident 23 was also ordered [MEDICATION NAME] 100 mg at bedtime at that time. (used to treat itching). Resident 23's Nutrition Care Plan, dated 1/15, indicates risk for potential for dehydration. Interventions include: Monitor for signs of dehydration, Encourage fluids unless contraindicated, Monitor fluid intake via care tracker. Resident 23's "Nutrition Progress Notes," dated 1/16/15 include: weight update of 264 pounds, question accuracy of admission weight. Resident was receiving 40 mg of [MEDICATION NAME], changed to 20 mg on 1/13/15, and [MEDICATION NAME] 50 mg daily which will contribute to weight fluctuations. Drinking approximately 897 cc daily. Re-calculated estimated fluid needs 1724-2067 cc per day. Nursing monitoring for signs and symptoms of dehydration. Remains on fluid watch, fluids offered and encouraged throughout the day. Plan to notify physician of weight change, will provide sugar free jello on each meal tray with additional 4 oz of water on each tray to increase fluid intake. Continue to monitor intake. Intakes for Resident 23: 1/8/15-70 cc 1/9/15-738 cc 1/10/15-600 cc 1/11/15- 1200 cc 1/12/15- 740 cc 1/13/15- 1030 cc 1/14/15- 1380 cc 1/15/15- 588 cc 1/16/15- 1680 cc 1/17/15- 1920 cc 1/18/15- 1290 cc 1/19/15- 780 cc 1/20/15- 540 cc Resident 23's nursing notes include: -1/15/15 at 5:00 PM Resident 23 complains of nausea. [MEDICATION NAME] given. -1/16/15 at 5:00 PM blood pressure 98/44 manual. Transferred to wheelchair and given fluids. Continue to monitor. -1/16/15 at 5:30 PM blood pressure recheck 100/55. Continue to monitor. -There are no notes or vitals for 1/17/15. -1/18/15 at 9:00 PM resting in bed will monitor. (No vitals documented.) -1/19/15 no time indicated, complains of nausea and vomiting. Resident vomited supper and all medication. Continue to monitor. -1/20/15 at 6:25 PM drowsy and disoriented. Speech is garbled, random thoughts. Blood pressure 98/58. Notified by staff urine is dark and cloudy. Physician on call contacted. -1/20/15 at 6:40 PM order for a urinalysis and micro and culture and sensitivity if indicated. -1/20/15 at 9:20 PM Resident 23 transported to the emergency room . There is no nursing assessment addressing Resident 23 not meeting her daily fluid needs. Resident 23's hospital notes for 1/20/15 indicate: Presents with altered mental status and foul smelling urine. Resident complaints of pain with urination. Physical Exam- blood pressure 115/52, dry mucus membranes. Lab results: -Sodium 133 mmol/L (low) -Potassium 7.5 mmol/ (high) -BUN 50 mg/dL (high) -Creatinine 3.1 mg/dL (high) -[MEDICAL CONDITION] positive Medical Decision Making- After reviewing the chart, immediately became concerned for [MEDICAL CONDITION] (elevated potassium in the blood, high levels can cause the heart and muscles to function improperly and result in death). Administered empiric calcium 2 grams IV (intravenous). I suspect urinary tract infection [MEDICAL CONDITION] causing AKI (acute kidney injury) leading to [MEDICAL CONDITION]. Resident 23 was given 10 units of IV and an amp of [MEDICATION NAME] in addition to the calcium to treat her [MEDICAL CONDITION]. She was treated with [MEDICATION NAME] given 2 liters IV fluids and had great urine output. Final Diagnosis-[MEDICAL CONDITION], Acute [MEDICAL CONDITION], UTI and Altered mental status. Resident 23 was transferred for critical care management to another hospital. On 2/9/15, at 1:31 PM, Surveyor interviewed Registered Nursing/Unit Manager (RN) K. RN K stated Resident 23's physician should have been called on 1/16/15, but Resident 23 did well with the extra fluids. RN K stated she would expect more documentation on Resident 23's condition. On 2/9/15, at 1:55 PM, Surveyor interviewed Dietician N about the hydration process. Dietician N stated that the intakes are monitored by Dietary Manager (DM) E every 3 days. Dietician N stated DM E then uses the nutrition assessment completed by Dietician N to ensure adequate food and fluid intakes. If the resident is not meeting their needs DM E discusses it with the Registered Nurse/Unit Manager. On 2/9/15, at 2:00 PM, Surveyor again interviewed RN K. RN K stated the certified nursing assistants enter resident intakes in the CareTraker computer system. RN K stated there is a fluid watch list and she looks at those residents daily to see the total intakes. If the resident is not meeting the goal RN K stated a registered nurse completes an assessment and if fluid intake is less than 1000 cc per day the resident's physician is called. RN K stated she vaguely remembers Resident 23 and could not provide additional information specifically about Resident 23. RN K stated there should have been better documentation on Resident 23's status and fluid intake. At 2:07 PM, DM E joined the interview. DM E stated residents are on the fluid watch on admission and that a 14 day average would be reviewed and if meeting needs removed from the fluid watch. (Resident 23 was only in the facility for 13 days). DM E stated she recalls Resident 23 was to receive jello and extra water at meals to increase her fluid intakes but could not recall any details.

Based on staff interview and record review, the facility did not implement policies and procedures to ensure that 5 of 17 (Residents 1, 18, 21, 23 and 24) residents reviewed for influenza and pneumococcal vaccinations were offered influenza and pneumococcal vaccines and received influenza and pneumococcal vaccines as requested. Resident 1's Healthcare Power of Attorney (HCPOA) was not offered the influenza vaccine during the fall of 2014. Resident 1 was diagnosed with [REDACTED]. Resident 21's Healthcare Power of Attorney (HCPOA) was not offered the influenza and pneumococcal vaccines during the fall of 2014. Resident 24 requested the Influenza immunization on admission. Resident 24 did not receive the influenza vaccine. Resident 24 was diagnosed with [REDACTED]. The facility did not accurately assess Resident 18's current influenza vaccination status. The facility did not have evidence to indicate if Resident 23 was offered an influenza vaccination. Evidenced by: The facility's "Immunization: Administration of" policy, dated 11/14, includes the following: ... will counsel residents, employees, and volunteers on the benefits and adverse effects of each vaccine prior to administration The resident, employee, and volunteer will sign a form stating they have been informed of benefits and adverse effects. Procedure: 1. Review with resident, employee, or volunteer the benefits and adverse effects of each vaccine prior to administration. 2. Obtain request or refusal of vaccine(s) on the applicable form. 3. Verify physician's orders [REDACTED]. The facility's "Immunizations: Standing Orders" policy, dated 11/14, includes the following: 1. All residents, staff and volunteers of (facility) centers, regardless of age and medical condition shall be offered the influenza vaccine annually unless there is a documented contraindication or refusal, and depending on availability of vaccine. Influenza Vaccine. Procedure: 3. Counsel resident and/or family on the benefits and adverse effects by providing educational materials of each vaccine prior to administration of the vaccines 5. Obtain a consent/refusal using the "Pneumococcal and Annual Influenza Vaccine - Information and Request" form for the annual influenza vaccination from the resident or family at the time of admission (or anytime afterwards) and place in the medical record. c. Re-offer immunization annually to those who refuse... Example 1 Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Healthcare Power of Attorney (HCPOA) was activated on 11/7/12, indicating Resident 1 does not make his own decisions regarding healthcare. Resident 1's most current MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/20/14, includes the following: Section C1000 Cognitive Skills for Daily Decision Making: 3. Severely Impaired. Section O0250 Influenza Vaccine: A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 0. No. C. If influenza vaccine not received, state reason: 4. Offered and declined. Resident 1's "Pneumococcal and Annual Influenza Information and Request" form, dated 12/5/14, includes the following: Refusal: refuse Annual Influenza, Offered and Refused. Information Provided to: Pt. (patient). It is important to know that Resident 1's HCPOA - who is the one who has the authority to make healthcare decisions - did not sign the document. On 2/3/15 at 6:15 PM Surveyor interviewed Family Member (FM) via telephone. FM is Resident 1's HCPOA. FM stated Resident 1 always gets an influenza vaccine every year. FM stated she wants Resident 1 to have an influenza vaccine every year. Resident 1's physician's orders [REDACTED]. 4/10/13: May have annual flu vaccine unless contraindicated. Resident 1's Emergency Department Notes, dated 12/18/14, includes the following information: History of Present Illness: Per EMS (Emergency Medical Services) they were called for evaluation of fever as high as 101 axillary per which they gave Tylenol. They report he has some coughing spells earlier today. He also has some rapid influenza testing done today. Notes: Patient with known influenza positive. We'll treat. ... He will be discharged ... and treatment for [REDACTED]. Resident 1's Progress Notes included the following entries: 12/22/14: 12/18/14 sent to ER (emergency room ) for eval (evaluation). Returned DX (diagnosis) Influenza A. Started on [MEDICATION NAME] (an [MEDICAL CONDITION] medication used to treat flu symptoms caused by influenza) [MEDICATION NAME]([MEDICATION NAME], an antibiotic). Placed on isolation. On 2/9/15 at 10:45 AM Surveyor interviewed Registered Nurse (RN) M. RN M is the unit manager for Resident 1's unit. RN M stated Resident 1 is unable to make his own decisions. RN M stated Resident 1's HCPOA should have been educated regarding influenza and consent gotten from her to give Resident 1 an influenza vaccine and signed the "Pneumococcal and Annual Influenza Information and Request" form to either request or refuse the vaccine. It is important to know that Resident 1's HCPOA did not receive any information regarding the influenza vaccine, nor was she asked if Resident 1 should get the influenza vaccine or not during the fall of 2014. Resident 1's HCPOA stated she would have wanted Resident 1 to have an influenza vaccine. Resident 1 cannot make his own decisions. Resident 1 was not vaccinated against influenza in the fall of 2014. Resident 1 was diagnosed with [REDACTED]. Example 2 Resident 21 was admitted to the facility on [DATE]. Resident 21's [DIAGNOSES REDACTED]. Resident 21's most current MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/19/14, indicates Resident 1 moderate cognitive impairment and has been offered and declined the influenza vaccine. Resident 21's "Pneumococcal and Annual Influenza Information and Request" form dated 10/14, includes the following: Refusal: refuse Annual Influenza, Offered and Refused. Information provided to: Pt. (patient). It is important to know that Resident 1's HCPOA did not sign the document. On 2/9/15 at 11:50 AM Surveyor interviewed Registered Nurse (RN) K. RN K is the unit manager on Resident 21's unit. RN K stated Resident 21 is unable to make her own decisions. RN K stated Resident 21's HCPOA should have been educated regarding the influenza vaccine and signed the "Pneumococcal and Annual Influenza Information and Request" form to either request or refuse the vaccine. Example 3 Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is her own legal decision maker. Resident 24's initial MDS (minimum data set) with an assessment reference date of 9/25/14 indicates the influenza section of the MDS is blank and the pneumococcal section of the MDS states that she was offered and declined the pneumococcal vaccine. Resident 24 most current MDS with an assessment reference date of 11/6/14 indicates that Resident 24 scored a 10 on her brief interview for mental status. A 10 indicates that she is moderately impaired decision making skills. Resident 24's Immunization section of the MDS is not filled out; all of the questions have a dash in each box instead of answering the questions. The influenza section and pneumococcal section of the MDS is not completed. Resident 24's admission orders [REDACTED]. On 8/25/14 a "Pneumococcal and Annual Influenza Vaccine Information and Request Form was signed and information was given to (Resident 24) and daughter POA (please note that the daughter is not activated POA). It is important to note that Resident 24 did not sign the document. The form discusses information about the influenza and pneumococcal vaccines and the risks and benefits. The request/refusal section indicates "Refuse Pneumococcal" due to received vaccine in 2013. Resident 24 checked "Request influenza vaccine annually." On 10/21/14 another Pneumococcal and Annual Influenza Vaccine Information and Request Form was filled out. This form indicates that the information was given to Resident 24 but she did not sign the form. There are no checks in the pneumococcal section either to request or refuse the vaccination the boxes are blank. The influenza section of the form indicates an "X" under refuse annual influenza 10/2014 received at MD office. The form does not indicate what date she received the influenza vaccination. On 12/9/14 another "Pneumococcal and Influenza Vaccine Information and Request Form was filled out. The resident did not sign or fill out the form. The Pneumococcal vaccine is checked refused and states "received vaccine." The influenza vaccine states offered and refused and handwritten on form states "received." On 2/5/15 Surveyor asked the facility to find out when Resident 24 received her pneumococcal and influenza vaccines at the clinic office. The facility stated they called the MD office and she had the pneumonia vaccine 12/6/13. The facility did go to the Wisconsin Immunization Registry website and printed off Resident 24's information. The information was run on 2/5/15 and indicated that Resident 24's last documented influenza vaccination was 9/27/13, indicating that Resident 24 did not have her influenza vaccine in the clinic office as the facility documented in 2014. On 1/16/15 a nurse practitioner saw Resident 24 for [MEDICAL CONDITIONS] transition of Care. A progress note written by NP AAA (Nurse Practitioner) on 1/16/15 indicated that Resident 24 has a cough, respirations are non-labored, Rhonchi L>R (left and right)....Cough is concerning but likely related to [MEDICAL CONDITION], requesting nursing to give her a nebulizer treatment. May need CXR (chest x-ray)if sx (symptoms) don't improve or develops a fever." A nursing progress note dated 12/17/15 at 1:00 PM states, "Call placed to (physician name) with current BGM (blood glucose monitoring) and assessment. BP 167/83 (blood pressure), temp 101.3 (temperature), HR 91 (heart rate), 02 sat 94% (oxygen saturation) on RA (room air), and physician ordered to send to ER (emergency room )." A note at 9:00 PM states, "Call placed to ER for update. Resident admitted to hospital for influenza A." On 2/5/15 at 2:00 PM Surveyor asked RN BB what the facility should do if a resident states they had a vaccine at their clinic especially since they were a resident in the facility at the time. RN BB stated, that the staff should have called the clinic to find out the date immunization was given for the facility records or if they actually had the immunization given. Resident 24 had requested an influenza vaccination upon arrival at the facility. Resident 24 had physician's orders [REDACTED]. With each re-admission to the facility a new consent was done by the facility (the resident didn't sign). The last 2 consents indicate that Resident 24 had declined due to receiving at clinic. The facility did not verify if Resident 24 received the influenza vaccine. The facility had an outbreak and Resident 24 contacted influenza A and was hospitalized with this. Example 4 Resident 18 was readmitted to the facility, from the hospital, on 10/24/14. Record review notes that there was no assessment completed for her influenza vaccine status on the significant change MDS (Minimum Data Set) dated 11/12/14. Record review of Resident 18's MDS dated [DATE] indicated that she had received an Influenza Vaccine outside the facility. On 2/5/2015 at 11:20 AM, Surveyor interviewed and asked RN (Registered Nurse) O for the date the influenza vaccine was given. RN O stated that the Resident 18 told her that she had received the vaccine when she was in the hospital in October. RN O did not know the exact date. Per request of Surveyor , RN O called the hospital on [DATE] and was told that the resident refused the influenza vaccine while in the hospital. RN O agreed that the documentation for Resident 18's influenza vaccine status on the MDS was inaccurate. Example 5 Resident 23 was admitted to the facility on [DATE] and discharged on [DATE]. On 2/5/15 Surveyor reviewed Resident 23 and did not note any information regarding Resident 23's immunization status for the influenza vaccination. There was no documentation the vaccination was offered or if it was previously received. On 2/9/15, at 9:32 AM, Surveyor spoke with Medical Records L. Medical Records L stated she looked on the Wisconsin Immunization Registry and there was no information that Resident 23 has received the influenza vaccination. Medical Records L stated there should be information in her medical record that she was offered the immunization. On 2/9/15, at 9:50 AM, Surveyor interviewed Registered Nursing/Unit Manager (RN) K. RN K stated on admission the immunization information is taken from the hospital history and physical. If it is not there we ask them to complete a form. RN K reviewed Resident 23's medical record and stated the information was not in the chart and she could not tell if the influenza vaccination was offered.

Based on interview and record review, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 4 residents reviewed (Residents 1 and 3). Resident 1 completed an Advance Directive related to code status. Resident 1 indicated that he desired CPR (cardiopulmonary resuscitation) in the case that he suffered a cardiopulmonary arrest. The facility did not provide CPR to Resident 1 when he was noted to be unresponsive and without vital signs on [DATE]. The facility denied Resident 1 the only chance he had for living. Regardless of the small chance for a positive outcome, there was virtually no chance for a positive outcome from failing to attempt CPR. The facility failed to provide Resident 1 with CPR. This created a situation of immediate jeopardy on [DATE]. The Nursing Home Administrator was informed of the immediate jeopardy situation on [DATE] at 4:30 PM. The facility removed the immediate jeopardy on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by the following: Resident 3's medical record contained a one page document from Hospice directing the facility staff to call Hospice before transporting the resident out of the facility for medical reasons. The facility staff did not have a clear understanding to send the resident out in an emergency situation without calling their supervisor for further direction. This is evidenced by: The facility's policy titled "Cardiopulmonary Resuscitation (CPR)-Basic Life Support (BLS)" dated April, 2000 states in part, "Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center. The applicable CPR (Cardiopulmonary Resuscitation) Consent form ...will be reviewed and signed by the resident or legal representative on admission or during their stay if they choose to change their original decision. The (CPR) Cardiopulmonary Resuscitation Consent will: Be presented to each resident/legal representative upon admission. Be presented to the resident/or legal representative if they change their original CPR choice ...Procedure: 1. Determine if an arrest has occurred and call for assistance. 2. All CPR certified person(s) report to the area of the cardiopulmonary arrest, or suspected cardiopulmonary arrest. 3. Determine if a code status has been established and documented using the CPR Consent form ...b. File original copy in the Advance Directives section of the resident's medical record. 4. Gather equipment and take to site of the cardiopulmonary arrest. 5. Assign the responsibility of notifying the following person(s) simultaneous with the initiation of CPR. Emergency medical services (911 where applicable), physician, family/legal representative ...8. Continue CPR until Emergency Medical Services arrive or the physician orders [REDACTED]." Example 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This document notes that Resident 1 is own decision-maker. This document also states, "Call (hospice provider) for emergencies. [DATE] (signed) (MD O)." It was noted during the survey on [DATE] that the front of Resident 1's medical record included a bright green sticker, that states, "Hospice Patient; Call (hospice provider name): Before calling 911; Before MD visit; To report a change in condition; Before initiating any new orders; After all falls; Date of care conference." Resident 1 signed "(CPR) Cardiopulmonary Resuscitation Consent" on [DATE]. This form states, "Once CPR has started, facility staff will call the local medical emergency transport team to take you to the hospital. Treatment may be continued or more advanced treatment may be initiated en route. At the hospital more advanced treatment is continued or discontinued in accordance with the institution's policy. A resident may choose to refuse CRP and AED (Automatic External Defibrillator). Please refer to the State approved DNR (Do Not Resuscitate) Identification form if required. I, or my legal representative, have been fully informed by my physician or his/her designee, as to the anticipated results of initiating or withholding CPR and/or AED if I stop breathing and my heart stops while a resident at this facility. It is my desire that: (Box checked) Resuscitation; I am expressing a desire to have CPR and/or external defibrillation performed in the event of [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved [MEDICAL CONDITION], nursing staff will initiate CPR and the use of the AED device and emergency medical personnel will be called." Resident 1's care plan titled "Advance Care Planning Care Plan" dated ,[DATE] (no year indicated) states in part, "Engage in ongoing advance care planning with resident/legal representative to discuss care options, and identify and update resident's preferences regarding future care and treatment. Refer to CPR consent form." "Progress Notes" dated [DATE] state, "On [DATE] Resident c/o (complained of) midsternal CP (chest pain). MD updated. Hospice and daughter notified. Sent to ER per resident request. Returned c (with) Dx (diagnosis) pneumonia, ABI (antibiotic) started. Afebrile (without fever), ? (no) adverse effects noted from ABI. On ,[DATE] Resident noted on knees next to bed. He states he was praying. ? injuries reported. On ,[DATE] Resident again noted on floor next to bed on knees. MD & hospice updated. Cont (continue) c safety interventions. Re ed (re-educated) resident on req (requesting) assist c transfers." "Progress Notes" state the following: "[DATE], 1310 (1:30 PM): A&O (alert and oriented) X 3, able to make needs known. Neuro (checks) WNL (within normal limits). TF (tube feeding) patent. No suctioning needed. LS (lung sounds) course throughout. Cont on ABT (antibiotic) s (without) adverse reaction." "[DATE], 18:30 (6:30 PM): G tube patent. Placement verified. No residual. Tube feeding, flush and meds given s problems. Res. (resident) alert. Voices no c/o any @ this time." "[DATE], 1930 (7:30 PM): Went into rm to check res roommate noted res in bed. Went to talk to res, ? responding. ? pulse, ? BP (blood pressure) or heart beat noted. Call placed to Hospice. 1935 (7:35 PM) Daughter (name) called r/t (related to) res passing away. 2300 (11:00 PM): Addendum to 1930. Res not responding to this writer. Sternal rub done X2 (twice) c no response. Res skin cool to the touch. Noted fingers & arms c blue tinge. Went to cart for stethoscope & res noted to be c ? heartbeat & radial pulse absent. Call placed to Hospice @ this time." The facility completed a "Misconduct Incident Report" which states, in part, the following: "Date Occurred: [DATE]; Time occurred: 1930 (7:30 PM). On [DATE], at approximately 1930, (Licensed Practical Nurse (LPN) K) was caring for the residing on wing (unit name). (LPN K) was providing care to the roommate of (Resident 1) when she noted (Resident 1) to be unresponsive. (LPN K) attempted to arouse the resident, performing a sternal rub, without success. She assessed the resident and identified the absence of vital signs, with the skin cool to the touch and cyanosis to the extremities. It was apparent to (LPN K) the resident had expired. (LPN K) was aware of (Resident 1's) ongoing decline and poor prognosis. She was also aware that the resident was currently receiving Hospice care. The supervisor for the facility was (Registered Nurse (RN) M) who went to lunch at 1927 (7:27 PM). At this time, (LPN K) informed the RN on the floor (RN N) of the resident's expiration. (LPN K) contacted (Resident 1's Hospice provider) and informed the provider that (Resident 1) had expired. The resident was an [AGE] year old male who had been receiving Hospice care since [DATE] for chronic [MEDICAL CONDITION], Failure to Thrive, Neuropathic pain of his mouth and neck, and CAD ([MEDICAL CONDITION]). "On [DATE], (MD O) had documented that the resident had a life expectancy of less than 6 months and anticipated his overall decline. On [DATE], (Hospice RN L) arrived at the center to provide family support and discontinue Hospice services. At approximately 2001 (8:01 PM) (RN M) returned from her lunch break. (LPN K) told her of (Resident 1's) expiration. (RN M) immediately informed (LPN K) that the resident had consented to have resuscitation performed, despite being a Hospice recipient. (Hospice RN L) was in the center and notified the Rock County Medical Examiner of resident's expiration without the intervention of CPR. Due to the fact that over 30 minute had passed since the confirmation of absent vital signs; the Medical Examiner agreed CPR should not be initiated. (Family member) of the resident was informed of her father's expiration. She and several other family members came into the center that evening to grieve his passing and provide support to one another. The Hospice nurse, as well as center staff, provided emotional support to family. An order was obtained to release the body to funeral home and the center proceeded to perform post mortem care. (Director of Nursing (DON) B) and (Nursing Home Administrator (NHA) A) were notified of the resident's passing without the intervention of CPR. (NHA A) proceeded to the center to immediately initiate an investigation. Upon arrival at the center, (NHA A) A also expressed his condolences to the resident's daughter and family. On [DATE] witness statements were gathered and the following interventions were immediately initiated: All on shift licensed nursing staff members were educated on the CPR policy and procedure, including validating the code status in the medical record. The stickers utilized by (hospice provider) which read, 'call hospice before calling 911' were removed and Hospice nurse was instructed that these stickers were not allowed in center due to their confusing nature...This writer interviewed the nurse in charge of cares for (Resident 1) (LPN K), at 9:45 PM. She told me that she found (Resident 1) at approximately 7:30 PM absent of vital signs with extremities cold. She grabbed her stethoscope and confirmed this. She reported that she then called (hospice provider) per instructions from hospice on the front of his chart and then family. (Hospice RN L) from (hospice provider) took over and contacted the physician at that point ..." The facility did not provide CPR to Resident 1 despite his desire to have CPR performed. Surveyor spoke with LPN K on [DATE] at 1:50 PM. LPN K stated that on [DATE] she gave (Resident 1) his PM meds, which he took fine and that she saw (Resident 1) around 6:00 PM and he was awake. LPN K stated that at 7:30 PM, she went in to care for (Resident 1's) roommate. LPN K stated that it was her understanding, that if a resident was a Hospice patient, they are a Do Not Resuscitate. LPN K stated that she found that (Resident 1) was unresponsive so she did a sternal rub and checked for vital signs. LPN K stated that she got her stethoscope and checked for a blood pressure, which there was none. LPN K stated that she then checked for respirations and a pulse, and they were absent. LPN K stated that she then went to get the charge nurse but she was on break. LPN K stated that she informed the other RN (RN N) but she did not tell her do anything, she was busy doing something. LPN K stated that she then called Hospice and (Hospice RN L) did not question her about (Resident 1's) code status. LPN K stated that (Hospice RN L) stated that it was a blessing that (Resident 1) expired. LPN K stated that she then called (Resident 1's) emergency contact. Surveyor asked LPN K if she called 911. LPN K stated that she did not call 911. LPN K stated that at this point, within a half hour, (RN M) was back from break and she informed her that (Resident 1) was a full code. LPN K stated that the idea of CPR being performed was not discussed with either the charge nurse (RN M) or (Hospice RN L). Surveyor spoke with Hospice RN L on [DATE] at 11:59 AM. Hospice RN L stated that she spoke with the coroner who stated that since an RN was on duty at the facility there is no concern that CPR was not completed and that it would be different if the person was a home patient. Hospice RN L stated that she did not question staff as to why CPR was not completed; she arrived at the facility and pronounced (Resident 1's) death. Hospice RN L stated that (LPN K) told her that she did not call 911. Hospice RN L stated that her current understanding related to CPR procedures at the facility is that 911 is to be called and CPR is to be initiated, if the resident is a full code. Hospice RN L stated that by the time she got to the facility, it was more than an hour past (Resident 1's) expiration. Surveyor asked Hospice RN L if the coroner she spoke to referred to a standard or regulation, as it relates to his statements. Hospice RN L stated that he did not. Hospice RN L stated that she had spoken to (DON B) and his response to her conversations with the coroner was relief. Surveyor spoke with charge nurse (RN M) on [DATE] at approximately 1:00 PM. RN M stated that she was the nurse manager on [DATE] and that she was on break until 8:00 PM. RN M stated that she was told by (LPN K) that (Resident 1) passed and she told her (LPN K) that he was a full code. RN M stated that she would have expected (LPN K) to check the chart first and then performed CPR and called 911. RN M stated that after she realized that no CPR had been performed, she called (DON B). RN M stated that she is CPR certified, as is (LPN K). Surveyor asked RN M about the sticker on the front of Resident 1's chart. RM M stated that there was a sticker directing staff to call hospice before calling 911. RM M stated that she would not have called hospice first, as she knew he was a full code. RN M stated that she would look under the Advance Directive tab in the chart to determine a resident's code status. Surveyor spoke with RN N on [DATE] at 12:42 PM. RN N worked on [DATE]. RN N stated that she was working a different unit on [DATE] than (LPN K). RN N stated that (LPN K) came out of the room and told her that (Resident 1) had passed. RN N stated that she asked (LPN K) if the resident was hospice and she said yes. RN N stated that she told (LPN K), "Okay." Surveyor asked RN N about her understanding as it relates to code status and hospice residents. RN N stated that, if a resident is hospice, that they can still be a full code. RN L stated that it did not occur to her to mention anything to (LPN K) about (Resident 1's) code status. Surveyor spoke with DON B on [DATE] at 10:25 PM. DON B stated that staff should have initiated CPR for (Resident 1). DON B sated that despite what the coroner told (Hospice RN L), his staff would be initiating CPR on residents who wish to be a full code. The facility did not initiate CPR on Resident 1, who wished for this intervention to be performed. Resident 1 passed away at the facility on [DATE]. This created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time the following had been completed: [DATE]-[DATE]: Education provided to all nurses regarding making sure that we check code status and if a full code 911 is called and CPR is initiated. This was completed [DATE]-[DATE] and ongoing for all staff prior to them working. NHA A removed stickers from front of charts of hospice patients that stated to call hospice prior to calling 911. [DATE]. All charts reviewed to ensure that CPR status is clearly stated on CPR form. Code drills conducted on all 3 shifts and are ongoing started on [DATE]. The medical director was informed of the occurrence. QAPI meeting was held and action plan initiated to ensure continued compliance. Example 2 Resident 3 was admitted to Hospice services on [DATE] according to Telephone order dated [DATE]. Surveyor opened the front cover of Resident 3's chart. The first form located under the cover was a one page document. The document information included. (Company Name) Hospice is involved in the care of this resident. Please call (Company name) Hospice 24 hours a day, 7 days a week for any of the following: 1. In an Emergency. 2. If the resident falls. 3. Before transporting the resident out of the facility for medical reason. 4. Any change in condition... Please note that all calls during and after office hours are answered by a person and never an answering machine. On [DATE], at 12:10 PM, Surveyor Spoke with Registered Nurse (RN) C regarding the one page document found in Resident 3's chart. Surveyor asked RN C how she would respond to question 3 of the form stating Before transporting out the facility for medical reason. RN C stated she would fill out the requested documents and would call Hospice prior to the resident leaving the facility. RN C stated she would have already started Cardio [MEDICAL CONDITION] resuscitation and would have informed the Hospice Nurse of the information. RN C stated if the Hospice Nurse directed to wait to send the resident out until she arrived or contacted the family she would have to contact her Supervisor or the Director of nursing (DON) for further instructions. On [DATE], at 12:10 PM, Surveyor Spoke with Licensed Practical Nurse (LPN) D regarding the one page document found in Resident 3's chart. Surveyor asked LPN D how she would respond to question 3 of the form stating Before transporting out the facility for medical reason Hospice is to be notified. LPN D stated she would call Hospice and notify Hospice of the resident change in condition and need of CPR. LPN D stated sometimes this is hard due to the Hospice workers do not call back in a timely matter and you may have to wait for a while for them to return a call. LPN D stated if the Hospice nurse directly informed LPN D not to transfer a full code person out until she arrived or contacted family LPN D would have to contact her Supervisor to see what direction she would follow. On [DATE], at 1:45 PM Surveyor spoke with DON B regarding the one page document in Resident 3's chart. DON B stated he was not aware of the document in Resident 3's chart. DON B stated he would immediately contact Hospice and discuss the form. DON B stated he would expect all nurse to send all resident to the hospital if they are a full code and have started CPR no matter if they are a Hospice resident.

Based on observation, interview, and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 resident out of 20 reviewed (Resident 18). Resident 18 did not have several fall prevention interventions in place during observation on survey. Resident 18 had a fall on 8/28/13 and on 10/7/13 that were not investigated to find the root cause of the fall to put preventions put in place to prevent future falls. Findings as follows: Resident 18 was admitted to the facility on [DATE] for rehabilitation from a fall downstairs at home where he suffered a Subdural Hematoma. Resident 18 has a history of falls. Resident is his own legal decision maker. Resident 18's admission MDS (Minimum data set) dated 6/27/13 indicates that his BIMS (Brief Interview of Mental Status) is a 7 and he is understood and understands others. (Resident 18) is his own legal decision maker. Resident 18's MDS quarterly dated 9/26/13 indicates that his BIMS is a 9 and is understood and understands others. Resident 18's safety device data collection form dated 8/7/13 states that Resident 18 will have antitip bars to his wheelchair to decrease risk of fall/ injury if attempt to self-transfer due to poor safety awareness. Resident 18's Safety Device Care plan initiated 6/20/13 and last updated 9/13 indicates the following interventions to be in place to prevent falls/injuries: grab bars (on bed), bed alarm, added on 8/7/13-gripper strips-bathroom and bedroom, chair alarm, low bed, mat to floor, bed next to wall, perimeter mattress with opening, antitip bars to wheelchair with auto lock brakes and a body pillow. Resident 18 has a Fall/Injury Assessment: Prevention and Management plan of Care. The care plan which repeats all of the interventions that were on the Safety Device Care plan but added on 10/8/13- 15 minute checks related to fall. Resident 18's care plan states 1 assist with ambulation and transfers. A review of Resident 18's Resident Incident form dated 8/28/13 states that the nurse had been called to the room by CNA and Resident 18 had been found lying on right side near bathroom entrance at 1:44 PM. There is no injury noted to Resident 18. Resident 18 was interviewed and stated that he attempted to get to the bathroom. Became dizzy and lost balance. The cause is documented as getting up too fast and having no supervision with transfers. The form states that Resident 18 was in bed before the incident. The form indicates that the Post Incident Actions states a Bowel/Bladder program was initiated or revised. Documentation 72 hour follow up, education - resident, interdisciplinary team review neuro check. Acute charting as completed. The final outcome documented on the form states that the CNA heard alarm sounding went to resident's room. Resident transferred self to bathroom, lost his balance on way out of the bathroom. No injury, neuros started resident educated and therapy notified. Resident 18's nursing progress notes dated 8/29/13 states that the IDT team reviewed his fall at 1:45 PM on 8/28. The note indicates the following information: Resident self-transferred and attempted to toilet self. Alarm did sound and staff observed him exiting bathroom. Reviewed present toileting schedule, changed toileting time after lunch instead of 12:00 and continue other toilet times per care tracker. Will also communicate with therapy regarding resident's appropriateness of low bed, etc. The incident reports have a box in the upper right hand corner of the form for the reporter, investigator, and a submit date after each title. The 8/28/13 fall incident report has a staff name typed in the reporter space with a date of 8/28/13 and the investigator spot has the name of DON (Director of Nursing) B and a date of 10/22/13 (this survey date). There is no investigation into Resident 18's fall other than the incident report. There are no staff interviews or more detailed resident interviews other than his statement right after the fall. There is no follow up as to why the alarm was answered only after Resident 18 was on his way back from the bathroom when the alarm should have been answered immediately. Resident 18 was scheduled for abdominal surgery at the hospital on [DATE] and returned to the facility on [DATE]. A nursing note on 10/3/13 at 11:30 states that therapy staff notified nursing staff that Resident was weak and dizzy. Resident 18 denied being dizzy at this time but was dizzy earlier. Resident 19 was stood up with assist of staff and became very weak, almost as if he was going to faint. BP 100/60. Resident 18 was sent to ER (emergency room ) and returned at 2:30 with no new orders. A nursing note on 10/7/13, no time noted, states "Called to residents room resident fell on to floor going to bathroom received a back of head laceration. 911 caleld to transport to (hospital name) for eval and treatment. BP 88/50 then 91/53 ..." A note at 2:30 states, "Resident brought back to facility via (ambulance name) orders to follow up with (physician name) in 10/14/13 for staple removal. Res has 2 staples to back of head ..." A review of Resident 18's Resident Incident Report indicates that he fell on [DATE] at 11:45 AM. BP 91/53 received a scalp laceration to back of head. Resident alert and oriented x 3 and stated that he fell going to the bathroom due to walking too fast and stated, 'I ain't hurt.' Resident 198 was in his wheelchair prior to falling. The form indicates that at the time of this incident all aspects of Resident 18's plan of care had been provided. The investigation Summary states that Resident 18 transferred self to bathroom lost balance fell hitting head on floor. Laceration to back of head. 911 called and sent to ER. Neither the nursing notes nor the incident report speaks to Resident 18's chair alarm that should have been sounding at the time of the fall. There are no interviews of staff regarding this fall and no investigation as to the root cause of the fall to prevent future falls/injuries. There is no investigation into Resident 18's complaints of dizziness which was at the time of the previous fall on 8/28/13 and during the therapy session on 10/3/13. The incident report for 10/7/13 indicates the same format as the 8/28/13 form, with a nurse documenting in the reporter section, submitted on 10/7/13, and the investigator as DON B with the submit date of 10/22/13 (this survey date). On 10/8/13, no time noted, an IDT note states, "IDT met to review: IR (incident report) of 10/713. Resident fell going to bathroom received head laceration sent 911 to (hospital name ER) returned with 2 staples to back of head. Neuros initiated and placed on 15 minute checks, care plan and Care Delivery Guide updated. A nursing note dated 10/12/13 at 9:50 PM states, " ...up ad lib cont. (continues) to not be compliant with using call light." A nursing note dated 10/13/13 at 9:45 PM states, " ...continues to be non-compliant with putting call light on B4 (before) self-transfer." There is no follow up review for Resident 18 continuing to self-transfer and not requesting assist and not using his call light. There are no meetings documented with Resident 19 as he is his own legal decision maker as to why he doesn't ask for assistance and to document if he is in agreement with the interventions used to prevent falls/injuries. Additionally, there is nothing assessed and care planned regarding the dizziness that Resident 18 exhibited during his fall on 8/28 and his therapy session on 10/3/13. On 10/22/13 at 10:30 AM Surveyor was conducting an interview with Resident 8 who was the roommate of Resident 18. Resident 18 got up out of his bed and into his wheelchair. The bed alarm did not sound until Resident 18 was almost seated in his wheelchair which was next to his bed. Resident 18 proceeded to exit his room and go down the hall toward nurses' station. Surveyor started to time the ringing alarm which went on at 10:35 AM, after 3 minutes of the alarm sounding and no staff answering alarm, Surveyor went out into hallway. No staff was observed currently in hallway. Surveyor walked down hallway near the medical records room door; the alarm could be heard by surveyor. Surveyor observed 2 staff walk out of the medical records room, the staff were talking so it was unclear if they could hear the alarm. CNA (Certified Nursing Assistant) O and another staff were sitting at the desk at end of the hall and did not respond to the alarm. After 4 1/2 minutes a nurse from another wing came to this wing carrying a device and noted the alarm and responded to the alarm and turned it off. The nurse stated "where did he go" and Surveyor stated that Resident 18 went down the hall. Surveyor went to charge nurse (CN) P and asked who the CNA on the short wing was where Resident 18 resides. CN P stated that CNA O was scheduled on the wing, but she could be on break. Surveyor asked CN P who was in charge of the hallway when CNA O was at break. CN P stated that she tells an aide from another wing and that aide watches for lights on the short wing. Surveyor asked CN P who is supervising the wing for alarms when they go off to get there as quickly as possible, and how is a staff person a wing away supposed to hear the alarm. CN P stated that it was a good question. On 10/22/13 at 1:00 PM Surveyor reviewed Resident 18's care plan with CNA O in Resident 18's room. In reviewing the care plan, the interventions that were not in place and verified by CNA O were as follows: Chair alarm (the chair alarm was on Resident 18's night stand), gripper strips in Resident 18's bathroom, low bed (Resident 18's bed was not in low position), bed next to wall, a perimeter mattress, and a body pillow. Surveyor asked CNA O to show Resident 18's care delivery guide (a care plan that the CNA's carry around for reference of cares for residents) for the interventions listed. The care delivery guide that CNA O showed Surveyor did not have the above interventions listed on it. CNA O states that Resident 18 sets off his alarm all the time he does not use his call light. CNA O also stated that she felt that Resident 18 should not have his bed in low position as she felt that it would hinder him getting out of bed safely. CNA O apologized for the interventions not in place but did not know about them as they were not on her guide. On 10/22/13 at 3:00 PM Surveyor interviewed DON B regarding Resident 18 and his safety interventions. DON B looked at Resident 18's care plan and indicated that all the interventions listed should be in place to assist in the prevention of falls and possible injuries. Surveyor showed DON B the Care Delivery Guide that CNA O received that day to follow. DON B confirmed that the CDG did not have the fall interventions listed for Resident 18. Surveyor asked the process of updating the care delivery guide. DON B stated that it is the unit manager's responsibility to update the guide and should have been done. DON B brought another wing's care delivery guide to Surveyor and indicated that Resident 18 had moved from another wing about a week ago and that the previous hall's care delivery guide did state all of the interventions on the comprehensive care plan, plus a reminder sign on the wall to use call light and ask for assistance. DON B did state that they should have been transferred to his new hallway CDG but wanted to let surveyor know that they were in place on his old hallway. The facility did not follow Resident 18 care plan by not having all of his fall interventions in place during observations by surveyor and furthermore he did not have all of his interventions in place due to not being his new wing care delivery guide. The facility did not ensure that his care plan was followed due to no plan in place and followed to answer alarms when the wing CNA is on break.

Based on interview and record review, the facility did not ensure that residents were free of significant medication errors for 1 of 6 residents reviewed for medication concerns in a sample of 20. Resident 10 received 17 medications in error; this caused a change in Resident 10's condition requiring hospitalization in the Intensive Care Unit. This is evidenced by: On 10/18/13, Resident 10 was given 17 medications, by Medication Tech (MT) N, that were actually prescribed for another resident. Resident 10 was given [MEDICATION NAME] 200mg, [MEDICATION NAME] 80 mg, [MEDICATION NAME] 12.5 mg, Isorbide monoitrate 60 mg, [MEDICATION NAME] 25 mcg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 150mg, Senna + 2 tabs, Cavedilol 6.25 mg, ASA 81 mg, [MEDICATION NAME] Oxide 400 mg 2 tabs, Vitamin D3 1,000 IU, [MEDICATION NAME] 125 mcg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 325 mg, [MEDICATION NAME] 400 mg, and [MEDICATION NAME] 20 mg. Per medical record documentation MT N did immediately note the medication error and report to the nurse in charge of Resident 10 and initial monitoring was started. Per documentation in the nursing notes within 2 hours Resident 10 was noted to be sitting looking straight ahead, unresponsive, fell back, then became responsive. Resident 10 was diaphoretic (sweaty) and was nauseous. The facility called 911 and the resident was taken to the emergency room . A hospital history and physical for Resident 10, dated 10/18/13, indicates "Approximately an hour later (after ingesting the medications in error) while he (Resident 10) was eating breakfast he did not feel well and went back to bed where he fell asleep. He became increasingly symptomatic with confusion, nausea. They attempted to check his vitals and he suffered a loss of consciousness, falling back into the bed. He was markedly hypotensive and pale and was brought to the emergency room for evaluation. Patient received [MEDICATION NAME] in the emergency room with good response. He also received IV (intravenous) fluids with improvement in his initial [MEDICAL CONDITION]. He did not require pressor therapy but admission into the intensive care unit for further monitoring due to the overdose." Resident 10 returned to the facility on [DATE].

Based on interview and record review the facility did not serve food under safe conditions to prevent a potentially life-threatening foodborne illness for 4 of 124 residents (Residents 7, 3, 1 and 2) . Residents were served undercooked chicken. The serving of undercooked chicken created a potential for salmonella or campylobacter poisoning and resulted in a finding of immediate jeopardy. The immediate jeopardy began on 1/3/13. The Nursing Home Adminstrator was officially notified of this finding on 1/9/13. The Immediate Jeopardy was removed on 1/8/13; however, the deficient practice continues at a scope and severity level of E (potential for harm that is not immediate jeopardy/pattern) because the facility had not fully implemented the corrective actions. Findings include: The 2009 Federal Department of Agriculture Food Code indicates: 3-401.11 Raw Animal Foods. (A) Except as specified under ? (B) and in ?? (C) and (D) of this section, raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked: Cooking, to be effective in eliminating pathogens, must be adjusted to a number of factors. These include the anticipated level of pathogenic bacteria in the raw product, the initial temperature of the food, and the food's bulk which affects the time to achieve the needed internal product temperature. Other factors to be considered include post cooking heat rise and the time the food must be held at a specified internal temperature. Annex 3 Greater numbers and varieties of pathogens generally are found on poultry than on other raw animal foods. Therefore, a higher temperature, in combination with the appropriate time is needed to cook these products. According to the Unites States Department of Agriculture Food Safety and Inspection Service, "Food Safety Information" the standard of practice for cooking time of chicken is as follows for chicken legs and thighs: weighing 4 to 8 ounces roasting time should be 40 to 50 minutes. Chicken may be cooked from the frozen state in the oven or on the stove. The cooking time may be about 50% longer. The "Fight Bac, Keep Food Safe from Bacteria" article from the Partners for Food Safety Education states that Salmonella is the most common cause of diarrhea in the United States, and the most common cause of foodborne deaths. Responsible for 1.4 million cases of foodborne illness a year. Sources: raw and undercooked eggs, undercooked poultry and meat, fresh fruits and vegetables, and unpasteurized dairy products. The article goes on to state to cook roasts and steaks to a minimum of 145?F. All poultry should reach a safe minimum internal temperature of 165?F as measured with a food thermometer. Check the internal temperature in the innermost part of the thigh and wing and the thickest part of the breast with a food thermometer. The facility procedure for "Cooking Foods" last revised July 2010 includes the following: 2. Follow recipes for proper cooking times and temperatures...4. Cook food to an internal temperature required to kill pathogenic organism (i.e. 165 degrees for 15 seconds for poultry...). 6. Cook foods properly: b. Meat juices should run clear, no signs of red blood. According to the article, The Dangers of Undercooked Chicken, Consumer's Report found that 66% of store-bought chickens contained bacteria, primarily Campylobacter and Salmonella. These generally lead to diarrhea or bloody diarrhea and resolves within 2 to 5 days; nonetheless, " Great care must be taken to avoid contact with raw chicken meat since even a single drop of infected raw chicken juice is enough to cause illness in a person." According to this article, Salmonella or Campylobacter can cause "serious illness and even death in humans." (<http://healthmad.com/nutrition/the-dangers-of-undercooked-chicken.html>) Undercooked chicken can be even more dangerous than raw chicken because the cooking process activates the bacteria present. According to the Centers for Disease Control, "Salmonellosis is an infection with bacteria called Salmonella. Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. The illness usually lasts 4 to 7 days, and most persons recover without treatment. The elderly, infants and those with impaired immune systems are more likely to have a severe illness." The Southern Regional Office received a complaint stating that the facility served undercooked chicken, to several residents, at the evening meal on 1/3/13. On 1/8/13 at 8:35 AM, Surveyor interviewed Resident 7. Resident 7 stated that last week Thursday (1/3/13) she was served chicken and "it was raw" and "I got sick." Resident 7 stated that she only took one bite of the chicken and you could see that it was not cooked so she did not eat anymore. On 1/8/13 at 1:30 PM, Surveyor had a follow-up interview with Resident 7. Resident 7 stated that the chicken was pink when she cut it. Resident 7 stated she ate only one bite. She was told to wait for more chicken (to be cooked) but instead got a peanut butter and jelly sandwich because she did not want to wait. Resident 7 stated that, later in the evening before bed she felt nauseous. Resident 7 stated she told the nurse and the nurse gave her some medicine. Resident 7 stated that 1-2 times per week she doesn't get what she ordered for meals because they run out. Resident 7 stated her table is always close to the last one served. Resident 7's Admission Minimum Data Set (MDS) assessment dated [DATE] lists a Brief Interview for Mental Status (BIMS) score of 13 which indicates no Cognitive Impairment. Resident 7's medical record for 1/3/13 shows no documentation of her report of nausea and no medications for nausea noted on the Medication Administration Record (MAR) of 1/3/13. On 1/8/13 at 1:00 PM, Surveyor interviewed Resident 3. Resident 3 stated that the "food is going downhill." Resident 3 stated that when she first came to the facility the food was good. Resident 3 stated that last week one night there was a problem with the chicken. Resident 3 stated that many residents waited until after 7 PM for the 5 PM meal. She stated that they often run out of food because people will change their meal orders at the last minute. Last week they ran out of chicken and had to cook more. Resident 3 stated that when she did get her chicken she ate most of it but the area by the bone was "red with blood." Resident 3 stated that she did not eat the chicken from that area. Resident 3 stated that she did not get sick. Resident 3 stated that they need to make changes to the way people order their meals because everyone should be served their first choice before giving the food to other people. That way they won't keep running out of food. Resident 3's Annual Minimum Data Set (MDS) assessment dated [DATE] lists a Brief Interview for Mental Status (BIMS) score of 15 which indicates no Cognitive Impairment. On 1/8/12 at 10:10 AM Surveyor asked Resident 1 if he had any concerns regarding food served in the dining room. Resident 1 stated, "We practically starve to death. The food is not fit at times to eat, sometimes it is too spicy to eat and sometimes it is not cooked. Meals are running late very often or they run out of food." Surveyor asked Resident 1 to give details about food not being cooked. Resident 1 stated, "About 1 week ago at supper I went to the dining room, around 5:30 PM as usual, shortly after 6:05 PM the cook (Cook G) came out of the kitchen and told us that they ran out of chicken and he had more on to bake. At around 6:40 PM (Cook G) brought chicken out to us residents that hadn't eaten yet. My chicken was cooked on the outside but when I peeled the skin back it was fleshy and bloody. There was blood on my plate and I cut into the chicken and it was raw. I wouldn't eat it and my daughter (Family Member J) saw it too and she went and told the kitchen staff. (Cook G) came back into the dining room looked at the chicken and said, 'I'm sorry, don't eat I didn't know it wasn't done, I'll make you more, I have some cooking still'." Resident 1 continued to state, "A lady next to me also stated that her chicken was raw and she ate some of it. (Cook G) stated to us that he even made 15 extra pieces of chicken and he apologized for the chicken not being done. I did get chicken around 7:20 or 7:30 PM and it was done and good. I did have a loose stool that evening which is not usual." Resident 1's most current MDS dated [DATE] indicates that his BIMS score was 13. On 1/8/13 at 3:00 PM Surveyor interviewed Resident 14 as he was a tablemate of Resident 1 and 2. Surveyor asked Resident 14 if he was aware of any concerns of chicken served at a supper meal about a week ago. Resident 14 stated, "Yes, we all heard. It was about a week or so ago and they ran out of chicken at supper. I didn't want to wait so I just had a sandwich. I didn't see the chicken but I heard it wasn't done as several other residents were talking and complaining about it. We often run out of food at the evening meal and have long wait times to be served. My tablemate is loud and will let people know when things are not right." On 1/8/13 at 4:30 PM Surveyor interviewed Resident 2 regarding his meal on 1/3/13. Resident 2 stated that he was in the dining room around 5:30-5:40 PM waiting for supper. Resident 2 states that he had chosen chicken as his choice for entree. Around 6:00 PM the cook came out and stated that they ran out of chicken but he had put more on to cook and it would be a little bit. Resident 2 went on to state that when his chicken came out it was definitely not cooked enough. Surveyor asked Resident 2 to describe the meat. Resident 2 stated that it looked "fleshy and had blood on it" and he didn't eat it and got something else. Resident 2 also stated that his tablemate, Resident 1, pulled the skin of his chicken back and it was definitely not cooked and his daughter (FM J) reported it to the staff. Resident 2 continued to state that the cook came out and apologized for the chicken but would cook more for them and the plates were pushed aside on the table. On 1/8/13 at 5:45 PM Surveyor interviewed Activity Aide I (AA I). Surveyor asked AA I about dinner service on 1/3/13. AA I stated, "I was in charge of the church service that evening which began at 7:00 PM. Residents were still in the dining room waiting on supper at 6:45 PM. I learned that they ran out of food and the cook was cooking more. Resident 1 was there with Family Member J (FM J), and he was very angry and vocal about having to wait for supper so long. Resident 1 and FM J stated to me that the chicken they were served was not done and the kitchen was cooking more." Surveyor asked AA I if he saw the chicken that was served the evening. AA I stated, "Yes, It was definitely not done. If you or I went to a restaurant and was served this we would get our money back. The chicken was dripping blood. The skin looked done but there was blood on the plate next to the chicken, a small pool of it. I did not cut into it. FM J was very concerned that the facility served undercooked chicken to the residents so I told her that I would report it to a nurse." AA I stated that he reported the issue to a nurse and she wrote it on a sticky note. On 1/8/13 at 7:30 PM via phone Surveyor interviewed Family Member J regarding 1/3/13 visit with Resident 1. Surveyor asked FM J about the dinner service on 1/3/13. FM J stated, "I was in the dining room with my father (Resident 1) and around 6 PM we were notified that the kitchen ran out of chicken, but more was put in the oven to cook. At about 6:35-6:40 PM the chicken was brought to my dad's table and tables next to ours. My Dad's chicken was not cooked and it had blood on the plate. The meat was fleshy and the bones had blood too. It was obviously not cooked. I went to dietary staff and told them that the chicken was not done and (Cook G) came out of the kitchen and apologized about the chicken and said that he had more cooking and would be done soon. The plates were left on the table. My concern really was for the residents that couldn't know better to not eat the chicken that wasn't done all the way, at least my dad and his tablemate could tell. One lady sitting next to us ate some of it." On 1/8/13 at 9:30 AM, Surveyor interviewed Dietary Manager F (DM F) regarding the complaint of undercooked chicken. DM F stated that she was not informed of undercooked chicken but she was informed that residents were not happy because the kitchen ran out of chicken and the cook had to cook extra chicken and supper ran very late. Surveyor asked DM F what she did to look into the concern. DM F stated that she talked to 2 residents and they complained that they had to wait a long time for the food as the cook ran out and had to make more. DM F stated that they did not complain that the food was undercooked. Surveyor asked DM F if she had talked to any dietary staff. DM F stated that she talked to the cook and he said he ran out of chicken and made a second batch. DM F stated that the cook said that he temped the chicken and it was fine. DM F states the process for preparing food for resident to ensure that there is enough at each mealtime is as follows: Dining room residents have kitchen staff go around with dietary slips and the resident chooses what food they want for the next meal. The residents that eat on the wings are given a slip and the aides bring them to the kitchen when the slips are filled out. The cook then gets the total and is able to prepare the correct number of servings of each choice to residents by using a formula. There has been an issue of running low or out lately as our census is grown and the CNA's are not getting the slips to the cook. Surveyor asked DM F what she was doing about fixing the issue of running out of food. DM F stated, "We have been trying new menu items, but nothing has been done about running out of food yet." On 1/8/13 at 1:30 PM Surveyor interviewed Cook G regarding the dining service concerns. Surveyor asked Cook G if he was aware of any complaints of undercooked chicken. Cook G stated, "Yes, I know exactly what you are talking about. Last week we ran out of chicken because 2 wings did not get their menu choices to the kitchen at all. The number 2 choice was chicken and I even cooked 15 pieces extra. When the staff served the residents they didn't follow the choice list and gave residents who didn't pre-order chicken that item so in the end we ran out before we were done serving the dining room. I was cleaning up when I was informed that we ran out. I went to the dining room and told the residents that wanted chicken still that I will cook them some. At 6:07 PM I put chicken thighs and legs from the freezer in the oven to cook. The thighs and legs would cook faster than other pieces. I knew the residents were not happy and I was trying to get them what they wanted. I took the chicken out of the oven and I only temped a thigh and 1 leg. I put the thermometer in and it went up to 165 degrees so I took it out after only a second or two. I took off the pan about 6 or 7 pieces and made plates for the residents. I put the rest of the chicken that was on the pan back into the oven to finish cooking. A few minutes later, I was informed that the chicken was not done. I went out to the table of residents and a family member and apologized and told them I would have more chicken in a few minutes, as I still had the batch in the oven." Surveyor asked Cook G if the chicken was done. Cook G stated, "It looked done on the outside, but it was deceiving. The outside looked done but the inside was not." Surveyor asked Cook G if he would eat the chicken and he stated, "No, I would put it back in the frying pan." Surveyor asked why he served the chicken to residents. Cook G stated, "I was frustrated for running out, we seem to be doing this a lot and the residents were mad. I really did not know it was not done or I wouldn't have served it." Surveyor reviewed the Food Temperature Record log, in the presence of Cook G, and the second entree (which was the chicken) had a temp documented of 189 degrees. Surveyor asked Cook G what chicken the 189 degrees came from. Cook G stated that the last batch of chicken that was taken out was the one that he recorded. Cook G stated that there is no documentation of the temperature of the chicken that the residents alleged undercooked. Cook G stated that he did not temp the chicken after residents complained of being undercooked. Surveyor asked Cook G how he is to check to see if chicken was appropriately cooked. Cook G stated, "I was supposed to temp each piece by leaving the thermometer in the chicken and the temp had to be at 165 degrees for 15 seconds. Surveyor asked Cook G if he followed the proper procedure for checking to see if the chicken was cooked properly and he stated, "No, I was supposed to leave the thermometer in the chicken piece for 15 sec and to temp each piece of chicken." Cook G also stated, "I've been having issues of running out or close to running out very often especially lately. The staff does not get the food choices to me in time and when they serve trays they do not follow the choices listed on the sheet. I have a formula to follow on how I plan for meals and it is hard when the staff do not follow the rules." Surveyor asked Cook G if he reported any of this info to DM F. Cook G stated, "Yes, the very next day I told her that the supper service was a disaster and residents complained about the chicken and the time that supper was served. I told her that residents were not happy with the way the chicken was cooked." Surveyor asked DM F for the recipes for the chicken that was cooked on 1/3/13. A recipe for Lemon Baked Chicken was given to the surveyor. The recipe states that the recipe was for a 3 ounce boneless chicken breast. The cooking directions state to cook at 350 for 25-30 minutes until the internal temperature reaches 165 degrees for 15 seconds. Surveyor asked for a recipe for directions for cooking chicken on the bone, exactly what was served 1/3/13. At 2:20 PM DM F stated the recipe says boneless chicken but because we have so many people who like dark meat we use bone-in chicken. Later another recipe for 2 ounce pieces of oven fried chicken recipe was provided to surveyor which states bake at 350 degrees until internal temperatures reaches at least 165 degrees for 15 seconds. The facility was unable to provide the survey team with a recipe for bone-in chicken and how it is to be cooked. On 1/8/13 at 4:10 PM Surveyor interviewed NHA A regarding the concern of undercooked chicken served on 1/3/13. NHA A stated that she did not know there was a concern of undercooked chicken but was aware of the concern of running out of food. Surveyor asked what was done to find the root cause of the issue and what was done to correct the situation. NHA A stated that she was not aware of what occurred after that incident but was aware that there had been some concerns in the kitchen and they had made an action plan. The action plan was put into place on 12/11/12 indicating that the concern is that meal service on PM shift is poor (service times are slow and temperature of food is not adequate) the PM shift in general lacked supervision (majority of concerns were identified on the PM shift). The root cause identified was that the majority of the concerns were on the PM shift and were the result of decreased supervision and lack of customer service skills. An action plan was to enlist the new PM supervisor to monitor meal service including room trays and ensure meal choices are offered and food temperatures are adequate. The facility's failure to cook chicken to a proper internal temperature created a situation of Immediate Jeopardy. The facility removed the Immediate Jeopardy on 1/8/13 when the facility implemented the following: 1. All food served to residents will be cooked to an internal temperature required to kill pathogenic organisms (i.e. 165 degrees for poultry). 2. Internal temperatures of food will be taken prior to meal service at breakfast, lunch and dinner and recorded on the "Food Temperature Record" The cook will ensure that temperatures obtained are within the guidelines for safe food service. 3. Residents served dinner at the center on 1/3/13 will be reviewed for signs and symptoms of possible food borne illness...Any possible symptoms identified will be addressed with the residents' physician. 4. The center dietary manager or designee will monitor food temperature completion each meal for the next 2 weeks to ensure food is served is completely cooked and is temperature required to kill pathogenic organisms. Any concerns identified will be addressed. No unsafe food will be served. 5. The center dietary manager will interview 5 residents a week for the next 3 months to ensure that food served is completely cooked. Any concerns identified will be addressed. The results of these interviews will be reviewed in the centers monthly QPI (quality assurance) meeting as well. The QPI team will make recommendations for improvements and suggest future interviewing schedule as indicted. 6. Dietary staff who serve as cooks will be re-educated on proper food services preparation and serving temperatures (and what to do if temperature is not attained) prior to the next scheduled shift. CNA staff will be re-education on what to do and who to report any food temperatures concerns (i.e. do not serve undercooked food, if food appears undercooked once served remove from service and ensure all food is served properly cooked). The above interventions were initiated 1/8/13 on the PM shift.

Based on observation, interview and record review, the facility did not ensure that 1 of 3 Residents (Resident 30) reviewed with pressure ulcers received the necessary treatment and services to promote healing and prevent new sores from developing. Resident 30 was readmitted to the facility with no pressure ulcers. Resident 1 subsequently developed a Stage 2 ulcer on his right heel. The facility failed to provide Resident 30 with appropriate measures to prevent the development of the pressure ulcer and did not provide ordered treatments per the physician's orders [REDACTED]. This is evidenced by: Facility Policy 1.5.1 Wound Prevention and Management (Effective November 1998, Revised April 2009) states: "PROCEDURE Turning and Repositioning - (Corporate Name) will follow Skin Care Protocols regarding the turning and positioning of residents that may include, but is not limited to a person with: -Sensory Impairment -Braden Risk Assessment that scores low in mobility and/or sensory perception...2) Turn and reposition every 1-2 hours when -in bed -in wheelchair/gerichair...6) Communicate the individualized turning and repositioning schedule using -Skin Integrity Assessment: Prevention and Treatment Plan of Care. -Care Delivery Guide/Nursing Assistant Assignment Sheet 7) Document repositioning using CareTracker." According to "The Long Term Care Nursing Desk Reference" (Acello, 2005),"...11. Keep heels elevated off the bed or hanging over the end of the mattress in bedfast residents. Note: Use of heel protectors reduces friction and shearing, but does not relieve pressure. Avoid doughnut-type devices, which increase pressure...Relieve pressure under the heel(s) with Category/Stage I or II pressure ulcers by placing legs on a pillow to "float the heels" off the bed or by using pressure-reducing devices with heel suspension." Resident 30 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30's Minimum Data Set assessment, reference date 11/14/12, indicates Resident 30 is able to make needs known and understand others and cognition is intact, and that Resident 30 is an extensive assist of two for bed mobility and transfers. Resident 30 is at risk for pressure ulcer development and currently has 2 venous/arterial ulcers present. Resident 30's Skin Integrity Assessment: Prevention and Treatment Plan of Care dated 10/17/12 states under the following but not all inclusive: Assessment/Problem column: "Braden Assessment Score at Risk (15-18) and Frequent Turning, Maximal Remobilization, Protect heels, Manage Moisture, Friction, Shear, Nutrition and Pressure Reduction Support Surface if Bed or Chair Bound are checked. Under the "Interventions" column the following items are checked: "Complete Push Tool weekly, Complete Braden Scale upon admission and weekly times 4 wks, quarterly and with change of condition. Activity/Mobility: Encourage ambulation, Provide ROM, Implement and individualize turning schedule if applicable, position body with pillows and/or other supportive devices... Monitor Skin weekly and PRN... Under 'Areas of Impairment Column with a date of 11/20/12 states," Stage II rt heel 4.5 X 6, increased lower extremity [MEDICAL CONDITION] interventions added dated 11/20/12 Heel Pads." Please note that there was no intervention to "Float Heels" on the 10/17/12 care plan. On 12/17/12 Surveyor reviewed Resident 30's Care Delivery Guide (CNA assignment sheet) with no updated date; the T & R (Turn and Reposition) Skin Intervention column is blank. Review of Resident 30's physician orders [REDACTED]. Treatment ordered was Skin Prep to the area every shift and elevate heels. Review of physicians orders dated 11/21/12 states, "Heel Pads for pressure ulcer right heel and skin prep TID (three times/day) until healed." Physician order [REDACTED]." Diagnosis: [REDACTED]. Resident 30's physician order [REDACTED]. Resident 30's TAR (Treatment Administration Record) for December 2012 indicates that on 12/6/12 "wear heel protective boots/Pillows" was added to the TAR. This treatment was never signed off as being completed. On 12/17/12 at 9:20 AM, Surveyor observed Resident 30 sitting in his wheelchair. Resident 30 was wearing blue gripper socks. No heel boots were in place. On 12/17/12 at 10:40 AM, Surveyor observed CNA G and CNA H lay Resident 30 down in bed. CNA G and CNA H placed a pillow under Resident 30's lower extremities with Resident 30's heels resting flat on the pillow. On 12/17/12 at 11:40 Am Surveyor observed RN (Registered Nurse) F provide wound care to Resident 30's right heel. RN F removed the covers and Resident 30's heels were resting flat on the pillows. Surveyor asked RN F if Resident 30's heels were floated, and RN F replied, "No the calves should be on the pillow." Surveyor then asked RN F if Resident 30 was receiving pressure reduction with the placement of the heels flat on the pillows. RN F stated, "No." RN F then proceeded to remove the old dressing, which was saturated with serosanguanous drainage. Surveyor then asked RN F what stage the pressure ulcer was on Resident 30's right heel, RN F replied, "It is unstageable." RN F then asked Resident 30 if he felt any pain in the right heel, Resident 30 stated, "No feeling." Surveyor asked Resident 30 if he had ever worn any type of boot to his right heel since getting the sore. Resident 30 replied, "No." RN F measured Resident 30's right heel pressure ulcer as 5.4 cm x 6.2 cm with 15% maceration to periwound and 80% of wound bed covered with necrotic tissue. RN F then cleansed the ulcer with normal saline, blotted dry, applied [MEDICATION NAME] ointment to the wound bed, covered with a 44 gauze, an abd pad and wrapped Resident 30's right heel with kerlix and secured the dressing with tape. On 12/17/12 at 12:00 PM, Surveyor asked RN F about the heel boots that had been ordered for Resident 30. RN F stated that she looked for the boots and could not locate them. RN F then asked what RN F knew about the heel boots that had been ordered for Resident 30 on 12/6/12. RN F stated, "I am looking into that." Surveyor then asked RN F if Resident 30 ever had any type of pressure relieving boot in place. RN F stated, "No, not to my knowledge." Surveyor then asked RN F who assesses Resident 30's right heel ulcer. RN F stated, "The wound nurse comes weekly and assesses, also the nurses who do the treatments assess, but they have to look under the heel to see the ulcer." Surveyor then asked RN F if the current treatment was appropriate for Resident 30's right heel, and if there had been a change in the wound status, RN F replied, "I am not wound certified, but from the previous documentation there is a change." A weekly skin assessment Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form has been completed for Right Calcaneous Pressure Ulcer on 11/20/12, notes an ulcer Stage II, 4.5 cm X 6 cm intact blister, recommend: skin prep to the area every shift and elevate heels. Please note that elevation of the heel was never added to the care plan. A weekly skin assessment Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form has been completed for Right Calcaneous Pressure Ulcer on 11/27/12, notes an ulcer Stage II, 7 cm X 7 cm intact blister, recommend: continue skin prep to the area every shift. An emergency room note dated 12/2/12, states, "The patient...presents to the emergency department by ambulance from the nursing home for a problem to his right heel. Patient states that he has not noticed any problems. He states that they had to change the dressing on his right foot and they noticed injury to his heel he was sent here for evaluation. Patient denies any pain or other comments. He states that prior to them changing the dressing today they 'had not looked at his foot in a long time.'" A weekly skin assessment Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form completed for Right Calcaneous Pressure Ulcer on 12/4/12 notes an ulcer Stage II, 6 cm X 6.5 cm no depth, serous drainage, blister open and flap covering entire wound bed. Recommend: Clean with normal saline, apply Idoflex to area and cover with allevyn heel pad and wrap with Kerlix every day. A physician progress notes [REDACTED]." A weekly skin assessment Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form completed for Right Calcaneous Pressure Ulcer on 12/11/12 notes an ulcer Stage II, 3 x 5 cm, x 2 x 1 cm, 1 x 1 cm, with depth of 0.1 cm, serous drainage, wound bed color pink. Island healing noted in 3 areas at this time. Wound bed clean. Recommend: Continue Current Treatment A weekly skin assessment Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form completed for Right Calcaneous Pressure Ulcer on 12/18/12 notes an ulcer, now Stage III after debridement, 3.5 x 5.8 x 0.5 cm and 0.8 x 3 x 0.1 cms, serous drainage, wound bed color red. Wound bed red and vascular, approximately 20% slough, wound post debridement. Recommend: Continue Current Treatment On 12/18/12 at 9:20 AM, Surveyor observed Resident 30 sitting in his wheelchair attending an activity. Resident 30 was wearing bilateral heel float boots and a Hoyer sling was visible in Resident 30's wheelchair. On 12/18/12 at 10:45 AM, Surveyor interviewed DON (Director of Nursing ) B and RN E as to the reason for the heel boots that were ordered for Resident 30 on 12/6/12 not being initiated until Surveyor brought it to the facility's attention. RN E stated, "There was confusion between the heel boots and the heel pads. We clarified the order yesterday." Surveyor asked RN E if the abd pad and the allevyn heel pad provided Resident 30 with pressure reducing properties, RN E did not reply. Surveyor then asked RN E what the facility does if a physician writes an order for [REDACTED]." On 12/18/12 at 11:00 AM, Surveyor interviewed DON B and RN F regarding Resident 30's emergency room evaluation on 12/2/12. RN F stated, "The CNA's were removing Resident 30's grippy sock and noticed that Resident 30's sock was soaking wet, and when they were removing the grippy sock the skin from Resident 30's right heel peeled off. RN F stated that it appeared as if the skin from Resident 30's right foot was coming off." Surveyor asked RN F if there had been a dressing on Resident 30's right heel. RN F stated, "There was no dressing on Resident 30's right heel" and also that "Resident 30 had been wearing shoes during the day." On 12/18/12 at 11:15 AM, Surveyor asked DON B why the heel boots were not put in place for Resident 30 until 12/17/12. DON B stated," When the heel boots were ordered Resident 30's feet were swollen. We did bring in a heel trough to elevate his heels but Resident 30 refused." Surveyor then asked DON B what the facility did to protect the intact blister on Resident 30's right heel, DON B did not answer. RN F stated, "Resident 30 went out to the surgeon yesterday (12/17/12) and Resident 30 has the right heel debrided again. The new orders are for the wound vac to be started. We have called the company to start the new treatment."

Based on record review and interview the facility did not ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 11 residents (Residents 23, 22, and 6) reviewed. Resident 23 was not deemed safe to use an electric wheelchair. The staff assisted Resident 23 into the electric wheelchair and an accident occurred and Resident 23 received a large laceration from the incident. Resident 22's fall interventions were not put into place following a fall. Resident 6 had seven (7) falls in the facility in a 6-month period. The facility did not implement new interventions and/or implemented interventions that were previously found to be ineffective for 6 of the 7 falls. This is evidenced by the following: Example 1 Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 23's Minimum Data Set assessment, reference date 8/17/12, indicates Resident 23's short term memory problem and decision making skills are modified independence with some difficulty in new situations. Resident 23's care plan, dated 8/10/12, indicates to use wheelchair pedals for positioning but does not indicate the use of an electric wheelchair. The care plan also indicates Resident 23 has poor safety awareness. Resident 23's nursing notes for 8/16/12, by Licensed Practical Nurse (LPN) K state: ...Resident 23 encouraged not to use electric wheelchair due to being unsafe in it. Resident 23's physical therapy notes, dated 8/16/12, indicate: Extensive resident education to resident and daughter regarding therapy goals...discussed concerns with safety using electric wheelchair as resident has displayed decreased ability to manage obstacles/traffic in room and hallway, all parties agreeable at this time. Resident 23's "Physician/NP/PA Communication and Progress Note" for 8/17/12 indicates: Resident 23 was in electric wheelchair due to bed being moved to another room. Resident 23 was sitting in the hallway, Resident 23 was asked to stay in the spot she was with her wheelchair off. Resident 23 then turned on her wheelchair and proceeded to go to new room. Resident 23 ran into the doorframe causing a gash in her left lower leg that was bleeding heavily, had blood all on floor and wheelchair. Resident 23 was sent to the emergency room . Resident 23's hospital/emergency department notes, dated 8/17/12, indicate Resident 23 had a laceration on her left shin measuring approximately 30 centimeters (cm) with a depth of 6 cm. The wound was a full thickness laceration that was irregularly shaped. The notes also indicate a physician attempted to close the wound with sutures but was unable to do so. After exam it was determined that it could not be closed with sutures due to skin fragility. Dressed with specialized dressing by physical therapy. The facility's incident report, submitted 8/21/12, indicates Resident 23 hit the door frame trying to go into a room. The report indicates the incident was not witnessed. The summary states: Resident 23 seated in power wheelchair. Had been in the process of assessment by therapy department to evaluate residents safe operation of chair within the facility, Resident 23 encouraged not to use the chair until the assessment was complete. States she can safely operate the chair and has been using it for years. Up in chair during bed linen change. (Note-was actually a room change). Turned on the power chair and drove out of her room and directly into the door jamb of adjacent room, bumping her leg on the door jamb/frame, causing a skin tear laceration to lateral left lower extremity. Power chair removed until safety assessment can be completed. On 11/14/12, at 10:05 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated if a resident has an electric wheelchair upon admission therapy completes a screen for safety. DON B stated residents are not able to use the electric wheelchair until the resident has been cleared by therapy. DON B stated this is usually done on the first day. DON B stated she did recall Resident 23 having an electric wheelchair and the facility was questioning the safety of its use. DON B stated she recalled talking about the electric wheelchair because the bariatric wheelchair would not fit through the doorway. DON B could not locate any documentation related to this conversation. DON B also stated that an electric wheelchair is also on the resident's care plan. DON B and Surveyor reviewed Resident 23's care plan and there was no indication of the use of an electric wheelchair. On 11/14/12, at 10:25 AM, Surveyor interviewed Rehabilitation Director (Rehab Dir) N. Rehab Dir N stated nursing communicates with therapy when a screen or assessment for safety is needed. Rehab Dir N stated she did not see a screen for Resident 23's electric wheelchair use. On 11/14/12, at 4:20 PM, Surveyor interviewed DON B and Nursing Home Administrator (NHA) A. NHA A stated Resident 23 was with a Certified Nursing Assistant (CNA) the entire time she was in the electric wheelchair. NHA A stated having Resident 23 in the electric wheelchair with staff supervision would be the safest thing during the room change as Resident 23's other wheelchair would not fit through the door. (Note-the incident report indicates the incident was not witnessed.) On 11/14/12, at 4:40 PM, Surveyor interviewed LPN K via the phone. LPN K stated when residents are admitted physical therapy does an assessment for the safe use of an electric wheelchair. Surveyor read LPN K her note from 8/16/12. LPN K stated therapy did not feel Resident 23 was safe with the electric wheelchair because Resident 23 had been running into the walls at the facility and family states she had done that also at home. LPN K stated therapy was going to work with Resident 23 for the use of the electric wheelchair. LPN K stated they were working on getting Resident 23 a different wheelchair because the one they had was too small so Resident 23 had been staying in bed. LPN K stated therapy did not want Resident 23 in the electric wheelchair until they worked with Resident 23. LPN K stated that on 8/17/12 they were doing a room change for Resident 23 and Resident 23 had to get out of the bed so they could break the bed down to get it out of the room and into the other room. LPN K stated Resident 23 would only agree to get out of the bed if she could go into the electric wheelchair. LPN K stated she and 2 CNAs assisted Resident 23 into the wheelchair but told her to stay where she was. LPN K stated then her and one CNA went into another resident's room and CNA L was left in the hallway. LPN K stated she came out of the room after about 5 minutes and noted Resident 23 was not sitting outside her room and she asked CNA L where Resident 23 went. LPN K then looked down the hallway and saw Resident 23 by the doorway and blood all over the floor. LPN K stated she asked Resident 23 why she moved and Resident 23 stated because her bed was ready. LPN K stated she thought she talked with Registered Nurse (RN) M about Resident 23's refusal to move unless she was in the electric wheelchair. On 11/14/12, at 4:52 PM, Surveyor interviewed RN M. RN M stated he did not recall talking with anyone about concerns with Resident 23 moving rooms. Surveyor asked if Resident 23 was supposed to use her electric wheelchair and RN M replied "No." RN M stated Resident 23 brought her electric wheelchair from home and was not able to use it until a safety evaluation was completed. RN M stated he did not know staff put Resident 23 into the electric wheelchair for the room move until after the laceration occurred. On 11/14/12, at 5:00 PM, Surveyor interviewed CNA L. CNA L stated Resident 23 was able to use her electric wheelchair in the facility and used it every day. CNA L stated staff would assist Resident 23 into the electric wheelchair in the morning before breakfast and would stay up in the electric wheelchair until after lunch. CNA L stated she was not aware that the wheelchair was not safe for Resident 23. CNA L stated on the day Resident 23 moved rooms they got her up for the morning and put her into her electric wheelchair as part of their typical daily cares for Resident 23. CNA L stated she was in the hall when she heard Resident 23 say she wanted to go somewhere. CNA L stated Resident 23 was outside her room door stating "I'm ready to go." CNA L stated she tried to talk Resident 23 down so CNA L could go and get the nurse then Resident 23 hit the electric wheelchair remote and the electric wheelchair went forward and then back and CNA L saw the blood and called for help. CNA L stated another staff came out of a room and then went and got the nurse. Resident 23 was put into the electric wheelchair which the facility had safety concerns with her using and had not deemed it safe and Resident 23 sustained and injury while in the electric wheelchair. Example 2 Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 22's Minimum Data Set, reference date 6/21/12, has a BIMS (basic interview for mental status) of 4 which indicates a cognitive impairment. Resident 22's nursing notes include: -7/5/12--Resident 22 found on floor in front of wheelchair by Certified Nursing Assistant... -7/6/12--IDT (interdisciplinary team) met. Will put resident 22 to bed when restless and therapy request for a tilt seat in wheelchair. -7/18/12--Resident 22 had witnessed fall...attempted to catch resident but Resident 22 still went down... -7/19/12--IDT met...therapy note for a tilt back seat on wheelchair. On 11//14/12, at 1:36 PM, Surveyor interviewed Rehabilitation Director (Rehab Dir) N. Rehab Dir N reviewed Resident 22's therapy notes and stated therapy was working on standing, transferring and strengthening for Resident 22. Rehab Dir N stated she did not see a referral to evaluate a tilt seat for Resident 22 at any time. Resident 22 was discharged from the facility on 7/25/12 and there is no indication an evaluation for a tilt seat was done or why not done. The facility fall policy entitled "Risk Reduction: Falls and Injuries Program" last revised April 2012 states in part: "Policy: (name of Corporation) strives to reduce the risk for falls and injuries by promoting implementation of the Risk Reduction: Falls and Injuries Program, and strives to provide an environment that is free from hazards over which the center has control and provides supervision and assistance devices to each resident to prevent avoidable accidents...Risk is any external factor or characteristic of an individual that influences the likelihood of an accident including, but not limited to, musculoskeletal, cognitive, medical sensory, environmental, pharmacological and neurological factors...Centers are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment...The use of tool or items such as personal alarms can help monitor resident's activities but does not eliminate the need for staff vigilance an are not to be utilized in lieu of supervision..." Example 3 Resident 6 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 6's Annual Minimum Data Set (MDS) assessment dated [DATE] noted that Resident 6 scored a 04 on her Brief Interview for Mental Status (BIMS) assessment and her Quarterly MDS assessment dated [DATE] noted a BIMS score of 01 (out of 15). These scores indicate severe cognitive impairment. Resident 6 sustained the following falls in the facility: 5/17/12 at 6:30 AM - Per the "Resident Incident" report, Resident 6 was found sitting on the floor in her room in the entryway to the bathroom. The resident stated she was trying to go to the bathroom. The resident had been in bed prior to the incident. There was no injury. The incident's "final disposition" as noted in the report states: "...Education was provided to resident on using the call light when needing assistance." An addendum added to the report on 11/9/12 states that a B and B (Bowel and Bladder) assessment was initiated. A note dated 5/20/12 was added to the "Bladder Data Collection and Assessment" form which states: "No change in status, will continue T.P. (toileting program) as resident incont (incontinent) of bladder upon rising, after breakfast, before lunch and dinner, HS (bedtime) and will call during NOC (night) shift." No changes were made to the care plan or toileting schedule based on the B and B assessment. Therefore, the only intervention was to educate the resident on the call light use. 6/10/12 at 5:15 PM - Per the "Resident Incident" report, Resident 6 was found "on her buttocks in bathroom with occiput (head) on lower door frame. A physical exam showed that the resident had pain that was "sore on area between occiput and top of head in center." The description of incident states: "was toileting self and lost balance, forgot to use wc (wheelchair) or ww (wheeled walker) to transfer." The "actions that were taken following the incident" are noted as: "Therapy screen request and 15 minute checks. The 15 minute checks were not added to the care plan and were in place for only 24 hours per the "24 hour resident flow record" provided by the facility. The therapy screen notes that patient education was done to remind Resident 6 to lock her wheelchair brakes. A reminder sign was posted in the Resident room. The increased supervision was short-term (24 hours) and the only other intervention was education provided to the resident. 8/10/12 at 10:45 PM - Per the "Resident Incident" report, Resident 6 was found sitting upright against her bed on the floor. A description of the incident states she "was getting up for breakfast" which indicates confusion as it is early in the night and not close to breakfast time. The description of "final outcome states in part "...Resident has a hx (history) of self-transferring and not calling for assistance when transferring." The incident's "final disposition" states: "Care plans were updated, and no sign of pain or injury. Education was provided for use of the call light." No updates to the care plan were noted for this date. 9/23/12 at 12:30 AM - Per the "Resident Incident" report, Resident 6 was found "sitting on her floor, sitting up against her bed with shoes on. Stated she was trying to get up into her w/c (wheelchair)." In the final disposition section it asks "Can a resident trend be identified?" The answer states "yes-Resident has a history of self-transferring." Actions taken are: "Care plan revision" and "education." The incident's final disposition is noted as: "Initiated B and B, and education provided on use of the call light for assistance." No changes were made to the toileting schedule or to the "Bladder Data Collection and Assessment" based on the B&B assessment. A note on the resident care plan states: "9/23/12-Reminder signs placed." Thus, the only intervention was Resident education both verbal and in writing (signs). 9/28/12 at 3:00 PM - Per the "Resident Incident" report: "Resident found, on floor by her bed with wheelchair by her bed. Resident was trying to get out of bed on her own at the time of the incident." The summary of investigative outcome states: "Resident attempting to self transfer and slid off of bed while trying to get into wheelchair." Summary of corrective action taken states: "Resident reminded not to self transfer and signs placed in room to remind to call for assistance." The facility also provided "24 hour Resident flow records" to show that Resident 6 was placed on 15 minute checks which were in place from 9/24 to 10/4 and 60 minute checks from 10/4 to 10/9 when they were discontinued. Thus, the only long-term intervention was Resident education. 10/1/12 at 6:07 AM - Per the "Resident Incident" report, Resident 6 was found "lying on right side by bedside table." Resident 6 complained of right shoulder pain and had a laceration to her left forehead and right elbow that required treatment with steri-strips. The final outcome section states: "Reason: Resident has dementia and tries to do things on her own." The final disposition section states in part: "Attempt at self transfer, dx (diagnosis) of dementia, call light working and available." Resident "trend determination" section states: "Isolated Occurrence" even though this is the 6th time that Resident 6 has fallen while trying to self-transfer. At this time the IDT (Interdisciplinary Team) did add a new intervention of "IMT mattress with bolsters." The Fall/Injury Assessment Care Plan was updated with the IMT mattress on 10/1/12. 11/3/12 at 4:45 PM - Per the "Resident Incident" report: "Resident was sitting on buttocks in front of wheelchair. No apparent injury noted. Resident attempted to stand but couldn't support herself. Resident unclear as to what happened at the time." The investigation summary states: "Resident was attempting to pick up a spoon off the floor in the dining room and slid out of the w/c onto bottom." The final disposition states in part: "...Care plans were updated to include resident education to ask for assistance in picking things up off the floor..." No other interventions were implemented. On 11/14/12 at 10:00 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and Nurse Educator/Registered Nurse (RN) Y regarding the falls sustained by Resident 6. ADON C provided some additional information that is already noted above including the "Bladder Data Collection and Assessment" form that was last updated on 5/20/12 and the "24 hour resident flow records" from 6/10/12 and the flowsheets completed during the period of 9/28/12 to 10/9/12 (flowsheets showing 15 minute and 60 minute checks). ADON C stated that there had been some education to staff following the 8/10/12 fall to instruct staff to check that Resident 6 was centered in bed while doing rounds every 2 hours at night. This information was not added to Resident 6's Care Plan. The rounds every 2 hours are standard and the frequency of checks was not changed. ADON C did not provide any information about additional interventions beyond the ones noted above. ADON C stated that, even though Resident 6 has cognitive impairment, they still feel it is important to give her reminders about the use of the call light and asking for assistance. ADON C stated that Resident 6 would be more likely to remember things if they are repeated often. However, ADON C agreed that the reminders appeared to be ineffective when they are the only intervention implemented. ADON C stated that the Unit Managers review each fall and the IDT team reviews them as well. However, ADON C stated that the IDT team does not look at the reports from previous falls when discussing current falls. Therefore, the team does not have information that would be helpful in identifying trends (location of fall, time of fall, relation to toileting schedule, etc.) when they are choosing new interventions. The IDT team does not have a system to track and trend multiple falls over a period of time. The facility policy does not provide guidance about tracking/trending of falls or root cause analysis of falls. The policy is not specific about adding interventions after each fall. ADON C agreed that trending would be useful to identify the root cause of each fall and choose appropriate interventions.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 6 out of 6 residents reviewed for pressure ulcers (Residents 7, 12, 14, 10, 11 and 15). Resident 7 entered the facility without a pressure ulcer and acquired a stage 4 pressure ulcer to her right heel. The facility did not adequately assess and care plan Resident 7's pressure ulcer risk and care. Resident 7 was observed to be without her air mattress, floating heels and bariatric bed on 8/17/11 and these were physician orders [REDACTED]. Resident 12 developed a pressure ulcer and was not receiving the treatment per care plan. Resident 14 entered the nursing home without a pressure ulcer and acquired a stage 4 pressure ulcer to her heel. The facility did not adequately assess and care plan Resident 14's pressure ulcer risk and care. Resident 10 entered the nursing home with a Stage 4 pressure ulcer. Resident 10 was placed on an IMT mattress. This mattress is not the appropriate mattress for a Resident with a Stage 4 pressure ulcer. Resident 11 currently has eschar noted to her ulcers. The facility assessed these wounds to be SDTIs (Suspected Deep Tissue Injuries). Resident 15 currently has eschar noted to his ulcers. The facility assessed these wounds to be SDTIs. Findings as follows: *The National Pressure Ulcer Advisory Panel, Updated Staging System Copy write: NPUAP 2007 indicates that a Suspected Deep Tissue Injury is defined as a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear. The area may be preceded by tissue that is painful, mushy boggy, warmer or cooler as compared to adjacent tissue. This definition is also noted on the facility's "Skin Grid - Pressure / [MEDICAL CONDITION] Ulcer / Other" form where staff document weekly wound measurements. A description of an unstageable wound is a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and /or eschar (tan, brown, or black) in the wound bed. Until enough slough and/ or eschar is removed to expose the base of the wound, the true depth and therefore stage, cannot be determined. Stable (dry, adherent, intact, without [DIAGNOSES REDACTED] or flatulence) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. *Weekly Skin Assessment policy and procedure last revised April 2009, includes the following information: 1. Complete the Weekly Skin Assessment weekly according to the Treatment Administration Record. 2. Document the weekly Skin Assessment by: a. (-) for no areas of impairment . b. (+) for area(s) of impairment. Refer to the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/other and/or the Treatment Administration record. *The facility support surface policy and procedure Algorithm indicates the following for each stage pressure ulcer: No wounds-ESHI prevention mattress Stage 1 and 2-ESHI prevention mattress Multiple stage 1 and 2 located on trunk or pelvis or ulcers that have worsened or remained the same over the past month-Statguard 4 AP, RecoverAir 100 powered, and RecoverAir 250. Large or multiple Stage 3 or 4 pressure ulcers on trunk or pelvis-StatGuard 3, StateGuard 2 LAL/AP, RecoverAir 2500, RecoverAir 3000 and Stat 5000. Example 1 Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's Skin Grid dated 2/17/10 indicates a pressure area on her right medial heel found unstageable 3 x 3.5 cm black eschar in color. The skin grid states that the area was resolved on 4/21/10. Resident 7 has a history of pressure ulcers. Resident 7's MDS (minimum data set) dated 5/18/11 indicates that Resident 7 is assessed to need extensive assistance of 2 persons for bed mobility, transfer, personal hygiene, and toilet use. Resident 7 is frequently incontinent of bowel and bladder. The MDS also states that Resident 7 is at risk for developing pressure ulcers, but currently has none and has pressure reducing devices in the chair and bed with a turning and repositioning program. Resident 7's care plan last updated on 5/26/11 indicates that Resident 7 has a moderate risk for developing pressure ulcers as a 13 and pressure reduction support surface, protect heels, and manage moisture, nutrition, friction, and shear boxes were checked. On the care plan the # 13 was crossed off (no date noted). High risk for developing pressure ulcers at a score of 11 with the areas of increase frequency of turning, pressure reduction support surface and protect heels was checked. (No date when added). The goals that were checked were to remain free of open areas, will be cooperative with position changes and will demonstrate healing without signs and symptoms of infection. The care plan continues to state that the interventions for skin integrity prevention and treatment includes the following: use commercial moisture barrier, use absorbent pads or diapers that wick and hold moisture, use lift sheet to move resident, no massage of reddened bony prominences, no donut type of devices, maintain good hydration, avoid dry skin, inspect skin for signs and symptoms of breakdown, provide ROM as applicable, Implement an individualized turning schedule if applicable, Increase frequency of turning if area of redness is nonblanchable, position body with pillow and or other support devices, keep linens dry and wrinkle free, provide a pressure reduction or pressure relief surface for bed and or wheelchair per (company name) support surface algorithm, involve therapy when indicated, and apply lotion frequently for protection. Hand written on the care plan (with no dates as to when initiated) are lay down after meals (lunch), blue boots when in bed and then (when in bed) crossed off and then it states "at all times". Resident 7's care plan has protect elbows and heels as needed and position calves on pillow to elevate heels off the bed pre printed on the care plan and these boxes were not checked. The care plan does not indicate any frequency of a turning or re-positioning program even though Resident 7's Braden risk score went from moderate risk to high risk. The care plan does not indicate any new or added interventions after Resident 7 was found with an unstageable heel ulcer. The blue boots were in place before the wound was found and no new interventions were noted to be placed. Resident 7's CAA (care assessment area) for pressure ulcers dated 5/18/11 states that Resident 7 requires staff assistance to move sufficiently to relieve pressure over any one site. Confined to a bed or a chair all or most of the time, needs special mattress or seat cushion to reduce or relieve pressure. Needs regular schedule of turning. Resident 7's Braden Risk Assessment Scale score on 3/18/11 was 13 moderate risk (moderate risk= 13-14) on 8/9/11 Resident 7's risk score was an 11. (10-12= High risk for developing skin impairments). A nursing note (late entry for 8/11/11) at 3:00 PM states, "5 x 6 blackened and boggy area to right heel discovered. Page out for (MD name). Guardian notified." A facility Accident/Incident report, for Resident 7, dated 8/11/11 states that upon inspection by the unit manager a black area that measured 5 x 6 was found. (The facility fills out an accident/incident report when pressure ulcers are found). The witness investigation statement from LPN C states, "I was called down to (Resident 7's) room by (nurse name) who showed me a 5 x 6 cm area on right heel that was black and boggy. Pt already had blue boots on to elevate heel. Skin prep to be applied." A witness statement dated 8/13/11 written by CNA D states. "Dark area on resident heel has been there for a couple of years since open area. Res was without boots in bed for several weeks as every time I asked for them no one responded with any. When another res was discharged I had laundry wash theirs for her. It was reported after she got the new shoes that they seemed too snug and I was told it was just because they were new". The facility has no further information or investigation regarding this interview. A Physician's Telephone order dated 8/11/11 states, Skin prep to right heel every shift. Keeping blue boots, needs an air mattress. Resident 7's Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form dated 8/11/11 indicates that resident has a facility acquired pressure ulcer on her right heel that measures 5 cm x 6 cm that is black (eschar) in color. The stage of the ulcer is a stage 4 then crossed off and SDTI is written next to the stage section. On 8/11/11 added to Resident 7's care plan is "float heels/keep using blue boots, skin prep every shift, and need air mattress." A nursing note on 8/12/11 (no time noted) states, "IDT (interdisciplinary team) reviewed, right heel has blackened 5 x 6 area. Skin intact boggy to palpations. Has had acute infection has dependant [MEDICAL CONDITION] and is diabetic. Is unable to verbalize needs to staff and requires total dependance for all ADL's and transfers. Treatment per MD. Podiatry appt set up. Continue blue boots and float heels. Care Plan updated." On 8/14/11 a Resident Summary form (weekly summary) was filled out by RN G. The form reviews the resident's current status of cares. Under the skin section of the form a question is asked if the resident is currently receiving treatment for [REDACTED]. On 8/17/11, at 4:00 PM, Surveyor interviewed RN G related to checking the box "no" for any pressure ulcer treatments. RN G stated that she just checked with the aide and she should have marked the box yes as a treatment is being done to her foot. On 8/16/11 the Skin Grid form measures Resident 7's pressure ulcer as 3.5 x 3 staged as a DSTI. Several boxes on the form are left blank-color of drainage, color (of the wound) odor, tunneling/undermining, and tunneling/undermining depth and RN/LPN initials. This is an incomplete assessment of Resident 7's wound. Handwritten on the form states, Black skin intact area hard skin, skin prep used. Please note that this black eschar wound is not a deep tissue injury by definition. On 8/16/11 a Facility Visit Report from the RN (Registered Nurse) Wound Care Nurse Consultant F indicates the following assessment: Unstageable right lateral heel that measures 3.5 x 3 cm with no odor nod undermining or tunneling with not drainage and dark hard black necrosis. Under the comments section of the form it states: Area found on skin prevalence last week per staff. Area hard-no drainage nor pain not signs of infection. Appropriately started skin prep and pressure reduction blue boots-continue. *Is area scar tissue-possible not new. (Please note that the previous heel ulcer noted in February was on her right medial heel not lateral as this new one is). On 8/17/11 at 1:30 PM, Surveyor observed Resident 7 to be in her bed. Resident 7 was on a standard mattress. Surveyor observed her feet had something on them, but asked CNA E view Resident 7's feet. Resident 7 had blue boots to both feet but were directly resting on the bed. Surveyor questioned CNA E regarding anything else that was to be done for Resident 7's feet. CNA E stated, "Not that I know of". Surveyor asked CNA E if she should have a pillow or float her heels in bed and CNA E responded, "She is to have blue boots on that's all, not a pillow. Not to my knowledge." Surveyor asked CNA E to see her nursing assistant plan of care/assignment sheet. CNA E showed Surveyor a sheet last revised 4/23/11 and for Resident 7's cares it states to get up if restless and check positioning every hour at NOC, blue boots and float heels, no shoes. Please note that Resident 7 was observed to not have her heels floated. On 8/17/11 at 2:00 PM Surveyor requested to view Resident 7's heel pressure ulcer. Resident 7's pressure ulcer was on her lateral right heel. The dark area was large (bigger than a 50 cent piece) and in the center was a lighter color. In Resident 7's blue boot was a small amount of drainage. During record review of Resident 7's orders it was noted that on the June 2011 physician orders [REDACTED]. There is no telephone order to discontinue the order or any reason found to discontinue the bed. On 8/17/11 at 4:30 PM Surveyor interviewed DON B regarding Resident 7's bariatric bed and floating her heels in bed. DON B states that Resident 7 is to have her heels floated in bed as well as the blue boots, and she should have an air mattress on her bed and does not know why it is not there. Surveyor asked about the bariatric bed and again DON B stated that she did not know why it was crossed off and why there was not one on her bed if there was an order. DON B stated that she would check into the questions and follow up. A nursing note on 8/17/11 at 9:00 PM states Bed changed to bariatric bed with air mattress for skin integrity, blue boots on during day float heels in bed, skin prep to heels. On 8/18/11, at 8:25 AM Surveyor observed Resident 7's room. A bariatric bed with an air mattress was placed on Resident 7's bed. Please note this took 6 days from the original order to receive the bed. The bed was ordered after the surveyors left the building on 8/17/11 and placed around 9:00 PM on 8/17/11. On 8/18/11 at 3:30 PM Surveyor asked CNA G if Resident 7 was laid down after lunch and she stated that in report the day shift stated that she laid down after breakfast so we did not lay her down after lunch. The facility did not follow resident 7's care plan to lay her down in bed after lunch. The facility did not ensure that Resident 7 had pressure ulcer prevention systems in place especially when her Braden score changed and her risk factor increased. No new interventions were placed at that time. Resident 7 developed an unstageable in house acquired pressure ulcer on her heel even when wearing protective boots. The facility received an order for [REDACTED]. The facility is calling Resident 7's black eschar heel a deep tissue injury and that is incorrect. On 8/17/11 at 3:45 PM Surveyor interviewed DON B and stated that she had identified a problem with pressure ulcers on 8/11/11 after she noted a resident with bilateral heel ulcers. The facility put a performance plan in place on 8/11/11 which was updated from 6/10/11 included skin sweep of entire building, review high risk resident and develop list and ensure interventions in place, educate caring partners on high risk impaired resident and interventions and every 2 hour checks of those residents, Review all admissions and resident for change of condition for risk and appropriate interventions. Re-education on skin protocols and interventions. Med tech/LPN to become skin champion and round on high risk/impaired residents every 2 hours to assure interventions. The facility had a list of residents on a skin intervention audit. Resident 7 was on the list as needing to be turned every 2 hours and blue boots in bed. The list did not have the interventions of an air mattress, bariatric bed nor float heels in bed. The person who would be doing the audit was not able to make sure that the interventions were in place as they were not on the form. Example 2 Resident 12 was admitted to the facility on [DATE] for Rehab after a [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Resident 12's MDS dated [DATE] indicates that Resident 12 was assessed to need extensive assistance of 2 people for bed mobility and transfers. Resident 12 is assessed to be at risk for developing pressure ulcers. Resident 12 has pressure relieving devices in his chair and bed with a turning and repositioning program in place. Resident 12's Care Area assessment for pressure ulcers dated July 6th indicates that there is increased risk of pressure ulcers developing with his new loss of self mobility. He has a pressure relieving mattress on his bed and cushion in his wheelchair. he is on a turning and repositioning program per staff assist. Staff will not skin integrity during daily cares and report any areas of concern to nursing for assessment and treatment as indicated. Proceed to the care plan. Resident 12's Skin Integrity Assessment: Prevention and Treatment Plan of Care for dated 6/25/11 states he is at risk and needs frequent turning, maximal re-mobilization, protect heels, and manage moisture, Nutrition, Friction and Shear. Resident 12's goals is will remain free of open areas and will bee cooperative with position changes. Interventions that are preprinted on the care plan that are checked to include: Complete Braden Scale upon admission and weekly time 4 weeks, quarterly, and with change of condition, offer bedpan urinal and glass of water in conjunction with turning schedules, Increase protein intake, protect elbows and heels if being exposed to friction, implement an individualized turning schedule if indicated, Protect elbows and heels as needed position calves on pillows to elevate heels of of the bed (this is yellowed out but not date noted). Specialty mattress: Air mattress. On 7/21/11 handwritten on the care plan are the following interventions: Float heels in bed leg board on w/c pedals, blue foam boots on at all times (may remove once a shift for cares and skin check). Air mattress-check inflation every shift, to see podiatrist as ordered. Added on 7/22/11 are the following interventions: Float foot and heel on pillow 3 hours a day on pillows after breakfast or lunch, make sure foot is above heart level. Surveyor was unable to locate Resident 12's Braden assessment to determine risk score. DON B and medical records were unable to find Resident 12's Pressure Ulcer Risk Assessment Braden form. Under the problem section of Resident 12's care plan added on 7/21/11 is a "blister on ball of right foot 5 x 4 cm, Deep tissue injury to Right Great toe, bottom of right heel opened blister". Resident 12's nursing notes dated 7/21/11 indicate a note at 4:00 AM which states that upon CNA cares a large blister filled area on bottom of right heel, no drainage boggy to touch. Measures 5 cm by 5.5 cm. Also found by writer was a 5 x 4 wound on ball of right foot unstageable 2.5 by 2.5 cm wound (center crusty) and deep tissue injury wound 2 x 2 cm on bottom of right great toe. (Colored like a bruise.) Resident states he has no pain. MD was faxed info and awaiting treatment. A nursing note on 7/21/11 not time noted, stated IDT reviewed found to have 3 new pressure ulcers on right foot. Has 3 + [MEDICAL CONDITION] bilateral lower extremities and feet. Fluid restriction initiated. Weight was up from 2 weeks ago. Requested podiatry to see today, air mattress implemented float heel and blue foam boots at all times and non weight bearing to right foot. Resident 12's Skin Grid dated 7/21/11 indicates a stage 2 on the bottom of his right heel, yellow in color and it measures 5 x 5.5 cm. The area is identified as pressure, and the grid stated that it was present on admission (Resident 12's admission skin assessment 6/25/11 does not indicate a pressure ulcer on his right heel). The comment section states, "No pain is noted and periwound is red but not dark red". A Podiatry Consultant Report dated 7/21/11 states the following: A [AGE] year old man with sores on right foot. (Resident 12) States that he has [MEDICAL CONDITION] in the right foot and was told that he has an ulcer beginning yesterday. He has heel protector boots on his feet right now. Was added to the schedule today as an emergent add-on. Moderate swelling in ankle and foot. Heel ulcer is 6.5 x 5 cm and the mid foot ulcer is 4 x 4 cm. Both look like they started as fluid filled blisters. The podiatrist debrided the ulcers today and wrote for a dressing change routine [MEDICATION NAME] AG and Meplix with Kerlix roll and an ace bandage. They will change this daily and follow up in a week. A nursing note on 7/22/11 indicates that Resident 12 stated that he cannot feel his feet. The nurse palpated below both knees and Resident 12 stated "I cannot feel anything below my knees." an order for [REDACTED]. Resident 12 received his air mattress 2 days after an order was received for an air mattress. A Facility Visit Report form was written by Wound Consultant F on 7/26/11 and indicates Resident 12's right heel is a stage 2 that measures 5 cm x 4 cm with 0.1 in depth with serosanguinous drainage with a wound base color of pink. A treatment suggestion was to discontinue the ace wrap due to causing bottle neck to ankle consider [MEDICATION NAME] toe to knee. A review of Resident 12's physician's telephone orders no orders could be found to discontinue the ace wraps that the wound nurse recommended. So the order for ace wraps was still current, and was the treatment ordered. A Podiatrist Consultant Note dictated dated 7/28/11 indicates that the location of the wound is right heel and the patient describes it as diabetic and pressure ulcer. The patient states that he thinks his wound is healing. The heel ulcer is 6.5 x 5 cm and the mid foot ulcer is 4 x 4 cm. The wounds are starting to dry up and the heel ulcer has some skin in the middle of the ulcer. The wound appears to be healing well. The patient will continue with the same dressing change routine. He needs to be completely off this foot this week and follow up in 1 week. Resident 12 is to continue current treatment to heel. A Podiatrist Consultation dictation note dated 8/4/11 indicates a Ulcer on Resident 12's right heal measuring 6 x 4 cm and is described as clean and dry with some necrosis. The injury is aggravated by local pressure. The wound was debrided of all necrotic and keratotic tissue. A Facility Visit Report written by Wound Consultant F on 8/9/11 indicates that area was not viewed by the wound consultant nurse but improved per (nurse name) open only 2 x 2 cm clear granulation tissue. On 8/9/11 the facility skin Grid for Resident 12's pressure ulcer states that she has a stage 2 that measures 4 cm by 6 cm and less that 0.1 cm deep with serosanguineous drainage with pink/IR tissue with not odor. (Please note that the facility could not tell surveyor what the IR was in the color section of the form). Continues to have dry peeling skin around periwound. A Facility Visit Report written by Wound Consultant F on 8/16/11 states that Resident 12 has a stage 2 ulcer to his right heel with serosanguinous drainage. Under the necrosis section of the form it states "see below". In the comments section of the form it states, "Right heel open only 0.2 x 1.0 x less than 0.1 cm deep. However dark area more proximal to open area. Please skin prep periwound and dark area of heel and bottom of foot. (Please note that a wound that has necrosis cannot be staged per NPUAP guidelines). On 8/16/11 the facility skin grid states that Resident 12 has a stage 2 pressure area that measures 0.2 by 1.0 by less than 0.1 cm deep with serosanguinous drainage. The color of the wound is blank and tunneling and undermining is blank on the form. In the comment section of the form it states that the heel is only open 0.2 x 1.0, however dark area more proximal to open area. There are no measurements of the dark area or the total area of the wound. On 8/18/11 at 10:00 AM Surveyor observed RN I and LPN J complete a treatment to Resident 12's foot ulcers. There was an open are about the size of a dime and an area of eschar that was oblong shaped about 3 by 2 cm next to the open area. The area was cleaned by LPN J and a strip of [MEDICATION NAME] AG was placed over the length of the wound, on the open area and black area. The area was covered by a Kling and stockinette. On 8/18/11 Resident 12 went to see the podiatrist around 1:00 PM. The podiatrist dictated note which states that Pt has pressure area on the right heel measuring 1.5 by 0.5 and is described as clean and granular. The patient has a pressure ulcer on the right heel measuring 3.5 by 1.0 cm and is described as necrotic. The necrotic area is irregular shape. The wound was debrided of all necrotic and keratotic tissue. I have also written an order for [REDACTED]. The facility audit was reviewed to see what interventions were double checked to ensure that they were in place and Resident 12's name was not on the list. Example 3 Resident 14 was admitted to the facility on [DATE]. Resident 14 has [DIAGNOSES REDACTED]. The PPOC (Patient Plan of Care) - Nursing Section of the hospital transfer form, dated 4/12/11, indicates history: poor skin ...very fragile skin, does get [MEDICAL CONDITION] in bilateral legs at times. Resident 14 had a Braden Risk Assessment Scale completed on 5/15/11. The scale indicated a score of 18, a score of 15 - 18 notes a minimal risk of pressure ulcer development. However, the scale notes a score of 4 for sensory perception, indicating no impairment. Resident 14 has Diabetes and the facility has no assessment of Resident 14's feet and sensory ability declines in the feet of Diabetic individuals. Additionally, the Braden Scale indicates a score of 4 for mobility, ability to change and control body position, indicating no limitations. However, an admission Minimum Data Set (MDS), assessment reference date of 4/19/11, indicates that Resident 14 requires extensive assistance, resident involved in activity; staff provide weight-bearing support, for bed mobility and resident transfers. Resident 14's admission MDS additionally indicates that Resident 14 has Diabetes Mellitus, has a stage 2 pressure ulcer on admission, and is at risk for developing pressure ulcers. The Care Area Assessment (CAA) completed for the admission MDS indicates that Resident 14, Requires staff assistance to move sufficiently to relieve pressure over any one site, is confined to bed or chair all or most of the time, needs a special mattress or seat cushion to reduce or relieve pressure and requires regular schedule of turning. The documentation also states, "Staff assure that she is routinely repositioned and kept clean and dry. She has a pressure reducing mattress on bed and a cushion in her w/c (wheelchair)." The CAA continues that the facility will proceed to the care plan to monitor the Stage 2 pressure ulcer to her coccyx and multiple bruises and skin tears. Her skin is very fragile." Resident 14's care plan, originally dated 4/14/11, updated 7/14/11, for Diabetes includes the approaches to monitor skin for irritation, and refer to skin integrity assessment prevention and treatment plan of care. Resident 14's has 4 Skin Integrity Assessment: Prevention and Treatment plans of care. The first dated 4/12/11 does not indicate the Braden Risk Assessment Score. The plan does indicate the facility should complete the Braden Scale upon admission and weekly times 4 weeks, quarterly, and with change of condition. The care plan notes that Resident 14 has risk factors to include [MEDICAL CONDITION] disease, Diabetes Mellitus, bowel and bladder incontinence, [MEDICAL CONDITION]. However, does not indicate Resident 14's Steroid use as a risk factor. The interventions include inspect the skin for signs and symptoms of breakdown. Position calves on pillows to elevate heels off the bed 2 pillows under calves was added to this care plan on 7/26/11. The second Skin Integrity care plan is dated 5/25/11, which notes the Braden Risk Assessment Score and several open areas the plan does not indicate Resident 14's risk factors, and does not indicate an approach to position calves on pillows to elevate the heels. The third Skin Integrity care plan is dated 7/19/11 does include the risk factors, including steroid use, however, does not indicate to position the calves on pillows to elevate the heels. The fourth Skin Integrity care plan, dated 8/10/11, this care plan lists some risk factors however does not indicate Diabetes as a factor but does indicate to position calves on pillows to elevate the heels. There is no indication of what Resident 14's heels looked like in the medical record before 6/2/11. An Accident/Incident Report, dated 6/2/11, states, "During HS (hour of sleep) cares CNA (Certified Nursing Assistant) took off sock and a piece of skin came off of R (right) heel with the sock, notified this nurse right away, oa (open area) measures 6.5 x 4 cm (centimeters) with bogginess around lower area causes no disc (discomfort) at this time." Immediate action taken: Pillow placed under R lower leg to keep heel off bed. The final disposition section, dated 6/8/11, states, "Skin tear to R heel when sock removed per CNA statement. Root cause Resident has [MEDICAL CONDITION] to foot and has poor skin condition. Sock is to (sic) tight. Action plan: ask pt to buy/wear looser socks and clothing. Note fragile skin is related to [MEDICATION NAME] use over years for respiratory issues. Resident on [MEDICATION NAME] for [MEDICAL CONDITION]." A Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form was completed for Resident 14, start date 6/2/11. The documentation states, "Was the wound present on admission?" "Yes" is checked even though this is clearly inaccurate. The form is not signed by the person initiating the form. The wound documentation noted as completed on 6/7/11 the wound is measured and is noted 4 x 6 cm, notes "yes" to drainage but does not indicate the kind/characteristics, and notes state "II." The form continues with dates of 6/14/11 and 6/21/11 that indicate the ulcer is a stage 2 and is getting smaller. However, the stage 2 designation is crossed out and "ST" is written in indicating that the wound was a skin tear and not a stage 2 pressure area as documented by the nurse completing the assessment. The 6/27/11, 7/5/11, and 7/12/11 wound notes also note that the area is a stage 2 pressure area and noted some improvement until the 7/12/11 date when the wound is back to 3.2 x 5 cm. A new form was started on 7/19/11 and notes the wound to now be 5 x 6 cm. On 7/22/11 the wound is now noted as only a ST on the form, is 5 x 6 cm and has "macerated skin edges, some black slough and yellow slough, approx 60% and 40% red pink granulation tissue. On 7/26/11 is again noted as a skin tear, 5 x 6 cm, the color is tan with a mild odor, "Eschar 60% to base 20% yellow slough 20% pink/red area granulation. BID Santyl tx." A wound consultant observed the area on 8/16/11 noted the area as a stage 4 pressure ulcer, 6 x 3, necrotic tissue more soft 90% with 10% pink at edges; continue daily santyl as order, resident in poor medical condition." This note indicates that the area is a pressure ulcer. However, with 90% necrotic the pressure ulcer would need to be classified as unstagable as there is no visualization of the underlying tissue. A Resident Transfer Form, completed 7/17/11 to transfer Resident 14 to the hospital notes on the form that Resident 14 is at high risk for pressure ulcers and has a pressure ulcer on her right heel. Even though this form indicates that the right heel is a pressure ulcer, documentation on the wound documentation form still indicates the area is a skin tear in documentation dated, 7/19, 7/22, 7/26, 8/2, and 8/9/11. An Accident Incident Report, dated 7/25/11 states that Resident 14 was found to have 2 skin tears and a bruise on left hip bone area. The bruise was noted at 3 x 9 cm and the skin tear as 2.5 x

Based on observation, interview and record review, the facility did not ensure that 2 of 10 Residents (Residents 1 and 3) with pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Resident 1 was admitted to the facility with no pressure ulcers. Resident 1 subsequently developed unstageable ulcers on her coccyx, heels and calf. The facility failed to correctly identify, document, and evaluate the wounds and did not consult with the physician or family concerning appropriate treatments when the wounds deteriorated. The coccyx wound became infected with multiple drug resistant organisms (MDROs) and required surgical debridement and 6-weeks of intravenous (IV) antibiotic therapy at a specialty hospital. The failure to provide Resident 1 with the care necessary to prevent the development of multiple, infected pressure ulcers created a finding of immediate jeopardy. The facility was notified on 3/17/11 of immediate jeopardy beginning 1/18/11. The immediate jeopardy was removed 2/2/11, when a Quality Performance Improvement Plan was initiated; the deficient practice continues at a scope/severity level of D (no actual harm with potential for more than minimal harm/isolated) as evidenced by the following example, observed during survey on 3/17/11: Resident 3 had a wound to her buttock and was at high risk for further skin breakdown. Heels were not floated as required by the care plan on 2 occasions. This is evidenced by: Example 1: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had been hospitalized [DATE] for bilateral leg weakness which progressed to paralysis in both legs. Her [DIAGNOSES REDACTED]. Resident 1 was admitted to a Rehabilitation (Rehab) hospital on [DATE]. The History and Physical from the Rehab hospital, dated 9/15/10, indicated that Resident 1's Rehabilitation Plan was "Physical therapy for progressive ambulation, occupational therapy for activities of daily living trainings". The Goals were "to be independent at a wheelchair level" and her prognosis was "good." Resident 1 was discharged from the Rehab hospital to the facility on [DATE]. A 13-page fax with "Interdisciplinary Discharge Instructions" was sent to the facility by the Rehab hospital on [DATE]. Page 3 of the fax has a section entitled "Skin". Under wound care instructions is a hand-written note that states: "Apply xen-derm to buttocks/coccyx q (every) shift and PRN (as needed.) - skin now intact, no open areas." Notes from a consultation at the Rehab hospital dated 9/22/10 state: "Apparently the patient was just diagnosed with [REDACTED]." On Resident 1's admitted to the facility of 10/13/10, a fax was sent to the Physician which stated: "New admit needs the following please: 1) Request regular diet 2) states no history of diabetes, does not want accu-checks-are scheduled QID (4 times daily), D/C (discontinue) sliding scale (insulin). This fax is signed by the MD with no notations and no evidence of consultation concerning the effect of high blood sugars on skin integrity. The facility's Admission Skin assessment dated [DATE] has a diagram of the human body (one front view and one back view.) This diagram is marked with circled areas and measurements. There are a large number of bruises noted over the front and back side of Resident 1's body on admission. There are no open areas noted. There are no skin issues circled or noted for the buttock/coccyx region. Both heels are circled with the word "soft" next to each circle. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicates that Resident 1 is at risk for pressure ulcers. It also indicates that she had 0 (zero) unhealed pressure ulcers on admission. The Pressure Ulcer Care Area Assessment (CAA) was triggered. The CAA summary states "(Resident 1) has dx (diagnosis) of [MEDICAL CONDITION] with decreased mobility. She does require staff assist repositioning self in bed. She has a pressure reducing mattress and cushion in her chair." Facility Procedure entitled "1.4.1 Wound prevention and Management (Effective November 1998, Revised April 2009)" states: "(Corporate name) requires the use of the Braden Risk Assessment and Skin Integrity Assessment: Prevention and Treatment Plan of Care. All residents will be assessed on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment...select appropriate interventions based on the following: Braden Risk Assessment Score...: A Braden Risk Assessment Scale was completed on 4 dates: 11/11/10 with a score of 16 (Minimal Risk); 11/13 with a score of 12 (high risk); 11/27 with a score of 12 (high risk); and 12/4 with a score of 13 (moderate risk). Surveyor spoke with DON B by phone on 3/24/11 at 11:50 AM. DON B states that there are no Braden Risk assessments found in the medical record for Resident 1 from her admission on 10/13/10 until those noted on 11/11/10. Facility Policy 1.5.1 Wound Prevention and Management (Effective November 1998, Revised April 2009) states: "PROCEDURE Turning and Repositioning - (Corporate Name) will follow Skin Care Protocols regarding the turning and positioning of residents that may include, but is not limited to a person with: -Sensory Impairment -Braden Risk Assessment that scores low in mobility and/or sensory perception...2) Turn and reposition every 1-2 hours when -in bed -in wheelchair/gerichair...6) Communicate the individualized turning and repositioning schedule using -Skin Integrity Assessment: Prevention and Treatment Plan of Care. -Care Delivery Guide/Nursing Assistant Assignment Sheet 7) Document repositioning using CareTracker." The "Skin Integrity Assessment: Prevention and Treatment Plan of Care (POC)" from admission is dated 10/13/10. It is a 4 page form with multiple blank boxes that can be checked in the areas of Assessment, Goal and Interventions. There is a check mark in the box for "Frequent Turning" in the "At Risk" (Braden Scale of 5-18) section of the POC. There is no notation as to how frequently Resident 1 should be turned. Resident 1 is paraplegic and requires staff assistance for position changes. A second "Skin Integrity Assessment: Prevention and Treatment Plan of Care (POC)" dated 11/11/10 also has "Frequent Turning" marked with a checkmark. A handwritten (undated) notation next to the pre-printed words says "Q2hrs" (every 2 hours). Both the 10/13/10 and 11/11/10 care plans are blank (no checkmarks) in front of the pre-printed interventions of "Protect Heels", "Manage Moisture, Nutrition, Friction and Shear", and "Pressure-Reduction Support Surface if Bed or Chair-bound." They are also blank (no checkmarks) in the areas of "protect elbows and heels as needed" and "position calves on pillows to elevate heels off the bed." The facility's "EHSI-Turn and Reposition Chart Detail Report" has information for Resident 1 dated 10/26/10 through 1/26/11. For each day in that period there are 3 shifts noted. Each shift says "Was Resident turned and repositioned per plan of care?" Each shift lists the name of a staff person and the word "Yes." There is nothing to indicate the frequency of turns and/or repositions (except the reference to the Plan of Care.) Note: there is no record of turns/repositions from 10/13/10 through 10/25/10 and Resident 1 is noted to have pressure ulcers on both heels by 10/27/10. On 3/24/11 at 8:50 AM, Surveyor spoke with DON B by telephone regarding the communication of the POC to the Certified Nursing Assistants (CNAs) who provide assistance. The CNAs carry charts (called care delivery guides) in their pocket that details the daily care for each resident. The care delivery guide would tell a CNA how frequently a resident should be turned based on the plan of care. The care delivery guides are not kept in the medical record. They are thrown away after use and cannot be viewed for Resident 1. Page 2 of the Skin Integrity Care Plan dated 10/13/10 has 10 pre-printed interventions marked with checkmarks. A box labeled "provide a pressure reduction or pressure relief surface for bed and/or wheelchair per support surface selection algorithm" is blank. On 3/17/11 at 3:00 PM, Surveyor interviewed RN M and RN V. RN M states that she believes Resident 1 had an air mattress right after she first came in on 10/13/10. Later, at 5:30 PM on 3/17/11, RN V pointed out the Fall/Injury Assessment Plan of Care dated 11/11/10. This care plan has the word "Air" handwritten (undated) next to the pre-printed word "BED" in the Interventions section of the Fall/Injury Assessment POC. No reference to an air mattress or other pressure relieving device is found on the 10/13/10 POC. Resident 1 developed Pressure Ulcers to heels, coccyx and left leg which are described here: Heel Ulcers: Facility form "Accident/Incident Report" dated 10/27/10 states Resident 1 "Has blisters to both heels." Bed Type is noted as "Hi/Lo" and Specialty Mattress Type is noted as "standard." The action taken is: "Ordered blue boots". A Physician's telephone order dated 10/27/10 states: Skin prep tid (three times per day) and prn (as needed). Bilateral blue boots on at all times except cares and therapy. The facility has a form entitled "Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other" where wound measurements and descriptions are charted. Skin Grid Left Heel - 10/27/10 - Stage 2, 5 x 3.5 cm. Sections for drainage, color, odor and tunneling/undermining are all left blank. A note on this dates states "Res adm with soft heels-was wearing profo brace which caused stage 2 area on both heels." 11/3/10 - Stage 2, 4 x 4 cm. Sections for drainage, color, odor, and tunneling/undermining are all left blank. 11/22 - Stage 2, 4 x 4 cm. Sections for drainage, color, and odor are all left blank. 12/1/10 - Stage 2, 3.6 x 3.6 x .1 cm, color noted as 0 (choices for color are P, R, Y, N or B which the key shows as Pink, Yellow, Necrotic/Slough, Red or Black). 12/8/10 - Stage 2, 3.6 x 3.6 x .1, color noted as 0. 12/15/10 - stage 2, 3.4 x 3.3 x .1, color noted as 0. Note in comments section states: "12/21/10-Resolved, 0 (no) open, 0 pink, 0 soft" Skin Grid Right Heel - 10/27/10 - Stage 2, 5 x 3.5 cm. Sections for drainage, color, and odor all have 0 (zeros). A note on this dates states "Res adm with soft heels-was wearing profo brace which caused stage 2 area on both heels." 11/3/10 - Stage 2, 4.5 x 5 cm. Sections for drainage, color, and odor all have 0 (zeros). 11/22 - Stage 2, 3 x 4 cm. Sections for drainage, color, and odor are all left blank. 12/1/10 - Stage 2, 2.6 x 3.4 x .1 cm, color noted as 0. 12/8/10 - Stage 2, 2.6 x 3.4 x .1, color noted as 0. 12/15/10 - stage 2, 2.4 x 3.1 x .1, color noted as 0. Note in comments section states: "12/21/10-Resolved, normal skin color, 0 (no) soft. Resident 1 was seen by a podiatrist on 11/15/10. The Physician report states: "The examination today shows dried blisters on the bottom of both heels. There does not appear to be any opening. As I debride through this, there does not appear to be any areas that are ready to come out...The hallux bilateral and the fifth bilateral are thickened, yellow, crumbly and dystrophic...pain with shoes, pain with palpation." On 3/17/11 at 3:00 PM, Surveyor interviewed RN V and RN M. Both RNs, when looking at the Skin Grid forms for Resident 1's right and left heel from 10/27/10-12/21/10, agree that the all sections are not complete. Surveyor noted that the color section was blank or noted to have a 0 (not a valid choice per the key) on each date of assessment. Both RN V and RN M agree that the color was not documented and is an important factor in determining the stage of a pressure ulcer. Resident 1 was seen in the Emergency Department (ED) of the local hospital on [DATE] for leg swelling. The Nurses Notes from that visit describe a skin assessment. This assessment notes "bilateral heels stage 3 has [DIAGNOSES REDACTED]tous (red) edges bed has eschar (necrotic tissue) present bed has granulation present." The ED report goes on to note that at 6:14 PM "Wound care to decubitus located on bilateral heels was cleansed with Shur-Clens dressed with opsite." The facility does not note any heel ulcerations in the period from 12/21/10 to 1/17/11 while the ED has reported treating stage 3 heel ulcers on 12/26/10. On an Accident/Incident Report form dated 1/17/11, it is noted "CNA reported change in heels-RN noted bilateral pressure areas on heels that were previously both unstageable areas that had resolved" (NOTE: all documentation of previous ulcers had described them as Stage 2). "Left heel now 6x3 cm black unstageable, Right 5 x 5.5 cm black unstageable." Skin Grid dated 1/17/11 for Rt heel documents: stage = U (unstageable), 5 x 5 cm. Sections for drainage, color, odor, and undermining are all left blank. No further documentation on this form from 1/17/11 to Resident's discharge date of [DATE]. Skin Grid dated 1/17/11 for Lt heel documents: stage = U, 6 x 3 cm. Sections for drainage, color, odor and undermining are all left blank. No further documentation on this form from 1/17/11 to Resident's discharge date of [DATE]. Surveyor interviewed RN W and RN V on 3/17/11 at 5:30 PM. RN V stated that the licensed nurse on the floor does a full body skin check weekly on bath day. The nurse marks his/her initials on the MAR (Medication Administration Record) when this task is completed. They would write a " + " sign on the chart if a new wound is found. All weekly checks are marked for Resident 1 on the January, 2011 MAR (1/1/11, 1/8/11, and 1/15/11). There are no + marks noted for Resident 1 in January. There was a weekly skin check done on 1/15/11 with no changes noted. RN W and RN V state they cannot explain how heels that were inspected on 1/15/11 with no problems noted can then have large unstageable ulcers on 1/17/11. Nurses also fill out a body diagram worksheet at the weekly skin checks. RN V stated that these diagrams are kept in her office for review. Once the resident is discharged , these forms are thrown away. They are not kept in the medical record. The diagrams completed for Resident 1 are no longer available. RN W also stated that she would expect there to be at least one other weekly wound assessment of the bilateral heel wounds in the period between 1/17/11 and 1/26/11 when the resident was discharged . There are no assessments of the heels after 1/17/11. A fax to Resident 1's Physician on 1/17/11 states: "Resident has history bilateral unstageable heels which were resolved" (NOTE: all documentation of previous ulcers had described them as Stage 2). "Now has pressure ulcers again bilateral heels-may we have an order for [REDACTED]. Physician signed and noted "OK to above" on 1/17/11. Physician's note from monthly rounds conducted on 1/23/11 state "There seems to be some areas of redness in the area of the heel." Surveyor interviewed MD X on 3/22/11 at 12:20 PM by phone. MD X stated that she did not see Resident 1's ulcers on 1/23 as they were covered. MD X states that she relies on nurses at the facility to update her on wound conditions when she is unable to view them. MD X states that no one was available to give her an update on the wounds on 1/23/11 possibly because her visit was on the weekend. Admission notes from Resident 1's hospitalization on [DATE] state: "Reason for admission-Patient transferred to emergency room for evaluation of a decubitus ulcer and [MEDICAL CONDITION]." Further history states: "Patient was noted with decubitus ulcer in sacral area and with a huge undermined ulcer on the right heel..." Blue Boots - Manufacturer information indicate the boots are Skil-Care Heel-Float boots. Instructions state that the boot "off-loads the heel by suspending it over an air cavity. The medical record indicates that the boots were ordered for Resident 1on 10/27/10. The first mention of the boots in the Plan of Care is on the Skin Integrity Care plan dated 11/11/10 when it is noted that Resident 1 has bilateral stage 2 heel ulcers. The blue boots were discontinued on 12/17/10 because they were thought to be the cause of an ulcer on the left lower leg. The plan of care was not updated with this change and does not reflect any other means of off-loading the heels in the period between 12/17/10 and 1/17/11. Left Calf Ulcer: There is an Accident/Incident Report form completed 12/17/10 that states "pt has bruise noted on Left outer calf 8 cm x 5 cm. Space for "Specialty Mattress Type" is left blank (no mention of air mattress). Immediate Action taken is noted as "blue boot removal." Fax to MD dated 12/17/10 states "pt. has bruise 8x5 cm noted on outer calf. Pt not sure how it happened. Pattern of bruise matches padding on back of blue boot. Blue boot removed. Any new orders?" Fax is signed by MD 12/17/10 and says "noted no new orders". Fax to MD dated 12/26/11 states "Pt wnd (wound) on left lateral shin surrounding area red. Wnd 25% slough 75% unstageable. Notified on call MD. Received order to send to ER for eval and tx (treatment). Pt returned [DIAGNOSES REDACTED].? Any new orders? Fax has notes from MD stating "yes do both and continue to observe wound" and signed by MD 12/27/10. 12/27/10 Physician Telephone Order states: "Left calf wound cleanse with NS, apply santyl and cover with dressing Q day. Continue to observe wound." Order is not signed by MD but states "per signed fax." Facility Policy 1.19.2 Wound Prevention and Management (Effective November 1998, Revised October 2010) states "TREATMENT PROTOCOL Infected Wound 2. Initiate/Revise the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other for documentation which may include but is not limited to: Length, Width, Depth, Odor, Drainage/Exudate, Periwound condition, Tunneling/Undermining, Wound Edges, Location, Pain, S/S of Infection, Wound Base" 3. "Initiate Push Tool 3.0 (Pressure Ulcer Scale for Healing) and complete weekly until healed." No further wound assessments are charted. On 3/17/11 at 5:30 PM, Surveyor met with RN V and RN W. They stated that they had reviewed the entire Medical Record and did not find any Skin Grid forms or PUSH Tool forms completed for this wound. RN V and RN W stated that, according to the facility policy, these forms should have been completed weekly to assess the left calf wound. Notes from the Surgical Consult during hospitalization dated 1/27/11 state "On the left lower extremity laterally on the calf the patient has a 10 x 5 cm ulcer that has a necrotic eschar on it." Coccyx Ulcer: Facility form "Accident/Incident Report" dated 12/3/10 states "Pt noted to have open area to coccyx." Spaces to note "Bed Type" and "Specialty Mattress Type" are left blank. The action taken is: "Lay pt down after meal, side to side laying position, not on back." It is noted that Resident 1's daughter was notified on 12/3/10 at 11:00 AM. The Skin Integrity POC dated 11/11/10 has a handwritten update dated 12/3 stating "allevyn change q 3 days, therapy screen, med review, side/side only, lie down after meals." There are no updates to the Skin Integrity POC after 12/3/10. Skin Grid dated 12/3/10 for Coccyx documents: stage = II, 2.6 x 0.4 x 0.2 cm. Sections for drainage, color, odor, and undermining all have 0 (zeros). Physician Telephone Order from 12/2/10 is: "Alleven (dressing) to coccyx area, change q 3 day until resolved." Skin Grid dated 12/8/10 for Coccyx documents: stage = 2, 2.6 x 0.4 x 0.2 cm. Color documented is "P" which key notes is Pink. No drainage and no odor. Skin Grid dated 12/15/10 for Coccyx documents: stage = II, 1.4 x 0.3 x 0.1 cm. Color documented is "P" which key notes is Pink. No drainage and no odor. Skin Grid dated 12/21/10 for Coccyx documents: stage = unstageable, 3 x 2.2 x 0 cm. Color of drainage states "tan." Comments indicate: "now with 100% dry yellow slough-started as superficial II, now with dry/brown slough area, treatment change recommendations." On 12/20/10 there is a fax to the physician stating "May we have an order for [REDACTED]. The request is signed and dated by the physician 12/20/10. On 12/21/10 there is a fax to the physician stating "seen by Omnicare wound care nurse today-report to follow this page. Recommendations: Coccyx cleanse with N.S. (normal saline), pat dry, apply [MEDICATION NAME] gel to area with tongue blade, fluff,, 4x4 gauze, secure with [MEDICATION NAME] tape daily and prn." There is no description of the wound to the physician. The request is signed and dated by the physician 12/21/10. Skin Grid dated 12/28/10 for Coccyx documents: stage = unstageable, 2.5 x 2 x <0.1 cm. Color is noted as Y (Yellow) with no drainage or odor. Comments indicate: "Continues with yellow slough to wound bed. No drainage." Skin Grid dated 1/5/11 for Coccyx documents: stage = U (unstageable), 6 x 4.7 x 0 cm. Color is noted of B/Y (Black/Yellow) with no drainage or odor. Comments indicate: "remains same, no change" even though the area of the wound is five times larger than it had been the previous week. On 3/17/11 at 3:00 PM Surveyor interviewed RN M and RN V. RN M and RN V, when shown the change in size and color of the coccyx wound on the Skin Grid dated 1/5/11, stated that the Physician should be notified of this type of change. RN V stated she is not sure why the comments indicate that there was no change to the wound. RN M and RN V stated that they would check the orders to see if treatment changes had been made. On 3/17/11 at 5:30 PM, RN W provided an IDT Weekly wound review note dated 1/5/10. These notes are signed by RN V and state "Unstageable coccyx-not improving-assessed by wound team fax out to MD for new tx (treatment)." There is a fax dated 1/8/11 (3 days later) sent to MD X that states: "Requesting to change dressing to coccyx site to Allyven and Santyl q 3 day." There is no description of the wound. This request is signed and dated by MD X on 1/10/11 (5 days after the change to the wound was first documented). Skin Grid dated 1/11/11 for Coccyx documents: stage = U (unstageable), 5 x 4.5 x 0 cm. Color is noted Y (Yellow) with no drainage or odor. Comments indicate: "Improving-slough remains." Skin Grid dated 1/18/11 for Coccyx documents: stage = U (unstageable), 5 x 5 x <0.1 cm. Color is noted of R/Y/B (Red/Yellow/Black) with Red drainage and foul odor. Comments indicate: "Area now has foul odor. Small dark dots noted under thin layer of skin. Some yellow slough thin layer noted. Dark reddish drainage noted on allevyn covering less than 1/2 of 3x3 pad." A fax on 1/18/11 to MD X states: "Coccyx open area measures 5x5, (picture) shaped. Can see areas of black under thin layer of tissue, foul smelling...Requesting a change in order: Cleanse open area to coccyx with wound cleaner, pat dry, apply [MEDICATION NAME] Ag (silver) dressing to open area-overlap wound edge by 0.5-1 cm, Apply skin prepto peri-wound area, cover [MEDICATION NAME] Ag with 4x4, secure with [MEDICATION NAME]-tape, change dressing daily and prn. Do not lay on back. OK?" Request is noted "OK to above" and signed by MD X on 1/18/11. On 3/17/11 at 5:30 PM, Surveyor interviewed RN W. RN W stated that she had looked at Resident 1's coccyx wound on 1/18/11. RN W stated that she sent the fax to MD X on that date. RN W stated that she determined the new dressing treatment by using the facility's wound protocol (not in consultation with the MD.) RN W stated that, in hindsight, she would have had the wound evaluated by a physician. RN W stated that if she sees a wound with that appearance in the future, she will have the wound evaluated by a physician and/or have the resident sent to the emergency room . There is also a fax to MD X in this same time frame on 1/17/11 stating "Pt producing sour smelling loose stools and not feeling well...may we have orders for immodium and for culture to r/o (rule out) [MEDICAL CONDITIONS]. This note is signed and dated by MD X on 1/18/11. There is a form dated 1/19/11 completed by the facility called "Mitigating Factors for the Development of Pressure Sores." This form states: "Clinical conditions this resident exhibits which make the likelihood of this pressure ulcer unavoidable include, but are not limited to, resident immobility and:" There are 23 pre-printed areas that can be marked on this form. Of those, 5 are marked. They are: Chronic bowel incontinence (which the resident has had since admission), [MEDICAL CONDITION] (since admission),[MEDICAL CONDITION] (Pt. has been treated for [REDACTED]. It also notes Non-compliance with care interventions: "Turning and Positioning" and "Pressure Relieving Devices". On 3/24/11, Surveyor spoke with DON B by telephone and requested documentation of Resident 1's non-compliance with turning and repositioning. DON B faxed 18 pages of Physical Therapy (PT) and Occupational Therapy (OT) notes and summaries. Therapy notes indicate anxiety, fearfulness, and confusion at times during therapy sessions. Refusals of some aspects of therapy and the need for "maximum encouragement" are noted at times. The refusals are not specific to turning and repositioning. A Resident Behavior Chart was also provided with dates from 12/20/10 to 1/22/11. That chart notes Resident 1 to have the behavior "Resists Cares" on 3 dates (1/1/11, 1/16/11, and 1/20/11) out of 34 dates. No notes were provided that indicate refusals of turning and positioning or the refusal of pressure relieving devices. One PT OT note dated 12/6/10 states "educated re: need to avoid pressure on blisters as that could create open sores which are particularly dangerous for diabetics." The notes do not indicate the Resident's response to (or any refusal of) the education or interventions. The Mitigating Factors form was faxed to and signed by MD X on 1/20/11. There is no indication that the family or HCPOA of Resident 1 was notified or consulted about the condition of the wound, about the "unavoidable" decline of the wound, or of the Resident's noted refusals of treatments. The resident ' s care plan did not address refusal of treatments. A note on 1/21/11 on the "Physical Therapy Daily/Weekly Summary" states "...pt is now on an air mattress for skin integrity issues." Physician's note (MD X) from monthly rounds conducted 1/23/11 state "There seems to be some areas of redness in the area of the heel as well as the buttocks." Surveyor interviewed MD X on 3/22/11 at 12:20 PM by phone. MD X stated that she did not see Resident 1's ulcers on 1/23 as they were covered. MD X states that she relies on nurses at the facility to update her on wound conditions when she is unable to view them. MD X states that no one was available to give her an update on the wounds on 1/23/11 possibly because her visit was on the weekend. Skin Grid dated 1/24/11 for Coccyx documents: stage = U (unstageable), 6 x 5.5 x <0.1 cm. Color is noted of Y/B (Yellow/Black) with drainage noted as "Y" and foul odor. Comments indicate: "odor improving." On 1/26/11, Resident 1 was discharged to the Emergency Department (ED) for [MEDICAL CONDITION] and evaluation of her pressure ulcers. Resident 1 was admitted to the hospital and had a surgical consultation. Surgeon's consult notes state: "Patient has a decubitus ulcer that currently has a roof of dermis however, a large cavity below that. The ulcer is approximately 7 cm in diameter and I would guess it to be at least a couple of centimeters deep. There is significant foul odor coming from this ulcer." Resident 1's hospital discharge summary dated 2/9/11 states: "Ultimately, the ulcers required surgical debridement, and (Surgeon's name) performed this in the OR. At that time, sacral bony cultures were obtained, which ultimately revealed [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) and E.coli..." "Due to the lengthy nature of required antibiotic coverage, it was felt a long-term care hospital setting would serve best for protracted antibiotic coverage and ongoing wound care..." "The [MEDICATION NAME] was highly resistant...the only remaining sensitivity potential for this [MEDICATION NAME] species was [MEDICATION NAME]" "...the patient will require at least 6 weeks of continued IV antibiotic as presently dosed for optimal osteo[DIAGNOSES REDACTED] coverage." Notes from the facility dated 1/26/11state that the wound care team was making rounds and noted Resident 1's wound to be much worse. The wound was charted as "appearance of terminal ulcer-butterfly shape with fast decline." This is the first instance where the ulcer is described as butterfly-shaped. Although the decline is noted as "fast", the ulcer has been present since 12/1/10, unstageable since 12/21/10, increased in size since 1/5/11 and showing signs of infection since 1/18/11. The facility and MD X refer to the coccyx ulcer as a "Kennedy Ulcer" on 1/27/10. The website www.kennedytermninalulcer.com is a site maintained by Karen Lou Kennedy-Evans for whom the Kennedy Ulcer is named. It describes Kennedy Ulcers as follows: A Kennedy Terminal Ulcer is a pressure ulcer some people get as they are dying. What does a Kennedy Terminal Ulcer look like? It can be shaped like a pear. It is usually on the sacrum. It can have the colors of red, yellow and black. The borders of the ulcer are usually irregular. It has a sudden onset. The statement you will usually hear is one of the following: 1 " Oh, my gosh, that was not there yesterday." 2 " I worked Friday, it was not there then, I was off the weekend and when I came back on Monday there it was. On 3/22/11 at 12:20 PM, Surveyor interviewed MD X by phone. MD X stated that she received a call from the facility around January 27th that there had been a huge decline in the coccyx wound since the previous Friday (1/21/11). MD X stated that this is the only time she was made aware of the decline. In checking her records she notes the fax from 1/17/11 (re: diarrhea and emesis) but does not see the fax from 1/18/11 regarding the condition of the wound. When surveyor read her the condition of the wound from the facility's skin grid dated 1/18/11, MD X stated that if she had been called and given that update, she would have had the wound evaluated sooner. MD X stated that nobody at the facility was "talking to me personally until the 27th." MD X stated that she usually gets a fax about the wound treatments and assumes that the wound care team at the facility is checking on the wound. Surveyor asked MD X about her [DIAGNOSES REDACTED]. MD X stated that this was based on the fact that the facility reported the condition of the wound had declined so fast. When Surveyor pointed out that Resident 1 had the coccyx ulcer since 12/1/10, MD X stated that there are variable opinions about how long it takes a Kennedy Ulcer to develop. When asked if Resident 1 had a Terminal Condition, MD X stated that Resident 1 was not terminal but had a lot of co-morbidities due to her [MEDICAL CONDITION], complications of many UTIs, development of many ulcers, and the facility report of the resident not eating well. MD X stated it seemed like there was "one thing after another" with ulcers developing so quickly. When asked if Resident 1's condition at this point is considered terminal, MD X stated that she understands Resident 1 is now being treated at a new facility and is "hopeful that she is OK" and is hoping that the ulcers can be healed and there are no further ulcers developing. MD X stated that what really struck her at the time is th