Every finding on record at Boulder Creek Post Acute

Based on observation, interview, and record review, the facility failed to ensure outdoor facility garbage and refuse (recyclable and non-recyclable trash) was not overflowing, and was secure with the dumpster's lids closed, for two facility dumpsters located outside the loading dock area near the kitchen hall exit. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: On 2/11/25 at 8:21 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), outside the back kitchen hallway exit. There were two dumpsters outside the loading dock area with overfilled trash containing clear plastic trash bags with miscellaneous items, mixed with brown cardboard/packing boxes, filled to the top with a fully opened lid for both dumpsters. In addition, two wet, clear plastic bags were on the floor by dumpster two. The DS stated that the dumpsters were used for all facility trash that included the kitchen and resident and facility use. The DS stated that the dumpster should not have been overfilled, and that trash should have been contained in the dumpsters with closed lids to prevent pests (unwanted animals, insects, or other organisms that can cause damage, spread disease, harmful to humans) from getting inside the dumpsters, which could have spread germs and contaminated the facility. A review of the facility's pest control service report identified: - 12/18/24 .Reported 11/22/24 .Trash Can or Bin Not properly Covered-Heavy rodent activity observed at night time near dumpsters .Action: Cover, Close, Repair or replace trash can . - 1/27/25 .Reported 11/22/24 .Trash Can or Bin Not properly Covered-Heavy rodent activity observed at night time near dumpsters .Action: Cover, Close, Repair or replace trash can . On 2/14/25 at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the dumpsters and trash bins to be securely closed with a lid to prevent pest infestation. A review of the facility's policy and procedure titled SANITATION dated 2023, indicated .Kitchen wastes which are not disposed of by garbage disposal units shall be kept in leak-proof, non-absorbent and tightly closed containers . A review of the facility's policy and procedure titled PEST CONTROL undated, indicated .Garbage and trash are not permitted to accumulate and are removed from the facility . The facility did not provide a DISPOSAL of GARBAGE and REFUSE policy and procedure.

Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for 28 of 28 sampled residents, when screws were observed protruding from handrails inside the facility. This failure had the potential to cause injury to all facility residents. Findings: On 2/13/25 and 2/14/25, observations were made of the handrails inside of the facility. A total of eight handrails were observed to have screws protruding through the interior aspect of the handrail. These screws were found to be at a height where an individual's hand grasping the handrail would contact the sharp end of the screw. During an interview on 2/13/25 at 3:36 P.M. with Certified Nursing Assistant 12 (CNA 12), CNA 12, upon touching the object, stated it was sharp, like a nail or screw. CNA 12 further stated it would definitely hurt someone. It should not be like that. During an interview on 2/13/24 at 3:40 P.M. with the Maintenance Director (MD), the MD stated That is probably a screw. That could hurt somebody. During an interview on 2/13/25 at 3:42 P.M. with the Director of Nursing (DON), the DON stated If a resident grabbed it, it would cut them. It should not be like that. During a review of the facility's policy titled Maintenance Service, the policy indicated .2. Functions of Maintenance personnel include .b. Maintaining the building in good repair and free from hazards .

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained with food storage, sanitation, and equipment maintenance according to standards of practice when: 1. One dented large can and two rusted large cans were found in the dry storage pantry. 2. A sink garbage disposal was not functioning and/or maintained in good working condition. 3. A frosting mix with a use by (U/B) date of [DATE] was found in the dry storage pantry. 4. Low-temperature dishwashing machine temperature did not reach sanitary temperature levels. These failures had the potential to cause widespread food borne illness among the 143 residents who received food from the kitchen. Findings: 1. On [DATE] at 7:51 A.M., an initial kitchen tour was conducted with the Dietary Supervisor (DS). In the dry storage pantry area was a shelf of canned goods that displayed a dented, 10 ounce (oz) can of diced peaches stored alongside canned goods that were in good condition. On the back canned shelf area, there were two cans, each containing seven pounds of pie filling, that had scattered rust shown on the upper side of each can's sides, and top area. One of the canned pie fillings had a splash-like calcium deposit white spot on the top of the can. The DS stated that the dented can and rusted cans should not have been displayed on the canned goods shelf and should have been removed to avoid using the product. The DS stated that cans that were expired, dented, broken, or rusted were put in a discard cardboard box to be thrown away. The DS further stated it was important to discard the dented can and the two rusted cans to prevent botulism (an infection caused by improperly canned food) that could have caused food-borne complications. On [DATE] at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the kitchen to be sanitary with clean and working equipment, along with (identified) food items to be discarded, such as cans (of food items) that were expired, dented, or rusted. The DON stated it was important to discard food items that may cause food-borne illnesses by checking to make sure they were safe to consume. Lastly, the DON stated it was important that the kitchen promoted environments with routine cleaning and maintenance along with equipment that were safe and functional for food preparation. A review of the facility's policy and procedure titled FOOD STORAGE-DENTED CANS dated 2023, indicated .All dented cans (defined as side seam, or rim dents) and rusty cans are to be separated from the remaining stock . 2. On [DATE] at 8:14 A.M., an observation and interview was conducted with the Dietary Supervisor (DS) and Dietary Aide (DA) 1. Next to the low temperature dishwasher area was a sink with a garbage disposal, with a controller attached under the sink table, which had a missing red stop button, and a missing bolt on the controller. There was no posted sign that indicated that it was a broken garbage disposal. The garbage disposal was directly attached to a sink and was heavily coated with white calcium-deposit-like film and scattered rust on the top side of the garbage disposal cutting chamber. The garbage disposal controller was also covered with white calcium-deposit-like film. The DS stated that they had not used the garbage disposal or maintained it because it had been broken for over a year. DA 1 stated it [garbage disposal] should be cleaned daily to prevent contamination of foods that are prepped in the kitchen. On [DATE] at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the kitchen to be sanitary with clean and working equipment, along with (identified) food items to be discarded, such as cans (of food items) that were expired, dented, or rusted. The DON stated it was important to discard food items that may cause food-borne illnesses by checking to make sure they were safe to consume. Lastly, the DON stated it was important that the kitchen promoted environments with routine cleaning and maintenance along with equipment that were safe and functional for food preparation. A review of the facility's policy and procedure titled SANITATION dated 2023, indicated .equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions . 3. On [DATE] at 8:33 A.M., a kitchen tour was conducted with the Dietary Supervisor (DS). A gallon-sized open bag of dried frosting mix, contained in a clear plastic wrap, was stored on top of a tray labeled with an O for opened and a U/B [DATE]. The DS stated the frosting mix needed to be discarded and should not have been left on the shelf of the dry storage pantry. On [DATE] at 10:36 A.M., an interview was conducted with Dietary Aide (DA) 1, outside of the dry storage pantry. DA 1 stated that the frosting mix should not have been used because they [facility residents] might get sick if an expired ingredient was used. On [DATE] at 10:37 A.M., an interview was conducted with the DS. The DS stated, the frosting mix was expired and can make someone sick. On [DATE] at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the kitchen to be sanitary with clean and working equipment, along with (identified) food items to be discarded, such as cans (of food items) that were expired, dented, or rusted. The DON stated it was important to discard food items that may cause food-borne illnesses by checking to make sure they were safe to consume. Lastly, the DON stated it was important that the kitchen promoted environments with routine cleaning and maintenance along with equipment that were safe and functional for food preparation. A review of the facility's guidelines titled DRY FOOD STORAGE GUIDELINES undated, indicated .The storage length is to be followed .Frosting mix .unopened 6 months opened on shelf 3 months . 4. On [DATE] at 8:06 A.M., a kitchen tour was conducted with the Dietary Supervisor (DS), by the low-temperature dishwashing machine. The DS demonstrated use of the dishwashing machine with a crate that went through the dishwashing machine. The temperature gauge indicated a temperature of 109 F (degrees Fahrenheit). A sign on the low-temperature dishwashing machine stated, LOW TEMPERATURE DISH MACHINE ,d+[DATE] DEGREES. On [DATE] at 8:10 A.M., an observation and interview was conducted with the DS and Dietary Aide (DA) 1. DA 1 demonstrated use of the dishwashing machine twice with the temperature gauge set at 118 F on both attempts. DA 1 stated the temperature should have been at 120 F because it's needed to kill the germs. The DS stated the low temperature dishwasher had to reach 120 F and agreed with DA 1 that it (120 F) was the temperature to sanitize dishware, utensils, and cookware items used in the kitchen. On [DATE] at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the kitchen to be sanitary with clean and working equipment along with (identified) food items to be discarded such as cans (of food items) that were expired, dented, or rusted. The DON stated it was important to discard food items that may cause food-borne illnesses by checking to make sure they were safe to consume. Lastly, the DON stated it was important that the kitchen promoted environments with routine cleaning and maintenance along with equipment that were safe and functional for food preparation. A review of the facility's policy and procedure titled DISHWASHING undated, indicated .Low-temperature machine .use the machine at a range of 120F to 140F .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control environment when the kitchen floor drain with food particles was observed infested with ants. This failure had the potential for ants to contaminate food and spread food-borne illnesses to all residents receiving food from the kitchen. The facility census was 143. Findings: According to the 2019 Centers for Disease Control, PEST CONTROL https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, stated .Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges [small fly-like insects], and mice are among the typical arthropod [insects with hard bodies like a shell] and vertebrate [back bones] pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms [tiny living organisms that are harmful to humans such as bacteria, germs, or virus], or as active participants in the disease transmission process by serving as a vector [living organisms that can transmit infectious disease] .Ants will often find their way into sterile packs of items as they forage in a warm, moist environment . On 2/11/25 at 8:08 A.M., an initial kitchen tour was conducted with the Dietary Supervisor (DS). The kitchen floor drain by the low-temperature dishwashing machine had a black polyvinyl chloride (PVC: made of plastic) pipe with no air gap space that lead into the floor drain. The floor drain surface sides were surrounded by a brownish/black, mud-like substance with mixed food particles on the bottom strainer, and was infested by ants. The DS stated there were ants around the drainage pipes because of the food accumulation coming out from the drainage pipes that attracted the ants. On 2/12/25 at 7:58 A.M., an observation and interview was conducted with the DS. The DS stated that the floor drains and drainage outlets should have been cleaned on a daily basis. The DS stated, if it's not clean this could attract ants and other pests. The DS stated that the ants could contaminate the food in the kitchen with germs that could potentially spread food-borne illnesses. The DS stated that the floor drains were supposed to be cleaned routinely during the evening shift. On 2/14/25 at 10:16 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectation was for the floor drains to be cleaned daily to prevent the attraction of pests and to prevent infestations that could contaminate foods and food-borne illness from spreading. A review of the kitchen's routine cleaning titled [Facility name] CLEANING SCHEDULES from December 2024 thru February 2025, indicated no record of routine cleaning for floor drains. A review of the facility's policy and procedure titled PEST CONTROL, indicated .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on interview and record review, the facility failed to respond to a pharmacist recommendation related to high levels of fat in the blood, for one of 30 sampled residents (23). This failure had the potential to affect Resident 23's health and well-being. Findings: Per the facility's Admission Record, Resident 23 was admitted to the facility on [DATE] with diagnoses of hyperlipidemia (high levels of fat in the blood). On 2/14/25 a review of the facility's Consultant Pharmacist's Medication Regimen Review, dated 12/5/24, was conducted. This record included a recommendation for the facility to provide a lipid panel (check the level of fat in the blood) for Resident 23. There was no documentation that the facility responded to the pharmacists's recommendation. On 2/14/25 a review of Resident 23's electronic medical record was conducted. There was no evidence that a lipid panel was completed for Resident 23. On 2/14/25 at 1:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the facility should have responded to the pharmacist recommendation. Per the facility's undated policy, titled Pharmacist Monthly Medication Regiment Review Reporting and Responses, .The nursing staff will document in response to the pharmacist's recommendation in the resident's medical record .

Based on observation, interview, and record review, the facility failed to promote infection control practices according to standards of practice for one or 30 sampled residents (Resident 38) to prevent respiratory illnesses and infection. This failure had the potential for Resident 38 to experience respiratory complications and infections from improper maintenance and storage of their nebulizer treatment equipment. Findings: A review of Resident 38's Admission Record indicated Resident 38 was readmitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD; chronic lung disease causing difficulty in breathing). A record review of Resident 38's minimum data set (MDS; nursing facility assessment tool) dated 12/23/24 indicated that Resident 38 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 2/11/25 at 8:30 A.M., an observation was conducted with Resident 38, in Resident 38's room. Resident 38 was asleep and lying on her bed covered with blankets. Resident 38's side table by the left wall had a nebulizer machine placed on top of the table with a mask and tubes placed on the nebulizer machine. The nebulizer mask had scattered condensation of clear liquid on the mask, along with a nebulizer chamber that had a heavy amount of condensation (mist-like moisture) throughout the chamber. On 2/12/25 at 2:49 P.M., an interview and clinical chart review for Resident 38 was conducted with respiratory therapist (RT) 1. RT 1 stated that Resident 38 was scheduled to receive DuoNeb (a combined respiratory therapy medication to treat COPD) via nebulizer at 7 A.M. and 7 P.M. RT 1 was shown Resident 38's nebulizer treatment picture, taken on 2/11/25 at 8:32 A.M. RT 1 stated that the mask looked used and not cleaned. RT 1 stated that Resident 38's nebulizer left on the table would be an infection control issue because it was not cleaned properly and placed to air dry on clean paper towels. RT 1 further stated once the nebulizer was clean and dry it should have been stored in a clear plastic bag to prevent contamination and germs. On 2/14/25 at 7:56 A.M., an interview and clinical chart review for Resident 38 was conducted with RT 2, outside of Resident 38's room. RT 2 stated the way she cleaned nebulizer treatment equipment was to rinse it [nebulizer mask, chamber and tubing] with water, air dry, and put back in the bag. RT 2 stated that she used sink water for rinsing and used sani-wipes (sanitizer wipes used to clean) for the masks. On 2/14/25 at 8:26 A.M., an interview and clinical chart review for Resident 38 was conducted with RT 1, at nursing station two. RT 1 stated it was important to use sterile water (water is free from bacteria and minerals) with nebulizers during the cleaning process to prevent contamination and infection in the lungs. On 2/14/24 at 9:51 A.M., an interview was conducted with the Director of Nursing (DON), in the DON's office. The DON stated it was important to follow cleaning procedures by using sterile water to clean nebulizers according to the facility's policies and procedures to prevent contamination and respiratory illnesses and infections. A review of the facility's policy and procedure titled CLEANING and DISINFECTION of RESIDENT-CARE ITEMS and EQUIPMENT, indicated .Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms .

Based on observation, interview, and record review, the facility failed to provide respiratory care according to standards of practice for one of eight reviewed residents (Resident 38) on a nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) treatment. As a result, Resident 38 was not properly monitored before and after nebulizer treatments were provided, and had the potential for ineffective nebulizer administration, respiratory complications, and infections that increased the risk of negative health outcomes. Findings: A review of Resident 38's Admission Record indicated Resident 38 was readmitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD; chronic lung disease causing difficulty in breathing). A record review of Resident 38's Minimum data set (MDS; nursing facility assessment tool) dated 12/23/24 indicated that Resident 38 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 2/11/25 at 8:30 A.M., an observation was conducted with Resident 38, in Resident 38's room. Resident 38 was asleep and lying on her bed covered with blankets. Resident 38's side table by the left wall had a nebulizer machine placed on top of the table with a mask and tubes placed on the nebulizer machine. The nebulizer mask had scattered condensation of clear liquid on the mask along with a nebulizer chamber that had a heavy amount of condensation (mist-like moisture) throughout the chamber. On 2/11/25 at 3:36 P.M., an interview and clinical chart review for Resident 38 was conducted with licensed nurse (LN) 1, at nursing station three. LN 1 stated that Respiratory Therapy (RT) provided nebulizer treatments to Resident 38. LN 1 stated the treatment administration record (TAR) did not record a post respiratory vital signs (lung sounds, heart rate, respiratory rate, oxygen saturation [below 90% means low oxygen levels]) and was not certain if the vital signs documented on the TAR at 7 A.M. were taken before or during the respiratory treatment. On 2/12/25 at 2:49 P.M., an interview and clinical chart review for Resident 38 was conducted with RT 1. RT 1 stated that Resident 38 was scheduled to receive DuoNeb (a combined respiratory therapy medication to treat COPD) via nebulizer at 7 A.M. and 7 P.M. On 2/14/25 at 7:56 A.M., an interview and clinical chart review for Resident 38 was conducted with RT 2, outside of Resident 38's room. RT 2 stated she gave Resident 38 a nebulizer treatment at 7 A.M. and stated during nebulizer treatments they [RTs] stay with the residents and the treatments lasted approximately 8-10 minutes. RT 1 stated there was no record of a pre (before) and post (after) documentation. RT 2 stated there is no before and after documentation for respiratory vital signs and further stated we only do it [vital signs] one time during the procedure. On 2/14/25 at 8:26 A.M., an interview and clinical chart review for Resident 38 was conducted with RT 1, at nursing station two. RT 1 stated that it was important to take pre and post respiratory vital signs for nebulizer treatments to know Resident 38's baseline and monitor for effectiveness and/or complications from the nebulizer treatment. RT 1 stated respiratory vital signs should not have been recorded and documented during or in the middle of the nebulizer treatment. On 2/14/24 at 9:51 A.M., an interview was conducted with the Director of Nursing (DON), in the DON's office. The DON stated her expectations were for the RTs to monitor Resident 38's respiratory vital signs before and after performing a nebulizer treatment and not during to get a baseline comparison and to monitor for respiratory complications after the nebulizer treatment. The DON acknowledged that ongoing monitoring for respiratory distress symptoms should have been monitored throughout the nebulizer treatment to prevent respiratory complications. A review of the facility's policy and procedure titled ADMINISTERING MEDICATIONS THROUGH a SMALL VOLUME (HANDHELD) NEBULIZER, indicated .26. Obtain post-treatment, pulse, respiratory rate and lung sounds .

Based on observation, interview, and record review, the facility failed to implement professional standards of care for a peripherally inserted central catheter (PICC: catheter [flexible plastic tubing] that is inserted into a vein in either arm and extends all the way to a location near the heart, where medication is delivered) dressing for one of seven sampled residents (Resident 340) receiving intravenous (IV: into the vein) medications, according to the facility's policies and procedures. This failure had the potential to expose Resident 340's PICC site to infections and lead to complications that may negatively impact the resident's health and well-being. Findings: A review of Resident 340's Admission Record indicated Resident 340 was admitted to the facility on [DATE] with diagnoses which included a history of osteomyelitis (inflammation of bone or bone marrow, usually due to infection). A record review of Resident 340's minimum data set (MDS - a federally mandated resident assessment tool) dated 2/7/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 340 did not have cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 340's care plan dated 2/6/25 indicated, .IV DRESSING: (RUA [right upper arm]). Observe dressing Q [every] shift. Change dressing and record observations of site . On 2/11/25 at 10:13 A.M., an observation and interview was conducted with Resident 340, in Resident 340's room. Resident 340 had a RUA PICC line that was dated 1/31/25. Resident 340 stated the nursing staff did not perform any PICC line dressing changes since her admission to the facility. Resident 340 stated she was on an IV antibiotic (medications used for infections) due to her middle toe amputation for osteomyelitis. On 2/11/25 at 10:30 A.M., an interview was conducted with licensed nurse (LN) 2. LN 2 stated PICC line dressings should be changed on a weekly basis to prevent infection and PICC line complications. On 2/12/25 at 2:27 P.M., an interview and record review was conducted with LN 1. LN 1 was shown a picture that was taken on 2/11/25 at 10:15 A.M. of Resident 340's PICC dressing that was dated 1/31/25. LN 1 stated that Resident 340 was admitted to the facility on [DATE] and stated that Resident 340's PICC line dressing should have been changed on 2/7/25. LN 1 stated PICC line dressings should have been changed every week to prevent infection and IV complications. LN 1 stated there was no documentation to support that a dressing change to the PICC site was done within the weekly time frame. On 2/14/25 at 10:10 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that her expectations were for the admission nurses to assess any residents with an IV site to check the dressing, and change the dressing according to the facility's policy's and procedure for IV dressing changes within seven days. The DON stated that it was important to provide IV site care and dressing changes to prevent IV site complications and infection. According to Centers for Disease Control (CDC) https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a3.htm .Central venous catheters including peripherally inserted central catheters and hemodialysis catheters .Replace gauze dressings every 2 days and transparent dressings every 7 days on short-term catheters . A review of the facility's policy and procedure titled Peripheral IV Dressing Changes undated, indicated .Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5-7 days .

Based on interview and record review, the facility failed to notify the physician of a high blood sugar reading for one of 30 sampled residents (23). As a result, Resident 23 had an increased risk of untreated symptoms of high blood sugar. Findings: Per the facility's Admission Record, Resident 23 was admitted to the facility on [DATE] with diagnoses to include, type 2 diabetes mellitus (unstable blood sugars). Per the facility's Medication Administration Record (MAR), dated 1/1/25 through 1/31/25, Resident 23 had an order for the physician to be notified of blood sugar readings greater than 290. Per the MAR, the following blood sugar readings were greater than 290. On 1/5/25 at 11:30 A.M., Resident 23's blood sugar was 322. On 1/8/25 at 4:30 P.M., Resident 23's blood sugar was 293. On 1/10/25 at 11:30 A.M., Resident 23's blood sugar was 337. On 1/11/25 at 11:30 A.M., Resident 23's blood sugar was 313. On 1/11/25 at 4:30 P.M., Resident 23's blood sugar was 294. On 1/19/25 at 11:30 A.M., Resident 23's blood sugar was 305. On 2/13/25, Resident 23's electronic medical record was reviewed. There were no progress notes on 1/5/25, 1/8/25, 1/10/25, 1/11/25, and 1/19/25 that indicated the physician was notified of Resident 23's high blood sugar readings. On 2/14/25 at 8:41 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated, when he notified the physician of a high blood sugar reading he documented it in the progress notes. The DSD further stated, he should have documented in the progress notes if he called the physician. On 2/14/25 at 12:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, the nurses who took the high blood sugar readings should have notified the physician and documented it in the progress notes. Per the facility's undated policy, titled Guidelines for Notifying Physicians of Clinical Problems, .The floor nurse .should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management .

Based on interview and record review, the facility failed to reevaluate two of 30 sampled residents (2, 57) reviewed for mental health services. As a result, residents may have had unmet mental health needs. Findings: 1. Per the facility's Admission Record, Resident 2 was admitted to the facility on [DATE]. Per the Admission Record, Resident 2 was diagnosed with major depressive disorder (a depressed mood impairing daily function) and schizoaffective disorder (a mental disconnection from reality) on 6/25/24. On 2/11/25 a review was conducted of Resident 2's electronic medical record. There was no documentation that a Level II Mental Health Evaluation (an evaluation for additional services for residents with mental illness) was conducted for Resident 2. On 2/13/25 at 1:30 P.M., an interview was conducted with the Minimum Data set (MDS, a federally mandated resident assessment tool) nurse. The MDS nurse stated, Resident 2 should have been reviewed for a Level II Mental Health Evaluation when she was diagnosed with major depressive disorder and schizoaffective disorder. 2. Per the facility's Admission Record, Resident 57 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD, a mental health condition caused by a traumatic event) and bipolar disorder (a mental health condition with significant shifts in mood). Per the Admission Record, Resident 57 had a new diagnosis of major depressive disorder on 2/27/21. On 2/11/25 a review was conducted of Resident 57's electronic medical record. There was no documentation that a Level II Mental Health Evaluation was conducted for Resident 57. On 2/13/25 at 1:30 P.M., an interview was conducted with the MDS nurse. The MDS nurse stated, Resident 57 should have been reviewed for a Level II Mental Health Evaluation when she was diagnosed with major depressive disorder. The facility's undated policy, titled PASRR (Patient Assessment and Resident Review) Completion Policy did not direct staff to reevaluate residents with a new diagnosis of a mental illness.

Based on interview, and record review, the facility failed to ensure one of three reviewed discharged resident's (Resident 139) or his family member received a notice to request a bed hold when the resident was transferred to the acute care hospital. As a result, Resident 139 and/or his family member did not receive a written notice from the facility at the time of transfer, about the option to pay to hold the resident's bed. Findings: A review of Resident 139's Admission Record indicated Resident 139 was admitted to the facility on [DATE] with diagnoses which included a history of atrial fibrillation (irregular and often very rapid heart rhythm). On 2/13/25 at 4:09 P.M., a review of Resident 139's clinical record was conducted. Resident 139's progress note indicated Resident 139 was transferred to an acute care hospital on 12/18/24 at 18:15 PM [6:15 P.M ] for positive norovirus (a contagious virus that causes vomiting and diarrhea). On 2/14/25 at 7:40 A.M., an interview and record review with licensed nurse (LN) 1 was conducted, at nursing station three. LN 1 stated Resident 139's clinical record did not indicate if Resident 139 and/or his responsible party (RP) were notified of the facility's bed hold policy. LN 1 further stated that it was important to notify Resident 139, and his RP of a bed hold policy as an option for Resident 139 to return to the facility (within seven days) without penalty, or to be notified about out-of-pocket payments that could occur. On 2/14/25 at 9:18 A.M., an interview and record review was conducted with the Admission's Coordinator (AC), in the AC's office. The AC stated she was unable to find documentation in Resident 139's clinical record that indicated if the facility's bed hold policy was provided to Resident 139 or Resident 139's family member. The AC further stated that Resident 139 and/or family should have been notified of the bed hold policy within 24 hours in order for Resident 139 and his family to be aware of a reserved bed for him at the facility, along with out-of-pocket expenses that may have been needed after the seven-day bed hold policy. On 2/14/25, a review of Resident 139's bed hold consent form was conducted. The bed hold consent form sections for confirmation of transfer & bed hold provision and the 24 hour notification were not completed. On 2/14/25 at 10:02 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that the case manager was involved with discharges to home. The DON stated that the nurses were responsible to inform the residents on admission, of the facility's seven-day bed hold policy. The DON stated, it was important to give Resident 139 and his family the opportunity that they can come back here and were explained non-coverage expenses. The facility did not provide a bed hold policy and procedure.

Based on interview and record review, the facility failed to send a copy of the transfer/discharge notice to the ombudsman's office when one of three reviewed discharged residents (Resident 139) required immediate transfer to an acute care hospital for urgent needs. This failure resulted in a lack of resident discharge notification to the State Long Term Care (LTC) Ombudsman representative and the potential advocate, to assist the resident with appeal rights. Findings: Resident 139 was admitted to the facility on [DATE] with diagnoses which included a history of atrial fibrillation (irregular and often very rapid heart rhythm), per the Admission Record. On 2/13/25 at 4:09 P.M., a review of Resident 139's clinical record was conducted. Resident 139's progress note indicated Resident 139 was transferred to an acute care hospital on 12/18/24 at 18:15 [6:15 P.M.] for positive norovirus (a contagious virus that causes vomiting and diarrhea). On 2/13/25 at 4:20 P.M., an interview was conducted with the Medical Records Director (MRD). The MRD stated she was not responsible to notify the ombudsman regarding hospital transfers, and further stated that the Case Manager and the Social Services Director (SSD) may be the ones who contacted the ombudsman for hospital transfers. On 2/13/25 at 4:23 P.M., an interview was conducted with the SSD. The SSD stated that he does not contact the ombudsman regarding hospital transfers. The SSD further stated, I would think it's the nurses that would do that. The SSD stated it was important to contact the ombudsman regarding hospital transfers because they were advocates for residents and can help with appeals as needed. On 2/14/25 at 7:40 A.M., an interview and record review with licensed nurse (LN) 1 was conducted, at nursing station three. LN 1 stated she did not think that the nursing staff was responsible for contacting the ombudsman regarding hospital transfers. LN 1 stated Resident 139's clinical record did not indicate if the ombudsman was notified. LN 1 stated that Resident 139's son and physician were the only ones notified during the hospital transfer. LN 1 stated it was important to notify the ombudsman of Resident 139's transfer to the hospital so that the ombudsman would know where Resident 139 was, and to advocate for the resident for any appeals and/or concerns. On 2/14/25 at 9:18 A.M., an interview and record review was conducted with the Admission's Coordinator (AC), in the AC's office. The AC stated she was unable to find documentation in Resident 139's clinical record that indicated if the ombudsman was notified. The AC stated she was not aware that she had to fax the ombudsman a Transfer/Discharge Notification and stated it was important to notify the ombudsman of Resident 139's hospital transfer in order for the ombudsman to know where Resident 139 was and to help advocate for any concerns and/or appeals. On 2/14/25 at 10:02 A.M., an interview with the Director of Nursing (DON) was conducted, in the DON's office. The DON stated that the case manager was involved with discharges to home. The DON stated that she planned on having the MRD and the AC work together to make sure that the Transfer/Discharge Notification form was faxed to the ombudsman for hospital transfers. The DON further stated it was important for the ombudsman to be notified about hospital transfers to help with concerns and appeals. A review of the facility's undated policy and procedure titled, TRANSFER or DISCHARGE NOTICE, indicated .A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .

Based on interview and record review, the facility failed to accurately document a resident's medications on the weekly summary for one of 30 sampled residents (2). This failure had the potential to miscommunicate Resident 2's status, care, and treatment. Findings: Per the facility's Admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (a mental disconnection from reality). On 2/14/25 a review of Resident 2's electronic medical record was conducted. Licensed nurse (LN) 21 completed the weekly summary for Resident 2 on 1/12/25, 1/19/25, 1/26/25, and 2/9/25. On all of the listed weekly summaries, LN 21 documented that Resident 2 had not been using antipsychotic (medication to treat a disconnection from reality) medication over the last seven days. Per the facility's Orders, there was an order dated 6/20/24 for Resident 2 to take risperidone (an antipsychotic medication) for schizoaffective disorder. On 2/14/25 at 10:17 A.M., an interview was conducted with LN 21. LN 21 stated, she must have overlooked the risperidone when completing the weekly summaries for Resident 2. On 2/14/25 at 10:56 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the LN should have checked the (resident's) orders when completing the weekly summaries and acknowledged that the resident's weekly summaries should have been accurately completed. Per the facility's undated policy, titled Charting and Documentation, .Documentation in the medical record will be .complete, and accurate .

Based on observation, interview, and record review, the facility failed to ensure handrails were appropriately secured. This failure had the potential to cause injury to all facility residents. Findings: On 2/13/25 and 2/14/25, observations were made of the handrails inside of the facility. One loose handrail was observed. The ends of the handrail moved in both directions from level. During an interview on 2/13/25 at 9:38 A.M. with certified nursing assistant (CNA) 11, CNA 11 stated the handrails should not move like that. CNA 11 further stated a resident could get really hurt if it tilted while they were holding it. During an interview on 2/14/25 at 9:40 A.M. with licensed nurse (LN) 11, LN 11 stated that the residents used the handrails for support. LN 11 further stated, not being secured could cause a major injury. During a review of the facility's policy titled Maintenance Service, the policy indicated .2. Functions of Maintenance personnel include .b. Maintaining the building in good repair and free from hazards .

Based on observation, interview and record review, the facility failed to implement a self administration recommendation for one resident (Resident 3) when a licensed nurse (LN 1) left medications which were not approve for self medication administration on Resident 3' s bedside table. As a result, the unattended medications on Resident 3's bedside table were not witnessed as administered as ordered. Findings: Resident 3 was admitted to the facility on [DATE] per the facility Admission Record. A review of the Admission orders dated 8/6/24 indicated Resident 3 was approved to self administer the following medications: topical diclofenac pain gel and cyclosporine eye drops for dry eyes. On 1/13/25 at 4:39 P.M. an interview and review of Resident 3's medication orders was conducted with LN 1 and the Assistant Director of Nursing (ADON). LN 1 stated on 12/31/24, she left the following medications aspirin, furosemide and two vitamins on Resident 3's bedside table. LN 1 stated after she left the unattended medications in Resident 3's room, a Certified Nursing Assistant (CNA) approached her and informed her Resident 3 was looking for her medications. Furthermore during the interview, LN 1 stated she knew she was not supposed to leave the medications at bedside however, she was giving Resident 3 a favor so she left the unattended medications of Resident 3's bedside table.

Based on observation, interview and record review, the facility failed to develop a resident's (Resident 4) baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) for one of one resident reviewed, related to the placement of a used urinal on top of the meal tray table. As a result, the lack of resident centered care plan with specific interventions to prevent contamination of the surface and the lack of education to Resident 4 had the potential for Resident 4 to acquire an infection. Findings: An unannounced onsite to the facility was conducted on 7/9/24 related to a complaint on physical environment and infection control. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), per the facility's Admission Record. On 7/9/24, Resident 4's clinical record was reviewed. Resident 4's history and physical dated 5/18/24 indicated Resident 1 had the capacity to understand and make decisions. Resident 4's minimum data set (MDS, an assessment tool) dated 4/29/24 indicated Resident 1 had a brief interview for mental status (BIMS, ability to recall) score of 10/15 (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) which meant Resident 4 had a moderately impaired cognition. During an observation and an interview of Resident 4 in his room on 7/9/24 at 11:21 A.M., Resident 4 laid in bed watching a television show. There was a urinal with a third of yellow urine output on top of the meal tray table. Beside the urinal was a cup with a straw. Resident 4 stated the staff placed the used urinal on top of the meal tray table. Resident 4 stated he used the same table for meals. During a joint observation and an interview with a certified nursing assistant (CNA) 1 on 7/9/24 at 11:35 A.M., CNA 1 stated Resident 4 placed the used urinal on top of the meal tray table. During a joint interview and record review with Infection Preventionist (IP) on 7/9/24 at 12:14 P.M., the IP stated the urinals should not have been on top of the bedside tables. The IP stated it was important to prevent spread of infection. The IP stated if the resident preferred to place the urinal on top of the meal tray table, the resident should have been educated related to infection prevention and a care plan should have been developed to indicate education was provided to the resident. The IP stated there was no care plan developed for Resident 4 about his preference to place the used urinal on the meal tray table. During an interview with the Assistant Director of Nursing (ADON) on 7/9/24 at 12:52 P.M., the ADON stated the urinals should not have been in the bedside table for infection control practices. The ADON stated the staff should have communicated what the resident preferred and there should be a care plan for Resident 4 about his preferences. Per the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 7. The comprehensive, person-centered care plan . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights .

Based on observation, interview and record review, the facility failed to implement their infection control program when a used urinal was placed on top of the resident's meal tray table for one of four sampled residents (Resident 1). This failure had the potential for contamination of the surface and could cause an infection to Resident 1. Findings: An unannounced onsite to the facility was conducted on 7/9/24 related to a complaint on physical environment and infection control. Resident 1 was readmitted to the facility on [DATE] with diagnoses which included aftercare following a surgery and diabetes (high blood sugar), per the facility's Admission Record. On 7/9/24, Resident 1's clinical record was reviewed. Resident 1's history and physical dated 5/18/24 indicated Resident 1 had the capacity to understand and make decisions. Resident 1's minimum data set (MDS, an assessment tool) dated 5/28/24 indicated Resident 1 had a brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) which meant Resident 1 had an intact cognition. During an observation and an interview of Resident 1 in his room on 7/9/24 at 11:09 A.M., Resident 1 was sitting up in a wheelchair. There was a used urinal on top of the meal tray table where a jar of olives laid. Resident 1 stated the staff from the previous shift placed the used urinal on top of the meal tray table. Resident 1 stated he used the same table for meals. Resident 1 stated That is where I eat. It was unsanitary. During a joint observation and an interview with rehabilitative nursing assistant (RNA) 1 on 7/9/24 at 11:12 A.M., RNA 1 stated, I just came in with bad situation. That is not what we usually do, I don't know what to say. It is for infection control. During an interview with Infection Preventionist (IP) on 7/9/24 at 12:14 P.M., the IP stated the urinals should not have been on top of the meal tray tables. The IP stated it was important to prevent spread of infection. During an interview with the Assistant Director of Nursing (ADON) on 7/9/24 at 12:52 P.M., the ADON stated the urinals should not have been in the meal tray table for infection control practices. Per the facility's policy titled Infection Prevention and Control, revised December 2023, The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on observation, interview and record review, the facility failed to fully implement their post fall protocol for a resident who self -reported a fall. This had the potential to compromise the safety and well-being of Resident 1. Findings: On 11/03/23 the Department of Public Health received a complaint of a fall for Resident 1 on 11/03/23. On 11/15/23, Resident 1 ' s records were reviewed. Resident 1 was admitted to the facility on [DATE] with diagnoses to include osteoarthritis of knee (swelling of knee joints), syncope (passing out) and collapse, opioid dependence (drug for pain relief and causing sleepiness) per the facility Admission Record. A review of Resident 1 ' s facility record indicated on 11/3/23 at 1:00 A.M., .Resident came down to nurses station mobile wheelchair stating he fell on his buttocks in his room at his bedside no c/o[sic] pain/discomfort v/s[sic] wnl[sic] breathing even and unlabored neurochecks initiated RN/MD[sic] made aware . Fall risk evaluation on 3/2/21 was 19, high risk for fall. Fall risk evaluation on 9/7/23 was 15, high risk for fall. There was no documented evidence of fall risk evaluation was done after Resident 1 ' s reported 11/3/23 fall. There was no documented evidence a pain assessment was performed after the fall. after Resident 1 ' s reported 11/3/23 fall. There was no documented evidence of an interdisciplinary team (IDT-health care team that included the nurse, social service, rehabilitation and activities) meeting to determine Resident ' s 1 incident of fall on 11/3/23 was done. On 11/15/2023 at 1:51 P.M., an interview with Resident 1 stated he had a fall four nights ago in the middle of the night. Resident 1 stated he used the power wheelchair and ended up on the floor. Resident 1 stated he then used the call light but nobody came. Resident 1 stated he went to the nurse station later on and informed the nurse of his fall. On 11/15/2023 at 1:55 P.M., and interview was conducted with the resident roommate. Resident roommate stated around four nights ago midnight, he heard Resident 1 fooling around and heard a thud. Resident roommate then heard Resident 1 yelling. Resident roommate stated no employee came to our room. Resident roommate stated Resident 1 fell asleep and resident roommate fell asleep too. On 11/15/23 at 2:19 P.M., A concurrent interview and record review with Licensed Nurse (LN) 1. LN 1 stated when there was an incident of fall, IDT for fall, fall risk assessment, pain evaluation and risk management for internal investigation and performed. LN 1 stated before, facility documented incidence of fall on _e-interact and now, facility documented on IDT. LN 1 stated there was no fall risk evaluation after the fall, no IDT and no pain evaluation was performed for Resident 1 ' s fall. On 11/03/23 at 3:33 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated when there was a claimed fall, the licensed nurse should have documented the fall, notify the doctor and go from there. The DON stated she just found out Resident 1 had a fall, the licensed nurse documented on a different form and that was why the facility did not catch the incident. The DON stated when a licensed nurse document an incident of fall, we could catch it when she run the report for all residents fall incidents. The DON stated then once we know the residents with fall, we do our IDT for fall. The DON stated this was missed because the licensed nurse used a different form to document resident 1 ' s incident of fall.

Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan related to repeated refusals of showers, dental examines, podiatry care, and eye exams, for one of two residents, (Resident 1), reviewed for Quality of Care. As a result, Resident 1 did not receive the necessary services to maintain the highest quality of care. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), and diabetes (abnormal sugar levels in the blood), per the facility's Admission Record. On 2/22/23, at 10:12 A.M., an observation and interview was conducted of Resident 1 as she laid on top of her bed. Resident 1 had on mismatched socks, and the bottom of the socks were dark and soiled from walking. Resident 1's hair looked unwashed. Resident 1 stated she did not like to take showers because she believed the sewer run-off came out of the shower. On 2/23/23 the facility's shower book was reviewed from 1/5/23 through 2/20/23. Resident 1 was schedule to have showers during the day every Monday and Thursday. Resident 1 refused shower six of the eight times offered by staff, according to the handwritten shower sheets. On 1/12/23 it was documented Resident 1 received a partial bath and a shower was provided on 1/30/23. According to the eight shower sheets, the area where it indicated Resident 1's nails were cleaned was blank six of the eight times. On 1/23/23, the staff documented N/A for nails being cleaned and refused on the 1/30/23 shower sheet. On 2/28/23, Resident 1's clinical record was reviewed: According to the Minimal Data Set (MDS-a clinical assessment tool), dated 2/2/23, Resident 1's cognitive assessment score was 13, indicating an intact cognition. The functional status indicated one person staff assist with activities of daily living. According to the physician's order, dated 10/18/21, .ophthalmology (eye doctor) consult and treatment as indicated .podiatry (foot doctor) q (every) 2 months prn (as needed) for nail/foot care .Dental evaluation and treatment as indicated . Per the Eye Doctor Consultation forms, dated 4/12/22 and 7/5/22, Resident 1 refused eye exams. There wase no other documented evidence Resident 1 had been assessed or examined for an eye evaluation. Per the Podiatric Evaluation and treatment forms, dated 11/12/21, 8/22/22, 12/28/22, and 1/30/23, Resident 1 refused eye examinations. Per the Dental Hygiene Progress Notes, dated 2/12/22, 4/26/44, and 8/23/22, Resident 1 refused dental services. According to the facility's care plan, titled Impaired cognitive function/dementia, dated 12/10/21, interventions were listed such as Cue, reorient and supervise, Monitor/document/report any changes in cognitive function, specifically changes in: decisions making ability, memory, recall and general awareness. According to the facility's care plan, titled ADL (activities of daily living) self-care performance deficit, dated 10/18/21, interventions were listed such as Bathing/Showering: Check nail length and trim. The resident requires limited assistance by (1) staff 2x a week and as necessary. On 2/22/23 at 11:30 A.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated Resident 1 was repeatedly resistant to care, it should be care planed by the LNs. LN 1 stated if it was not care planned, staff would be unaware of the behavior and there would be no consistent approaches to resolve the issue. On 2/22/23 at 11:41 A.M., an interview was conducted with LN 2. LN 2 stated refusals of care should always be care planed. LN 2 stated care plans were important to provide interventions consistently, so staff were all aware of things that worked and did not work. On 2/22/23 at 11:44 A.M., an interview was conducted with LN 3. LN 3 stated refusal of care should be monitored, and care planned. LN 3 stated if the behavior of refusals was not care planned the problem could not be assessed and resolved. On 2/22/23 at 11:49 A.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated Resident 1 did refuse the eye doctor, dentist and podiatrist several times. The SSD stated he should have completed a care plan for the refusal of those services, and he did not. The SSD stated the staff should have completed the refusal for showers. The SSD stated with the resident refusing these services, her basic needs were not being met and a care plan should have been developed so interventions could have been attempted for compliance. The SSD stated he did discuss the refusal with the case manager during a care conference, but after reviewing the care conference notes, the SSD acknowledged it was never documented as being recognized or discussed. On 2/22/23 at 12 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 should have had a care plan for refusing showers, dental, vision and podiatry exams. The DON stated Resident 1 was not having her needs met and there were no coordinated interventions put in place to address the refusals of care. According to the facility's policy, titled Requesting, Refusing and/or Discontinuing Care or Treatment, undated, .5. If a resident/representative .refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to: a. Determine why he or she is .refusing .7. If the decision to refuse .results in a significant change of condition .changes will be made to the resident's care plan . According to the facility's policy, titled Goals and Objective, Care Plans, dated April 2009, .Care plans goals and objectives are defined as the desired outcome for a specific problem .

Based on observation and interview, the facility failed to ensure the call bell system alerted staff to a resident requesting an assistant when the call bell system only lighted up. As a result, call light may not have been answered in a timely manner. Findings: On 5/17/22 at 8:55 A.M., Resident 12 was interviewed. Resident 12 stated, I had to wait 2 hours to be changed after pressing the call light. On 5/17/22 at 9:535 A.M., Resident 46 was interviewed. Resident 46 stated, I waited 1 hour for the call bell to be answered. On 5/17/22 at 9:50 A.M., Resident 90 was interviewed. Resident 90 stated that his roommate waited 3 hours for someone to answer the call light. On 5/17/22 at 9:18 A.M., room 120 was toured. The resident in room 120 required assistance and the in room call bell was activated. There was no audible alert to the call bell, and the call light outside of room did not light up. The Social Services Director was just outside the room, and she stated the call bell had no audible alarm just the light at the door. The Social Services Director stated the staff help residents after identifying the call bell light is on during rounds. She was unaware the call bell light outside room 120 did not light up. On 5/18/22 at 10:30 A.M., a resident council meeting was held. Majority of the residents in the meeting voiced a concern regarding long call bell response time throughout the facility. On 5/20/22 at 8:42 A.M., at Station 1. The call bell light was on in room 108. Two staff were sitting at the nurse's station. The call panel at the station, had a light on, but the phone was placed in front of it to block anyone seeing that light. The light was on but there was no sound at all, to indicate a resident used a call bell to summon help. A few minutes later, on Station 2, again a light was on outside of a resident's room, the call bell panel was lit up. There was barely a beeping sound at the control panel. If you were more than a few feet away from the desk, you would not have heard the sound. The facility provided their Answering the Call Light policy, last revised in October 2010. The policies general guidelines 7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the residents call as soon as possible. 9. Be courteous in answering the resident's call. Steps in the procedure. 1. Turn off the signal light. 2. Identify yourself and call the resident by his/her name . The policy did not address how the call bell summons help. Whether it is audible or visual, or how staff are to monitor the residents rooms to ensure they identify a call light has been activated promptly.

Based on observation, interview and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of three sampled residents (Resident 1), when: 1. The identified cause of Resident 1's weight loss was not addressed. 2. There was lack of documented evidence to show Resident 1 received the ordered amount of tube feeding (liquid food provided via tube) daily, through intake and output monitoring. 3. The physician was not consistently informed of Resident 1's weight loss. As a result, Resident 1 had an unplanned weight loss while receiving nutrition via a tube feeding. Resident 1 continued to lose weight and was diagnosed in the acute hospital with Severe protein-calorie malnutrition (a form of malnutrition where there is lack of dietary protein and/or calorie). Findings: An observation and interview was conducted with Resident 1 on 1/18/19 at 10:45 A.M. Resident 1 was lying in bed awake. Resident 1 stated They pretend to take care of me. A review of Resident 1's medical record was conducted on 1/18/19. Resident 1 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's MDS (Minimum Data Set - an assessment tool) assessment, dated 8/17/18, Resident 1's BIMS (Brief Interview for Mental Status - a screening tool use to assess cognition) score was 8. A BIMS score of 8-12 indicated moderate intellectual impairment. A telephone interview was conducted with a hospital medical doctor (MD) 1 on 2/27/19 at 11:33 A.M. MD 1 stated the resident was malnourished (lack of proper nutrition) and had muscle wasting (a weakening, shrinking, and loss of muscle). MD 1 stated, I could count his ribs. MD 1 stated, If he was getting enough calories, you wouldn't have seen this much muscle wasting. MD 1 also stated Resident 1 was dehydrated based on examination and laboratory results. MD 1 stated it did not look like Resident 1 was given enough fluids at the facility. A review of Resident 1's hospital medical record was conducted on 2/27/19. According to the undated Patient Information sheet, Resident 1 was admitted to the hospital on [DATE]. According to the History and Physical, dated 1/7/19, indicated Resident 1's BUN (blood urea nitrogen- blood test to check urine function) was 186 mg/dL (milligrams per deciliters), with a normal range of 7 to 20 mg/dL. The physician progress notes [REDACTED]. The progress note also indicated that Resident 1's sodium level (sodium in the blood; high levels may indicate kidney problems, dehydration, or other medical condition) was at 166 mEq/L (milliequivalents per liter), with normal range at 135 to 145 mEq/L. Resident 1's Discharge Summary, dated 1/12/19, indicated, one of the resident's [DIAGNOSES REDACTED]. A review of Resident 1's weight record was conducted on 3/5/19 at 8 A.M. The resident's weights were as follows: 5/10/18 - 119.6 pounds (lbs.) 5/11/18 - 119.6 lbs. 6/1/18 - 117.1 lbs. 6/11/18 - 115.8 lbs. 6/18/18 - 118.3 lbs. 6/25/18 - 120.9 lbs. 7/1/18 - 121.1 lbs. 7/9/18 - 117.7 lbs. 7/23/18 - 117.5 lbs. 7/29/18 - 118.6 lbs. 8/12/18 - 122.3 lbs. 8/19/18 - 119.9 lbs. 8/26/18 - 122.5 lbs. 9/1/18 - 123.1 lbs. 9/16/18 - 135.7 lbs. 9/23/18 - 128.2 lbs. 10/1/18 - 128.9 lbs. 10/7/18 - 126.1 lbs. 10/14/18 - 128.4 lbs. 10/21/18 - 126.8 lbs. 10/28/18 - 125.3 lbs. 11/2/18 - 125.3 lbs. 11/4/18 - 122.1 lbs. 11/11/18 - 123.1 lbs. 11/18/18 - 124.6 lbs. 11/25/18 - 125.6 lbs. 12/9/18 - 123.4 lbs. 12/16/18 - 122.7 lbs. 12/23/18 - 121.7 lbs. 1/2/19 - 120.5 lbs. 1/20/19 - 119.8 lbs. 1/27/19 - 120.2 lbs. 2/1/19 - 120.2 lbs. 3/1/19 - 118 lbs. An interview and joint record review with the Assistant Director of Nursing (ADON) was conducted on 3/5/19 at 10:30 A.M. The ADON reviewed Resident 1's Interdisciplinary Team (IDT) - Weight Committee Notes, documented by the facility Registered Dietitian (RD). The notes indicated the following: · 6/13/18 at 1:15 P.M. - Resident 1 lost 1.3 lbs. in a week. Per the note, Root cause: delay in TF (tube feeding) not being administered to resident due (sic) RNA (restorative nursing assistant) ambulation and hx (history) of PT (physical therapy). TF rate was recently increased from 70 to 85 ml (milliliters) per hour. Is on a weight gain program to gain 1-2 # (lbs) a week to reach 130. Current weight 115.8. No labs (laboratory test) yet. The ADON stated there was no documentation to indicate what interventions were implemented in response to the identified cause of the resident's weight loss. The ADON stated the note did not indicate the resident's physician was notified regarding Resident 1's weight loss. · 7/10/18 at 6:12 P.M. - Resident 1 lost 3.4 lbs. in a week. Per the note, Root cause: delay in TF not being administered to resident due (sic) RNA ambulation, hx of falls, hx [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease - when stomach acid flows back into the tube connecting the mouth and stomach).Current wt (weight) 117.7. No labs yet.Was placed on [MEDICATION NAME] (a medication which reduces stomach acid) . The ADON stated three causes were identified, as a cause for Resident 1's weight loss. The ADON stated out of the three causes for the resident's weight loss,[MEDICAL CONDITION] addressed. The concern regarding RNA ambulation and the resident's falls were not addressed. The ADON stated the note did not indicate the resident's physician was notified regarding Resident 1's weight loss. · 8/22/18 at 11:01 A.M. - Resident 1 lost 2.4 lbs. in a week. Per the note, TF rate was increased on 8/16/18 at 90 ml/hr x (for) 20 hours.Current wt 119.9.rec (recommend) CMP (comprehensive metabolic panel - blood test to check liver and kidney function, electrolyte levels (such as sodium, potassium, etc.), blood sugar levels, blood proteins, etc.) . Cont (continue) weekly weights and monitor. The ADON stated the note did not indicate Resident 1's physician was notified regarding Resident 1's weight loss. Per review of Resident 1's medical record, there was no ordered blood test for CMP for the month of (MONTH) (YEAR) for Resident 1. · 9/26/18 at 4:07 P.M. - Resident 1 lost 7.5 lbs. in a week. Per the note, Root cause: s/p (status [REDACTED]. So TF rate was increased on 9/24/18 to 90 ml/hr x 20 hours. The ADON stated there was no documentation that Resident 1 had swelling after hip surgery. The ADON stated the note did not indicate the resident's physician was notified regarding Resident 1's weight loss. · 11/3/18 at 9:56 A.M. - Resident 1 lost 1.5 lbs. in a week. Per the note, RD recommends to inc (increase) TF to 100 ml/hr x 20 hours to provide 2000 ml/3000 kcals (kilocalories)/128 grams protein/1520 ml free water. Rec (recommend) to change flush to 250 ml q4 (every 4 hours). Wt goal: 130. Current wt 125. Cont (continue) to monitor . The ADON stated the note did not indicate the resident's physician was notified regarding Resident 1's weight loss. · 11/7/18 at 4:27 P.M. - Resident 1 lost an additional 3.2 # (lbs.) x 1 week (in a week) after a wt loss of 1.5 # last week.Current wt 122.1 Cont to monitor . Per review of Resident 1's medical record, there was no new recommendation given by the RD. The ADON stated the note did not indicate Resident 1's physician was notified regarding Resident 1's weight loss. · 12/11/18 at 11:45 A.M. - Resident 1 lost 2.2 lbs. in a week. Per the note, Root cause: on IVABT (intravenous antibiotic) for rt (right) [MEDICAL CONDITION] ([MEDICAL CONDITION] - a type of infection resistant to some antibiotic) .Labs: 12/7/18 - . creat (creatinine - a waste product in your blood that comes from protein in your diet and the normal breakdown of muscles of your body) 0.47 (L) . Current wt: 123.4 . Per review of Resident 1's medical record, there was no new recommendation given by the RD. The ADON stated the note did not indicate Resident 1's physician was notified regarding Resident 1's weight loss. An interview and joint record review with the ADON was conducted on 3/5/19 at 2:15 P.M. The ADON reviewed Resident 1's Medication Administration Record [REDACTED]. The ADON stated the amount of TF Resident 1 received was not documented. The ADON reviewed Resident 1's Intake and Output Record from (MONTH) (YEAR) through (MONTH) (YEAR). Out of the 214 days (June (YEAR) through (MONTH) (YEAR)), Resident 1's intake and output was completely monitored (monitored by all shifts in a 24-hour period) 12 times. The ADON stated the resident's intake and output was not consistently and completely monitored. An interview and joint record review with the RD was conducted on 3/5/19 at 3 P.M. The RD reviewed Resident 1's Dietary Nutritional Assessment, dated 5/15/18. The RD stated Resident 1 was admitted to the facility on [DATE] with a weight of 119.6 lbs. The RD stated the weight goal for Resident 1 was 130 lbs. Per the RD, Resident 1's estimated needs were the following: Calories - 2175-2446 kcals Protein - 82-98 grams Fluids - 2175-2446 ml On 3/5/19 at 3:15 P.M., the RD reviewed Resident 1's Interdisciplinary Team (IDT) - Weight Committee Notes and the resident's weight record. The RD stated she had identified one of the causes for Resident 1's weight loss was the TF not being completely administered to the resident. The RD stated Resident 1's TF was turned-off during physical therapy. The RD stated she had seen Resident 1's TF off, when it should have been on. The RD stated she communicated her concern to the Director of Nursing (DON), at that time, and that the DON defended the licensed nurses, and did not believe her. The RD stated she increased the resident's TF rate to address the issue. The RD acknowledged that increasing the TF rate did not solve the problem. The RD acknowledged it was not known whether Resident 1 received the ordered amount of TF and the resident's recommended daily nutritional intake. The RD stated she recommended for CMP to be checked on 8/22/18. The CMP levels would have identified Resident 1's protein levels. Per review of Resident 1's medical record, there was no documented evidence that the recommendation was communicated to the physician. Per the physician's orders [REDACTED]. The RD acknowledged Resident 1 continued to have weight loss from (MONTH) (YEAR) through (MONTH) (YEAR), and did not reach the weight goal of 130 lbs. The RD acknowledged there was no documentation that Resident 1's physician was informed regarding the resident's weight loss, and the causes for the resident's weight loss. A telephone interview with Resident 1's physician (MD) 2 was conducted on 3/6/19 at 3:20 P.M. MD 2 stated the RD was knowledgeable when it came to nutrition and TF formulas. MD 2 stated he relied on the RD to communicate to him any recommendation to improve Resident 1's nutrition. MD 2 stated it was his expectation to have been informed of Resident 1's continued weight loss in order to address the concerns. MD 2 stated he was not aware Resident 1 did not receive the full amount of TF. A telephone interview with the Director of Nursing (DON) was conducted on 3/6/19 at 10:55 A.M. The DON stated Resident 1's identified causes for weight loss should have been addressed. The DON acknowledged a thorough and complete intake and output monitoring should have been conducted for Resident 1 to ensure that the resident was getting all of his TF. The DON stated Resident 1's physician should have been informed regarding the resident's continued weight loss, as part of the IDT, to help identify contributing factors to the resident's weight loss, and help develop interventions to address them. A review of the facility's policy and procedure titled Weight Assessment and Intervention, revised on (MONTH) 2008, was conducted on 3/6/19. The policy indicated, The multidisciplinary team will strive, prevent, monitor, and intervene for undesirable weight loss for our residents.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to achieve the highest practicable physical, mental and psychosocial (emotional and social) well-being for one of three sampled residents (Resident 1) when: 1. Resident 1 was not provided with proper catheter care that would have prevented the development of encrustation (covered with a hard surface layer) on the urinary catheter insertion site. 2. Resident 1's physician was not informed when the resident's urine output decreased. 3. Resident 1 was not thoroughly and completely assessed for change of condition. As a result, Resident 1 developed acute [MEDICAL CONDITION] (the kidneys suddenly stop functioning), caused by a blocked urinary catheter (a tube inserted into the bladder through the urethra allowing the normal flow of urine). Findings: On 1/18/19 at 10:45 A.M., an observation and interview was conducted with Resident 1. Resident 1 was in bed awake. Resident 1 stated, they pretend to take care of me. On 1/18/19, a review of Resident 1's medical record was conducted. Resident 1 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission Record. A review was conducted of Resident 1's MDS (Minimum Data Set - an assessment tool) assessment, dated 8/17/18. Resident 1's BIMS (Brief Interview for Mental Status) score was 8. A BIMS score of 8-12 indicated moderate intellectual impairment. A review was conducted of Resident 1's MDS assessment, dated 9/22/18. Per the MDS, Resident 1 was totally dependent on staff for toileting and personal hygiene. On 2/27/19, a review was conducted of Resident 1's hospital medical records. The following medical records were reviewed: Per the emergency room (ER) documentation, dated 1/7/19, Resident 1 was admitted to the hospital's ER, on 1/7/19 at 11:29 A.M. for [MEDICAL CONDITION] (high potassium levels in the blood) and a raised BUN (blood, urea and nitrogen - a test to measure kidney function) level. Per the ER documentation, dated 1/7/19, Resident 1 had a potassium level of 6.6 mmol per liter (a millimole is a thousandth of a mole, and a mole is the amount of a chemical substance that contains many particles such as potassium, contained in one liter, or 34 ounces, of fluid). Normal potassium levels ranged between 3.6 - 5.2 mmol per liter. Per the same ER documentation, Resident 1 had a BUN level of 172 mls (milliliters) per deciliter. Normal BUN ranged between 7-20 milliliters per deciliter (a deciliter equals 3.4 ounces). The ER documentation, dated 1/7/19, indicated Resident 1 had [MEDICAL CONDITION] (inability to completely or partially empty the bladder). Per the same document, the urinary catheter was replaced and 1500 mls of urine came out, which was infected. According to the hospital History and Physical (H&P), dated 1/7/19, Resident 1 was brought into the ER after being found lethargic and less responsive by staff and family. Per the H&P, dated 1/7/19, Resident 1's family member informed the hospital medical doctor (MD) 1 that he (Resident 1's family member) last saw Resident 1 at the Skilled Nursing Facility (SNF) on 1/6/19. Resident 1's family member informed MD 1 that Resident 1 was significantly worse than his baseline. Resident 1's baseline was oriented x 1 (to name only) and does try to answer questions . Resident 1's family member stated on 1/6/19 at the SNF, he found Resident 1 lying in bed in the fetal position, drooling, and unresponsive. Per the H&P, on 1/7/19, the ER staff found Resident 1's urinary catheter bag had no urine output. MD 1 stated the ER nurse had a hard time removing the urinary catheter. A new urinary catheter was inserted and 1500 mls of urine was immediately removed. A review of Resident 1's Hospital Discharge Summary, dated 1/12/19, indicated the Resident's final [DIAGNOSES REDACTED]. 1. Post obstructive acute renal kidney injury (kidney failure cause by blockage in the flow of urine), status [REDACTED]. 2. [MEDICAL CONDITION], resolved, that is due to acute [MEDICAL CONDITION]. Per the Hospital Discharge Summary, Resident 1 was admitted to the hospital in acute [MEDICAL CONDITION]. Resident 1's acute kidney failure resolved (returned to normal functioning) after a new urinary catheter was placed. On 2/27/19 at 11:33 A.M., a telephone interview was conducted with hospital medical doctor (MD) 1. MD 1 stated Resident 1's catheter was difficult to remove because the urinary catheter insertion site was encrusted. MD 1 stated the ER nurse had to use lubricant (a moisturizing gel) to remove the encrustation in order to take out the urinary catheter. MD 1 stated a new urinary catheter was inserted, and 1500 mls of urine immediately came out. MD 1 stated as soon as the urinary catheter was changed, Resident 1's kidney function improved. MD 1 stated permanent catheters should be changed every 4-6 weeks. The ER nurse stated the urinary catheter had not been changed. MD 1 stated there was bacteria in Resident 1's urine, and Resident 1 was treated for [REDACTED]. On 2/27/19 at 2:11 P.M., a telephone interview was conducted with Resident 1's family member. Resident 1's family member stated, on 1/6/19, he had concerns about Resident 1's condition. Resident 1 looked catatonic (not moving and not reacting), drooling, and with a blank stare. Resident 1's family member stated the nurse on duty seemed surprised that he asked questions about Resident 1's condition. The family member stated the facility staff did not notice anything wrong with Resident 1. Resident 1's family member stated he thought Resident 1 looked bad, and that Resident 1 was going to die. Resident 1 family member stated Resident 1 was dramatically worse than the last time he saw the resident. Resident 1's family member stated he was concerned that Resident 1 went from being awake and aware of his name, to looking like a vegetable. On 3/5/19 at 8:30 A.M., a joint interview and record review was conducted with the ADON. Resident 1's physician orders, dated 5/11/18, indicated, Insert (name brand) catheter 16 French (catheter size) / 10cc (cubic centimeters) as needed for soilage (dirty), leakage, blockage, or dislodgement (comes out). The resident's physician orders, dated 11/24/18, indicated, (name brand) catheter care with soap and water every shift. The ADON reviewed Resident 1's treatment administration record and nursing progress notes from (MONTH) (YEAR) through (MONTH) 2019. The ADON stated Resident 1's urinary catheter was last changed on 9/2/18. The ADON stated if catheter care (clean with soap and water) was performed on Resident 1 every day and every shift, a build-up of encrustation would not have occurred. On 3/5/19 at 8:45 A.M., a joint record review and interview was conducted with the ADON. The ADON reviewed Resident 1's urine output record from 1/4/19 through 1/7/19. Per the output record, Resident 1's urine output was as follows: 1/4/19 at 5:39 A.M. (11-7 shift) - 100 mls 1/4/19 at 10:53 A.M. (7-3 shift) - 300 mls 1/4/19 at 8:30 P.M. (3-11 shift) - 200 mls 1/5/19 at 5:50 A.M. (11-7 shift) - 100 mls 1/5/19 at 2:05 P.M. (7-3 shift) - 100 mls 1/5/19 at 8:40 P.M. (3-11 shift) - 150 mls 1/6/19 at 1:41 A.M. (11-7 shift) - 400 mls 1/6/19 at 1:29 P.M. (7-3 shift) - 0 mls 1/6/19 at 9:07 P.M. (3-11 shift) - 0 mls 1/7/19 at 3:58 A.M. (11-7 shift) - 350 mls The ADON stated Resident 1's physician should have been informed of the low urine output of 100 mls on 1/4/19 during the 11-7 shift. The ADON stated there was no documented evidence that Resident 1's physician was informed of the resident's decreased urine output on 1/4/19 and 1/5/19, and lack of urine on 1/6/19. Per the ADON, the nurse practitioner (NP) was informed about Resident 1's decreased urine output on 1/6/19 at 8:53 P.M. The ADON stated the notification to the nurse practitioner was not timely. On 3/5/19 at 9:15 A.M., a joint interview and record review was conducted with the ADON. The ADON reviewed Resident 1's nursing progress notes, dated 1/6/19, documented by licensed nurse (LN) 1. The progress notes indicated at 8:53 P.M., Resident has very dry skin and low urine output. On call NP (name of NP) is made aware . Per the progress notes, the NP ordered blood tests. The progress notes also indicated Resident 1's family member was at the bedside. The ADON stated LN 1's documentation did not reflect Resident 1's family member's observation of the resident's condition. The ADON acknowledged LN 1's documentation, on 1/6/19, did not indicate that a full assessment of Resident 1's condition was completed. The ADON also stated the documentation did not indicate the resident's family member's concerns of the resident's condition, and whether these concerns communicated to the NP. On 3/6/19 at 2:49 P.M., a telephone interview was conducted with LN 1. LN 1 stated he took over the care of Resident 1 on 1/6/19 at approximately 8 P.M., because LN 2 had to leave. LN 1 stated LN 2 informed him that Resident 1's family member was at the bedside, and had inquired about Resident 1's condition. LN 1 stated he did not recall whether the family member's inquiry was a general inquiry or due to a concern. LN 1 stated when he went to Resident 1's room, LN 1 noticed Resident 1's urine output was decreased. LN 1 stated he palpated (examined by touch) Resident 1's bladder for distension (enlarged), but the bladder did not appear distended. LN 1 stated while he palpated Resident 1's bladder, the resident reacted by opening his eyes and closing them again. LN 1 stated Resident 1 did not appear to be in pain. LN 1 stated he did not talk to the resident or ask the resident how he felt, in order to determine if there was a change in the resident's level of consciousness. LN 1 stated the only assessment he performed on Resident 1 was to palpate the resident's bladder for distension. LN 1 stated he called the NP on 1/6/19 and informed the NP that Resident 1's urine output was low, vital signs were within normal limits, and Resident 1 was at his baseline (resident's normal condition). LN 1 stated Resident 1's baseline could not have been determined, since he only assessed the resident's bladder and not the resident's level of consciousness and pain. LN 1 stated his report to the NP regarding Resident 1 being at his baseline, was inaccurate and incomplete since LN 1 only assessed the resident's bladder and not the resident's level of consciousness and pain. LN 1 further stated providing the NP with an inaccurate and incomplete assessment of Resident 1's condition could affect the NP's decisions regarding the appropriate medical intervention needed for Resident 1. On 3/6/19 at 3:20 P.M., a telephone interview was conducted with MD 2. MD 2 was Resident 1's primary physician at the facility. MD 2 stated he was not informed when Resident 1's urine output started to decrease on 1/4/19. MD 2 stated he should have been informed as soon as a change in Resident 1's condition occurred. MD 2 stated physicians and NP's were dependent on nurses to provide them with complete and accurate information regarding a resident's condition in order to provide the necessary care. On 3/7/19 at 10:12 A.M., a telephone interview was conducted with LN 2. LN 2 stated she was the nurse initially assigned to Resident 1, on 1/6/19, on the 3-11 shift. LN 2 stated at the beginning of LN 2's shift, Resident 1 did not have any urine output. LN 2 stated she checked Resident 1's catheter and it did not appear encrusted. LN 2 stated she did not perform catheter care that evening on Resident 1. LN 2 stated encrustation on the urinary catheter site could not develop overnight, and LN 2 could not explain how it occurred on Resident 1 that quickly. On 3/7/19 at 10:45 A.M., an interview was conducted with the DON. The DON acknowledged if proper catheter care was provided to Resident 1, encrustation would not have developed on the urinary catheter insertion site, which led to obstruction and subsequent acute [MEDICAL CONDITION]. The DON stated MD 2 should have been notified on 1/4/19, concerning Resident 1's decreased urine output. The DON acknowledged a complete and thorough assessment of Resident 1 was not conducted on 1/6/19, when a change in Resident 1's condition was reported by the family member. The DON acknowledged LN 1 provided the NP an incomplete assessment of Resident 1's condition, on 1/6/19, and could affect the resident's treatment plan. Per the facility's policy titled Catheter Care, Urinary, revised 9/2014, .Input/Output 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor . Managing Obstruction 1. If the catheter material is contributing to obstruction, notify the physician . Per the facility's policy titled Change in a Resident's Condition or Status, revised 5/17, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 3. Prior to notifying the Physician (sic) or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Per the undated Manufacturer's Guidelines, Bard - A Guide For Nurses, . Duration of Use . Catheters are generally categorized as short-term (maximum 28 days duration) and long term (maximum 12 weeks duration) . Changing Catheters .Where encrustation is a problem in a particular patient, it is usually possible to estimate the lifespan of a catheter by observing and recording the length of time that the catheter remains functional before becoming blocked. This simple technique allows planned re-catheterization to take place before blockage develops .

Based on observation, interview, and record review, the facility failed to: 1. Answer a call light request for 1 of 8 sampled residents with falls (95), who required walking assistance to the bathroom. 2. Investigate the cause of residents' falls, did not initiate fall safety precautions, and/or did not implement resident specific interventions for 3 of 8 sampled residents with falls (115, 487, and 61). As a result: 1. Resident 95 walked herself to the bathroom, fell , and fractured her wrist. Resident 95 suffered pain and became more dependent on staff for activities of daily living. 2. Residents 115, 487, and 61 were at increased risk for additional falls. Findings: 1. Resident 95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/15/18, Resident 95's quarterly MDS, (an assessment tool), dated 9/7/18 was reviewed. Resident 95 had a BIMS, (a test to check if thought process was intact) score of 12 (8-12, the person has moderate cognitive impairment). Per the MDS assessment for Activities of Daily Living, functional status, Resident 95 required one-person assistance for ambulating in her room and in the hallway. Resident 95's care plan, dated 7/13/17, related to falls was reviewed. The care plan indicated Resident 95 fell twice on 7/13/17, from a wheel chair, while in her room. The care plan interventions included, .educate patient about safety, instruct to use call light for assist . The facility's nursing notes for Resident 95, dated 7/19/18, were reviewed. The nursing notes indicated Resident 95 had an unwitnessed fall in her room at 9:45 P.M., and complained of left shoulder pain. Resident 95's fall care plan was revised to include monitoring for pain and bruising. Resident 95's Fall Risk Assessment at the time of the fall was rated as High Risk with a score of 14 (score of 10 or greater considered to be high risk for potential falls). The fall risk assessment indicated Resident 95 had .3 or more falls in the last 3 months with balance problems while standing and walking. On 7/23/18, Resident 95's Fall Risk Assessment was changed, indicating Low Risk with a score of 8. Resident 95's nursing notes, dated 8/9/18 were reviewed. The nursing notes indicated the resident had an unwitnessed fall in her room at 4:07 P.M. Resident 95 informed the staff she hit the side of her head on the floor. Resident 95 complained of pain in her neck, which was rated 6/10 (zero being no pain, and 10 being the worst pain). Resident 95 also complained of left elbow pain, rated 7/10 and left hip pain, rated 5/10. Resident 95's Fall care plan was reviewed and there were no revisions or additional interventions documented for the 8/9/18 fall. Resident 95's Fall Risk Assessment was updated 8/9/18, at 4:36 P.M., to indicate the recent fall, however, Resident 95 remained in the category of Low Risk with a score of 8. Resident 95's nursing notes, dated 10/3/18 were reviewed. Per the nursing entry at 11:59 P.M., Resident 95 was found on the floor in her room, by the bathroom door. Swelling and discoloration were noted by staff to Resident 95's right hand and wrist. Resident 95 told staff she did not know what happened, I just know my wrist hurts really bad. On 10/15/18 at 8:51 A.M., an observation and interview was conducted with Resident 95. Resident 95 had a symbol of a falling star outside her door, which indicated she was a fall risk. Resident 95 was observed lying in bed with a cast on her right hand and lower arm. The bed was in a high position and no fall floor mats were present. Resident 95 stated she fell because she needed to go to the bathroom one night. Resident 95 stated she used her call light, watched the clock and waited for 40 minutes. Resident 95 stated she could not wait any longer, so she got up and tried to go to the bathroom, but she fell before she got there. Resident 95 stated she yelled and yelled, until someone finally came. Resident 95 stated she fractured her wrist and it hurt really bad. Per the facility's nursing notes, dated 10/4/18 at 9:04 A.M., X-ray Wrist RT (right) 3V (3 view) shows distal radial fracture (the larger bone in the forearm, close to the wrist) .Hand RT 3V .soft tissue swelling . The nursing notes for 10/4/18 at 9:35 A.M., 10:09 A.M., 10:39 A.M., documented Resident 95, Strongly refused her morning medications and only wanted her pain medication. On 10/04/18 at 12 P.M., the nursing notes indicated Resident 95 was transported by ambulance to a hospital for evaluation of the right distal radial fracture. Resident 95's MAR indicated [REDACTED]. Resident 95 did not require any pain medications prior to the fall on 10/3/18. Per the MAR, from 10/3/18 to 10/5/18, Resident 95 was administered two tablets of [MEDICATION NAME] (a medication for severe pain), each day with pain scale ratings between 9-10. On 10/7/18, Resident 95 was administered 2 [MEDICATION NAME] tablets at 3:27 A.M., and again 7:03 P.M., for pain rated 9-10. From 10/9/18 through 10/12/18, Resident 95 continued to complain of pain in her right wrist and was administered [MEDICATION NAME] each day with a pain scales ranging between 7-10. On 10/15/18, Resident 95's medical record was reviewed. There was no documented evidence of a post fall, IDT meeting for the fall occurring on 10/3/18. On 10/16/18, upon further review of Resident 95's medical record, there was a late entry IDT note, dated 10/15/18 at 6:38 P.M., indicating the IDT met on 10/4/18. The facility's IDT note, titled Fall Committee Note, recommended . continue to encourage the use of call light for assistance . An intervention was added to Resident 95's Fall care plan on 10/5/18, Continuously reinforce use of call light for assistance prior to ambulation. On 10/17/18 at 1:12 P.M., an interview was conducted with the DON. The DON stated she just started last week and did not attend the IDT meeting following Resident 95's fall on 10/3/18. The DON stated the IDT was responsible for investigating the cause of the fall, by interviewing staff and the resident. The IDT would develop or revise a fall care plan to prevent further falls from occurring. On 10/17/18 at 1:45 P.M., an interview was conducted with the SSD. The SSD stated she learned of Resident 95's fall the following morning on 10/4/18, during a stand-up meeting. The SSD stated a stand up meeting was done every morning when all the facility's department heads met to learn what happened the night before, and to identify any issues that would need to be addressed. The SSD stated they did not have an IDT meeting on 10/4/18, regarding Resident 95's fall, it was only discussed during the stand-up meeting. The SSD stated she did not feel a stand-up meeting was the same as an IDT meeting, because the resident and staff would need to be interviewed to determine the root cause of the fall, and then interventions would need to be developed to prevent future falls. The SSD stated Resident 95 was never interviewed as to why she fell . On 10/18/18 at 8:30 A.M., an additional observation and interview was conducted with Resident 95. Resident 95 was sitting up, eating breakfast with her left hand. A Band-Aid was noted on the resident's left thumb. Resident 95 stated she pressed the call button so much this month, she got a blister on the pad of her thumb. Resident 95 stated she still had pain in her left shoulder from when she fell a year ago, which limited her independence. Resident 95 stated since she broke her right arm, she felt completely dependent. Resident 95 stated she could no longer comb her own hair, because she could not lift her left arm up due to her shoulder injury and she could not hold the comb in her right hand, because of the cast. On 10/18/18 at 10:32 A.M., an interview was conducted with Resident 95's RP. The RP stated she was informed of Resident 95's fall the following day. The RP was told the fall occurred around midnight when Resident 95 got up to use the bathroom by herself, instead of waiting for staff to arrive. On 10/18/18 at 3:11 P.M., a concurrent interview and record review was conducted with the DSD. The DSD stated she mentioned the importance of answering call lights promptly during all staff meetings. The DSD expected all the staff to answer call lights, not just the CNAs. The DSD reviewed previous in-services for resident call light responses. In-services were conducted on 7/6/18, with 15 staff members attending and on 8/24/18, with 29 staff in attendance. The facility's staffing list was reviewed, which contained a total of 79 CNAs, 21 licensed vocational nurses and 31 registered nurses. The DSD could not provide any proof of fall prevention in-services conducted over the past year. Per the facility's policy, titled Falls and Fall Risk, Managing, revised 3/2018, indicated .5. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions .the staff reconsider possible causes that may not previously have been identified. 2a. Resident 115 was admitted to the facility on [DATE] with diagnoses, which included abnormalities of gait (a person's pattern of walking) and mobility, difficulty in walking, and muscle weakness, per the facility's Admission Record. Per the MDS (an assessment tool), dated 4/25/18, Resident 115 had a BIMS (a test to check if thought process was intact) of 15 out of 15, indicating the resident was mentally intact. On 10/15/18 at 11:22 A.M., an interview was conducted with Resident 115. Resident 115 stated she fell when she tried to walk during physical therapy. Resident 115 stated she was bruised with no broken bones. Resident 115 stated she did not feel safe. On 10/16/18 at 11:17 A.M., a record review of Resident 115's medical record was conducted. The medical record did not contain the cause of the fall, an updated care plan for a fall, or the post fall risk assessment. On 10/18/18 at 2:05 P.M., an interview and record review was conducted with ADON. The ADON stated when a resident had a fall, staff should immediately assess the situation, conduct an assessment, provide interventions, monitor the resident each shift for 72 hours, conduct neurological assessments if needed, inform the physician of the fall, document a change of condition, conduct a post fall assessment and pain assessment, update the care plan, and initiate a short term care plan for an actual fall. The ADON stated if the resident fell during physical therapy, then the therapist would tell a nurse, gather all the details about the fall, find out the root cause of the fall, and still conduct all the other aspects of the process. The ADON reviewed Resident 115's medical record. The ADON stated nursing staff did not conduct a thorough investigation as to what caused Resident 115's fall and it should have been done. The ADON stated a care plan, post fall risk assessment, and pain assessment should have been completed immediately after the fall and none of these things were done. The ADON further stated nursing staff were inconsistent in monitoring Resident 115 for 72 hours after the fall. The ADON stated an IDT meeting should have been done 24 to 48 hours after the fall and it was not done. An IDT meeting was a meeting with different disciplines, including but not limited to nursing, dietary, and rehab, to discuss and resolve specific resident care issues. 2b. Resident 487 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/15/18, a record review was conducted. Resident 487's progress note, dated 10/15/18 at 6:55 A.M., indicated, Resident is found lying on the floor next to her bed A review of Resident 487's admission Fall Risk Assessment, dated 10/11/18, indicated the resident was High Risk for falls. On 10/15/18 at 10:24 A.M., a joint observation and interview was conducted with HN 21 at Resident 487's bedside. HN 21 stated, There is no landing mat (a pad placed by the bed to cushion a fall) at the bedside. It is not covered by hospice. Maybe the family will have to bring something in. On 10/15/18 at 10:30 A.M., an interview was conducted with LN 22. LN 22 stated she was taking care of Resident 487. LN 22 stated Resident 487, Is very high risk for falls. LN 22 stated the facility used fall safety alarms (an alarm placed in a resident's bed or wheelchair to alert staff a resident was getting up unassisted) and landing mats as fall safety precautions. LN 22 stated Resident 487 did not have those fall safety precautions in place and should have. LN 22 further stated Resident 487 received hospice care and hospice was responsible for ordering fall safety precautions. A review of Resident 487's (name omitted) hospice contract, revised 2/18, indicated, . 3. Responsibilities of Facility . (b) Facility will keep patients comfortable, clean, well groomed and protected from accident, injury On 10/16/18 at 1:28 P.M., a joint interview and record review was conducted with LN 13. LN 13 stated residents who were at high risk for falls had to have the following fall safety precautions in place: bedrails (a metal frame attached to the bed to assist with repositioning), frequent monitoring of the resident, fall safety alarms, and a landing mat. On 10/16/18 at 1:54 P.M., an interview was conducted with LN 13 at Resident 487's bedside. LN 13 stated Resident 487 did not have fall safety alarms nor a landing mat. LN 13 stated there should have been a landing mat in place to protect the resident from injury if she fell . On 10/16/18 at 1:59 P.M., a joint observation and interview was conducted with LN 11 by Resident 487's room. LN 11 stated residents who were at high risk for falls had to have a landing mat at the bedside, and a green dot by their name placard to communicate to all staff that the resident was a fall risk. LN 11 stated Resident 487 did not have a landing mat and did not have a green dot on her name placard. LN 11 stated the facility should have provided a landing mat upon admission to Resident 487. LN 11 further stated the facility was responsible for the resident's safety, regardless of a resident's hospice status. On 10/17/18 at 2:35 P.M., an observation of Resident 487 was conducted. Resident 487 was in bed, and there was no landing mat in place. On 10/18/18 at 7:40 A.M., a joint interview and record review was conducted with the ADON. The ADON stated the facility's staff did not have an understanding of the facility's fall protocol. The ADON stated the facility no longer used fall safety alarms and all staff should have been aware of that. The ADON stated, Not everyone's on the same page about fall prevention. The ADON further stated Resident 487 was at high risk for falls and should have had a landing mat in place upon admission. The ADON further stated a fall should be thoroughly investigated and an IDT meeting conducted within 24 hours of a fall incident. The ADON stated there was no root cause analysis done for Resident 487's fall on 10/15/18. The ADON stated without knowing the cause, it would be difficult to have resident specific interventions to prevent further falls. The ADON stated the absence of the landing mat should have been identified during the fall investigation. The ADON stated the investigation into Resident 487's fall could have been better. The ADON reviewed Resident 487's IDT -Fall Committee Note, dated 10/16/18, . IDteam recommendations include moving the hospital bed against the wall, side rails (bedrails) to assist with turning and repositioning, and frequent visual checks The ADON reviewed Resident 487's fall care plan titled, With Episode of Unwitnessed Fall, dated 10/15/18. The ADON stated Resident 487's fall care plan had not been effectively revised since none of the IDT recommendations were included in the new fall care plan. The ADON stated the IDT's recommendations should have been carried out. The ADON stated it was her expectation for care plans to be revised after a fall to include resident specific interventions and recommendations from the IDT meeting in order to prevent further falls. On 10/18/18 at 3 P.M., an interview was conducted with the DON. The DON stated all staff should know what the facility's fall protocol was and have current knowledge of the facility's fall safety precautions. The DON acknowledged Resident 487's fall on 10/15/18 had not been thoroughly investigated. 2c. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/15/18 at 9:10 A.M., an observation was conducted. Resident 61 was in bed and there was no landing mat in place. On 10/15/18, a record review was conducted. Resident 61's progress notes indicated: 8/6/18 Resident found sitting on the floor next to her bed and wheelchair 9/2/18 . resident was on the floor . she was lying down on the floor on her R (right) side 9/19/18 . Resident was on found sitting with back against her bed 9/30/18 . resident was found by CNA with back against bed sitting on floor 10/9/18 . resident fell forward onto the floor near nursing station 1 while being pushed in her WC (wheelchair) by CNA. Resident's feet were caught under the WC, causing her to fall forward . Foot rests were obtained for resident's WC to prevent further fall On 10/18/18 at 7:40 A.M., a joint interview and record review was conducted with the ADON. The ADON stated a fall should be thoroughly investigated and an IDT meeting conducted within 24 hours of a fall incident. The ADON stated the recommendations of the IDT Fall Committee were to be carried out in a revised care plan after a resident fell . The ADON reviewed Resident 61's fall IDT on 8/7/18 and the resident's plan of care. The ADON stated Resident 61's fall IDT's recommendations were not carried over to Resident 61's care plan, and should have been. The ADON stated the resident's next falls could have been avoided had there been follow through on the IDT's recommendations. The ADON further stated there were no IDT meetings for Resident 61's falls that took place on 9/2, 9/19, 9/30, and 10/9 and there should have been. The ADON stated Resident 61's care plan was not revised after each fall and should have been to prevent further falls. The ADON stated landing mats were a standard fall safety precaution for residents at high risk for a fall. The ADON stated Resident 61 did not have a landing mat in place and should have had one. The ADON reviewed Resident 61's fall on 10/9/18. The ADON stated foot rests were required to be used for every resident when being pushed in the wheelchair. The ADON stated the fall incident on 10/9/18 should not have happened. On 10/18/18 at 3 P.M., an interview was conducted with the DON. The DON stated there should have been an IDT meeting for each of Resident 61's falls. The DON stated the resident's care plan should have been revised after each fall to prevent further falls. Per the facility's policy, titled Falls and Fall Risk, Managing, revised 3/2018, indicated .5. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change the current interventions .the staff reconsider possible causes that may not previously have been identified. Per the facility's policy, titled Falls and Fall Risk, Managing, revised (MONTH) (YEAR), Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . 1. The staff . will implement a resident-centered fall prevention plan . for each resident at risk or with a history of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions . Per the facility's policy, titled Assessing Falls and Their Causes, revised (MONTH) (YEAR), The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of a fall . After a Fall: . 6. Observe for delayed complications of a fall . and will document findings in the medical record . 7. Document any observed signs or symptoms of . bruising . 8. Complete an incident report for resident falls . Identifying Causes of a Fall or Fall Risk: . 1. Within 24 hours of a fall . identify possible or likely causes of the incident . 3. Continue to collect and evaluate information until the cause of falling is identified . 5. document the basis for identifying specific factors as the cause . 6. If the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why . Documentation . When a resident falls, the following information should be recorded in the resident's medical record: . 5. Completion of a falls risk assessment . 6. Appropriate interventions taken to prevent future falls.

Based on interview and closed record review, the facility failed to ensure 1 of 3 sampled residents (3) received adequate treatment of [REDACTED]. The facility also failed to notify the physician (MD 1), until the back wound was a Stage III (extended into tissue beneath the skin, forming a small crater), and for the entire length of his stay, there was no documented evidence a physician or wound care consultant observed the pressure sores. As a result, Resident 3 was transferred to an acute care facility for an overwhelming infection and treatment of [REDACTED]. Resident 3 died after 3 days in the hospital. Findings: Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS - an assessment tool), dated [DATE], indicated Resident 3 was alert, oriented, and had no problems with memory or cognition, but required maximum assistance for the activities of daily living (ADLs) of transfer, dressing, and personal hygiene. The full admission nursing assessment was done by Licensed Nurse (LN 1) on [DATE] at 3:30 P.M. LN 1 documented 3 areas of redness or raw, irritated skin, on the resident's mid-back. Area #1 was documented as 1.2 cm (centimeters) x 1.2 cm (all measurements recorded in width (W) and length (L) in centimeters, where 2.5 cm = 1 inch). Area #2 measured 1 cm x 1 cm. Area # 3 recorded as 1.5 cm x 1.5 cm. All the areas were described as open with a small amount of yellow slough. (Slough is yellow, green, or gray dead/nonviable tissue - caused by no blood flow.) On [DATE], during Resident 3's admission process, LN 1 initiated a care plan, risk for developing pressure ulcers.and other types of skin breakdown in r/t (relation to): immobility, arterial insufficiency (any condition that slows or stops the flow of blood through the arteries) of both feet, and [MEDICAL CONDITION]. The Goal: to minimize the risk of skin breakdown, bruising, or pressure sores daily. The Approach/Action column included, but was not limited to: assess skin integrity during care; pressure relieving devices prn (as needed); weekly body checks; and notify MD (physician) for any changes (i.e., deterioration in existing wounds and/or lack of effectiveness in a specified treatment). During an interview with LN 1 on [DATE] at 3:50 P.M., she stated that upon her initial assessment, Resident 3's back wounds, were not pressure sores. LN 1 also clarified that any further documentation and treatment of [REDACTED]. When asked why she documented the moist, open-areas as wounds and not pressure sores, LN 1 stated, I felt the wounds, and they appeared not deep. Resident 3's Treatment Sheets, which included a weekly assessment and evaluation of the resident's pressure sores, were reviewed. According to the Wound/Skin Healing Record, initiated on [DATE], LN 2 documented the resident's mid-back lesion (#1) as unstageable, with no odor and no drainage. LN 2 also documented the resident's other mid-back [MEDICAL CONDITION], #2 and #3, gradually improved and shrunk in size. On [DATE], LN 2 documented that both these pressure sores had resolved. The Wound/Skin Healing Record for the resident's mid-back lesion (#1) was further reviewed for assessment and documentation of wound deterioration. From [DATE] to [DATE], LN 2 documented the wound had developed into a Stage III, with a small amount of purulent (containing pus) discharge. On [DATE], LN 2 described the ulcer as a Stage II (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) with a scant amount of serous (clear) drainage, with maceration (where surrounding skin retains too much moisture, turns white, and softens) to the wound edges. On [DATE], LN 2 described the surrounding skin as bright red with extensive, surrounding maceration of 3 x 4 cms. By [DATE], according to LN 2, Resident 3's pressure ulcer had increased by 5 times over the previous week, to 1.7 cm x 1.5 cm. For the first time, LN 2 documented the pressure ulcer had deteriorated, and the resident experienced pain of his wound, rated at 2-,[DATE]. (Using the numeric pain scale ,[DATE]: 0 = no pain; ,[DATE] = mild-to-moderate pain; ,[DATE] = severe pain; and 10 = the worst pain possible). LN 2 also checked the pressure ulcer had a moderate amount of serosanguinous (pink-tinged) drainage with maceration. According to the form, LN 2 did not notify the attending physician, MD 1, of the deterioration of the wound, nor the pain experienced by the resident. During further review of Resident 3's Wound/Skin Healing Record, LN 2 documented a significant change in the pressure sore on [DATE]. According to LN 2, the wound now measured 6 cm x 5 cm, and the resident's level of pain had increased to ,[DATE] (moderate pain). LN 2 still described the pressure sore as Stage III, with the depth marked as UTD (unable to determine), even though the drainage was now large and purulent, with 50 % slough. LN 2 documented the wound had again deteriorated, and that the physician was notified on [DATE]. In the Comment section, LN 2 wrote, 3.0 cm dark-red maceration; however, the Plan Of Care portion of the form was left blank, or not updated. On [DATE], according to LN 2, the resident's wound again increased in size, to 11 cm x 7 cm, with an UTD depth. LN 2 classified the wound as unstageable. At this point, the wound had a large amount of purulent drainage, and 100% slough. LN 2 continued to document Resident 3 experienced pain of his wound, and deterioration of the wound in response to treatment. The wound assessment by LN 2, on [DATE], indicated the pressure sore was a Stage IV, with dimensions of 18.2 cm x 7.5 cm x 2.5 cm. (A Stage IV is a full thickness tissue loss with exposed bone, tendon, or muscle, and often includes undermining and tunneling). The wound also had a foul-odor, and a copious (huge) amount of purulent drainage. LN 2 failed to include a pain assessment, but marked that the physician (MD 1) was notified. The nurses' progress notes were reviewed for additional documentation of Resident 3's status prior to transfer to the ED. From [DATE] through [DATE], there were no progress notes entered on the resident until the day of transfer. The Resident Transfer Record, dated [DATE], included the reason for transfer; Further treatment and evaluation of open area on mid-back. On [DATE] at 2:30 P.M., LN 2 was interviewed regarding his documentation, in chronological order, of Resident 3's pressure sores on the Wound/Skin Healing Record. The interview focused on the resident's #1 mid-back wound, since, according to LN 2, the #2 and #3 [MEDICAL CONDITION] were considered resolved. LN 2 was asked about his [DATE] assessment, in which he documented a purulent discharge, an increase in slough (necrotic or dead tissue), and, for the first time, pain from the pressure sore itself. When asked why the physician was not notified regarding these changes, LN 2 stated, I felt the wound was improved due to a decrease in size. LN 2's wound assessments, dated [DATE] and [DATE], were jointly reviewed. LN 2 was asked about his documentation of the skin surrounding the wound, which was checked as normal on [DATE], but described as bright red with maceration on [DATE]. When asked why, on [DATE], he marked the wound improved, LN 2 stated, Because the wound decreased in size. When asked to define maceration, LN 2 stated, Sort of moist. During the same interview, on [DATE] at 2:40 P.M., LN 2 was asked about the significant change in the resident's wound, according to his [DATE] assessment. LN 2 was asked why MD 1 was not notified when the wound was 5 times larger than the previous week, and the wound had deteriorated in response to treatment. LN 2 stated, since the pressure sore had a clean wound bed (a sign of wound healing) and was still superficial, he didn't feel it was necessary to notify the physician. LN 2's assessment of Resident 3's pressure sore, dated [DATE], was jointly reviewed. LN 2 acknowledged the wound had increased nearly 4 times in size from his assessment on [DATE], and now had large amounts of purulent drainage. LN 2 stated he notified MD 1, who ordered Santyl ointment (a protein-based [MEDICATION NAME] agent) daily to the wound. When asked why no wound culture was obtained, LN 2 stated, Because the doctor didn't order it. LN 2's wound assessments, dated [DATE] and [DATE], were jointly reviewed. LN 2 stated, because the wound was covered with slough on [DATE], he documented the pressure sore as unstageable and the depth as unable to determine. LN 2 verified he did not notify the physician, even though the wound had deteriorated in response to the Santyl ointment. LN 2 verified that, on [DATE], when the pressure sore reached a Stage IV, and again increased in size, MD 1 was notified. Subsequently, Resident 3 was transferred to the ED for wound evaluation. On [DATE] at 3:15 P.M., during the same interview, LN 2 was asked about his documentation of wound deterioration, on [DATE], [DATE], and [DATE]. When asked if a wound care physician, or a certified wound care nurse was ever contacted regarding Resident 3's pressure sores, LN 2 stated he wasn't sure. When asked if a Wound-Vac (a vacuum source which removes drainage and infection to prepare the wound for healing) would have been appropriate for this resident, LN 2 stated, No, not in this case. When asked if the resident's wound, at any time, should have been debrided (removal of dead, damages, or infected tissue to improve the healing potential), LN 2 stated that he never considered it. When asked if he was wound care certified, LN 2 stated, No, but he was taking classes towards certification. On [DATE] at 3:30 P.M., LN 2 stated he didn't think MD 1 ever observed Resident 3's mid-back pressure sores. On [DATE] at 3:40 P.M., the Director of Nursing (DON) was interviewed regarding the deterioration of Resident 3's pressure sore. The DON stated Resident 3 was non-compliant, because he resisted being turned and repositioned. The DON was informed of the significant increase in size and depth of the resident's back wound in the ED vs the facility's documentation. The DON stated she felt this happened because the three pressure sores merged into one. MD 1 failed to respond to phone calls and requests to schedule an interview regarding Resident 3. The facility's policy & procedure, Wound Care Suggestions & Documentation, dated ,[DATE], was reviewed. The policy included, but was not limited to: Documentation: Wounds will be staged in accordance with the NPUAP (National Pressure Ulcer Advisory Panel) guidelines as follows: Unstageable (UTD) Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar. Until the slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore, stage, cannot be determined. Infection/Cultures: Changes in drainage that is foul-smelling or purulent should be promptly called to the MD and cultures ordered as indicated. The History and Physical (H&P) from the Emergency Department physician (MD 2), dated [DATE] at 8:36 P.M., was reviewed. MD 2's Impression: Multiple Stage IV decubitus ulcers, on the [MEDICATION NAME] spine, and needed wound care. At this point, he is admitted for wound care. MD 2 ordered a wound care consult, and placed Resident 3 on IV (administered directly into the vein) antibiotics. At the time of the wound care consult, dated [DATE] at 8:27 P.M., MD 3 recorded the [MEDICATION NAME], mid-back pressure sore measured 20 cm x 15 cm x 4 cm. MD 3 described the ulcer as full thickness all the way down to the level of the bone.with purulent exudate (drainage) throughout, which was pouring out. On [DATE] at 8:45 A.M., during a telephone interview, the wound care nurse (WCN 1) from the acute care facility clarified she reviewed the ED documentation, and the photos of Resident 3's Stage IV back wound. WCN 1 remarked that the spinal wound was very large and deep, and she was surprised something further wasn't done at the nursing home. The wound assessment and documentation from LN 2 was reviewed with WCN 1. WCN 1 commented, When a wound is unstageable, it is either a Stage III or a Stage IV - a full thickness loss. When asked to explain maceration, WCN 1 stated, Maceration on the wound edges means infection. WCN 1 was informed of the documentation of the first time the wound had deteriorated, on [DATE]. WCN 1 stated, At this point, the facility should have called in a wound care consultant. On [DATE] at 1:15 P.M., during a telephone interview, MD 3 stated, I didn't feel a thorough work-up was done (in reference to the facility). MD 3 further stated Resident 3 needed to have a wound care specialist consult on his treatment. MD 3 also stated a Wound-Vac would have helped earlier, but not at this late stage. When asked if he felt the pressure sores contributed to this death, MD 3 stated, This was definitely a factor in the resident's death. By the time I saw him, I recommended Hospice (end of life care).