Every finding on record at Casa Real

Based on observation and interview, the facility failed to create a homelike environment for 2 (R #1 and #2) of 3 (R #1, #2 and #3) residents residing in the facility. If the facility does not create a homelike environment, then residents may feel as if they do not matter, which may lead to anxiety and depression. The findings are:A. On 08/26/26 at 9:10 am, during an observation, R #1 and R #2's room contained two large patched and unpainted areas behind R #1's bed and two large patched and unpainted areas behind R #2's bed. B. On 08/26/26 at 9:25 am, during an interview, Housekeeper (HK) #1 stated housekeeping staff were responsible to clean the facility and was not responsible to paint or patch the walls. She stated if housekeeping staff saw any issues in the residents' room, then they were to report them to a Supervisor. HK #1 stated she did not report the unpatched and unpainted areas behind the beds in R #1's and R #2's room. C. On 08/27/26 at 8:50 am, during an interview, Certified Nurse Aide (CNA) #1 stated R #1 informed her of a light was not working on 08/06/26, and the light was located in the bathroom shared by R#1 and R #2. She stated she entered a work order in the computer to alert maintenance the light needed to be repaired. D. On 08/27/26 at 9:04 am, during an interview, Housekeeper #2 stated housekeeping was responsible for cleaning the rooms. She stated housekeepers check for stains and cleanliness but were not responsible for room maintenance. She stated if they observe a hole in the wall or broken items in the room, then they will document it if they have time. She stated CNAs were in the rooms more often than housekeeping staff, and they had access to the computer to let maintenance know of the issues. E. On 08/27/26 at 2:10 pm, during an interview, R #1 stated R #2's overhead bed light and the bathroom light did not work. R#1 stated he informed his CNA several times the lights did not work, with the most recent report on 08/26/26. R #1 stated he was afraid to get up at night to use the bathroom. He stated he feared falling, and his roommate was unable to see in the bathroom at night. R #1 stated he did not complain about the patched areas behind the bed, because they were present when he moved into the room. He stated staff told him the walls would be repaired when all the rooms were repainted. F. On 08/27/26 at 2:11 pm, during an interview, CNA #1 stated she was aware the lights were not working in R #1 and R #2's room. She stated she entered a work order in the computer for maintenance on 08/26/26, and it was not addressed as of 08/27/26. She stated she was also aware of the large patches on the wall that were unpainted and unfinished. G. On 08/27/26 at 2:15 pm, during an interview, the Maintenance Director (MD) stated he was not aware the light in R #1 and R #2's room were not working. He stated he was aware of the patches in the room and did not repair them. He stated he was waiting for the company to make a decision on what colors they were going to paint the inside of all resident rooms, and he did not want to repaint again. The MD stated rooms should be inspected before anyone moves into them or after someone vacates. H. On 08/27/26 at 2:27 pm, during an interview, the Director of Nursing (DON) stated all rooms should be fixed as soon as possible. She stated the whole building was painted, so there was not any reason the rooms were patched and unpainted. She stated it was expected staff would inspect resident rooms weekly, and staff would fix any issues before residents moved into the rooms. I. On 08/28/26 at 9:16 am, during an interview, R #1's sister stated R #1 called her several days earlier, but she could not recall the exact date. She stated R #1 complained the bathroom light and his roommate's light were not working. She stated R #1 said he reported the issues several days earlier and the lights had not been repaired.

Based on record review, observation, and interview, the facility failed to secure and lock the medication cart in the 100 hall. This failure has the potential to affect all residents in the 100 hall. This deficient practice is likely to cause harm if a resident were to access and consume unprescribed medications.The findings are: A. Record review of the facility's Medication Storage Policy, January 2026, revealed staff were directed to store medications according to manufacturer's or pharmacy's guidelines and keep all supplies accessible only to licensed or authorized personnel. Staff were to limit access to prescription medications and to keep medication rooms, cabinets, and carts locked when not in use or when unattended. B. On 08/27/26 at 8:28am, observation revealed an unlocked, unattended medication cart next to the nurse station. C. On 08/27/26 at 8:30am, during an interview, the Certified Medication Assistant stated the medication cart was unlocked and the expectation was for staff to lock the medication carts when unattended.

Based on interview and record review, the facility failed to ensure residents were free from verbal and sexual abuse for 2 (R #26, R #95) of 3 (R #26, R #95, and R #29) residents reviewed when:- R #50 was verbally inappropriate with R #26.- R #50 was physically and sexually inappropriate with R #95.If the facility fails to provide an environment free from sexual, physical, and verbal abuse, then residents are at risk for physical and psychological harm. The findings are: A. Record review of the facility's Abuse Prohibition policy, dated 11/14/25, revealed the following:- Sexual Abuse is non- consensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual coercion, or sexual assault. - Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. - Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation or degradation. - Facility staff will protect the residents from further harm while investigating allegations of abuse, and they will provide a safe environment by identifying persons with whom resident feels safe and conditions that would feel safe. R #50B. Record review of R #50's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/06/26, revealed R #50 was admitted on [DATE], Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 6, severe cognitive impairment. C. Record review of R #50's Medical Record revealed the following diagnoses: - Adjustment disorder with mixed disturbance of emotions and conduct,- Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severity with other behavioral disturbance,- Neurocognitive disorder a group of medical conditions that cause a decrease in mental function) with lewy bodies (gradual damage to the brain cells impairing function). D. Record review of R #50's care plan, dated 07/06/26, revealed the following:- R #50 had a tendency to exhibit sexually inappropriate behaviors related to poor impulse control. Continued to go after women (one specifically) and engaged in kissing and inappropriate touching. Report from another female of inappropriate behavior. Resident continued to verbalize, I need a woman. Female resident accused him of inappropriate sexual comments.- Continue to monitor behaviors.- Staff to provide one-to-one supervision with R #50 due to a complaint from another female. The female resident stated R #50 was allegedly making inappropriate comments of a sexual nature to her in the activity room. Staff removed R #50 from the area immediately and told him the comments were inappropriate. A CNA reported witnessing R #50 put his hands between the legs of another female resident. Staff separated them immediately. Staff are to keep R #50 within their line of sight until further notice.- Staff directed to keep R #50 away from female residents in dining room, television room, etc.- Interdisciplinary Team meeting with resident, female resident, and her brother to discuss concerns regarding behaviors. Female resident clearly stated she wanted R #50 to leave her alone. R #50 has been notified to stay away from her and no inappropriate touching, etc.- Evaluate the nature and circumstances of the sexually inappropriate behavior, such as past experiences, triggers or stimulation, and involvement with others. R #26E. Record review of R #26's MDS, dated [DATE], revealed the following:- R #26 was admitted to the facility on [DATE].- R #26 had a BIMS score of 15, cognitively intact. F. Record review of R #26's care plan, dated 04/30/26, revealed R #26 stated it was important to have opportunities to engage in daily routines that were meaningful and relative to her preferences while in the facility. The care plan directed staff to encourage and facilitate the resident's activity preferences, such as coffee socials, trivia, bingo, movies, and crafting. G. On 07/22/26 at 1:16 PM, during an interview, the Activity Assistant (AA) stated R #26 refused to attend activities, because R #50 was sexually inappropriate with her [R #26]. She stated R #25 reported R # 50 moved his hand up and down in a pumping motion close to his crotch area and licked his lips. She stated she observed R #50 making these motions and name calling towards R #26 on 07/15/26 during an activity. She stated she let the Business Office Manager (BOM) know about the incident, and the AA stated the BOM told the Administrator. The AA stated R #50 frequently asked others to retrieve items from his pant pocket, because he liked to be touched. The AA stated that usually happened when he was in an activity, and he performed this behavior quite often. The AA stated R #50 liked to hang out in the activity room. H. On 07/22/26 at 1:20 pm, during an interview, the Activity Director (AD) stated she was aware of the incident between R #26 and R #50, because the AA mentioned it to her on the day of the incident (07/15/26). She stated she R #50 always had sexual behaviors. The AD stated R #50 continued to attend activities, but R #26 would not attend any activities if R #50 was there. I. On 07/22/26 at 3:07 PM, during an interview, the Administrator stated she was aware of the incident and brought it up with R #50's medical provider. She stated R #50 had a BIMS score of 5, cognitively impaired; and he would not understand if staff redirected him. The Administrator stated she felt R #50 thought he was being funny. The Administrator stated she did not document the incident between R #26 and R #50. The Administrator stated she did not interview the AA, R #26, or any other residents or staff. The Administrator stated R #50 had this behavior for a long time. The Administrator stated she had conversations with R #50's provider on 07/17/26 about a medication review, but she could not provide any documentation of the conversations. The Administrator stated R #50 had these behaviors for a long time. The Administrator stated all she could do was re-direct R #50, discourage his behaviors, and let him know what he was doing was not right. The Administrator stated, [Name of R #50] will be [Name of R #50]. J. On 07/22/26 at 3:26 PM, during an interview, R #26 stated she was very upset and angry, because R #50 made inappropriate gestures to her [R #26 demonstrated what R #50 did with his mouth, tongue, and hand gestures]. She stated he also called her names such as whore and slut. She stated R #50 did all kinds of nasty things. R #26 stated staff allowed R #50 to talk and act any way he liked, and staff did not do anything about it. She stated she stopped going to activities, because she was tired of being disrespected by R #50. K. Record review of R #26's progress notes, dated 07/15/26 to 07/22/26, revealed staff did not document the incident between R #26 and R #50. L. Record review of R #50's progress notes, dated 07/15/26 to 07/22/26, revealed staff did not document the incident between R #26 and R #50. R #95 M. Record review of R #95's MDS, dated [DATE], revealed R #95 was admitted to the facility on [DATE] and had a BIMS score of 03, cognitively impaired. N. Record review of R #95's nursing progress notes revealed the following:- Dated 07/06/26 at 5:30 pm, staff reported they observed another resident with his hands in between R #95's thighs. Staff assessed R #95, and they did not note any redness to the area. The resident denied any pain and did not have any signs of distress. - Dated 07/07/26 at 12:40 am, staff documented a change of condition follow up note. The resident did not have any signs or symptoms of pain or distress. The resident stayed up at nursing station and watched television until 10 am [sic]. Staff kept R #95 away from the other resident. O. On 07/22/26 at 3:07 PM, during an interview, the Administrator stated she was aware of the incident between R #50 and R #95, but she did not have any documentation for an investigation into the incident. P. On 07/30/26 at 3:19 pm during an interview, the Hospice Director of Nursing (DON #2) stated she received a call from the hospice on-call nurse on 07/24/26 at about 9:00 pm. DON #2 stated the on-call nurse stated R #95 was involved in a sexual assault incident. DON #2 stated staff observed R #50 with his hands down R #95's pants on 07/06/26. DON #2 stated she called the facility on 07/25/26 to speak to facility's DON, but the facility's DON did not return her calls. DON #2 stated R #95's son/Power of Attorney (POA) contacted hospice and stated the facility staff informed him of the incident, and he wanted his mother taken to the emergency room for examination. DON #2 stated the hospital conducted a SANE (sexual assault nurse assessment) and concluded current sexual assault did not occur. DON #2 stated R #95 was discharged back to the facility on [DATE]. R #29Q. On 07/22/26 at 3:23 PM, during an interview, R #29 stated R #50 was very inappropriate with her roommate [R #26]. She stated R #50 will often say very nasty things to other people. R #29 stated R #50 said nasty things to her daughter when she would visit. R #29 stated she told R #50 often to stop being nasty to her daughter and to other residents. She stated R #50 continued his behaviors, and she felt the facility was not doing anything about it. R #29 stated if R #50 was in the hallway or at an activity, then she did not want to leave her room or go to activities. She stated R #50's behavior has been going on for a long time. She stated it was at least six months or more, but she was not exactly sure how long.

Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #46 and R #55) of 2 (R #46 and R #55) residents when staff did not provide meaningful individualized activities based upon residents' interests. If residents are not provided activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. Record review of the facility's Recreation Services Policies and Procedures, dated 08/07/23, revealed staff were to provide regularly scheduled programming to all residents who were not able to tolerate or preferred not to participate in group or independent leisure opportunities and to residents who were at risk of a lack of meaningful recreational or social engagement. An individualize program was to include interactions and experiences that supported the resident's overall well-being. R #46 B. Record review of R #46 face sheet revealed R #46 was admitted on [DATE]. C. Record review of R #46's Minimum Data Set (MDS; a Federally mandated assessment instrument completed by facility staff), dated 05/22/26, revealed staff documented the resident felt it was somewhat important to have books, magazines, and newspapers to read, to listen to music, to keep up with the news, to do things with groups of people, to do his favorite activities, and to go outside to get fresh air when the weather was good. D. Record review of R #46's care plan, dated 04/04/26, revealed R #46 will have the opportunity to engage in daily routines that were meaningful to him. R #46 liked to look through the newspaper, keep up with current events by talking to others, read and watch the news. The resident enjoyed fishing and working outdoors when the weather was nice. R #46 will be invited to join daily coffee socials. E. Record review of R #46's Recreation Comprehensive Assessment, dated 05/21/26, revealed staff documented the resident stated it was important that he has opportunity to engage in daily routines that were meaningful while at the facility. He stated it was important for him to have reading materials, listen to music, keep up with the news by discussions with another person or group discussions, listen to radio, read magazines or the newspaper, use the computer, and watch TV. F. On 07/16/26 at 9:26 AM during an interview, R #46 stated the staff did not offer him any type activities, and they did not invite him to any of the activity programs. R #46 stated he liked to watch TV after therapy sessions. He stated he also likes to rest after his therapy. G. Record review of R #46's Activity Log, dated 05/23/26 to 05/31/26, revealed R #46 participated in independent activities on 05/23/26, 05/30/26 and 05/31/26. Staff did not document any other activities for the resident. H. Record review of R #46's Activity Log, dated 06/01/26 through 06/30/26, revealed R #46 participated in independent activities on 06/01/26 through 06/15/26. Staff did not document any other activities for the resident. I. Record review of R #46's activity documentation in his electronic medical record, dated 07/01/26 through 07/23/26, revealed staff did not document any activity participation for R #45 for the month of July 2026. J. On 07/16/26 at 4:05 PM during an interview, the Activity Director (AD) stated R #46 was on one-on-one room visits, because he did not like to go out of his room. The AD stated R #46 will read in his room. The AD stated R #46 received daily room visits from the activity staff, and they offer him books magazines and coloring things. The AD stated she trusts the Activity Assistant (AA) to document when activities are completed with the residents. The AD did not have a list of residents who received one-to-one activities. The AD stated she did not follow up on residents after she completed their initial assessment to see if they received their activities. K. On 07/17/26 at 9:52 AM during an interview, the Activity Assistant (AA) stated she did not chart on R #46. The AA stated she did not see the resident and did not offer the resident any type of activity. The AA stated she was not familiar with the activity assessments, and she did not review them. The AA stated she did not keep a list of residents that were on a one-on-one activities, and she did not know of what one-to-one activities consisted. R #55 L. Record review of R #55's admission Record revealed R #55 was admitted on [DATE]. M. Record review of R #55's care plan, dated 06/10/26, revealed R #55 would receive one-to-one visits. N. Record review of R #55's Recreation Comprehensive Assessment, dated 06/10/26, revealed staff documented the resident stated it was not very important to do things with groups of people. The resident enjoyed lying down and resting. The resident was Catholic. O. On 07/09/26 at 2:19 pm during an observation, R #55 sat in her room. Further observation revealed the resident's TV was not on, and she did not have any magazines, coloring pages, books, or electronic devices available. P. On 07/10/26 at 10:17 am during observation, R #55 sat in her chair. Further observation revealed the resident's TV was not on, and she did not have any magazines, coloring pages, books, or electronic devices available. Q. Record review of R #55's Activity Log, dated June 2026, revealed R #55 did not participate in the facility activity program and did not receive one-to-one room visits from 06/08/26 through 06/30/26. R. Record review of R #55's activity documentation in her electronic medical record, dated July 2026, revealed R #55 did not participate in the facility activity program and did not receive one-to-one room visits from 07/01/26 through 07/23/26. S. On 07/17/26 at 9:52 AM and on 07/17/26 at 10:03 AM during an interview, the Activity Assistant (AA) stated she did not chart on R #55. The AA stated she did not see the resident and did not offer the resident any type of activity. The AA stated she did not do any one-on-one activities or room visits with R #55. The AA stated, It is hard when you do not have help. It is very busy, and there is no set program for one-to-one visits that I know of. I have not gone to visit, because I have not had time. T. On 07/21/26 at 1:43 PM during an interview, the Director of Nursing stated it was expected the Activities Staff conducted bedside activities. The DON stated the Activity Director should assess residents and put together some kind of individual activities for those residents that want to stay in their rooms. The DON stated the Activity staff should do room visits and should chart what services one-to-one offered.

Based on record review and interview, the facility did not respond to or follow up on resident grievances related to room changes and privacy concerns for 1 (R #11) of 1 (R #11) resident. If the facility is not ensuring grievances are answered without delay, then residents are likely at risk of feeling isolated, to experience continued concerns, and feel as though their issues were unimportant to the facility. The findings are: A. Record review of the facility's Grievance/Concern policy, dated 06/01/96, revealed the following:1. The patient or resident representative were provided with the Grievance/Concern policy which informed them of their right to voice grievances or concerns and the process for doing so.2. The resident or resident representative have the right to file grievances orally or in writing and the right to file grievances anonymously.3. A staff member will initiate the grievance or concern upon receipt, and the Administrator will document the grievance or concern on the facility's Grievance Concern Log. 4. Staff will take immediate action to prevent further potential violations of any resident right while staff is investigating the alleged violation.5. The Department Manager will contact the resident or resident representative to acknowledge receipt of the grievance or concern. 6. The facility has a reasonable expected time frame for completing the review of the grievance.7. The Department Manager will notify the person filing the grievance of the resolution in a timely manner. 8. The resident or resident representative has the right to receive a written decision from the facility regarding their grievance and the contact information of independent advocacy entities, such as the State Survey Agency and the State Long Term Ombudsman program. B. On 07/22/26 at 9:34 am, during an interview, R #11 stated she would like to have private meetings with her family and to enjoy private phone calls. R #11 stated she and her family were unable to have privacy during visits and unable to speak freely on their phone during phone calls. R #11 stated she let staff know she wanted a room change, but she did not remember who she told. She stated she did not receive a response from the facility regarding her grievance. C. On 07/22/26 at 11:10 am, during an interview, R#11's family representative stated they requested for R #11 to be relocated due to space concerns and for privacy during visits and phone calls. The family representative stated the side of the room where R #11 was located did not allow space for R #11 to sit up in a wheelchair and have family visit in the room at the same time. The family representative stated they recently made a relocation request to the Business Office Manager (BOM) in May or June 2026. R #11's family representative stated they did not receive a response from the facility regarding their grievance. D. On 07/22/26 at 12:05 pm, during an interview, the BOM stated she was aware the resident requested a room change over a month ago. She stated she forwarded the request to the Social Services Director (SSD). E. On 07/22/26 at 12:46 pm, during an interview, the SSD stated all requests were submitted verbally, and she created a grievance form to ensure all requests were handled appropriately. The SSD stated she was unable to locate a grievance for the resident's request to change rooms. The SSD stated she was not the SSD during the request, but there should be a paper trail for any requests that were submitted. F. On 07/22/26 at 3:32 pm, during an interview, Director of Nursing (DON) stated the staff never brought R #11's room change request to her attention. The DON stated it was her expectation for staff to complete a grievance form and give it to the SSD. The DON stated the SSD was expected to follow up on the grievance. The DON stated the staff were trained on the process of grievances, and staff should respond within 24hours.

Based on observation, record reviews, and interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASARR; a Federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) prior to admission for 1 (R #23) of 5 (R #13, R #12, R #45 and R #4) residents reviewed. This deficient practice is likely to result in the facility not providing the specialized services and support needed by residents. The findings are: A. Record review of the facility's Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients policy, dated 2/16/24, revealed the following:Social services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if it is learned after admission that the Pre-admission Screening and Resident Review (PASRR) was not completed or is incorrectSocial services will review the PASRR to determine appropriate care needs.B. Record review of R 23's face sheet revealed R #23 was admitted to the facility on [DATE] with the following diagnoses:Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),Post-traumatic stress disorder (PTSD; a mental health condition caused by experiencing or witnessing a very stressful, scary, or life-threatening event),Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),Anxiety disorder (a mental health condition featuring intense, ongoing worry, fear, and physical tension that interfere with daily life),Epilepsy (a seizure disorder).C. Record review of R #23's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/20/26, revealed the following:A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact.R #23 had a diagnosis of PTSD.R #23 received antianxiety medication (used to control anxiety).D. Record review of R #23's PASARR form, dated 10/23/25, revealed the following: Staff documented the resident did not have a diagnosis or suspected mental illness, such as post-traumatic stress disorder or anxiety.Staff documented the resident did not have a history, diagnosis or evidence of a related condition, such as epilepsy, affecting their intellectual or adaptive functioning.E. On 07/08/26 at 10:15 am, during an observation and interview, R #23 sat on her bed in her room. R #23 stated she had PTSD and did not feel like the facility was doing anything to help her with it. F. On 07/22/26 at 10:21 am, during an interview, the Administrator and Social Services (SS) stated R #23's PASARR was incorrect. The Administrator and SS stated this did not meet their expectations, because the PASARRs should reflect all relevant diagnoses and be aligned with the information in the medical orders.

Based on observation, interview, and record review the facility failed to ensure residents obtained dental services for 1 (R #86) of 3 (R #45, R #86, and R #11) residents sampled for dental care. The deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing; cause residents unnecessary pain and embarrassment over the condition of their teeth; and lead to potential dental complications. The findings are:A. Record review of facility's Oral Health policy revealed the following:Patient's oral health will be evaluated as part of the nursing assessment upon admission, annually, and with a change in oral health.At the time of admission and throughout their stay, patients will have access to oral health professionals including dentists and dental hygienists. B. Record review of R #86's Face Sheet revealed an admission date of 07/07/23. C. On 07/08/26 at 11:35 am, during an observation, R #86 had discolored and broken teeth. D. Record review of R #86's progress notes revealed R #86's family representative requested dental services during care plan conference on 03/20/26. E. Record review of R #86's electronic health record revealed staff did not document they scheduled a dental appointment for R #86 after the care conference. F. On 07/21/26 at 3:24pm, during an interview, R #86's family representative revealed they made the request in March 2026 and never received a follow-up from the facility. G. On 07/23/26 at 4:03 pm during an interview with the Hospice Registered Nurse (HRN) revealed that R#86 has been complaining of severe toothache and asked DON schedule a dental appointment for R #86.

Based on observation, record review and interview, the facility failed to ensure a resident was free from physical restraints for 1 (R #1) of 2 (R #1 and #2) residents when staff failed to assess the resident for the use of a seatbelt. If staff do not assess residents before implementing the use of a seatbelt, then residents may experience injury, entrapment, or a decline in independence and participation. The findings are:A. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/07/26, revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. B. Record review of R #1's care plans revealed, R #1 the following: - admission date of 06/05/19. - Diagnoses included long term use of anticoagulants, muscle weakness, hemiplegia and hemiparesis following a stroke affecting the left non-dominant side. - Focus: ADL care due to left sided hemiplegia. Intervention, dated 05/26/26, the resident wanted a seat belt to his motorized wheelchair. Staff to assist with putting on the seat belt, but the resident could release the belt himself. This was evaluated by therapy. - Focus: At risk for falls. Intervention, dated 05/26/26, resident fell asleep in his wheelchair. Therapy evaluated him for a seat belt per his choice for safety. The resident required assistance to put the seat belt on, but he was able to release the seat belt. Staff encouraged the resident to use his bed, but his choice was to stay/sleep in his wheelchair or recliner. - Focus: At risk for falls. Intervention, dated 06/10/26, resident fell out of his wheelchair while sleeping, and he was sent to the emergency room due to hitting his head and use of blood thinner. The resident is on the occupational therapy caseload, and physical therapy will also place him on their caseload. Educate the resident on his seatbelt at nighttime for his safety. Resident refused to use the seat belt. He reported it was uncomfortable. C. Record review of R #1's Interdisciplinary Screen Form, dated 05/26/26, revealed the following: - The purpose of the Interdisciplinary Therapy Screen is to provide residents with the opportunity to receive therapy services if functional impairments and potential risks are present and skilled services are required. - Information regarding the resident's current functional status was obtained via resident observation, staff interviews, and chart review. - Reason for the screening: Resident fall. - The resident reported a fall from his wheelchair after falling asleep and hitting his head. - The resident's wheelchair was motorized and has a built-in lap belt. - The resident reported he used the seat belt before, but he often forgets it was on. He stated the seatbelt impedes some activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). - Therapy staff reviewed the resident's status in cognition, swallowing, self-care, mobility, pain, skin conditions, and positioning. Staff documented the resident did not have any change of status in these areas. - Staff recommend and ordered occupational therapy, wheelchair specialist, or nursing staff to evaluate to determine if the restraint (seat belt) was appropriate. D. Record review of R #1's Occupational Therapy (OT) notes revealed the following: - Dated 06/08/26, OT evaluation completed to address if a new power wheelchair was indicated since the resident currently had a wheelchair which was a poor fit and increased his risk for falls. Resident fell asleep in his wheelchair during the day, because he tended to prefer being a night owl. - Dated 06/11/26, OT received the okay for a wheelchair assessment to work on tilt in space power wheelchair. Worked on adjusting self in wheelchair to get to the midline. Resident was a heavy leaner to the right side due to left side hemiparesis. E. Record review of R #1's medical record revealed it did not contain an assessment for the use of a seatbelt. F. On 06/23/26 at 11:35 am, during an observation, R #1 wore a seatbelt. G. On 06/23/26 at 11:36 am, during an interview, R #1 stated he had two falls, and the facility decided to put a seatbelt on him for safety reasons. R #1 stated he spoke to the Nurse Practitioner (NP) and told her that he did not need a seatbelt. He stated he just needed sleep H. On 06/23/26 at 12:55 pm, R #1 sat in his wheelchair. Further observation revealed his seat belt was buckled and hung loosely on his lap. I. On 06/23/26 at 1:04 pm, during an interview, the Director of Nursing (DON) stated R #1 wore a seat belt, because he always wanted to be in his wheelchair. The DON stated therapy staff evaluated the resident for use of the seat belt due to his increased fall risk. The DON was unable to locate the resident's assessment for the use of a seatbelt. J. On 06/23/26 at 3:25 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated she updated R #1's care plan after his fall. LPN #1 stated she was told during a morning meeting that R #1 wore a seatbelt while in his wheelchair. LPN #1 stated she was not aware if therapy staff completed an assessment. She stated she just assumed therapy staff completed the assessment before the resident utilized the seatbelt. K. On 06/24/26 at 1:50 pm, during an interview, Occupational Therapist (OT) #1 stated the last time staff completed an assessment for R #1's wheelchair seat belt use was in 2025. OT #1 stated if a resident had to use a seat belt, then therapy should assess the resident quarterly. OT #1 stated the seat belt slipped her radar, and she did not assess R #1 for the use of a seat belt. OT #1 stated she did not complete an assessment of R #1 for the seatbelt, and she could not find an assessment completed by another therapist for the seat belt. L. On 06/24/26 at 2:04 pm, during an interview, the Director of Rehabilitation (DOR) stated R #1 had a fall on 05/23/26 and 06/08/26, and therapy staff screened (a preliminary tool used to determine if an assessment should be completed) him after the falls. The DOR stated the Speech and Language Pathologist (SLP) recommended the use of a seat belt and for staff to complete an assessment to determine if the use of a restraint was appropriate. The DOR stated staff should have completed a follow-up assessment to determine if it was safe for R #1 to use a seatbelt.

Based on observation and interviews, the facility failed to ensure a prescribed medication was kept out of reach and unavailable to 1 (R #1) of 1 (R #1). If the facility does not keep medications protected from unauthorized access, then residents are at risk of accessing the medication, medicating without physician orders, and experiencing adverse effects. The findings are:A. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/07/26, revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. B. On 06/23/26 at 11:36 am, during an observation of R #1's room, a tube of Mupirocin (topical antibiotic used to treat skin infections), sat on top of the dresser unattended and readily accessible. Further observation revealed the medication was prescribed for R #1 on 04/16/26. C. Record review of R #1's Authorization of Self Administration of Drugs, dated 06/15/26, revealed, R #1 did not want to self-administer medications. D. On 06/23/26 at 12:28 pm during an interview, the Nurse Practitioner (NP) stated she did not know why the medication was left in the resident's room. The NP stated medications should not be left in resident rooms. E. On 06/23/26 at 12:55 pm during interview, R #1 stated the Mupirocin was prescribed to him, and it was in his room since April 2026. He stated he did not know why it was in his room. F. On 06/23/26 at 1:04 pm during an interview, Director of Nursing (DON) stated R #1 did not have an order to self-administer medication. The DON stated it was not acceptable for a resident to have any type of medication in their room unless they had a self-administer assessment. The DON state R #1 did not have an authorization to self-administer medication. The DON stated medications should be kept under lock and key, and only medical staff should have access to the medications.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #1) of 2 (R #1 and R #4) residents reviewed for respiratory care when the facility failed to:1. Ensure medical orders indicated when to administer R #1's oxygen.2. Change the oxygen tubing on R #1's portable concentrator (a medical device that provides extra oxygen) and nebulizer (device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or mask).These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are:A. Record review of R #1's Face Sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Systemic lupus erythematosus (SLE; a chronic autoimmune disease),2. Morbid obesity (severely overweight),3. Chronic respiratory failure (condition where lungs cannot adequately exchange oxygen and carbon dioxide) with hypoxia (not getting adequate oxygen), 4. Cor pulmonale (right-sided heart failure),5. Hypertension (high blood pressure).B. Record review of R #1's physician orders revealed:1. An order dated 04/26/26 for Ipratropium-Albuterol Solution (a combination medication used to improve breathing) 3 milliliters (ml) to inhale orally three times a day for persistent congestion for seven days.2. No order for supplemental oxygen.C. On 04/08/26 at 10:09 am during a random observation of R #1's room revealed:1. R #1 was wearing a nasal canula (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) connected to a portable oxygen concentrator (medical device designed to provide supplemental oxygen). The nasal cannula was not dated.2. A nebulizer machine was on top of her dresser with tubing and a mask. The tube was not dated.D. On 04/08/26 at 10:11 am during an interview with Certified Nurse Aide (CNA) #1, She confirmed R #1 was wearing oxygen. She confirmed neither tubing connected to the concentrator and the nebulizer was dated and should be.

Based on observation and interview, the facility failed to ensure nursing staff were competent to provide nursing related services for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) due to the Infection Preventionist's (IP) lack of understanding of Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) requirements for PPE use. This deficient practice is likely to affect all residents that have pressure ulcers and/or wounds by increasing the risk of infections due to repeated and ongoing exposure of infections. The findings are: A. On 04/07/26 at 1:52 pm, an observation of R #1's wound care (cleaning, dressing, monitoring, and evaluation of a wound) in her room revealed:1. No signage posted indicating R #1 required EBP.2. PPE was not readily accessible to perform activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care, wound care, or high contact resident care activities for R #1.B. On 04/07/26 at 1:52 pm, Licensed Practical Nurse (LPN) #1 was observed providing wound care for R #1 without donning a gown before performing a high-contact treatment.C. During an interview on 04/07/26 at 2:00 pm LPN #1 stated she was unaware that gowns were required for all wound care and reported the IP had instructed staff that gowns were only needed for residents on transmission-based precautions (TBP, used to prevent the spread of infectious agents from individuals who are suspected to be infected. Includes contact precautions, droplet precautions, and airborne precautions. Examples are wearing gloves, face masks, and gowns or using disposable equipment).D. On 04/08/26 at 10:20 am during an interview with the IP, she stated that EBP is not needed for all residents that have a pressure ulcer or a wound, it is only needed for residents that have an infected wound.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #1) of 3 (R #1, R #2 and R #3) residents, when: 1. The facility failed to post the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) signage for R #1.2. The facility failed to ensure staff utilized EBP during high contact resident care activities.This deficient practice is likely to affect all residents that have pressure ulcers and/or wounds by increasing the risk of infections due to repeated and ongoing exposure of infections. The findings are: The findings are: A. Record review of R #1's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnosis:1. Sepsis (a serious condition in which the body responds improperly to an infection),2. Morbid obesity (severely overweight),3. Cutaneous abscess of abdominal wall (localized infection characterized by a collection of pus within the layers of the skin in the abdominal area).B. On 04/07/26 at 12:15 pm, an observation of R #1's room revealed:1. No signage posted indicating R #1 required EBP.2. Personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) was not readily accessible.C. Record review of R #1's physician orders revealed the following:1. An order dated 03/23/26 for wound care for an unstageable pressure ulcer [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined] on R #1's sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis).2. An order dated 02/19/26 to check the placement and proper suction of the wound vac to R #1's abdomen.D. Record review of R #1's care plan revealed the following focus areas:1. A focus area dated 02/19/26, R #1 is at risk for skin breakdown related to decreased activity, incontinence, limited mobility, recent surgery, refusals to get out of bed or stay in wheelchair, abdominal surgery of abscess, and has a wound vac in place.2. A focus area dated 02/19/26 for nutritional risk due to advanced age, multiple diagnoses including respiratory failure, HTN, lupus, morbid obesity, increased nutrient needs for wound healing.3. A focus area dated 03/19/26, stating R #1 has an actual infection and a surgical wound.E. On 04/07/26 at 1:52 pm, an observation of R #1's wound care (cleaning, dressing, monitoring, and evaluation of a wound) in her room revealed Licensed Practical Nurse (LPN) #1 provided wound care for R #1 without donning a gown before performing the treatment.F. During an interview on 04/07/26 at 2:00 pm, LPN #1 stated she was unaware that gowns were required for all wound care and reported the Infection Preventionist (IP) had instructed staff that gowns were only needed for residents on transmission-based precautions (TBP, used to prevent the spread of infectious agents from individuals who are suspected to be infected. Includes contact precautions, droplet precautions, and airborne precautions. Examples are wearing gloves, face masks, and gowns or using disposable equipment).G. On 04/08/26 at 10:20 am during an interview with the IP, she stated that EBP is not needed for all residents that have a pressure ulcer or a wound, it is only needed for residents that have an infected wound.

Based on record reviews, observation, and interviews, the facility failed to honor resident's shower preferences for 2 (R #9, and R #13) of 2 (R #9, R #13, and R #15) reviewed for showers. If the facility fails to honor resident preferences, then the residents are likely to feel as if they are not heard and that the facility does not care about their choices. The findings are:R #9:A. Record review of R #9's bathing schedule stated that he should receive 3 showers per week (Tuesday, Thursday, and Saturday)B. On [DATE] at 11:08 am during an interview with R #9, he stated They finally got the water working. They wanted us to take a shower in cold water and I refused. They only offered the sponge baths once or twice during the time the hot water was not working. If they would have offered them (sponge bath, shower) I would have taken them. I like to be clean, and I don't feel like myself if I am dirty. R #15C. Record review of R #15 Bathing schedule stated that R #15 was to receive two showers per week: Tuesday and Thursday. D. On [DATE] at 10:45 am during an interview. R #15 stated that the shower situation had been remedied for a couple of weeks, R #15 further stated that she did receive cold showers and started to refuse showers because of how cold the water was. The water used to run cold, and you didn't know whether or not you would get a shower. There was a time when the water was nice and warm then it got cold while I still had soap, so they had to rinse it off with cold water and it was horrible.E. Record review of Social Services Director (SSD)'s note dated [DATE] revealed, met to discuss concerns for R #15, R #15's daughter had concerns. R #15's daughter stated [name of R #15] had been declining showers and bed baths that were offered because the water was too cold. F. On [DATE] at 3:00 pm during an interview with Certified Nurse Assistant (CNA) #1, she stated that the water was ice cold. My coworker (CNA #3) decided to give residents bed (sponge) baths. The issue with the cold water was resolved about 2 weeks ago. Residents started to complain about the water being cold and not wanting to take around the middle of December. There was no hot water from the middle of December until early March in the resident care areas. Infection control Preventionist (ICP) got us big barrels of warm water, and we placed them in the shower rooms in order to offer sponge baths in the shower rooms. R #9 refused sponge baths.G. On [DATE] at 3:30 pm during an interview with Maintenance Director, (MD) stated It takes it a while for the hot water to kick in the shower room. The part that we needed to fix the problem with the cold water in the facility was on back order and that is why it took so long to get it fixed.

Based on observation, record review and interview, the facility failed to ensure that 1 (R #1) of 1 (R #1) resident reviewed for catheter care had a privacy cover on their drainage bag while seated in the dining room during the breakfast food service. This deficient is likely to result in the resident's medical device being visible to other residents and staff, thereby failing to maintain the resident's dignity.The findings are:A. On 03/24/26 at 9:09 am, during an observation of the locked unit dining room, R #11 was sitting in his wheelchair. Further observation revealed R #11's drainage bag was exposed under his wheelchair with no dignity cover.B. Record review of R #11's physician's order revealed an indwelling catheter (tube inserted into the bladder to continuously drain urine, held in place by a retention balloon) was ordered on 02/01/26. C. On 03/24/26 at 9:11 am, during an interview with Registered Nurse (RN) #3, she confirmed R #11's drainage bag is exposed with no dignity cover on. RN #3 stated all drainage should be covered with a dignity cover and it did not have a cover.

Based on observation, and interview, the facility failed to ensure unused medications were properly disposed of on the north hallway, when two medications were observed in the trash bin attached to the medication cart. This deficient practice is likely to affect any resident that may acquire and ingest the medication causing potential medication side effects. The findings are:A. On 03/25/26 at 8:27 am, during an observation of the north hall nurses station, two medications were found in the trash bin attached to the medication cart. Further observation revealed these medications were: a round blue pill stamped with 61, and an oblong orange pill stamped with 20 were together inside an unlabeled medication cup. B. On 03/25/26 at 8:28 am, interview with Registered Nurse (RN) #1, she confirmed those medications were in the trash bin. She also stated unused medications should be disposed in the drug buster (sealed container used for drug disposal) that is located on the bottom drawer. C. On 03/25/26 at 8:34 am, during an interview with the Unit Manager (UM), he stated all unused medications are to be disposed using the drug buster and it did not happen. The UM also stated if the medications are controlled like narcotics then two licensed personnel are to dispose the medication together and updated on the narcotic count sheet.

Based on observation, interviews, and record review, the facility failed to ensure residents were served meals consistent with posted menus and food preferences for 1 (R #7) of 3 (R #7, R #12, R #14) residents reviewed:R #7 received food that they are allergic to.R #7 did not receive food according to their meal ticket.These deficient practices have the potential to make resident feel unheard, or have an allergic reaction. The findings areR#7 A. Record review of R #7's face sheet revealed R #7 was admitted to the facility on [DATE] with the diagnosis of an allergy to chocolate.B. On 03/26/26 at 12:16 pm, during an observation of lunch, R #7's lunch ticket revealed that R #7 is not to have any chocolate. R #7 was observed to have been served and was eating chocolate ice cream. C. On 03/26/26 at 12:18 pm. during an interview, Licensed Practice Nurse #1 (LPN # 1) stated R #7 is allergic to chocolate and she should not be eating it. D. On 03/26/26 at 12:22 pm, during an interview, Nutrition Director #1 (ND #1) stated that the meal ticket states that she should not have chocolate; ND #1 served R #7 chocolate ice cream and after R #7 requested ice cream. ND #1 stated he had not read that she was allergic to chocolate.

Based on observation, record and interview the facility failed to ensure R #12 was served food in accordance with his prescribed diet. If the facility fails to provide food as prescribed than residents are likely not able to consume it and experience weight loss and choking risks. the findings are: R #12A. Record review of R #12's face sheet revealed R #12 was admitted to the facility on [DATE] with the diagnosis of Hypokalemia;( a condition characterized by low blood potassium levels).B. Record review of R #12's Minimum Data Set (MDS) revealed R #12 is to ha a regular/liberalized pureed diet. C. On 3/26/26 at 11:42 am, during an observation of lunch, R #12's lunch ticket revealed that R #12 is on a pureed diet. R #12 received whole Mandarin oranges not pureed.D. On 03/26/26 CNA #2 confirmed that R #12's dessert (mandarin oranges) were whole and not pureed.

Based on observation, and interview, the facility failed to protect residents' personal health information (PHI) by leaving a document unattended containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) on top of a south nurse's counter. This deficient practice is likely to result in passerby's to have unauthorized access to sensitive information, putting residents' privacy at risk.The findings are:A. On 03/16/26 at 9:04 am, during an observation of the south nurse's station, a piece of paper on a clipboard with complete residents information (full name, assigned room number and code status) was left unattended and exposed to public view.B. On 03/16/26 at 9:06 am, during an interview with Registered Nurse (RN) #2, he confirmed the list contained resident's list, assigned room number and their code status was left exposed to public view and unattended. RN #2 confirmed that personal health information should not be left unattended.

Based on observation, interview, and record review; the facility failed to store and serve food under sanitary conditions when staff failed to ensure:1. Food items were labeled and dated in the kitchen refrigerators. 2. Food was stored appropriately and not left open to air in the kitchen refrigerator. 3. Staff personal belongings were not stored next to a food serving line.These deficient practices are likely to affect all 121 residents listed on the resident census list provided by the Administrator on 09/16/25 and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 09/22/25 at 10:00 a.m., observation of the kitchen revealed the following: One sheet pan of food item that was not labeled or dated stored in the kitchen refrigerator. One pack of yellow American Sliced Cheese was open to air. One tobacco cigarette and cigarette lighter in the kitchen near the food serving line. B. On 09/22/25 at 10:02 a.m., during an interview, the Dietary Manager (DM) he stated that all food items should be stored appropriately, labeled, dated. The DM also stated that the cigarette and lighter should not be in the kitchen. c. On 09/23/25 at 8:23 AM during random observation of the facility kitchen the following was observed: 1. 4 tubes of hamburger meat were sitting in a sink with stagnant water defrosting This was confirmed by Dietary Manager (DM) at the time of observation. 2. A 32 oz,(ounce) bottle of vanilla and a 16 oz container of garlic powder were observed sitting on the bare floor in the dry storage room. This was confirmed by the Dietary Aide (DA) #1. 3. A container of chili beans was sitting on the preparation table with no label or date. DA (DA) #2 confirmed it was her own personal food item and she stated it should not have been sitting on the counter. 4. A package of cheese, and a block of butter was sitting on the grill open to air, alongside a egg sandwich. Sitting on steam table were 2 loaves of bread open to air. Confirmed by DM that packages should be sealed and not open to air. 5. A 5 gallon bucket of dish soap was sitting on the bare floor in the dish room this was confirmed by the DM, DM stated it should not have been sitting on the bare floor.

Based on observations, record reviews and interviews, the facility failed to maintain a safe, controlled environment for 2 (R #10 and #17) of 2 (R #10 and #17) residents reviewed. The facility failed to:Notify staff of R#10's infection control status by not recognizing R#10's COVID condition and not posting at his doorway a notice of his infectious status.Ensure proper hand hygiene was performed by staff and that a glucometer was cleaned and disinfected which could potentially cause cross-contamination for residents.This deficient practice is likely to result in residents and staff being exposed to infectious diseases that could be transmitted between staff and residents. The findings are: R#10A) On 09/23/25 at 9:59am, observed R#10's call light was on and Licensed Practical Nurse (LPN) #6 went in the room to answer the call light. LPN #6 was wearing a disposable mask the entire time. Observed R#10 telling her that he has COVID-19 (an infectious viral disease that causes flu-like symptoms) and that she has to keep her distance.B) On 09/23/25 at 9:59am, interview with LPN #6 stated that she is an agency nurse and was told that for his condition they are only required to wear a disposable mask (single-use face coverings that create a physical barrier between the wearer's nose and mouth and their environment).C) On 09/23/25 at 10:02am, interview with R#10 stated that he has covid as of yesterday and has stated medications for it today.D) On 09/23/25 at 10:04am, record review of R#10's listed diagnosis revealed the following (includes, but not limited to): - COVID-19E) On 09/24/25 at 9:36am, observed Certified Nursing Assistant (CNA)#3 was wearing a disposable mask while providing perineal care (involves cleaning the genital and anal areas of a patient) to R#10. R#10 is on Transmission-Based Precaution (are implemented for residents who are known or suspected to be infected with certain pathogens) for COVID-19 . F) On 09/24/25 at 9:37am, during an interview with CNA#3, stated today is her first day back and no one told her about the precaution. Stated she is an agency staff. Stated she did not see the Transmission-Based Precaution posted outside R#10's room. Stated that she should wear an N95 for this type of infection when providing care.G) On 09/26/25 at 1:30pm, interview with the Infection Preventionist (IP) stated the following: - They use a messaging software called Re-group (a text system that sends group text to notify employees), to notify staff of COVID-19 related issues at work. - Travelers are not part of it, they are informed before they start their shift. - Once a provider places an order for PAXLOVID (an oral prescription medication used to treat mild to moderate COVID-19), IP is responsible for adding Transmission-Based Precaution (TBP) and should provide the necessary education and protocol associated to COVID-19. - Confirmed that per facility policy, there should be an order for TBP and nurses should help and place the order for TBP when they see a new order for PAXLOVID.- Confirmed that per facility policy, TBP includes wearing N95 (are masks that help protect against viruses like COVID-19).R#17H) On 09/23/25 at 11:18am during noon medication administration time, the surveyor observed the following: - LPN #6 checked R#17 blood glucose (a blood test that mainly screens for diabetes) using a glucometer (a portable device used to measure the amount of glucose [sugar] in the blood). - LPN #6 did not perform hand hygiene after removing her gloves. - LPN #6 placed the recently used glucometer back into the top drawer of her medication cart.I) On 09/23/25 at 11:19am, interview with LPN #6 stated she failed to wash her hands and disinfect the glucometer. Confirmed that per facility policy, she is required to perform hand hygiene between patient care and disinfect the glucometer after use using the facility approved disinfectant.

Based on record review and interview, the facility failed to protect 1 (R #1) of 3 (R #1-3) residents reviewed from abuse and neglect when a staff member used loud, foul, abusive language and then abandoned R #1 instead of providing care by leaving the unit. This deficient practice is likely resulted in R #1 being left covered in feces. The findings are: A. Record review of R #1's face sheet, dated 09/24/24, revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including: - Dementia (loss of cognitive functioning), - Altered mental status (a change in how well the brain functions), - Hallucinations (false perceptions, where you sense an object, person, or event even though it is not really there or did not happen). B. Record review of R #1's daily care note, dated 09/15/24, revealed Licensed Practical Nurse (LPN) #1 and LPN #2 heard CNA #1 verbally yelling and cursing at 9:30 pm. LPN #1 went to investigate and found R #1 in his room, alone, and covered in feces. Nursing assessment completed and management was notified. Certified Nurses Aide (CNA) # 2 and LPN #1 cleaned up R #1. Staff were unable to locate CNA #1, who was originally heard verbally yelling and cursing. C. On 09/20/24 at 12:40 pm during phone interview with LPN #1, she stated she and CNA #1 were assigned to provide care to residents on the memory care unit during the night shift on 09/14/24. LPN #1 stated R #1 was a resident of the memory care unit. She stated R #1 was generally very kind and pleasant, but he was very confused. LPN #1 stated R #1 sat on his chair for approximately an hour and wanted to go to bed. She stated she had asked CNA #1 to get R #1 changed and put him to bed. LPN #1 stated she administered medications on the evening of 09/14/24 and she heard CNA #1 in R #1's room yelling profanities and stating he quit. She stated she went to R #1's room, and CNA #1 was no longer in the resident's room. She stated R #1 sat in a chair and wore only a t-shirt. She stated R #1 was covered in feces (his face, his hands, his mouth, his legs and all over his body) and some of the feces was already dried. LPN #1 stated R #1 had feces on his hand which he had in his mouth. She stated feces was also all over the resident's bed, floor, and walls. LPN #1 stated she was unable to locate CNA #1 on the memory care unit. LPN #1 stated she called CNA #2 from another unit to come to the memory unit to assist R #1 with a shower and clean up the feces on the chair and bed. LPN #1 stated CNA #1 returned to the unit later, continued to yell profanities, and left again. LPN #1 stated CNA #1 was upset, because R #1 got feces on his clothing while he tried to move R #1 onto the bed. She stated CNA #1 reported loose feces spread all over the room when he removed the resident's brief. LPN #1 stated she felt CNA #1's behavior was threatening. She stated CNA #1 was full of anger and rage and acting erratic, and she felt the safety of the other residents was at risk. LPN #1 stated CNA #1 returned again to the unit and was asked to leave. LPN #1 stated CNA #1 was only in the room with R #1 for approximately 5 to 10 minutes. D. On 09/20/24 at 1:35 pm during phone interview with LPN #2, she stated she was assigned to the memory care unit on 09/14/24. LPN #2 stated she heard CNA #1 yell profanities in the hallway of the unit. LPN #2 stated she saw CNA #1 walk down the hallway yelling, with a brief in his hands. She stated the brief had so much feces on it, that the feces dripped on the floor. LPN #2 stated she walked into R #1's room, and R #1 had feces on his face, his shirt, and on his body. LPN #2 stated CNA #1 left the unit and was gone for some time. She stated CNA #1 returned later, continued to yell profanities, and then left the unit again. LPN #2 stated she did not see CNA #1 after that. E. On 09/20/24 at 2:37 pm during interview with Administrator (ADM), he stated he was contacted by telephone between 9:00 pm and 10:00 pm on 09/14/24 and was informed CNA #1 used loud profane language while working on the memory care unit. The ADM stated he was able to speak with CNA #1 and confirmed CNA #1 used loud profane language in front of R #1 and in the hallway of the memory unit. The ADM stated CNA #1 left the building and left R #1 to sit in his room while covered in feces. The ADM stated he submitted a report of the incident to the State Agency, and he was investigating the incident. F. Several attempts were made to contact CNA #1 with no results.

Based on record review and interview, the facility staff failed to prevent an accident when staff did not appropriately transfer 1 (R #2) of 1 (R #2) resident reviewed for accidents. This deficient practice likely resulted in R #2's fractured knee. The findings are: A. Record review of the facility's Complaint Narrative Investigation Report (also called a five day report) revealed: - Resident had a history of dementia, diabetes, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). R #2 had a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact. - The facility arranged a Telehealth visit by the provider which resulted in a request for x-ray. The facility had mobile x-ray provider (a rolling x-ray machine that comes to the bedside to take x-ray pictures) come to the facility and x-ray the resident's left knee area. Initial x-rays indicated the resident did not have a leg fracture but were inconclusive. The facility then sent the resident to acute hospital for additional x-rays, which were positive for a fracture of left lower femur. R #2 underwent surgery to repair the fracture. B. Record review of R #2's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including: - Hemiplegia (partial or complete paralysis of one side of the body) and hemiparesis (partial or complete lack of muscle tone and control on one side of the body) following cerebral infarction. - Dementia (a chronic, progressive decline of mental abilities and memory). - Malignant neoplasm (cancer) of the skin. C. Record review of R #2's care plan, dated 10/07/21, revealed R #2 required extensive assistance for activities of daily living (ADL; every day needs such as bathing, dressing, eating) care, extensive assistance with dressing, and staff to stand on weaker left side when assisting with ADLs or other activities. D. Record review of R #2's daily care notes revealed the following: - Dated 07/06/24, R #2 complained of left knee pain. Telehealth (computer assisted video visit with a licensed provider) visit with provider. Order for x-ray of left knee. - Dated 07/06/24, R #2's daughter brought R #2 to the nurses station, because she complained of knee pain. Daughter stated to nurse that R #2's knee was hurt while being changed and transferred by a Certified Nurses Aide (CNA). PRN (Pro Re Nata-medication given as needed or requested) pain reliever given and resident assisted to bed. X-ray obtained within facility. - Dated 07/07/24, R #2 possible left distal (away from) femur fracture. Sent to emergency room (ER) for evaluation. - Dated 07/10/24, follow-up visit. R #2 stated to provider she never fell . She stated her leg was overextended when she was transferred from her wheelchair to her bed. Hospital Course (treatment and services provided while in the hospital) open reduction internal fixation (ORIF; surgical repair of a broken bone using screws and plates to stabilize a broken bone). E. Record review of a written statement provided by CNA #1, dated 07/06/24, revealed CNA #1 stated she assisted R #2 with her brief change. While transferring R #2 from wheelchair to bed, R #2 told CNA #1 that her (R #2's) foot had got caught. CNA #1's statement stated R #2 did not tell her of any pain or discomfort so she continued with the brief change and assisted R #2 back to her wheelchair. CNA #1's statement did not indicate she reported any incident to the nurse or that a nurse was called to check and assess R #2. F. On 08/07/24 at 11:05 am during interview with R #2, she stated she was getting ready to leave the facility to attend a family function on 07/06/24. She stated her daughter was coming to pick her up. She stated she asked CNA #1 to change her brief, because it was soiled. R #2 stated CNA #1 was upset, and CNA #1 told her (R #2) she had too much work to do and too many residents to change. R #2 was sitting in her wheelchair. CNA #1 bent down and picked R #2 up by placing arms around her chest from the front. CNA #1 then transferred R #2 to her bed and had her sitting on the side of the bed. CNA #1 then placed R #2's head on the bed at the foot of the bed and lifted her feet to the head of the bed. R #2 stated that CNA #1 was now standing to her left side. R #2 stated that when CNA #1 did this, her (R #2) feet became tangled and her left leg was trapped. R #2 stated she felt intense pain and loudly yelled out. R #2 stated CNA #1 then straightened her legs out and changed her brief. R #2 stated she was in pain during the change. She stated CNA #1 assisted her back to her wheelchair. R #2 stated her daughter arrived, and R #2 told her daughter her left knee was very painful. R #2 stated her daughter propelled her in her wheelchair to the nurses station and complained to the nurse about R #2's knee pain. R #2 stated she was x-rayed and eventually sent to hospital where she had an operation to repair her fractured knee. R #2 stated she returned to the facility a few days later. G. On 08/07/24 at 11:10 am during interview of R #6, she stated she was roommate with R #2 on 07/06/24. She stated she did not see what happened, but she did hear R #2 assisted by CNA #1 from wheelchair to bed. R #6 stated she heard R #2 yell out loudly in pain as she was moved by CNA #1. H. On 08/07/24 at 2:20 pm during interview with Administrator (ADM), he stated he conducted an investigation of this incident. The ADM stated all CNAs were trained to transfer residents from one position to another. He stated this training included the use of a gait belt (a large belt that is placed around the waist of a person that allows them to be lifted and assisted to change position from standing to sitting and sitting to standing) and properly supporting the resident's legs when moving from sitting to lying position, so their legs did not become crossed or tangled. The ADM stated CNA #1 admitted to him that she did not used proper technique and training when she transferred R #2 from the wheelchair to the bed. The ADM stated CNA #1 was discharged from her employment with the facility as a result of the investigation. I. On 08/07/24 at 2:40 pm, an attempt was made to contact CNA #1 by telephone, but the CNA did not answer or respond back. J. On 08/07/24 at 3:45 pm during interview with CNA #2, he stated he was employed with the facility as a CNA for more than a year. He stated he participated in annual trainings regarding transfers (movement from one position to another i.e.: sitting to standing/standing to sitting/right or left) of residents. He stated his training required staff to utilize a gait belt when assisting a resident to transfer. He stated he was trained to use the gait belt to lift the resident from sitting to standing, hold the gait belt when moving the resident, and to use the gait belt to assist the resident to change from a standing to sitting position. He stated he was trained to brace the resident's back and neck while also lifting the knees to place the resident into a lying position. He stated the support of the resident's neck and knees was to keep the body aligned and prevent legs from getting tangled and twisted. K. On 08/07/24 at 3:45 pm during interview with CNA #3, she stated she was employed with the facility as a CNA for more than two years. She stated she participated in annual trainings regarding transfer of residents. She stated this training required staff to utilize a gait belt when assisting a resident to transfer. She stated she was trained to use the gait belt to lift the resident from sitting to standing, hold the gait belt when moving the resident, and to use the gait belt to assist the resident to change from a standing to sitting position. She stated she was trained to brace the resident's back and neck while also lifting the knees to place the resident in a lying position. She stated this support of the resident's neck and knees was to keep the body aligned and prevent legs from getting tangled and twisted.

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 2 (R #50 and #69) of 2 (R #50 and #69) residents reviewed when staff failed to: 1. Timely identify the new wound, monitor for changes in the wound, provide daily treatments as ordered and notify the physician that the wound was worsening for R #50. 2. Complete and document weekly skin evaluations for R #69. This deficient practice likely resulted in R #50's pressure ulcer worsening and leading to an amputation. This deficient practice is also likely to lead to residents developing pressure ulcers and wounds worsening. The findings are: R #50: A. Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE]. B. Record review of R #50's Braden Scale for Predicting Pressure Sore Risk (a tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers), dated 10/04/23, revealed R #50 was at risk for developing pressure ulcers. C. Record review of R #50's facility skin checks completed by the facility's Wound Care Nurse (WCN) revealed the following: - On 10/19/23, R #50 had a skin wound to her left rear thigh. No other wounds identified. - On 11/07/23, R #50 refused the skin assessment. D. Record review of R #50's hospital wound care notes, dated 11/23/23 revealed R #50 was sent to the hospital due to a fever and altered mental status, and R #50 was admitted into the hospital. E. Record review of R #50's hospital notes, dated 11/24/23, revealed R #50 had an unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined] posterior (further back in position) eschar pressure injury on her left heel. The hospital notes did not include measurements of the pressure injury. R #50 was also diagnosed with encephalopathy (a disease that affects brain structure or function) and sepsis (an infection in the blood stream) due to a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). R #50 was discharged from the hospital on 11/28/23. F. Review of R #50's facility skin check dated 11/29/23, revealed staff documented R #50 had a black pressure ulcer on the left heel. Staff did not document measurements or any other information related to R #50's left heel pressure ulcer. G. Record review of R #50's facility wound evaluation, dated 11/30/23, revealed R #50's left heel pressure ulcer was unstageable and present on admission with age [of wound] unknown. R #50's left heel pressure ulcer measured 1.53 centimeters (cm) length and 0.96 cm width. H. Record review of R #50's physician orders, dated 11/30/24, revealed an order for wound care to left heel. Paint with betadine (antiseptic medication), cover with heel /foam, wrap with kerlix (bandage), and secure with tape every night shift for unstageable pressure ulcer. R #50's order was discontinued on 01/03/24. I. Record review of R #50's Treatment Administration Record (TAR), dated 12/01/23 through 12/31/23, revealed staff completed R #50's order for wound care to left heel every night R #50 was in the facility. J. Record review of R #50's hospital history and physical documentation, dated 12/07/23, revealed R #50 went to the emergency room (ER) due to R #50 experienced hypoxia (low blood oxygen levels), vomiting, and confusion. R #50's hospital documents revealed R #50 had an unstageable left heel pressure ulcer. R #50 was admitted into theER on [DATE] and discharged back to the facility on [DATE]. K. Record review of R #50's skin and wound evaluations revealed the following: - Two evaluations, dated 12/18/23 (one completed at 12:20 pm and the other completed at 12:23 pm), staff did not document R #50's left heel pressure ulcer on either skin and wound evaluations - One evaluation, dated 12/27/23, staff did not document R #50's left heel pressure ulcer. L. Record review of R #50's facility wound evaluations (of the same document type), completed by the WCN, revealed staff documented the following: - On 12/27/23, R #50's left heel pressure ulcer measured 1.89 cm length and 0.98 cm width. - On 01/03/24, R #50's left heel pressure ulcer measured 2.6 cm length and 1.43 cm width. M. Record review of R #50's medical record revealed the record did not contain an update or change to the wound care orders for the resident's left heel pressure ulcer. N. Record review of R #50's TAR, dated 01/01/24 through 01/05/24, revealed staff completed R #50's order for wound care to left heel one time on 01/02/24. O. Record review of R #50's nursing progress notes, dated 01/05/24 at 2:42 pm, revealed R #50 was discharged with all medications to live with her niece. Further review revealed staff did not document they gave wound care instructions to R #50 prior to discharge. P. Record review of R #50's physician orders, dated 01/05/24 at 6:00 pm [after R #50's discharge], revealed an updated order for wound care to left heel. Cleanse with wound cleanser, pat dry, apply ManukaHD (natural antibiotic) honey to wound bed, and cover with foam dressing every night shift, every other day for unstageable pressure ulcer. There is no evidence in the record that this wound care was provided. Q. Record review of R #50's hospital documentation, dated 01/07/24, revealed R #50 was taken to the ER by ambulance (from R #50's niece's home) for an evaluation of a non-healing left foot ulcer with erythematous (reddening of the skin) margins and purulent (containing pus) discharge with concerns for osteomyelitis (infection in the bone caused by bacteria or fungi). R #50 was consulted and had a below the left knee amputation on 01/12/24. R. Record review of R #50's care plan dated 01/18/24, revealed R #50 was at risk for skin breakdown due to diabetes, compromised skin related to previous multiple open areas, and limited mobility. One intervention was for staff to observe R #50's skin condition daily and report any skin abnormalities. S. On 06/24/24 at 12:18 pm during an interview with R #50, she stated the facility did not routinely assess and treat her left foot, which led to it becoming infected. R #50 stated an ambulance took her to the ER in January 2024 for an evaluation, because her foot was not better. She stated it smelled badly and her left lower leg was amputated as a result of the wound. T. On 06/26/24 at 10:54 am and on 07/02/24 at 11:55 am during an interview with the WCN, she stated R #50 was in and out of the hospital multiple times in 2023 and returned to the facility in November 2023 with an unstageable pressure ulcer to her left heel. The WCN stated she evaluated R #50 weekly as much as she could, but R #50's left heel pressure ulcer began to open and deteriorated from 12/27/23 to 01/03/24. The WCN stated she was asked to work the floor due to short staffing during this time as well. The WCN stated she did not consult a wound care clinic for R #50. She stated R #50 returned to the facility on [DATE], and R #50's left lower leg was amputated. The WCN stated she oversaw the facility's wound care program, but the nurses know they are supposed to complete skin evaluations for residents every week. The WCN also stated every nurse was assigned skin evaluations to complete. She stated completing the skin evaluations has been an on going issue due to staffing and staff turnover. The WCN stated R #50 did not have consistent weekly skin evaluations, and staff documented R #50's left heel pressure ulcer only one time in the weekly skin evaluations. The WCN stated staff should have monitored and documented more frequently for the status of R #50's left heel pressure ulcer. The WCN confirmed R #50's January 2024 TAR indicated the nurses completed wound care for R #50 on 01/02/24, but the nurse should have completed wound care each day R #50 was in the facility. U. On 07/01/24 at 1:05 pm during an interview with Nurse Practitioner (NP) #1, she stated her expectation was for facility nursing staff to check on resident wounds daily, conduct weekly skin evaluations, and document the progress or decline of a resident's wound for providers and the WCN to see. The NP confirmed that she was not aware of the wound worsening and would have liked to be notified sooner. V. On 07/02/24 at 12:35 pm during an interview with R #50's Sister-In-Law (SIL), she stated R #50 went to stay with her niece in January 2024. She stated R #50 was with her niece for one night due to R #50's left heel pressure ulcer smelled really bad and looked infected. The SIL stated R #50's left lower leg was amputated shortly after that. W. On 07/02/24 at 12:40 pm during an interview with R #50's niece, she stated she helped R #50 on the first night R #50 was with her. She stated R #50's left heel pressure ulcer was black and had a distinctly bad smell coming from it. R #50's Niece stated R #50 wanted to go to the hospital so they called 911. She stated an ambulance took R #50 to the hospital for her left heel pressure ulcer, which resulted in a left lower leg amputation. R #69: X. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE]. Y. Record review of R #69's physician orders, dated 03/13/24, revealed an order for a unstageable pressure ulcer to the right heel. Apply sureprep (skin protectant) every day shift for pressure ulcer wound care. Z. Record review of R #69's Electronic Health Record (EHR) revealed nursing staff completed a skin evaluation for R #69 on 05/28/24. Further review revealed the WCN did not complete another skin evaluation for R #69 until 07/02/24. R #69's EHR indicated the WCN did not see R #69's wound from 05/28/24 until 07/02/24. AA. Record review of R #69's care plan, reviewed on 07/02/24, revealed the following: - Focus: R #69 was at risk for skin breakdown. - Interventions: Observe skin for signs and symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that did not blanche easily. Observe skin condition daily with activities of daily living (ADLs; personal care activities that most people perform daily) care and report abnormalities. BB. On 07/01/24 at 3:09 pm during an interview with the WCN, she stated nurses should complete a skin evaluation for R #69 weekly, but they did not. Based upon observation, interview, and record review, Immediate Jeopardy was identified on 07/02/24 at 3:43 pm. The facility Administrator and Director of Nursing were notified in person and by e-mail at this time. The facility took corrective action by providing an acceptable Plan of Removal (POR) and implementation was verified onsite on 07/03/24. The scope and severity was reduced to level 2, E. The plan of removal included: 1. On 7/2/24, the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed. 2. Nurses will be educated on completion of skin assessments on admission and weekly per schedule. 3. Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). 4. Nurses will be educated on [Name of facility company] wound processes which include the DIMES (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, wound Edge preparation and wound depth), timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. 5. CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes) and stop and watch.

Based on record review and interview, the facility failed to ensure 1(R #34) of 1(R#34) resident reviewed for dehydration maintain adequate hydration when they failed to: 1. Provide IV (intravenous; a thin plastic tube inserted into a vein using a needle) fluid hydration as ordered by a physician for R #34, 2. Document and monitor fluid intake for R #34. This deficient practice likely resulted in R #34 to have prolonged dehydration and worsened an untreated UTI. The findings are: A. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE]. B. Record review of R #34's care plan, dated 05/06/24, revealed the following: - Focus: R #34 was at risk for dehydration as evidence by diuretic (medication used to increase urine output and reduce fluid retention) medication. She had chronic kidney disease (CKD; gradual loss of kidney function) and hypertension (HTN; high blood pressure.) She was cognitively impaired and dependent on staff for fluid intake. She was also on poly-pharmacy (the use of multiple drugs to treat a single ailment or condition) and had poor appetite. - Interventions: Encourage resident to consume all fluids during meals, monitor for signs and symptoms of dehydration [symptoms can include increased temperature, decrease output (of urine or other bodily fluids), mental status changes, dry mucous membranes, orthostatic hypotension (low blood pressure), tachycardia (rapid heart rate)]. Offer and encourage fluids of choice. C. Record review of R #34's physician orders, dated 06/05/24, revealed an order to insert peripheral (away from the center of the body) IV for fluids. One time only for hypercalcemia (high levels of calcium), UTI, and dehydration for three days. D. Record review of R #34's provider progress notes revealed the provider documented the following: - On 06/06/24, peripheral IV ordered last night for IV fluid was not completed. The resident likely had a UTI, but primarily suspected dehydration in the setting of hypercalcemia (elevated calcium levels). Nurse to try on 06/06/24. Hypercalcemia may be resolved with IV hydration. Resident was awake, anxious, and crying. - On 06/07/24, peripheral IV insertion for IV fluids ordered two nights ago but was not completed by nursing. Suspected UTI, dehydration in the setting of hypercalcemia. Was not started on antibiotics due to dehydration and CKD. Plan to start when resident was given fluids to flush out kidneys. E. Record review Documentation Survey Report (Activities of Daily Living Tracking Form in R #34's electronic health record), dated 06/05/24 through 06/10/24 revealed staff documented the following: - R #34's urinary output one time on 06/05/24 (which indicated R #34 only urinated one time for the day.) - R #34's urinary output one time on 06/06/24. - R #34's urinary output zero times on 06/07/24. - R #34's urinary output three times on 06/08/24. - R #34's urinary output one time on 06/09/24. - R #34's urinary output three times on 06/10/24. F. Record review of R #34's nursing progress notes revealed staff documented the following: - On 06/09/24, the writer and Registered Nurse (RN) attempted IV. Only one extension tubing (a small and short tube that is added to an existing IV line) was found, and IV attempt was unsuccessful. Passed on to incoming nurse. - On 06/10/24, R #34 received her peripheral IV [five days after the physician's order]. G. Record review of R #34's Documentation Survey Report, dated 06/01/24 through 06/11/24, revealed staff documented R #34 drank a beverage 19 out of 42 opportunities. Further review showed staff did not document any fluid intake on 06/07/24, and staff documented only the night shift drink/snack on 06/09/24. H. On 06/24/24 at 1:50 pm during an interview with R #34's husband, he stated R #34 got very thirsty throughout the day. I. On 06/30/24 at 2:51 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated staff should document whether or not R #34 accepted (drank) fluid for every meal and snack. J. On 07/01/24 at 1:08 pm during an interview with Nurse Practitioner (NP) #1, she stated the facility did not have IV supplies to use on R #34 when she put in the IV order on 06/05/24. NP #1 confirmed it should not have taken five days to administer IV fluid to R #34, and nursing staff should have monitored and documented whether or not R #34 accepted her beverage at each meal and snack. K. On 07/03/24 at 1:46 pm during an interview with the Director of Nursing (DON), she stated the expectation was the nursing staff administered an IV to R #34 after receiving the physician order to do so. The DON stated the nursing staff was not aware of where the IV supplies were and did not look for them. She stated a nurse went to a nearby hospital to retrieve IV supplies for R #34. The DON stated staff should have documented R #34's drink intake for every meal and snack, because that was how the facility tracked fluid intake.

Based on record review and interview, the facility failed to provide a discharge summary and post discharge plan of care which included wound care for 1 (R #50) of 1 (R #50) residents reviewed for wounds. This deficient practice likely resulted in R #50's pressure wound worsening and needing emergency care in the hospital. The findings are: Cross reference to F686 A. Record review of R #50's facility wound evaluations (of the same document type), completed by the Wound Care Nurse, revealed on 01/03/24, R #50's left heel pressure ulcer measured 2.6 cm length and 1.43 cm width. B. Record review of R #50's nursing progress notes, dated 01/05/24 at 2:42 pm, revealed R #50 was discharged with all medications to live with her niece. Further review revealed staff did not document they gave wound care instructions to R #50 prior to discharge. C. Record review of R #50's hospital documentation, dated 01/07/24, revealed R #50 went to the emergency room (ER) for an evaluation of a non-healing left foot ulcer with erythematous (reddening of the skin) margins and purulent discharge with concerns for osteomyelitis (infection in the bone caused by bacteria or fungi.) R #50 was consulted and had a left below knee amputation on 01/12/24. D. On 06/24/24 at 12:18 pm during an interview with R #50, she stated the facility did not routinely assess and treated her left foot, which led to it becoming infected. R #50 stated an ambulance took her to the ER in January 2024 for an evaluation, because her foot smelled badly. R #50 stated she was not given any discharge documents. E. On 07/02/24 at 11:34 am during an interview with the Social Services Director (SSD), she stated the previous SSD should have discharged R #50 with a discharge packet, but she did not. The SSD stated when a resident is discharged , the facility nurses will document wound care instructions and medications in the nursing discharge summary, a discharge assessment will be completed and any referrals for home health services if needed. The SSD stated none of that occurred for R #50. F. On 07/02/24 at 11:58 am during an interview with the Wound Care Nurse (WCN), she stated she never spoke to R #50's Niece when R #50 was discharged in January 2024. The WCN confirmed she would expect the facility nurses to educate R #50 on wound care prior to discharge and should have provided R #50 with the appropriate wound care instructions in January 2024. G. On 07/02/24 at 12:40 pm during an interview with R #50's niece, she stated she helped R #50 on the first night R #50 was with her. She stated R #50's left heel pressure ulcer was black and had a distinctly bad smell coming from it. R #50's Niece stated R #50 wanted to go to the hospital so they called 911. She stated an ambulance took R #50 to the hospital for her left heel pressure ulcer, which resulted in a left lower leg amputation. R #50's niece confirmed that when R #50 was discharged home with her, the facility did not provide any instructions related to wound care. H. On 07/03/24 at 4:48 pm during an interview with the Director of Nursing (DON), she stated R #50 should have been discharged with specific wound care instructions in January 2024, but she was not.

Based on record review and interview, the facility failed to ensure residents received bowel movement (BM) monitoring and interventions for 1 (R #31) of 1 (R #31) residents reviewed when staff failed to: 1. Monitor R #31 for constipation (problem with passing stool). 2. Notify the provider R #31's constipation medication was not working and R #31 did not have a BM days before R #31 went to the hospital. This deficient practice likely resulted in R #31 having ongoing constipation, fecal impaction (hardened stool stuck in rectum or lower colon due to chronic constipation), and abdominal pain. The findings are: A. Record review of R #31's face sheet revealed R #31 was admitted into the facility on [DATE] and was discharged to the hospital on 07/01/24. R #31 had the following diagnoses: 1. Chronic Pain. 2. Constipation. B. Record review of R #31's physician orders revealed the following: 1. Order, dated 12/28/22, for sennosides docusate sodium tablet (a laxative; a medication used to treat constipation) 8.6 - 50 milligrams (mg). Give one tablet by mouth one time a day for constipation. 2. Order, dated 07/14/23, for colace capsule (stool softener), 100 mg. Give one capsule by mouth two times a day as needed for constipation. 3. Order, dated 07/15/23 for glycoLax powder (a laxative.) Give 17 grams (g) by mouth one time a day for constipation. C. Record review of R #31's care plan, dated 05/24/24 and updated on 07/02/24, revealed - Focus: R #31 was at risk for gastrointestinal symptoms or complications related to constipation. - Interventions: Monitor and record BM in electronic health record (EHR) daily to include color, size, consistency. Alert nurse if no BM in three days. Nurse Practitioner (NP) to review bowel medication regime for effectiveness due to severe constipation and prevent fecal impaction. Nurse to review bowel movements (BMs) with staff daily. Assess for and report signs and symptoms of nausea or vomiting, abdominal distention (a sensation of increased pressure with swelling in the abdomen), decrease in bowel movements, decrease bowel sounds, and abdominal pain. Monitor and record bowel movements. D. Record review of R #31's Medication Administration Record (MAR), dated 06/01/24 through 06/30/24, revealed staff administered the following: 1. Sennosides - docusate sodium tablet, 8.6-50 mg, to R #31 every day of the month. 2. Colace capsule, 100 mg, to R #31 twice a day, every day of the month. 3. GlycoLax powder to R #31 every day of the month. E. Record review of R #31's Documentation Survey Report (Activities of Daily Living tracking form), dated 06/01/24 through 06/30/24, revealed staff did not document R #31's bowel movements for the dates of 06/25/24, 06/26/24, 06/27/24, 06/28/24, 06/30/24. Staff documented R #31 had one BM on 06/29/24. F. Record review of R #31's provider progress notes revealed the provider documented the following (Note: Similar type documents combined into one entry): - On dated 06/30/24, the resident's abdomen was distended, firm, and tender with palpation. - On 07/01/24, R #31 was sent to Emergency Department on 06/30/24 for abdominal pain and distention. He had a fecal impaction. G. On 07/03/24 12:47 pm during an interview with Certified Nursing Assistant (CNA) #1, he stated CNAs were to monitor and document R #31's BMs every day. He stated if R #31 did not have a BM, then CNAs were to document that and let the nurses know. CNA #1 also stated R #31 discharged to the hospital two hours into his shift due to a fecal impaction. CNA #1 stated he was off during the days when R #31 did not have a BM, but the CNAs on those shifts should have notified the nursing staff. H. On 07/03/24 at 12:48 pm during an interview with CNA #2, she stated CNAs were to document R #31's BMs in the EHR and to notify nursing staff if R #31 did not have a BM. CNA #2 stated she was unaware R #31 did not have a BM for several days prior, because no one gave her that information. I. On 07/03/24 at 1:16 pm during an interview with the Physician's Assistant (PA) #1, she stated she was notified of R #31's constipation on the day he was sent to the emergency room (ER). She stated if a resident did not have a BM for three days then the nurses were to give the resident PRN medication and to notify her. PA #1 stated CNAs should have documented when R #31 did not have a BM. She stated staff should have notified her of R #31's constipation sooner, and she should be notified if a PRN medication was not working. J. On 07/03/24 at 1:44 pm during an interview with the Director of Nursing (DON), she stated CNAs should have documented R #31's BMs or constipation every day, but they did not. The DON also stated CNAs should notify nursing if a resident did not have a BM in 24 hours, and they will contact the provider if a resident was constipated for three days. The DON confirmed nursing staff is responsible for monitoring a residents EHR to see if a resident does not have a BM. The DON also stated the facility nursing staff should have notified PA #1 of R #31's constipation and that the medications were not working for R #31.

Based on record review, observation, and interview, the facility failed to ensure that 3 (R #42, 96 and 98) of 3 (R #s 42, 96 and 98) residents reviewed for pressure ulcers received monitoring and care to prevent the development and worsening of pressure ulcers by: 1. Not accurately assessing residents skin upon admission/re-admission or immediately implementing treatment and monitoring for skin issues once identified for R #42, 96 and 98. 2. Not implementing effective interventions to prevent new skin wounds from developing and worsening for R #96 and R #98. These deficient practices likely resulted in the development and worsening of resident pressure wounds, including a Stage 3 (full thickness tissue loss) pressure ulcer and Stage 4 (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) pressure ulcer. The findings are: Findings for R #98: A. Record review of R #98's medical record indicated that he was readmitted to the facility [from the hospital] on 04/18/23. His diagnoses included fracture of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture of with routine healing; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; urinary tract infection (a common infection that happens when bacteria, enter the urethra {hollow tube that lets urine leave the body} and enter the urinary tract), site not specified; repeated falls; depression, unspecified; and adult failure to thrive. These diagnoses are not all inclusive. B. Record review of R #98's in-patient hospital stay of 04/14/23 to 04/18/23 revealed the following: R #98 was hospitalized from 04/14/23 to 04/18/23 due to combative behaviors. He was discovered to have a pseudomonal (pseudomonas is a type of germ found commonly in the environment) urinary tract infection (UTI). The infection was treated with antibiotics and R #98 returned to the facility on [DATE]. C. Record review of R #98's care plan dated . revealed the following: 1. Revision on 04/23/23: (name of resident) requires assistance/is dependent for Activities of Daily Living (ADL) care in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: Dementia, weakness, Update: Fracture to right femur post fall so he requires extensive assist with most ADL's .Extensive to total assist for transfers, Extension assist with locomotion in w/c (wheelchair), dressing, toileting and personal hygiene. Total care for incontinent (having no or insufficient voluntary control over urination or defecation) care . D. Record review of R #98's Electronic Health Record revealed the following scores on his Braden Scale for Predicting Pressure Sore Risk assessments (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries-mild risk: 16-18; moderate risk 13-14; high risk 10-12; and severe risk-less than 9): 1. 02/16/23 score 18 2. 02/23/23 score 18 3. 03/02/23 score 18 4. 04/08/23 score 16 E. Record review of R #98's skin checks revealed the following: 1. 04/10/23 identified no wounds on heels or sacrum (a triangular bone in the lower back formed from fused backbones and situated between the two hipbones of the pelvis). 2. 04/27/23 identified 3 new injuries: a) left heel deep tissue injury (DTI) measuring 8 centimeters (cm) by 4.5 centimeters (cm), b) a right lateral dorsum (shown in picture to be located on the side and bottom of the outer right foot) measuring 1 cm x 1 cm, and, c) a right foot dorsum (dorsum of foot, the top of the foot) fifth digit (pinky toe) deep tissue injury were identified. F. Record review of R #98's medical record did not identify that an admission skin assessment was completed by the admitting nurse upon re-admission [04/18/23]. G. Record review of shower sheet for R #98 dated 04/18/23 indicated by a circled area on the body diagram that R #98 had red and macerated (maceration-the softening of skin as part of the process of skin tissue breaking down) skin on his coccyx/sacral (the shield shaped area located at the base of the spine and includes the tailbone). The sheet also indicated that the area on R #98's left heel was dark, red, and intact. The right heel indicated redness and intact. The sheet indicated a medical provider had been contacted and that barrier cream had been applied. There was no corresponding progress note regarding the skin condition, physician notification or any new orders. H. Record review of the Medication Administration Records/Treatment Administration Record (MAR/TAR) for April 2023 for R #98 revealed the following: 1. No treatment orders or interventions documented for the red and macerated skin of the coccyx/sacral area for the month of April 2023 for the damaged skin identified on 04/18/23. No orders or interventions were documented for the reddened areas of the left and right heels. 2. An order to Apply Optifoam Heel (a brand of dressing applied to the heels of the feet that provides an ideal healing environment because of its well-known property of handling high fluid, provides strong protection against outside contaminants and is highly absorptive and is considered ideal for partial and full-thickness wounds, lacerations, abrasions, pressure ulcers, and foot ulcers) to bilateral (both heels of feet) heels every day shift every 3 day(s) for wound care starting 04/27/23. I. On 05/17/23 at 3:10 pm during interview with the Wound Care Nurse (WCN), she reported that R #98 went to the hospital in April and returned on 04/18/23. She confirmed the the admitting nurse did not conduct a skin assessment upon his return from the hospital and when she realized a skin assessment had not been completed, she did her own assessment as part of the weekly skin assessment on 04/27/23 in which she identified wounds to his heels. WCN confirmed that it is the Nurse on duty's responsibility to do skin assessments upon admission and re-admission. WCN also confirmed that CNA (certified nurse aides) are expected to document resident's skin condition on the shower sheets and they then give the shower sheets to the nurse. If something is identified, the nurse should assess and then should be identifying a change in condition and notifying the nurse managers and provider. Regarding what interventions were implemented for R #98's heel wounds, the WCN stated that staff were floating his heels while he was in bed and they had optifoam heels under his socks when he was in his wheelchair. When asked why heel protectors weren't ordered sooner, she replied We didn't have heel protectors in Central Supply. I don't like putting in an order for something we don't have. WCN confirmed the heel protectors were ordered 05/16/23 and implemented 05/16/23. J. Record review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for May 2023 for R #98 revealed the following: 1. And order to apply Optifoam heel to both heels every day shift every day starting on 04/27/23 and discharged on [DATE] 2. An order to treat Moisture Associated Skin Damage (MASD) with a start date of 05/03/23, using Calmazide (calmoseptine- used to treat red or irritated skin two to four times daily after incontinence {lack of voluntary control over urination or defecation} episodes, which protects the skin and promotes healing) ointment to buttocks twice a day. There was no documentation of application of this treatment on the MAR/TAR until 05/09/23. 3. An order to apply purple heel protectors to both heels every day and night shift starting 05/16/23. 4. An order for wound care for a stage 4 wound to the coccyx indicates to clean the wound with wound cleaner, pat dry, pack with Aquacel Ag (name brand of a primary dressing indicated for moderate to highly exuding {wound drainage} chronic and acute wounds where there is infection or an increased risk of infection), cover with Allevyn (an adhesive dressing indicated for exudate {pus} absorption and the management of partial- to full-thickness wounds every day shift starting 05/17/23. 5. An order for wound care to unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) wound on the right ankle by applying skin prep daily every day shift starting 05/18/23. 6. An order for a wound culture of the coccyx one time only for two days starting 05/16/23. K. Record review of physician orders for R #98 revealed the following orders: 1. Protein liquid two times a day for wound care starting 05/18/23. 2. House supplement 3 time a day starting 05/18/23. 3. Wound culture to coccyx starting 05/16/23. 4. Schedule for wound clinic as soon as possible for multiple deep tissue injuries, and stage 4 to the coccyx starting 05/17/23. 5. Wound care to unstageable on right ankle; apply skin prep daily starting 05/18/23. 6. Doxycycline Hyclate (a medication used in the management and treatment of a variety of infections. Oral Tablet 100 milligrams ( mg) with a start date of 05/17/23. 7. Wound care to Stage 4 to coccyx. Cleanse with wound cleanser, pat dry pack with Aquacel Ag, cover with sacral Allevyn every day shift with a start date of 05/17/23. 8. Roho cushion (cushion that is designed to decrease the amount of pressure on the sitting area on a chair) with no start date indicated, and a revision date of 05/19/23. No start date was observed. 9. Apply Purple Heel protectors to bilateral heels every day and night shift with a start date of 05/16/23. 10. Wound care for moisture associated skin damage apply Calmazide ointment to buttocks twice a day starting 05/03/23 and discontinued on 05/16/23. 11. Low air loss mattress (a mattress that provides airflow to help keep skin dry, as well as to relieve pressure to bed for pressure ulcers) for pressure ulcers with a revision date of 04/27/23. No start date was observed. 13. Float heels (means that a patient's heel should be positioned in such a way as to remove all contact between the heel and the bed) while in bed with a revision date of 04/27/23. No start date was observed. L. On 05/16/23 at 11:03 am, during an observation and interview, R #98 was observed sitting upright in a wheelchair in the common area located in front of the south nursing station. He was awake and alert, with a pleasant affect. He was not observed to be in distress. His feet were covered with socks only and no shoes were observed. M. Record review of Skin and Wound Evaluations revealed the following: 1. Lateral Right Foot a. 04/27/23 deep tissue injury: area = 1.0 centimeters squared, length = 1.0 cm, width = 1.0 cm b. 05/02/23 deep tissue injury: area = 1.2 centimeters squared, length = 1.3 cm, width = 1.2 cm c. 05/09/23 deep tissue injury: area= 2.3 centimeters squared. length = 1.6 cm, width = 1.7 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared. Length = 0 cm width = 0 cm 2. Dorsum Right foot a. 04/27/23 deep tissue injury: area = .6 centimeters squared, length = .8 cm, width = .8 cm b. 05/02/23 deep tissue injury: area = 2.5 centimeters squared, length = 1.6 cm. width = 1.5 cm c. 05/09/23 deep tissue injury: area= 4.7 centimeters squared. length = 2.0 cm. width = 3.2 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared. Length = 0 cm, width = 0 cm 3. Left Heel a. 04/27/23 deep tissue injury: area = 0 centimeters squared, length = 0 cm, width = 0 cm Notes: Area is closed with fluid-filled Deep Tissue Injury. Optifoam heel applied b. 05/02/23 deep tissue injury: area = 21.3 centimeters squared, length = 5.7 cm. width = 5.2 cm c. 05/09/23 deep tissue injury: area= 7.7 centimeters squared, length = 3.7 cm, width = 2.9 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared, Length = 0 cm, width = 0 cm 4. Sacrum Wound Evaluation a. 05/16/23 stage 4: area =18.42 cm squared, length 6.68 cm, width = 4.43 cm, depth = 4.0 cm, max undermining = 4.5 cm, undermining 4.5 cm 8 to 8 o'clock 5. Right Lateral Malleolus a. 05/16/23 unstageable: area = .9 centimeters squared, length = 1.3 cm, width = 1.0 cm N. Record review of the nursing progress revealed the following: 1. A nursing progress note dated 05/12/23, a change in condition was made by the nurse for R #98 after a Certified Nursing Assistant (CNA) reported the skin breakdown was .worse due to some open/raw areas . The progress note indicated that there was .skin breakdown on inner butt cheeks area . The primary care provider was notified and the recommendation by the provider was to continue the treatment as ordered and have resident seen by WC (wound clinic) Monday [05/15/23] . 2. A nursing progress note by Wound Care Nurse (WCN #1) dated 05/16/23 indicated that a change of condition was created after a skin check was performed following notification that CNAs were changing R #98's brief on 05/16/23 and reported R #98 had a hole in his bottom. As a result of the assessment, the following new and worsening skin injuries/wounds were identified: a stage 4 pressure injury (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) to the coccyx, with tunneling (a wound that's progressed to form passageways underneath the surface of the skin) a stage 3 (full thickness tissue loss) pressure injury to the right buttock, and a stage 3 pressure injury to R #98's right ankle. 3. A progress note dated 05/16/23 indicated a correction to a wound's status was made. The wound to R #98's right ankle was considered unstageable (an ulcer covered with slough {dead tissue, usually cream or yellow in colour}or eschar {dry, black, hard necrotic tissue}-the base of the ulcer needs to be visible in order to properly stage the ulcer, though, as slough and eschar do not form on stage 1 pressure injuries or 2 pressure ulcers, the ulcer will reveal either a stage 3 or stage 4 pressure ulcer) 4. An order was written on 05/16/23 for R #98 to be seen in the Wound Clinic, after assessing worsening wounds to the sacrum and the new ankle pressure wound. 5. An observation of a photo taken as part of the of R #98's coccyx wound assessment was observed to show a coccyx wound located at the 12:00 o'clock position, directly above the anus (the opening where bowel movement passes from the body), consisting of 3 holes (open wounds) clustered closely together, with sinewy (stringy) yellow appearance border around all three. One of the three wounds had bubbly clear fluid in it. The largest open wound appeared to be cavernous with a tunnel-like appearance going into the resident's lower backside; outside of the sinewy border is another border around all 3 wounds that is a rectangular border surrounding all three wounds and the skin there is yellow-white in color and appears to look like raw skin with the top layer of skin missing. There were red bumps throughout the rectangular border of white skin. The next border around the periphery of the rectangular shaped wound was a thin, red border (edge) of skin. Above the rectangular shaped wound was another small open wound that was separate from the large rectangular wound. It was pink with a small depression, and it had a red and pink edge. This wound was located on the right buttock at the 2:00 o'clock position above the 3 clustered, open wounds. O. Record review of Skin and Wound Evaluation completed for R # 98's sacrum and right lateral malleolus (ankle bone) dated 05/16/23 revealed the following: 1. The sacral wound had an area of 18.4 centimeters (cm) squared; length of 6.7 centimeters; width of 4.4 centimeters; depth of 4.0 centimeters; and undermining (refers to the damage underneath the wound edge that spans a wider area in multiple directions, but isn't that deep) of 4.5 centimeters. 2. The right lateral malleolus had an area of .9 centimeters squared; a length of 1.3 centimeters; and a width of 1.0 centimeter. P. On 05/17/23 at 3:11 pm, during an interview with the WCN #1, she stated she was made aware R #98 having some maceration (when the skin is broken down by moisture on a cellular level) over the weekend, on 05/12/23 of the coccyx. She had last observed R #98 in the early part of the previous week. There was only redness and maceration at that time. LPN #1 stated at 4:30 pm on 05/16/23, a CNA informed her that during a brief change of R #98 there a hole wound was observed. WCN #1 then completed a skin assessment of R #98 on 05/16/23 and R #98 with a new wound to his coccyx, which was also described as an hole (open wound). She stated that the current wound on R #98's coccyx had developed from the inside out. She stated that it was a stage 4 pressure ulcer. WCN #1 explained that a stage 4 pressure ulcer was a wound that was all the way to the bone. It was being treated by packing with Aquacel (name brand of dressing that is an antimicrobial primary dressing for use in acute and hard-to-heal wounds that are infected or at risk of infection with varying exudate {pus} levels) and covered with skin prep (moisture barrier cream) to all areas. She also assessed a new wound on R #98's ankle. Regarding how a MASD (moisture Associated Skin Damage) can so quickly turn into a Stage 4 pressure wound, WCN insisted that during the week of 05/08/23 when she observed the sacrum, the skin was still blanchable and with R #98's limited mobility, he is at high risk for deep tissue injury and it [break down] can happen quickly. Q. On 05/18/23 at 10:28 am, during an interview with the Director of Nursing (DON) regarding R #98's new heel wounds when he returned from the hospital on 04/18/23, the DON stated that a skin assessment had been completed for R #98 when he returned from the hospital by an agency nurse on a shower sheet. The shower sheet indicated there was redness to the bottom and to the back of R #98's heels. Also indicated on the shower sheet was red macerated skin to the coccyx, and redness to the left heel and right heel with the skin intact. The DON stated the shower sheet indicated that a MD (Medical Doctor) had been notified and that barrier cream had been applied, however she stated there was no documentation of new orders and no documentation of which medical provider was notified. The DON stated the skin information can be initially documented on a shower sheet by nurses and then transferred to Point Click Care (PCC-the medical charting system used by the facility) but that did not happen in this case. DON confirmed that there was no documentation in the progress notes by the agency nurse who completed the skin assessment. R. On 05/18/23 at 3:39 pm, during an interview, CNA #2 reported that he first noticed that R # 98 was having some skin issues while changing R #98's brief two weeks ago (the week of 05/01/23) and that he reported it to the nurse and the nurse manager. CNA #2 stated he had observed more changes in R #98's bottom last week on Wednesday (05/10/23) and that it looked like lines in R #98's skin. He informed the Unit Manager. By Friday or Saturday (05/12/23, 05/13/23) CNA #2 stated it looked like a pocket of pus that would burst if you popped it with a pin, but that the skin was flat on R #98's inner cheeks. He observed it to be about the size of a large sandwich in area and that it looked bad. It had an infection smell. There were no holes in R #98's skin. He let the nurse and Unit Manager know. He stated the Unit Manager told the nurse to complete a change in condition form. The nurse was trying to get an order. CNA #2 applied barrier cream to R #98 after his brief change on 05/12/23 after informing the nurse. CNA #2 stated R #98 always had the purple things (foam heel protectors) on his feet, no shoes. S. On 05/18/23 at 4:00 pm, during an interview, Registered Nurse (RN) #3 stated R #98 had moisture associated skin damage and an unstageable wound on his left foot and nothing on the right foot that he was aware of. RN #3 worked with R #98 the weekend of 05/12/23. He stated an order for MASD kept popping up for R #98, so the CNA applied the barrier cream. RN #3 stated he completed a change in condition form [on 05/12/23] to be reviewed by the Wound Care Nurse and kept the wound as MASD because he did not know what type of wound it was. RN #3 also stated he was not great with wounds The wound was located between both cheeks. There was some skin breakdown and the wound was light colored with raw skin on the edges. It looked fresh. The wound was flush and not puffed out. It was the CNA who brought the wound to his attention [on 05/12/23]. He informed the supervisor of the change in condition [on 05/12/23]. Barrier cream continued to be applied over the weekend but there was no change in the appearance of the wound. He does not believe it got better. R #98's heels were now covered with Optifoam (a brand of dressing applied to the heels of the feet that provides an ideal healing environment because of its well-known property of handling high fluid, provides strong protection against outside contaminants and is highly absorptive and is considered ideal for partial and full-thickness wounds, lacerations, abrasions, pressure ulcers, and foot ulcers). The left heel appeared dark in color. He did not remember anything being on the right heel. T. On 05/18/23 at 12:16 pm during an interview with RN #2, she stated R #98 had started Doxycycline (an antibiotic) yesterday on 05/17/23 for the wound on his coccyx. It had a discharge and a foul odor. Currently the wound was being treated with wound cleanser, Aquacel Ag for packing the wound, and Allevyn. She reported that R #98 was not able to be seen at the wound clinic this morning due to being late and that he was now being sent out to the emergency department because his appointment was rescheduled to Tuesday [05/23/23] of the following week. RN #2 stated, she last saw R #98's sacral area last Thursday [05/11/23] and that it was red and macerated. She first became aware of the maceration on 05/03/23 and that it was being treated with a barrier cream. 35632 Resident #96 U. Record review of the face sheet for R #96 indicated that he was admitted on [DATE] with diagnosis of Sepsis (a serious condition in which the body responds improperly to an infection), Gangrene and Necrosis of Lung (is a complication of severe lung infection that causes a secondary infection and necrosis (premature cell death)), Type II Diabetes (means that your body doesn't use insulin properly) , Stage III Kidney Disease (condition that impairs kidney function), Congestive Heart Failure (your heart can't supply enough blood to meet your body's needs), Hypertension (high blood pressure), alcohol abuse (is a pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol or continuing to use alcohol even when it causes problems), Anemia (deficiency of healthy red blood cells in blood). This is not all inclusive list. V. Record review of the Braden Scale Assessment (for Predicting Pressure Sore Risk. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status) completed on 12/01/22 indicated resident scored a 17 which is at risk for skin breakdown, and on 12/15/22 the Braden score was 18. Scoring: at risk 15-18 moderate risk 13-14 high risk 10-12 very high risk 9 or below. W. Record review of the skin check completed on 12/20/22, 01/10/23 and 01/17/23 did not indicate that R #96 had any skin breakdown. X. Record review of the nursing progress notes dated 12/27/22 indicated the following: Resident developing Pressure ulcers to L. (left) foot Stage 1 (skin looks red or pink, but there isn't an open wound) to bottom of heel. Measuring at 1.6 x 1.1 cm (centimeter), and on side of heel is 2.0 x 1.3 cm. Left voicemail for (name of provider) for orders. Y. Record review of the History and Progress Note dated 12/27/22 indicated the physician or Nurse Practitioner (NP) knew about the stage I pressure injury to left heel and said to dress it and provide pressure relief. Z. Record review of the physician orders dated 01/02/23 indicated the following: Paint heels bilaterally with skin prep (liquid that when applied to the skin forms a protective film or barrier). Keep heels offloaded while in bed one time a day for wound care. AA. Record review of the Treatment Administration Record (TAR) for the month of January 2023 indicated that the above physician order was not on the TAR and was not getting done. BB. Record review of the nursing assessment note dated 1/18/23 indicated that the pressure wound stage 3 (the wound may go into your skin's fatty layer (the hypodermis)) in-house acquired, Location: Left Heel was assessed today. Prognosis: Healable. CC. Record review of the physician orders dated 01/19/23 indicated that the following order was in place: left heel pressure ulcer: Clean with wound cleanser, pat dry, apply Allevyn foam dressing (dressings for wound care that remove fluid faster than regular dressings). Place heel protectors every day shift for wound care. DD. On 05/23/23 at 11:56 am, during an interview with the wound care nurse she stated that R #96 was bed bound for a little while in December 2022. She stated that he had precautions in place like purple heel protectors, off loading of heels and an air mattress was put into place on 12/28/22. EE. Record review of the physician orders indicated that an order was in place for a air mattress because of new pressure area and not mobile dated 12/28/22 FF. On 05/23/23 at 3:44 pm, during an interview with the Center Executive Nurse (CNE) she stated that the order placed on 01/02/23 by the physician should have been on the Treatment Administration Record (TAR). She stated that the physicians and the nurses have access to enter orders. She stated that when you enter orders if you want it to be on the Medication Administration Record or the TAR you have to click a button indicating that when you put the order in. She stated that looking at this order neither of them were clicked so it didn't show up. She stated that ancillary was clicked and that doesn't link to anything. So the nursing staff didn't know that there were orders in place and it didn't get treated. Resident #42 GG. Record review of R #42's face sheet indicated that his initial admitted was 04/07/23. HH. Record review of the Braden Scale for predicating Pressure Ulcers had R #42 listed as a 14 on the scale which is a moderate risk. II. Record review of Hospital Records indicated that on 04/05/23 resident had skin assessment completed and stated under skin turgor epidermis thin with loss of subcanteous tissue. JJ. Record review of the skin check assessment completed 04/07/23, on admission, did not indicate any wounds. KK. Record review of the Initial Minimum Data Set (MDS) completed on 04/11/23 captured that resident had 2 stage II PU's (shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters), location not identified. LL. Record review of a skin check assessment completed on 04/15/23 indicated that resident had new wounds on right and left buttock . MM. Record review dated 04/18/23 as a Late Entry: Indicated the following note written by Wound Care Nurse Paperwork from hospital indicated he has pressure to his left and right buttock on admission here. Ulcers are not in-house acquired. NN. Record review of the physician orders indicated that on 04/18/23 an order for wound care to bilateral buttocks: Apply barrier (protects the skin) cream at each brief change every day and night shift for Stage 2 pressure ulcers. OO. On 05/23/23 at 11:56 am, during an interview with the Wound Care Nurse, she stated that R #42 was admitted on [DATE]. She stated that the MDS nurse had brought up that the stage II pressure ulcers were noted on the hospital paperwork and that he came in with those wounds, that is why she wrote the progress note. She stated that the admitting nurse should have caught it on the skin check. She stated that the skin check on 04/15/23 was when the wounds were first documented by the facility. She found out about them on 04/18/23 and orders were put into place. She stated that sometimes the Certified Nursing Assistant's will tell the nurse that an area is red or there is moisture associated skin damage and the nurse will tell them to put barrier cream on it. So, even if she has not been made aware of a new wound like a stage II, or the physician is not aware of it [on 04/15/23], they [wounds] are still being treated because the treatment for those would be barrier cream anyway which is standard practice. This resulted in an Immediate Jeopardy (IJ) a scope and severity of J which was announced in person on 05/18/23 at 6:15 pm to the Center Executive Director. The facility provided an acceptable Plan of Removal (POR) and implementation of the POR was verified through observation, interview, and record review on 05/22/23. Plan of Removal: The Immediate Jeopardy finding was identified in the following area: Failure to timely identify wounds and delaying in implementing treatment . All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 5/19/23: -On 5/18/23 the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment . Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Systematic Measures Beginning 5/18/23 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee: -Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). -Nurses will be educated on (name of facility) wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. -CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNAs (including skin changes) and stop and watch. As of 5/19/23 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN (As needed) staff will be educated prior to returning to their next shift. Quality Assurance and Monitoring The Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random wound audits weekly for wound care process compliance. An Ad Hoc QAPI Meeting will be held on 5/19/23 to approve the above plan. The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee

Based on record review and interview, the facility failed to monitor wound for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for wound care of surgical sites by: 1. Not clarify medication and treatment orders from an outside provider and; 2. Not evaluating wound healing and wound treatment. These deficient practices likely result in the resident not receiving the appropriate type of treatment to prevent and treat infection that may possibly result in death. The findings are: A. Record review of the facility policy Skin Integrity and Wound Management, last revised 02/01/23, revealed the following: Practice Standards 4. Identify patient's skin integrity status and need for prevention or treatment interventions . 6. The licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds; . 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change in condition. 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds . B. Record review of R #1's EHR (Electronic Health Record) revealed that R #1 was admitted to the facility on [DATE] with the following pertinent diagnoses: peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), onset date: 09/01/22 artherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque) of the native arteries of extremities (5 lower extremity arteries- femoral artery, the superficial femoral artery, the popliteal artery, the posterior tibial artery, and the dorsalis pedis artery) with rest pain, left leg, onset date: 09/01/22 prediabetes (blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes), onset date: 11/05/22 methicillin resistant staphylococcus aureus (MRSA- Methicillin-resistant Staphylococcus aureus- an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) infection, unspecified site, onset date: 02/2/23 cellulitis (bacterial skin infection) of left lower limb, onset date: 02/25/23 infection following a procedure, other surgical site, subsequent encounter, onset date: 02/25/23 C. Record review of hospital documentation, encounter dates from 01/09/23 to 01/16/23, revealed that R #1 was hospitalized for the status of his ischemic ulcers (slow healing wounds as a result of poor blood circulation). After previous treatments, testing revealed that amputation [surgical removal of limb] was unavoidable. On 01/11/23 he underwent an above the knee amputation (AKA) of his left leg. D. Record review of physician orders revealed the following wound care orders for R #1's LAKA (Left Above Knee Amputation) 1. 01/19/23 to 01/23/23, Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable Additional Documentation in NN [nursing notes] if needed s/p [status post] LAKA every day and night shift 2. 01/21/23 to 02/25/23, Wound Care LAKA: Cleanse with wound cleanser, pat dry, apply Adaptic dressing [type of wound bandage], apply 4x 4 [inches] gauze, wrap with kerlix [type of wound bandage] and ACE bandage. Apply stump shrinker [a compression garment to help shape the limb] every other day, one time a day every other day for wound care [wound care orders began 11 days after amputation] E. Record review of the TAR (Treatment Administration Record) revealed the following documentation of wound care administration and resident refusals: January 2023: Physician order, date 01/21/23-02/25/23, Wound Care LAKA: Cleanse with wound cleanser, pat dry, apply Adaptic dressing, apply 4x4 gauze, wrap with kerlix and ACE bandage. Apply stump shrinker. every other day one time a day every other day for wound care. Wound care was not documented as being administered or if the patient refused (blank) on the following dates: 01/21/23 and 01/29/23. February 2023: R #1 refused wound care on 02/10/23 and 02/18/23. March 2023: Physician order, dated 03/11/23-03/14/23, Wound Care: Left AKA - clean with sound cleanser, pat dry, apply adaptic gauze, and cover with border gauze. one time a day for wound care R #1 refused wound care on 03/12/23 Physician order, dated 03/14/23-04/03/2023, Wound Care: Left AKA - clean with sound cleanser, pat dry, apply adaptic gauze, and cover with border gauze. every evening shift for wound care. R #1 refused wound care on the following dates 03/14/23, 03/19/23, and 03/21/23. Wound care was not documented as being administered or if the patient refused on the following dates: 03/15/23, 03/17/23, and 03/18/23. April 2023: Physician order, dated 04/05/23, Wound Care: Left Stump - clean with wound cleanser, apply thick layer of Santyl to all necrotic areas of the wound. Apply Opticell AG(ok to use Maxosorb Ag) to wound and cover with border gauze. every day shift for left stump wound care R #1 refused on the following dates: 04/07/23, 04/09/23, 04/13/23, and 04/15/23. Wound care was not documented as being administered or if the patient refused on the following dates: 04/10/23 and 04/12/23. F. Record review of the weekly wound assessments revealed the following documentation for all LAKA wound assessments: 11/17/22- Venous wound [A wound on the leg or ankle caused by abnormal or damaged veins to left shin]. Total area: 42.6 cm. 8.2 X 5.2 0.3 (length by width by depth in centimeters). Improving. 11/28/22- Venous wound to left shin. Total area: 41.6 cm. 8.0 X 5.2 X 0.1(length by width by depth in centimeters). Improving. 12/15/22- Venous wound to left shin. Total area: 37.5 cm. 7.5 X 5.0 X 0.3 (length by width by depth in centimeters). Stable. 02/08/22- Surgical wound to left knee. Total area: 21.9 cm. 7.2 X 4.3 X N/A (depth not applicable on surgical wound). Wound bed: eschar 100%. Edges: attached. Surrounding tissue: black and blue. Goal of care: monitor/manage- wound healing not achievable due to untreatable underlying conditions. Deteriorating. 04/04/23- Surgical wound to left knee. 0 sutures, Incision Approximated. Total area: 43.4 cm. 10.4 X 6.5 X N/A (depth not applicable on surgical wound). 30% granulated [the development of new tissue and vessels], 40% slough [the accumulation of dead cells that are yellow/white in appearance], 30% eschar [necrotic tissue that needs to be removed to promote wound healing], moderate drainage- seropurulent [a type of drainage that is a usual sign of infection]- no odor, non-attached edges [open wound], surrounding skin- erythema (redness to skin), no swelling, dressing intact. Generic wound cleanser. Debridement- enzymatic. MD [medical doctor] diagnosed infection. Using santyl ointment for enzymatic debridement [the application of a prescribed topical agent that chemically liquefies necrotic tissues with enzymes]. Resident on antibiotics. Practitioner notified. G. Record review of nursing notes related to wound care of the left limb revealed the following: 12/06/22- wound assessment done 12/13/22- IDT [Interdisciplinary Team meeting]- [Name of R #1] has refused wound assessment and treatments. He states that clinic will change. Educated him increased risk of infection and that the clinic wrote orders for wound care to be done here. He states that he doesn't care. 12/19/22- wound assessment done 12/22/22- wound care done by wound clinic 12/28/22- wound clinic did wound care 01/04/23- Resident went to wound clinic today. New orders given. Wound to left lower leg measures 6 cm (centimeters) x (by) 3.8cm x 0.3cm with a moderate amount of serous exudate [a thin liquid that drains from the wound, usually a part of a normal wound healing process] and is erythematous [redness of the skin]. 02/08/23- A deteriorating [worsening] surgical wound in-house acquired Location: Left Knee was assessed today 03/07/23- Wound vac removed by [name of outside prosthetic consultant] and dressing change done at this time as well 04/04/23- Left Knee was assessed today 04/05/23- Resident refused to shower this shift and refused dressing changes 04/06/23- Wound care provided 04/07/23- Refused wound care 04/13/23- Resident asked 3x [three times] to do wound care and refused 04/14/23- Wound dressing changed 04/15/23- Resident refused X 3 today stating 'Can you just do it tomorrow' 04/17/23- Resident refused to let writer do his dressing H. On 04/24/23 at 12:13 pm, during an interview with the Wound Nurse, she explained that she recently stepped into the position of being the wound care nurse. When asked to explained her role in the facility she explained, I became the skin health lead [wound nurse] in April [2023]. Before I became the skin health lead, the staff who would do the assessment would be the floor nurse. The floor nurse would be the ones who would have charted and communicated with the doctor . It was up to the floor nurse to assess the wounds. When asked to explain her interactions with R #1, she explained According to the nurses on duty, he was refusing wound care pretty often. He started off with a venous wound and they had to do the amputation [01/11/23], he was refusing a lot of the time. He was very persistent and would say 'no, not today or how about tomorrow'. At that time, I wasn't the team lead yet. Then he had a further amputation [02/23/23] and after that he would refuse treatments fairly often. I would tell the nurses to document his refusals. The last time I saw him [04/04/23], he went to the hospital, his surgical site was completely necrotic [dead tissue]. When he came back [02/25/23] they must have debrided [to remove damaged tissue] it because it was open and raw. I. Record review of nursing notes, dated 01/16/23, revealed Resident readmitted to facility today after LLE [Left Lower Extremity] AKA . When I informed resident that I would need to check his skin and do his admission, he states 'I just don't want to be bothered today. I just want to relax, smoke a cigarette, and watch the football game. Just do it all tomorrow.' Further review of nursing notes dated 01/18/23, revealed Spoke with [name of outside prosthetic consultant] regarding leg amputation care. [Name of outside prosthetic consultant] will visit resident tomorrow [01/19/23] and will contact surgeon for dressing orders. Will continue to monitor surgical site and notify surgeon with concerns/changes. J. On 04/24/23 at 12:37 pm, during an interview with Licensed Practical Nurse (LPN) #2 (the author of the nursing note dated 01/16/23), when asked if R #1 returned with wound care orders on 01/16/23, she explained There should be orders, a lot of time, if he returns from the hospital and you see that he has a bandage, there should be orders. When he (R #1) readmitted on ,d+[DATE] [2023] he didn't want to do his skin assessment, so I passed that onto the night nurse. I let the night nurse know that she would have to do it. K. Record review of hospital documentation, encounter dates from 02/20/23-02/25/23, revealed that R #1 returned to the hospital due to poor wound healing. The surgical wound was found to be dehisced (a partial or total separation of previously sutured wound edges, due to a failure of proper wound healing) and infected. On 02/23/23 he required a revision (additional amputation) of his LAKA stump. During his stay, hospital documentation revealed that R #1 was ordered to receive Clindamycin [type of antibiotic] in 300 MG [milligrams] capsule. Take 1 capsule (300 mg total) by mouth every 6 hours for 21 days. Further review revealed that on 02/25/23, R #1 received a wound vac [a medical device used to suction out drainage to promote wound healing] to the LAKA. L. Record review of physician orders revealed the following: 1. An order, dated 02/25/23, for Clindamycin HCl Powder (Clindamycin HCl (Bulk)) Give 300 milligram by mouth four times a day for Wound Infection for 21 Administrations [not 21 days] 2. R #1 did not have any orders for wound vac care after his return from the hospital on 02/25/23, however; there was a physician order, dated 03/11/23, to Discontinue wound vac to left AKA one time only for post-op wound care for 1 day per [name of outside prosthetic consultation services]. M. Record review of hospital documentation, encounter dates from 03/22/23-04/02/23, revealed that R #1 returned to the hospital for stump pain where he was evaluated and treated for sepsis [a body's reaction to infection that causes chemicals to be released in the bloodstream to fight an infection but also triggers inflammation throughout the body leading to organ failure and often death]. Further review of the assessment and plan revealed plan for IV (intravenously) vancomycin [a type of antibiotic] until 4/20/23, followed by a few weeks of PO (oral administration) Zyvox 600 mg [milligrams] PO, BID [twice a day] (EOT [End of Treatment] 5/4/23). N. Record review of physician orders revealed that R #1 did not have an order for antibiotics after his return from the hospital on 04/02/23. O. On 04/24/23 at 2:13 pm, during an interview with the Director of Nursing (DON) , when asked what nursing staff are expected to do for wound assessments, she explained that nurses are expected to document a skin assessment on a weekly basis and if a resident refuses, the nurse should document that the resident refused. When asked to describe the process nurses follow when admitting a resident form the hospital, she explained that the nurses call the facility's physician group to confirm orders and enter the orders into the resident's EHR. When asked if the progress notes from the hospital packet are reviewed, she explained that the hospital is not consistent in sending progress notes. Sometime they do and sometimes they do not send progress notes so, it depends on what information is available. When asked if R #1 returned on 04/02/23 with a Peripherally Inserted Central Catheter (PICC) (a form of intravenous access that can be used for a prolonged period of time or for administration of medications) for vancomycin, she explained I believe there was a progress note where they said he would not be discharged with the PICC line and he would instead receive oral antibiotics. He got here and didn't have a PICC, so we just followed the discharge orders however; the antibiotics were not listed on the discharge orders. P. On 04/25/23 at 9:52 am, during an interview with the DON, when asked why R #1 didn't have wound care orders until 01/21/23, she explained, He returned on the 16th [01/16/23]and the orders didn't start until the 19th [01/19/23]. We can't put orders in, so we have to call the on-call [physician group] to get them. For him, we had numerous refusals from [name of R #1] so I think that his refusals held up the process. If we can't assess the patient then we can't let the doctor know the status, and then we can't get orders. The person who did his admission [on 01/16/23] was an agency nurse and if she didn't know that he had a wound and he was refusing, then she wouldn't have known to requested them. When asked if she should have been aware of his amputation through the hospital documentation, she explained For admissions, we don't usually get packets [hospital stay documentation] with the residents. We can call and call and they [the hospital] will never answer the phone. When asked if the nurse should have notified the physician of his refusal to assess him upon admission, she stated Yes, she should have notified the physician. Q. On 04/25/23 at 12:09 pm, during an interview with the DON, when asked if R #1 should have received physician's orders for wound vac care, she explained We didn't have wound vac orders until 03/01/23. It [the physician's order] should have been more specific from the hospital. We cannot put the wound vac on [without a doctor's order] because it is a specialty device. The doctor should have given us a clear order. We did not call to get clear orders. We should have called to get clear orders. R. On 04/25/23 at 2:59 pm, during an interview with the DON, when asked if the order for Clindamycin should have been administered for 21 days, she confirmed yes and explained that while entering the order into the EHR, it was done incorrectly for 21 Administrations. S. Record review of nursing notes, dated 04/14/23, revealed Resident [R #1] approached this nurse [RN #1] with a paper from an appointment he had on 4/11/23. The paper appears to be a copy of a progress note from a wound care visit. The paper requested the resident be admitted to the hospital for wound treatment. This nurse along with unit manager [RN #4] discussed this with the resident and he refused to go to the hospital. T. Record review of hospital follow-up visit, as noted by the infectious disease doctor, dated 04/11/23, revealed We may presume the wound problem is related to MRSA (methicillin resistant staphylococcus aureus) though at this point he could have secondary nosocomial pathogens superimposed. Also high risk for osteomyelitis [infection from nearby tissue that spreads to the bone] at femur [thigh bone] . Further review revealed 76 yo [year old] man with severe PAD [Peripheral Arterial Disease]. Here for wound and antibiotic assessment. His wound isn't better . He says he is NOT on IV medications (vancomycin). Assessment and Plan: Refractory LAKA stump wound infection now with dehiscence [partial or total separation of wound edges, due to a failure of proper wound healing] and necrotic eschar [dead tissue]. He is not systemically ill acutely, but wound appears worse now than he did in hospital. He has not been receiving the Rx [prescription] I advised. Seems he isn't on any antibiotics and has not had good wound care. Recommend: Readmit to hospital for wound care, debridement, antibiotics. I indicated this in writing to the SNF [Skilled Nursing Facility] (don't know medical contact there) and gave letter to patient. As advised in hospital: Zyvox 600 mg po BID for 10-14 days . U. Record review of EHR revealed that R #1 passed away on 04/17/23 while in the facility. V. On 04/26/23 at 2:21 pm, during an interview with the DON, when asked how communication is executed between the facility and outside care, she explained that if there is a change in treatment, she expects the outside care provider to send the facility documentation of treatment changes. When asked about the note from R #1's follow-up visit on 04/11/23, she explained that the facility did not receive the note and that the outside care provider should have been more clear with his recommendations. When asked why a facility nurse didn't call to request notes from the follow-up visit, she explained, We have a lot to do in the facility. I would expect them [outside clinic] to send it. We probably did assume that there were no changes for him. When asked if the facility should have some type of communication process between outside providers, she confirmed yes. W. On 05/01/23 at 10:54 am during interview with the Administrator and Director of Nursing, the Administrator (DON) stated It was common knowledge that his [R #1] wound was infectious. Administrator and DON stated that R #1 would consistently refuse wound care. X. On 05/01/23 at 11:57 am during interview with the Wound Nurse (WN), regarding R #1, she stated I wasn't the only one seeing his [R #1's] skin. They [nurses] are supposed to be doing the wound assessments. The WN confirmed that she had heard [from staff] that he [R #1] was refusing wound care but wasn't aware that it was happening consistently. She confirmed that she had seen the wound one week and then the next week, he (R #1) let her look at his skin except the wound. The WN confirmed that she only saw the wound one time. When asked how can she be sure the wound care orders were still appropriate if she hadn't seen the wound, she said that the nurses would be expected to let her know. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced in-person on 04/28/23 at 2:00 pm to the Center Executive Director. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 04/28/23. Implementation of the POR was verified onsite on 05/01/23 at 4:20 pm by conducting record reviews and staff interviews. Plan of Removal: The Immediate Jeopardy finding was identified in the following area: Failure to consistently document, assess, monitor and notify the physician when a wound became worsened potentially because antibiotic treatments were not accurately provided . All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 4/29/23: - On 4/24/23 the nursing team (Director of Nursing responsible) initiated a 30-day audit on all antibiotics to ensure all orders are accurate with the correct duration/routes. Any discrepancies will include a provider notification and review to ensure accurate medication orders are in place. - On 4/25/23 the nursing team (Director of Nursing responsible) initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment . Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Systematic Measures: Beginning 4/28/23 the Center Nurses will be re-educated on the following areas: - Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). - Nurses will be educated on proper wound processes which include accurate documentation for wounds/wound changes, change in condition when a wound is new or worsened, appropriate treatment options, weekly skin checks, wound measurements, and signs and symptoms of a wound infection. If a resident is consistently refusing needed interventions such as wound assessments and treatment, the provider needs to be notified immediately so further interventions can be placed if necessary. All communication needs to be documented in the change in condition documentation, or follow-up documentation. All refusals need to be documented in the chart, and the care plan should be updated including interventions. - Medication reconciliation process, and reviewing clinic notes when a resident returns from an appointment. If there are clarification questions at that time, the nurse should call the clinic and get clarification immediately. Clear documentation needs to occur for medication reconciliation, as well as when communication occurs to providers or outside clinics. Clinic notes and follow-up will be reviewed by nurse managers to ensure correct orders and plan of treatment are initiated. The IP Nurse will track all new antibiotics on admission and as they are ordered within the center to ensure the order is correct, being tracked for antibiotic stewardship, and that providers have been involved and want to continue therapy after 48 hours. The Director of Nursing/Designee will send a letter to all outside providers/clinics requesting that documentation from resident appointments be given to the van driver following the appointment. Documentation will be given to the Receptionist/Designee for distribution to Nursing and Medical Records. If there is no documentation delivered following an appointment, the Receptionist will follow up with the provider and work with Medical Records to get the documentation needed to provide continuity of care. The Nurse Educator/designee will begin education 4/28/23. As of 5/1 /23 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance and Monitoring The Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Medical Records Director will audit resident appointments for follow-up documentation. The Director of Nursing/Designee will conduct random audits weekly for wound care and antibiotics and will provide any needed immediate interventions. An Ad Hoc QAPI Meeting will be held on 5/1/23 to approve the above plan. The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.

Based on record review and interview, the facility failed to provide the necessary care to effectively treat pain for 2 (R #1 and R #3) of 3 (R #1, R #3, and R #4) residents reviewed for having pain medication available. This deficient practice likely resulted in residents experiencing significant pain without sufficient relief. The findings are: Findings for R #1 A. Record review of R #1's physician orders dated 04/03/23 revealed, Oxycodone (narcotic pain medication)- Schedule ll (The drug of other substance has a high potential for abuse and has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions. Abuse of drug or other substances may lead to severe psychological or physical dependence) tablet (tab); 10 mg (milligrams); Amount to administer; 1 tab, oral (by mouth), every 6 hours-PRN (as needed) for pain. B. Record review of the Electronic Medication Administration Record (EMAR) revealed R #1 was getting Oxycodone 10 mg PRN (as needed) for pain every 6 hours. Resident reported the medication was ineffective eight times, and it was unknown if it was effective twice. This was documented by the nurses in the EMAR when they (nurses) have to go in and say if a pain medication was effective or not. This was reported from 04/04/23 to 04/11/23. C. Record review of R #1's provider progress note dated 04/11/23 revealed, R #1 expressed frustration about not getting enough pain medication when he spoke with infectious disease provider. When he was at this appointment for follow up on 04/11/23. D. On 04/26/23 at 12:32 pm during an interview with Registered Nurse (RN) #1, stated, Pain he kept asking like it was effective when they switched him to Lyrica (this medication is used to treat pain caused by nerve damage due to diabetes, shingles (herpes zoster) infection, or spinal cord injury), and Oxycodone, but it didn't last him. E. On 04/26/23 at 1:13 pm during an interview with Prosthetic Consultant replied, He (R#1)had a neck issue, and had a lot of back pain, he was hunched back. He did have residual limb pain; I have seen many of the amputees have pain like he did. F. On 04/26/23 at 2:21 pm during an interview with Center Nurse Executive (CNE), she stated, His pain management was adjusted by our Medical Director. The pain process is based on people's history, dependence, and tolerance. It will look different. If a change needs to be made, then the provider will be the one that determines that. R #1 pain assessments revealed his pain levels were rated at a 7 to 9 out of a 10 pain score and that the pain medication was not effective, and no notes stating the provider was notified that the pain medication was not effective. Findings for R #3 G. On 04/27/23 at 9:30 am during an interview with R #3, he stated, Yes, I have a lot of pain. More so a night than in the day. Last night I asked for pain medication, and they never brought them to me. The same thing this morning. I have always had that problem of them not giving me my medications. H. On 04/27/23 at 9:42 am during an interview with RN #4, she stated, Oh, another fun one. He is tough. His pain is mostly at night, and it is his legs. During the day we do his wound care. He doesn't complain about pain during the day. RN #4 stated, He did ask for pain medication this morning and I forgot to give it to him. I. Record review of EMAR revealed that the resident didn't receive any pain meds (medications) on 04/21/23 he complained of a 7/10 pain level (This pain scale is most commonly used. A person rates their pain on a scale of 0 to 10 or 0 to 5. Zero means no pain, and 5 or 10 means the worst possible pain. These pain intensity levels may be assessed upon initial treatment, or periodically after treatment). EMAR revealed that on 04/27/23 at 9:30 am when he complained of pain, he was given nothing, and his pain level was recorded in the Emergency Treatment Administration Record (ETAR) at 0.

Based on record review and interview, the facility failed to ensure residents were receiving behavioral health for 1 (R #1) of 3 (R #1, R #3, and R #4) residents reviewed for behavioral health concerns. This deficient practice likely resulted in R #1 not receiving behavioral or mental health care and assistance needed to improve and reduce depression and anxiety. The findings are: A. Record Review of R #1's hospital record dated 01/15/23 revealed R #1 had limited social and family support. R #1 did not have a stable living environment and had been living at the [Name of Nursing Home]. Nursing home prior to hospitalization . The resident was also protective regarding his room at [Name of Nursing Home] and he feels the need to have his pants on so that it will define his leg [due to amputation]. B. Record review of the Electronic Medication Administration Record (EMAR) revealed that R #1 was on Amitriptyline (from a group of medicines called tricyclic antidepressants) for depression to be given 1 tablet at bedtime. Order date was 04/03/23. C. Record Review of the Minimum Data Set (MDS) Section D (SECTION D: MOOD Intent: The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity) for 04/11/23 revealed that R #1 had little interest and feels down or hopeless. R #1 was marked yes for depressed. D. On 04/25/23 at 2:59 pm during an interview, the Center Nurse Executive (CNE) was asked if the resident was receiving any psych services (services included in the branch of medicine that treats mental and neurotic disorders and the pathologic or psychopathologic changes associated with them). She replied, I'm not sure. That's Social Services' responsibility, you'd have to ask them. E. On 04/25/23 at 12:31 pm during an interview, the Social Services Director (SSD) stated, I remember when I first met him (R #1) and we always talk to our residents about Psych (psychological services). I did bring it up, and [Name of R #1] got offended and said, 'I'm not crazy.' She (SSD) didn't remember when, and no documentation was found. SSD never received an order for Psych services referral. SSD was never approached by anyone telling her that R #1 needed any Psych services, and her evaluation in the MDS is a standardized assessment tool that measures health status in nursing home residents. F. On 04/26/23 at 1:13 pm during an interview with Prosthetic Consultant services stated, Nurses stated that he was depressed. I think everybody noticed it and was aware of it. He was depressed and upset. I follow a lot of amputated patients they tend to get into a [NAME]. He was not happy. He was not happy with it, any of it. He felt like a burden because he wasn't getting what he wanted from the facility. The Nurses and Doctors didn't care. They didn't give him the time of day. Didn't pay attention to him. He would get frustrated. The nurses would just say 'He is depressed.' G. On 04/26/23 at 2:21 pm during an interview with the CNE, she stated that R #1 would not benefit from Psych services. He doesn't trust anyone. This is his home. It's the kind of guy he was. We know our residents and he wouldn't have spoken to anyone.

Based on record review and interview, the facility performed a medication error for 1 (R #1) of 3 (R #1, R #2, and R #3) resident reviewed for wound treatment by not: 1. Transcribing (accurately copy physician orders into the resident's chart) medication administration orders correctly and; 2. Not requesting clarifying orders from the hospital for antibiotic treatment, and follow-up consultation/recommendation notes. These deficient practice likely resulted in a resident not receiving proper treatment for a wound infection. The findings are: A. Record review of R #1's Electronic Health Record (EHR) revealed that R #1 was admitted to the facility on [DATE] with the following pertinent diagnoses: peripheral vascular disease, onset date: 09/01/22 arteriosclerosis of the native arteries of extremities with rest pain, left leg, onset date: 09/01/22 prediabetes, onset date: 11/05/22 methicillin resistant staphylococcus aureus infection, unspecified site, onset date: 02/2/23 cellulitis of left lower limb, onset date: 02/25/23 infection following a procedure, other surgical site (above the knee of left leg), subsequent encounter (after the patient has received active treatment), onset date: 02/25/23 B. Record review of hospital documentation, encounter dates from 01/09/23-01/16/23, revealed that R #1 was hospitalized for the status of his ischemic ulcers (slow healing wounds as a result of poor blood circulation) located on his left shin. After previous treatments, testing revealed that amputation (surgical removal of limb) was unavoidable. On 01/11/23 he underwent an above the knee amputation (AKA) of his left leg (LAKA). C. Record review of hospital documentation, encounter dates from 02/20/23-02/25/23, revealed that R #1 returned to the hospital due to poor wound healing and required a revision (additional amputation) of his LAKA (Left Above Knee Amputation) stump. During his stay, hospital documentation revealed that R #1 was ordered to receive Clindamycin [type of antibiotic] in 300 MG [milligrams] capsule. Take 1 capsule (300 mg total) by mouth every 6 hours for 21 days. D. Record review of physician orders, dated 02/25/23, revealed an order for Clindamycin HCl Powder (Clindamycin HCl (Bulk)) Give 300 milligram by mouth four times a day for Wound Infection for 21 Administrations [not 21 days] E. Record review of the Medication Administration Record (MAR) for February and March of 2023 revealed that R #1 received Clindamycin HCl Powder for 6 days: 02/25/23, 02/26/23, 02/27/23, 02/28/23, 03/01/23, and 03/02/23. F. On 04/24/23 at 11:44 am, during an interview with the facility's physician, she confirmed that the order for Clindamycin was transcribed incorrectly for 21 administrations instead of 21 days. G. Record review of hospital documentation, encounter dates from 03/22/23-04/02/23, revealed that R #1 returned to the hospital for stump pain where he was evaluated and treated for sepsis (the body's response to an infection that results in organ failure and sometimes death). Further review of the assessment and plan revealed plan for IV (intravenously) vancomycin [a type of antibiotic] until 4/20/23 followed by a few weeks of PO (oral administration) Zyvox (an antibiotic used to treat bacterial infections) 600 mg [milligrams] PO BID [twice a day] (EOT [End of Treatment] 5/4/23). H. Record review of physician orders revealed that R #1 did not have an order for an antibiotic after his return form the hospital on 04/02/23. I. Record review of hospital follow-up visit, as noted by the infectious disease doctor, dated 04/11/23, revealed We may presume the wound problem is related to MRSA (methicillin resistant staphylococcus aureus) though at this point he could have secondary nosocomial pathogens superimposed [microorganisms that may have been contracted while receiving care at the hospital]. Also high risk for osteomyelitis [infection from nearby tissue that spreads to the bone] at femur [thigh bone] . Further review revealed 76 yo [year old] man with severe PAD [Peripheral Arterial Disease]. Here for wound and antibiotic assessment. His wound isn't better . He says he is NOT on IV medications (vancomycin) [antibiotic]. Assessment and Plan: Refractory LAKA stump wound infection now with dehiscence [partial or total separation of wound edges, due to a failure of proper wound healing] and necrotic eschar [dead tissue]. He is not systemically ill acutely, but wound appears worse now than he did in hospital. He has not been receiving the Rx [prescription] I advised. Seems he isn't on any antibiotics and has not had good wound care. Recommend: Readmit to hospital for wound care, debridement, antibiotics. I indicated this in writing to the SNF [Skilled Nursing Facility] (don't know medical contact there) and gave letter to patient. As advised in hospital: Zyvox 600 mg po BID for 10-14 days . J. On 04/24/23 at 2:13 pm, during an interview with the Director of Nursing (DON), when asked to describe the process nurses follow when admitting a resident form the hospital, she explained We put in orders from the hospital, and we call the on-call providers or [name of facility's medical group] and we clarify orders. Nurses always have to clarify the orders and then we put them in the system. We fax the admission orders to the doctor, and we talk over the phone and verify if it is correct and pharmacy will do a medication review to ensure that everything was transcribed correctly into [name of EHR platform]. When asked if the progress notes from the hospital packet are reviewed, she explained It depends, sometimes we only get discharge orders or progress notes. Sometimes the doctors will request more info from the hospital. It just depends on what the hospital sends us. When asked if R #1 returned on 04/02/23 with a Peripherally Inserted Central Catheter (PICC) (a form of intravenous access that can be used for a prolonged period of time or for administration of medications) for vancomycin, she explained I believe there was a progress note where they said he would not be discharged with the PICC line and he would instead receive oral antibiotics. He got here and didn't have a PICC, so we just followed the discharge orders however; the antibiotics were not listed on the discharge orders. K. On 04/25/23 at 2:59 pm, during an interview with the DON, when asked if the order for Clindamycin should have been administered for 21 days, she confirmed yes and explained that while entering the order into the EHR, it was done incorrectly for 21 administrations. L. Record review of nursing notes, dated 04/14/23, revealed Resident approached this nurse with a paper from an appointment he had on 4/11/23. The paper appears to be a copy of a progress note from a wound care visit. The paper requested the resident be admitted to the hospital for wound treatment. This nurse along with unit manager [RN #4] discussed this with the resident and he refused to go to the hospital. M. Record review of EHR revealed that R #1 passed away on 04/17/23, while in the facility. N. On 04/26/23 at 2:21 pm, during an interview with the DON, when asked how communication is executed between the facility and outside care, she explained that if there is a change in treatment, she expects the outside care provider to send the facility documentation of treatment changes. When asked about the note from R #1's follow-up visit on 04/11/23, she explained that the facility did not receive the note and that the outside care provider should have been more clear with his recommendations. When asked why a facility nurse didn't call to request notes from the follow-up visit, she explained, We have a lot to do in the facility. I would expect them [outside clinic] to send it. We probably did assume that there were no changes for him. When asked if the facility should have some type of communication process between outside providers, she confirmed yes.

Based on record review and interview, the facility failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Failure to provide R #10 anticoagulant medication (blood thinner) for 10 days likely resulted in R #10 experiencing a stroke [[CONDITION(S)] (a type of [CONDITION(S)], or stroke, which results in the loss of blood flow, nutrients, and oxygen to multiple regions of the brain, resulting in [CONDITION(S)] damage and subsequent neurological deficits)]. The findings are: A. Record review of R #10's EHR (Electronic Health Record) revealed that he was admitted on [DATE] with the following pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the Radiology physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Elequis can be re-started on May 12. C. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Fibb [[CONDITION(S)]]. Further review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Dated 05/03/22, [MEDICATION(S)] Tablet 2.5 MG Give 1 tablet by mouth two times a day for A.Fib until 05/06/2022 23: 59 STOP 5 DAYS BEFORE ANGIOGRAM MAY 11 2022. Dated 05/04/22, [MEDICATION(S)] Tablet 2.5 MG Give 1 tablet by mouth two times a day for A.Fib until 05/06/2022 23: 59 STOP 5 DAYS BEFORE ANGIOGRAM MAY 11 2022. D. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] E. On 07/20/22 at 1:15 pm, during an interview with the Center Nurse Executive (CNE), she confirmed that the medication was only to remain on hold until 05/11/22 and then resume on 05/12/22. F. Record review of nursing notes by RN (Registered Nurse) #1, dated 05/22/22, revealed Resident had some changes in cognition since Friday [05/20/22] progressively getting incoherent by the day. Unable to Follow Simple Commands. Spontaneous Eye Opening Confused on Verbal response Moves to Localize Pain E4V4M5 [a stroke scoring assessment where each ability to move upper and lower limbs, is a number between 0 and 4, 0 being normal functioning and 4 being completely impaired]. Sent to ER (emergency room ) for further Evaluation. G. On 07/19/22 at 9:39 am, during an interview, R #10's family member explained that R #10 was scheduled for an appointment to receive an angiogram (a scan that shows the blood flow through veins or arteries) on 05/11/22. To perform this scan, the performing physician ordered R #10's anticoagulant (medication that prevents the blood form clotting) to hold for 5 days prior to the appointment. She then explained that R #10 did not attend the angiogram appointment due to transportation issues and the that the anticoagulant medication did not resume as ordered. Later in his stay, he was sent to the hospital due a stroke. H. Record review of hospital documentation, dated 07/04/22, revealed that R #10 was in the hospital for 42 days and 18 hours where he presents with confusion and expressive asphasia . Found to have acute multifocal [CONDITION(S)]. I. On 7/20/22 at 11:05 during interview with CNA (Certified Nurse Aide) #2, she confirmed that after the stroke R #10 now requires hoyer lift (assistive device that assist in transfers between a bed and a chair or other similar resting places) with total support for transfers.

Based on record review and interview, the facility failed to notify the physician when a change in cognitive status (an individual's level of awareness with perception, reasoning, judgment, intuition, and memory) was observed for 1 (R #10) of 3 (R #10, R #11, and R #12) residents reviewed for change in condition. The delay in treatment likely resulted in R #10 experiencing a stroke [[CONDITION(S)] (a type of [CONDITION(S)], or stroke, which results in the loss of blood flow, nutrients, and oxygen to multiple regions of the brain, resulting in [CONDITION(S)] damage and subsequent neurological deficits). The findings are: A. Record review of R #10's EHR (Electronic Health Record) revealed that he was admitted on [DATE] with the following pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the Radiology physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Elequis can be re-started on May 12. C. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Fibb [[CONDITION(S)]]. Further review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Dated 05/03/22, [MEDICATION(S)] Tablet 2.5 MG Give 1 tablet by mouth two times a day for A.Fib until 05/06/2022 23: 59 STOP 5 DAYS BEFORE ANGIOGRAM MAY 11 2022. Dated 05/04/22, [MEDICATION(S)] Tablet 2.5 MG Give 1 tablet by mouth two times a day for A.Fib until 05/06/2022 23: 59 STOP 5 DAYS BEFORE ANGIOGRAM MAY 11 2022. D. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] E. On 07/20/22 at 1:15 pm, during an interview with the Center Nurse Executive (CNE), she confirmed that the medication was only to remain on hold until 05/11/22 and then resume on 05/12/22. F. Record review of nursing notes by RN (Registered Nurse) #1, dated 05/22/22, revealed Resident had some changes in cognition since Friday [05/20/22] progressively getting incoherent by the day. Unable to Follow Simple Commands. Spontaneous Eye Opening Confused on Verbal response Moves to Localize Pain E4V4M5 [a stroke scoring assessment where each ability to move upper and lower limbs, is a number between 0 and 4, 0 being normal functioning and 4 being completely impaired]. Sent to ER (emergency room ) for further Evaluation. G. On 7/21/22 at 12:16 pm, during an interview with the Staffing Coordinator, when asked to confirm who worked with R #10 on 05/19/22, 05/20/22, and 05/21/22, she explained that LPN #2 worked 05/19/22, RN #3 worked on 05/20/22 and 05/21/22. H. On 07/21/22 at 12:02 pm, during an interview with RN #1, when asked to explain R #10 at his baseline [regular day-to-day function], he explained He is very particular about how we help him. When asked to recall R #10 prior to his discharge to the hospital, he explained that upon starting his shift, he immediately saw that R #10 needed to go to the hospital. He then stated, When I was there, right before he was hospitalized , he was not answering questions appropriately. He wasn't making any sense. He used to know a lot about his meds [medications] but [before going to the hospital] he didn't know anything. When asked if the physician was notified of this change, he replied, Usually, the doctor is notified on what is going on. When I sent him out [to the ER] the physician was notified. RN #1 confirmed that he did not notify the physician of R #10's change in condition prior to 05/22/22. He stated I only work there 3 days a week. The day I sent him to the hospital [05/22/22], that was my first day for the week. When asked how he was aware that he was progressively getting incoherent by the day he replied, The nurse [that he was relieving] let me know during report [a reporting process where one shift will communicate with the oncoming shift] and when I did my assessments, I noticed the change. The nurse told me that he was different. I. On 07/21/22 at 12:35 pm, during an interview with RN #3, when asked to recall R #10 prior to his ER visit, he stated He was incoherent and confused. When asked how he became aware of his (R #10) confusion, he stated The nurse [from the previous shift] let me know of his changes. J. On 07/19/22 at 9:39 am, during an interview, R #10's family member explained that R #10 was scheduled for an appointment to receive an angiogram (a scan that shows the blood flow through veins or arteries) on 05/11/22. To perform this scan, the performing physician ordered R #10's anticoagulant (medication that prevents the blood form clotting) to hold for 5 days prior to the appointment. She then explained that R #10 did not attend the angiogram appointment due to transportation issues and the that the anticoagulant medication did not resume as ordered. Later in his stay, he was sent to the hospital due a stroke. K. Record review of hospital documentation, dated 07/04/22, revealed that R #10 was in the hospital for 42 days and 18 hours where he presents with confusion and expressive asphasia . Found to have acute multifocal [CONDITION(S)]. I. On 7/20/22 at 11:05 during interview with CNA (Certified Nurse Aide) #2, she confirmed that after the stroke R #10 now requires hoyer lift (assistive device that assist in transfers between a bed and a chair or other similar resting places) with total support for transfers.

Based on record review, observation, and interview, the facility failed to ensure that 2 (R #s 29 and 83) of 2 (R #s 29 and 83) resident's noted to have facility acquired Pressure Ulcers (PU's) [localized injury to the skin and/or underlying tissue usually over bony prominence, as a result of pressure, or pressure in combination with shear {applied force causing a sliding motion that cause tissues and blood vessels to move in such a way that blood flow may be kinked}, and/or friction [rubbing motion}] received all needed services to prevent development of and provide timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Not completing weekly skin assessments/observations to monitor for new skin injury so care could be implemented timely and minor skin injury would not become more serious for R #29 and R #83. 2. Not accurately completing wound assessments [to include size measurements, description of tissue, wound drainage and the appearance of the skin around the wound] upon admission, when wounds were first noted and at least weekly thereafter for R #s 29 and R #83 3. Not implementing new wound orders/interventions for 3 days after the pressure wound was identified for R #29. These deficient practices likely resulted in R #29 developing an unstageable PU [the depth of damage is not known due to being obscured [hidden] by the dead tissue overlying it] and may likely result in other resident's developing PU's than they might otherwise have, because the skin defect(s) is not noted timely and treatment implemented to prevent further skin damage. The findings are: A. Record review of policy titled, NSG236 Skin Integrity Management Revision date 06/01/21 revealed, Perform skin inspection on admission/readmission and weekly .Perform wound observations and measurements and complete Skin Integrity Report [a document that would record the wound assessment] .upon initial identification of altered skin integrity, weekly . Findings for R #29 B. Record review of admission record revealed R #29 was initially admitted on [DATE] and most recently readmitted on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of nursing progress notes for R #29 dated 12/24/21 to 02/10/22 revealed no mention of any wounds to the right hip area. D. Record review of the available skin assessments/observations that refer to the right hip ulcer after readmission on 12/24/21 for R #29 revealed: 1. On 02/10/22 at 9:54 pm, the Interact SBAR [Situation, Background, Assessment, Recommendation,[a method for health care professionals to communicate effectively with one another] Communication Form, This change of condition .Skin wound or ulcer this started [was first noted] on: 02/10/22 .Pressure [PU] .unstageable wound to right hip. 2. On 02/14/22 at 9:08 am, in the nursing progress notes, unstageable wound on right hip .dressing changed. Less purple and more red in color. 3. On 02/15/22 at 9:08 am, unstageable discoloration to right hip. 4. On 02/16/22 at 9:08 am, management unstageable wound on right hip .Dressing intact . No drainage noted. No C/O [complaint of] pain to area. 5. On 02/18/22 at 3:05 am, Res [resident] w/ [with] unstageable to R [right] hip (new) 6. On 03/01/22 at 7:06 pm, in the nursing progress notes, Wound on right hip beginning to change. Purple in color & hardened with edges lifting. [resident] Denies pain. 7. On 03/09/22 at 10:40 am, the first, Skin Check, was documented, Pressure .unstageable to right hip. 8. On 03/16/22 at 10:40 am, the second Skin Check, was documented, Pressure .unstageable to R [right] hip. 9. There were not measurements of the wound documented on any of the skin assessment/observations. 10. There was no initial skin check for R #83 upon re-admission on 12/24/21. E. Record review of the Order Recap Report, for orders on treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with Allevyn [a wound dressing that provides a thin foam for protection of impaired skin and absorption of moisture] 3. Turn side to side Q [every] 2 hours in bed 4. Air mattress [a mattress meant to decrease pressure , friction and shear forces to skin] for Unstageable Pressure Ulcer to R. Hip. F. On 03/16/22 at 7:25 am, during an interview with Registered Nurse (RN #3) who revealed, we all [staff nurses] do our own wound care [change the topical dressings] and someone who says they can come in for extra time that week [a staff nurse ] comes in once a week and does the measurements/assessments. G. On 03/22/22 at 11:01 am, during observation of wound care to R #29's right hip PU by RN #1 the ulcer is approximately 3 centimeters [cm's] top to bottom and X 6 cm's side to side and is covered with black-brown dead tissue. H. On 03/22/22 at 11:10 am, during an interview with RN #1, she revealed R #29's right hip PU appeared to her to be the same as the previous time she had seen it a week or more ago. I. On 03/22/22 at 12:40 pm, during an interview with the Director of Nursing (DON), she confirmed that, Skin Checks, should be completed weekly on every resident by the nurse caring for the resident. DON also confined that the first time the right hip wound on R #29 was identified by staff and documented was on an incident report dated 02/10/22 at 9:00 pm in which the wound was identified as unstageable. DON confirmed that there were no recorded measurements or complete assessments of the right hip wound documented since identified on 02/10/22 until present. Findings for R #83 J. Record review of admission assessment for R #83 revealed he was initially admitted on [DATE] and most recently readmitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . K. Record review of available Skin Check, documentation for R #83 since most recent admission on 01/13/22 revealed: 1. On 01/14/22 at 2:00 pm, The following New skin injury/wound(s) were identified: Pressure Area(s): Location(s): coccyx [tail-bone] there was no measurements or other observations/assessment documented. 2. On 01/28/22 at 3:51 pm, New skin Injury/Wound(s) identified .Yes .Pressure .coccyx there was no measurements or other observations/assessment documented. 3. On 02/11/22 at 3:51 pm, Skin Injury/Wound Identified .No L. Record review of the, Skin Integrity Report, documentation available for coccyx ulcer since most recent admission on 01/13/22 for R #83 revealed: 1. On 01/27/22 [not timed] Coccyx .Pressure . 1.00 cm length 1.00 cm width 0 cm depth .Stage 1 [when depth of tissue damage can be seen, PU's are classified/staged from 1 to 4 based on the layers of tissue affected, a stage one only involves the outer most part of skin and does not involve loss of skin tissue {not an open wound}, a stage two is slightly deeper often involving the outer and next deeper level of skin, a stage 3 goes through all layers of the skin and involves the fatty tissue under the skin layers, a stage 4 PU is the most severe stage and denotes a wound that affects skin, fatty tissue, muscle and sometimes bone] exudate [drainage] none .Tissue Type Closed 100 % 2. On 02/10/22 [not timed] Coccyx .Pressure . 0 cm length 0 cm width 0 cm depth .Stage 1 . exudate none . 3. On 03/22/22 [not timed] Coccyx .Pressure .Healed M. On 03/22/22 at 12:40 pm during an interview with the the DON confirmed that the documentation of the coccyx ulcer observations/assessments was not completed weekly. N. On 03/22/22 at 8:20 am, during an interview with RN #3 she revealed that R #83 no longer had a coccyx ulcer. It was healed yesterday but I wanted to check it again today before discontinuing the dressing. O. On 03/22/22 at 9:48 am, during observation of skin care to coccyx area for R #83 by RN #3 there was no PU.

Based on observation, record review and interview, the facility failed to: 1. Maintain acceptable parameters of nutritional status. 2. Recognize the nutritional needs of an at risk resident already experiencing impaired nutritional status by only having staff available to assist her with eating twice each day (12 hours interval). 3. Provide R #1 with preferred nutritional needs to obtain residents highest practicable level of well-being for 1 (R#1) of 3 (R#1, 4, and 5) This deficient practice likely resulted in resident not receiving the required nutritional support she needs. The findings are: [NAME] On 02/17/20 at 9:50 am during observations R#1 was observed sitting in her room, she was wearing clothing that appeared to be too large and R #1 appeared to be very thin and underweight. In the room was a small personal refrigerator. Inside the refrigerator were a number of small individual pureed food pouches (fruits and vegetables) with a sealed screw top. Each pouch indicated it provided 130 calories per pouch. B. Record review of R#1 face sheet dated 02/17/20 revealed that her date of birth was 04/20/73 and she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Dysphagia, (difficulty swallowing) Oral Phase Dysphagia, Oropharyngeal phase (From the mouth to the upper throat) Dysphagia, Pharyngeal phase (from the upper throat to the esophagus) Personal History of [MEDICAL CONDITION] Adult Failure to Thrive Muscle Weakness (Generalized) Dysphagia unspecified Feeding Difficulties Diarrhea unspecified Encounter for Health Counseling related to Travel Unspecified Speech Disturbances Weakness Other Specified Disease of Blood and Blood-Forming Organs [MEDICAL CONDITION] (low function of the [MEDICAL CONDITION]) unspecified Adjustment [MEDICAL CONDITION] (difficulty sleeping Extrapyramidal and Movement Disorders (Abnormal, Involuntary muscle movement) [MEDICAL CONDITION] ([MEDICAL CONDITION] disorder) unspecified not Intractable (unstoppable) without [DIAGNOSES REDACTED] (continuous recurring [MEDICAL CONDITION]) Migraine (headache) unspecified not intractable without status migrainosus (continuous recurring headache) [MEDICAL CONDITION] (lack of muscular control to one side of the body) and [MEDICAL CONDITION] (weakness to one side of the body) following Cerebral (brain) Infarction (stroke) affecting right dominant side Neuromuscular Dysfunction of Bladder unspecified Difficulty in Walking not Elsewhere Classified Anorexia (an eating disorder characterized by low body weight, a fear of gaining weight and low self-image) Unspecified Intracranial (brain) Injury without loss of consciousness History of Falling C. Record review of R#1 weights revealed the following: 12/07/18 106.9 LBS (pounds) 01/04/19 100.5 LBS MDS: -5.0% change over 30 days 01/18/19 94.6 LBS -7.5% change 02/01/19 93.6 LBS -7.5% change 02/08/19 96.2 LBS -7.5% change 02/15/19 97.3 LBS -7.5% change 02/22/19 93.4 LBS -7.5% change 03/02/19 93.8 LBS -7.5% change 04/02/19 89 LBS 7.5% change 05/02/19 89 LBS -7.5% change 05/17/19 89.5 LBS -7.5% change 06/04/19 89 LBS MDS: -10% change over 180 days 07/15/19 89.7 LBS 08/04/19 89.5 LBS 09/11/19 93.5 LBS 10/15/19 86.9 LBS MDS: -5.0% change over 30 days 12/16/19 86.9 LBS (Last weight obtained-Refused) 02/09/20 86.2 LBS D. Record review of daily notes dated 11/20/19 states A nutrition Assessment was completed today. The resident's nutrition concerns category score is Nutrition Problems. There are nutrition problems. NC-3.1 underweight E. Record review of daily progress note reveals the following dietary related notes: 02/16/20 every 12 hours related to ADULT FAILURE TO THRIVE offer and assist with nutritional pouch twice a day, assure CNA (Certified Nursing Aide) or Nurse is present during consumption of nutritional pouch. 02/17/20 .86.2 LBS (Pounds), Staff are tasked offer and assist with nutritional pouch twice a day, assure CNA or Nurse is present during consumption of nutritional pouch . F. Record review of Minimum Data Set ((MDS) dated [DATE] reveals: Section C BIMS (Brief Interve of Mental Status) Summary Score=15 (0=lowest, 15=highest functioning status) Section D Resident Mood Interview=Feeling down, depressed or hopeless=1 (1=yes/0-1 days per week), Poor appetite or over eating=2 (Yes/2-6 days per week) Section [NAME] Rejection of Care=1 (behavior occurs 1-3 days per week) Section G Functional Status-ADL (Activities of Daily Living)= extensive assistance with eating self performance Section J Health Conditions=no pain, [NAME] Record review of R#1 care plan dated 02/17/20 reveals: R#1 requires assistance/is dependent for ADL (activities of daily living) care in eating. The care plan does not reveal any intervention related to eating assistance. H. Record review of R#1 physician orders [REDACTED]. This is an active order. I. Record review of R#1's Medication Administration Record [REDACTED]. This record indicates that starting on 02/13/19 at 6:00 pm and every twelve hours thereafter the pouch has been offered and consumed with one refusal 02/16/20 at 6:00 pm K. On 02/17/20 at 9:50 am during interview with R#1 she stated that she hates the food provided by the facility kitchen and that it makes her sick so she doesn't eat any of the facility provided meals or snacks. She stated that she is a vegetarian and that she purchases her own foods which she keeps in her refrigerator in her room. She stated that these foods are consistent with her dietary needs and her preferences for a vegetarian diet. She stated that due to her tremors and muscle weakness she is unable to open the packets without assistance,and when she eats, she has to rely on staff to assist her with opening her food packs. She reported that she is uncertain wheather she would eat more if she was offered more food but assistance in opening the food pouches is not offered more than twice a day. She stated that in the past, this (more offers to assist with opening pouches) seldom happened. She stated that the prior week, on or about 02/13/20, she and her counselor participated in a care plan meeting in which it was decided that staff would assist her with the opening and consumption of a (one) food pouch twice daily. She stated that as of 02/17/20 staff had come to her room both morning and night and offered to assist her with opening and consuming a (one) food pouch. She stated that on one occasion she had refused. [NAME] On 02/18/20 at 8:45 am during interview with R#1's Advocate/Friend (ADV), she stated that she is a counselor with an outside facility who has known R#1 for 2+ years. She stated she was present and attended the last care plan meeting and that during this meeting there were negotiations regarding R#1's need for assistance when eating. ADV stated the facility was insisting that R #1 come to the dining area for meals where assistance would be more available and it was also decided that R #1 would be allowed to eat in her room and the assisted feeding would be done twice daily at 6:00 am and 6:00 pm because this would be done by the night shift staff and this staff would have more time to assist her. L. On 02/18/20 at 11:10 am during interview with Registered Dietician (RD), she confirmed that she was aware of R#1's weight loss but stated that her weight had been stable for the past several months. She confirmed that R#1's BMI was about 13 and that this ideally should be 18+. She further confirmed that R#1 was vegetarian and had very specific dietary requests. She stated that she believed that the facility could not provide her dietary requests as her foods were not a part of the suppliers foods. RD stated that R#1 often goes out for appointments and while out, she purchases certain foods that meet her dietary needs for a pureed diet and met her specific dietary desires. She stated that in her monitoring of R#1's progress that she was believed that R#1 would consume between 700 and 1000 calories per day and that this was barely adequate to sustain her needs. RD also confirmed that R #1 was unable to feed herself due to her tremors and weakness and that R #1 required a great deal of supervision when eating. M. On 02/18/20 at 2:25 pm during interview with Director of Nursing (DON) she stated that there was a care plan meeting that occurred on 02/13/20 and at this meeting it was decided that the need for R#1 to receive meal time assistance would become a physician's orders [REDACTED]. DON confirmed that she was aware of R#1's special needs for assistance at meal time and her desire to consume specific foods. She confirmed that R#1 could not open her own food containers and therefore required dining assistance. DON also confirmed that R #1 purchases her own food for consumption from a local grocer, and the facility does not provide any of the food that is consumed by R #1. DON also confirmed, that food consumed by R #1 is not available from food vendor used by the facility, so therefore R #1 is left to purchase her own food for consumption.

Survey team entered the facility responding to a complaint regarding urinary catheter (urinary catheters are hollow, partially flexible tubes that collect urine from the bladder) care. R #1 unknowingly had an obstructed urinary catheter and was complaining of pain in the morning of 10/12/16 and the Hospice Nurse arrived in the afternoon and drained 2500 cc (cubic centimeter) of urine. During interview, staff confirmed that although they noticed the empty urinary catheter bag, during their shift they had assumed that the urinary catheter bag was recently emptied. During further investigation, the team discovered that another resident, R #2 had also recently had a obstructed urinary catheter that went unnoticed by staff, until family alerted staff that the urinary catheter bag was empty. At this point, it was addressed by staff and staff was able to drain 2 bags of urine from R #2. Interview with staff revealed inconsistencies with how and who provides urinary catheter care, when concerns are reported to Nursing staff, and inconsistencies with documenting urinary catheter output. This resulted in Immediate Jeopardy (IJ) being identified. The facility Administrator, Acting Director of Nursing (DON) and Regional Nurse were notified of the immediate jeopardy on 10/27/16 at 3:53 pm. The first Plan of Removal (POR) was received on 10/27/16 at 4:55 pm and was rejected at 5:14 pm. The second Plan of Removal was received on 10/28/16 and accepted at 8:18 am. This resulted in the scope and severity to be lowered from a K, Level 4 to a G, Level 3. The Plan of removal included the following: 1. The DON/designee will in-serviced all working nursing/ Certified Nursing Assistant (CNA) staff today, October 27, 2016, on Indwelling Foley/ Suprapubic (an indwelling catheter is fixed in a person's body for a long period of time, with a flexible tube that is often passed through the urethra and into the bladder. Suprabpubic Catheter is a surgically implanted flexible rubber or plastic tube that is placed directly into the bladder and is used as a urinary drainage method) catheter and filling out the Activities of Daily Living (ADL) sheets per the IJ notification reason as provided to the center Licensed Nursing Home Administrator (LNHA). 2. Changes in resident condition due to the Foley catheter/Suprapubic catheter (eg. no urine output for 8 hours, blood in catheter bag, straw-colored, dark or red and clarity such as cloudy, solid particles, odor and any other unusual Signs/Symptoms (S/S)) will be reported to Medical Director (MD)/Nurse Practitioner (NP) and family member/Power of Attorney (POA) and placed on the 24-hour report tool by the floor nurse and discussed at the daily stand-up meeting with the center Inter-Disciplinary Team (IDT). In-service will be done by the DON/designee with nursing staff/CNA's on filling out the ADL sheets and placing the urine output on the ADL sheet. CNA's will also be responsible to empty the Foley/Suprapubic catheters on assigned residents , the process will be monitored by the Charge nurse assigned to the hall. Follow up will be done by the DON/designee daily for 2 weeks then monthly times 1 month. Any negative finding will result in one on one training/disciplinary actions and brought to Quality Performance Improvement Plan (QPIP) monthly meeting. Monitoring will continue as long as the residents have Foley/Suprapubic catheter by charge nurse every (Q) shift and assure documentation has been done before CNA's leave their shift. 3. The resident's MD will be notified by the floor nurse of any changes in condition for additional orders, diagnostic testing, follow-up and assessment/evaluation. However, nurses at (Name of facility) will use nursing judgment in instances requiring emergency transport to acute care, even without an MD order unless otherwise stated int he resident's advance directive. The MD and Responsible Party notification will occur following the acute transport in these emergency situations as patient safety is the first priority. 4. All oncoming nursing/CNA staff going forward will be in-serviced at the beginning of their shift on the center Stop and Watch (Early Intervention) principles related to informing the floor nurse of observed changes in the resident's urine output from the Foley/Suprapubic catheters. New nurses/CNA's will be in-serviced as part of their classroom orientation. 5. All oncoming nurses/CNA's will be in-serviced by DON/designee at the beginning of their shift. 6. Residents with Foley/Suprapubic catheters will be re-assessed to assure no negative outcome has occurred. Any negative findings will be reported to the MD and Responsible Party. New orders will be implemented upon notification, if necessary. Based on record review and interview, the facility failed to provide the necessary care and assistance to maintain the highest practicable physical well being for 2 (R #1 and 2) of 8 (R #1, 2, 9, 10, 11, 12, 13 and 14) residents reviewed for urinary catheter care by: 1. Not identifying that an empty urinary catheter bag may be an indicator of obstruction. 2. Not monitoring for urine output. 3. Not responding timely to a change in condition and providing immediate treatment/care. These deficient practices is are likely to result in residents not receiving appropriate urinary catheter care, which puts residents at risk for pain/discomfort, developing urinary catheter infections [MEDICAL CONDITION]. The findings are: A. On 10/26/16 at 3:16 pm, during an interview with CNA #2, she stated, We are to document urine output on all residents that have a catheter. Night shift empties the catheter bags. B. On 10/26/16 at 3:24 pm, during an interview with CNA #3, she stated, When we come on shift most of the time we check the catheter bag, the night shift tells us if they emptied it. It should be draining if the resident is drinking sometimes it is kinked or they are sitting on it. We should report it to the nurse if there is an empty bag. C. On 10/27/16 at 8:15 am, during interview RN #1 stated Intake and output should be recorded daily in the accu-nurse system by nursing staff. D. On 10/27/16 at 8:20 am, during an interview with the Minimum Data Set (MDS) coordinator, she stated, I put a Activities of Daily Living (ADL) tracking form in the ADL book. For foley output I would put the total output for the shift, staff should be checking residents several times per day. If staff are doing rounds every 2 hours they should be doing foley care every 2 hours. For the output on the foley they should put a running total for the shift, if they empty it 3 times they just add it up 3 times. It (total output) is not in a permanent note and they just do the total for that shift. I don't know their policy at this facility for foley care. E. On 10/27/16 at 8:36 am, during an interview with Nurse Specialist, she stated, Urine Intake and Output should be documented on the ADL flow sheet daily if it is ordered by the physician. If there was no urine output the CNA would tell the nurse and the nurse would document it on the treatment sheet. If there is an empty box in the ADL flow sheet that means they (CNA) did not document. F. On 10/27/16 at 1:24 pm, during an interview with Anonymous Staff AS #1, she confirmed staff does not always communicate to each other as to when foley catheter bags are emptied. Hallway assignments are not always done so it is hard to know what residents staff are responsible for on the unit. G. On 10/27/16 at 1:46 pm, during an interview CNA #4, she stated, CNA's are all responsible for all the residents on the unit which consists of 3 sections. H. On 10/27/16 at 2:02 pm, during an interview with CNA #5, she stated, CNA's are assigned a hallway and work 3 sections we all work together and we are all responsible for all the residents on the hallway and the 3 sections. I. On 10/27/16 at 2:06 pm, during an interview with CNA #6, she stated, We (CNA's) empty the foley bags and record the output in the ADL Sheet. We are assigned a hallway and we all work together, but as busy as we are things can get missed. J. On 10/27/16 at 3:15 pm, during an interview with RN #3, she stated, I as a nurse do not document on input and output. Findings for R #1: K. Record review of the departmental nursing notes dated 10/13/16 revealed, Late note for 10/12/16 at 12:30 pm. This writer (RN#1) was alerted by staff that the resident was not feeling well. When spoke to the resident he said that he had diarrhea last evening and that he was not having any output from urinary catheter. Leg bag noted to have a scant amount of urine in it. This writer (RN #1) then went to go get equipment to do vitals and to possible change catheter when Hospice Registered Nurse (HRN) #1 from hospice came in. HRN #1 stated that (R #1's) family called him to let hospice know he was not feeling well. HRN #1 did the urinary foley catheter change and stated there was large amount of output that was cloudy. Resident susceptible to Urinary Tract Infections (UTIs) [MEDICATION NAME] (medication used to treat urinary tract infections) 500 mg (miligrams) ordered qday (daily) x (times) 5 days to start 10/12/16 evening. It came in and was given. Continue to monitor. (sic) L. On 10/25/16 at 8:45 am, during observation, R #1 was sitting in his room on his bed and his urinary catheter tube was on the bare floor. M. On 10/25/16 at 8:53 am, during an interview with family member (FM) #1, she stated, It is the lack of care with his foley catheter, on that day (10/12/16) he (R #1) was in pain and he couldn't get anyone to respond, so he called me then I called hospice and met him (HRN #1) at the facility. She further explained that R #1 had a distended abdomen when they (FM #1 and HRN #1) arrived at his room; HRN #1 drained 2500 cc (cubic centimeters) of urine from his catheter. R #1's (urinary catheter) bag had blood in it and R #1 was in agony. FM #1 stated, I believe that no one had monitored R #1 for 12 hours. The dangers are that his bladder could rupture and he could get a bladder infection. CNA's are non-existent or are overworked and sometimes you can't find a nurse so the response time is slow. N. On 10/25/16 at 2:46 pm, during an interview with HRN #1, he stated, I got a call from (name of R #1's) sister around 11:30 am, he had called her (FM #1) about his stomach not feeling well. HRN #1 further stated I got to the facility at 12:25 pm, met with the nurse (RN #1) and (name of R #1). I asked how he was feeling, looked at his bag and noticed there wasn't any urine going into the bag and his stomach was distended. I told (FM#1) that I would have to change the bag. When I changed the catheter out the urine was cloudy and 900 cc of urine flowed into the leg bag (catheter bag attached to the leg) and I emptied another 900 cc of urine into another bag. Then I changed the bag and a fire drill went off so I took him outside and the urine kept flowing and it looked cloudy for a UTI. At the end 2500 cc of urine were calculated. When asked if prior to this had he seen them (facility staff) emptying out the foley bag, HRN #1 stated, No, I was concerned about them not emptying the foley bag, so I put him on a larger bag. O. On 10/25/16 at 3:46 pm, during an interview with RN #1, when asked about the incident with (name of R #1) on 10/12/16, she stated that she went in to check on him, HRN #1 arrived, changed the catheter and put him on an antibiotic for a possible UTI. HRN #1 told her he had drained a large amount of urine. RN #1 stated The CNA's do the catheter care and they check the foley bag daily in the morning, afternoon, evening and report if there isn't any output, the normal process is to empty it before they go home, give a report on every resident to the next shift as to their (resident) status and chart the urine output on the Medication Administration Record [REDACTED]I would imagine they would. RN #1 confirmed there was no urine output reported for (name of resident). P. On 10/25/16 at 4:30 pm, during interview with the Nurse Specialist regarding R #1, she stated, They (CNA staff) are not going to follow (name of R # 1) around and keep checking on him to see if his foley bag is full. The staff is only going to empty the foley bag at the end of the shift or if it is full. Q. On 10/25/16 at 4 :50 pm, during an interview, RN #2 stated that she could not remember if she had checked R #1's foley bag in the morning. She believed that the night staff had emptied the foley bag which is why she may have not alerted staff about the empty bag. RN #2 stated, It is safe to say that catheter care is not always done and just about a week ago they started charting urine output. R. On 10/26/16 at 9:41 am, during an interview with R #1, when asked if he told staff that he was having problems on the day of 10/12/16, he stated I think so. I used my call light, but no one answered and I didn't have the number to the nurses station so I called my sister. After (name of HRN# 1) took care of me (emptied the catheter) I felt relief. S. Record review of Care Plan dated 04/22/16 reveals, Foley cath care q (every) shift and PRN (as needed). Keep F/C (foley catheter) drainage tube free from kinks. Report changes to characteristics of urine such as color, odor, sediment. Catheter care per protocol Q shift and intake and output Q shift. T. Record review of the CNA-ADL tracking form dated 10/01/16-10/31/16 reveals urine output was charted 26 out of 90 opportunities. Findings for R #2: U. On 10/26/16 at 8:42 am, during an interview with R #15 (R #2's wife that is also resident at this facility), she stated that she had concerns about staff not checking the cateter bag when it was empty or providing catheter care for her husband. She further stated that her son (family member #2) had alerted staff that R #2 was in pain and his foley bag didn't have any urine in it. On 08/09/16 after staff removed the foley, they discovered a blood clot had caused an obstruction and prevented urine from flowing. Once the blood clot was removed urine began to flow and filled two catheter bags. V. Record review of the departmental nursing notes dated 08/09/16 revealed Resident (R #2) family member reported to the writer that they noticed that the resident had not urinated in his foley bag all day. Resident was assessed. Distended abdomen and pain upon touch noticed. Medical Director (MD) called to notify of new findings. Received a verbal order to 1.) Flush/irrigate the foley and to 2.) Foley replacement after irrigation if needed. Resident foley was then irrigated. Foley catheter still did not let out any urine so the writer began to remove the catheter. Upon removal of the catheter, a blood clot was noticed to have been blocking drainage. Clot removed and the foley began to drain the urine. Resident immediately showed relief of distension and no more facial grimacing of pain.(sic) Signed (name of nurse) W. On 10/26/16 at 2:50 pm, during an interview with Certified Nursing Assistant (CNA) #1, she stated, When I come on shift I empty the bag and record how much urine output they had in accunurse (a voice activated head set system used for documenting medical information), if they have no output I report it to the nurse and push (encourage to drink) fluids. Sometimes it is because the tube is bent. Some people don't chart. X. Record review of care plan for R #2 dated 08/04/16 reveals: Problems: alteration in elimination AEB (as evidenced by) bowel incontinence, risk for complication r/t (related to) {F/C} (foley catheter) use. Approaches: Foley Cath Care Q shift and PRN. Keep F/C drainage tube free from kinks. Report changes to characteristics of urine such as color, odor,sediment. Y. Record review of CNA-ADL Tracking form dated 09/01/16-09/30/16 reveals urine output for R #2 was charted 49 out of 90 opportunities. Z. Record review of CNA-ADL Tracking form dated 10/01/16-10/25/16 reveals urine output for R #2 was charted 55 out of 75 opportunities. AA. Record review of facilities Policies and Procedures on Catheter Care, Urinary dated October 2010 reveal: Input/Output 1. Observe the resident's urine level for noticeable increases or decreases Maintaining Unobstructed Urine Flow 1. Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Infection Control: b. Be sure the catheter tubing and drainage bag are kept off the floor. d. Empty the collection bag at least every eight (8) hours. Complication: 1. Observe the resident for complications associated with urinary catheters. a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify supervisor. b. Check the urine for unusual appearance (i.e., color, blood,ect.). c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. e. Observe for other signs and symptoms of urinary tract infection or [MEDICAL CONDITION]. Report findings to the physician or supervisor immediately. Managing Obstruction: 1. If the catheter material is contributing to obstruction, notify the physician and change the catheter if instructed to do so. 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.

During tour of the facility, there was a cart located outside a resident's room, room [ROOM NUMBER]. On the cart, there were 2 previously worn isolation gowns and a dirty glove on the floor. There was no sign on the resident's door indicating any precaution. Upon further review of the resident's medical record and through interview with staff, the resident had a Methicillin resistant Staphylococcus aureus(MRSA: contagious and antibiotic resistant staph bacteria that leads to potentially dangerous infection) [DIAGNOSES REDACTED]. Interview with staff revealed a lack of knowledge regarding the infections and what precautions should be taken. Observation of the resident's room and staff inside the room revealed poor infection control practices. This resulted in Immediate Jeopardy (IJ) to be identified. The facility Administrator and Acting Director of Nursing (DON) were notified on the immediate jeopardy on 09/20/16 at 11:04 pm. The first Plan of Removal (POR) was received on 09/21/16 at 4:42 pm and was rejected at 5:25 pm. The second Plan of Removal was received on 09/22/16 at 12:05 pm and rejected at 12:25 pm. The third Plan of removal was received on 09/22/16 at 2:05 pm and was rejected at 2:37 pm. The forth Plan of Removal was received on 09/22/16 at 2:50 pm approved at 2:55 pm. This resulted in the scope and severity to be lowered from a L, Level 4 to a F, Level 2. The Plan of Removal included: 1. Signage was reposted on door, room [ROOM NUMBER] Please see nurse prior to entering. 2. Trash can with red bag was placed in room by door for placement of gloves/gowns prior to exit. 3. Any disposable articles were disposed of in the room. 4. Used gown on top of cart were removed immediately and disposable gowns were made available. 5. Staff re-educated upon notification of IJ status on contact precautions and how to respond appropriately. All staff will be in-serviced on isolation, universal and contact precautions prior to working on the floor. 6. Charge Nurse responsible to give report to CNAs that will include residents on infections control precautions. Based on observation, record review and interview, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment to prevent the transmission of infection by: 1. Not providing singage on door to alert others that a resident on isolation precautions. 2. Not properly disposing of dirty gloves and gown. 3. Not having available equipment, including biohazard trash can prior to exiting room for staff to disrobe and gowns. 4. Not informing all staff if a resident is on contact precautions. 5. Removing resident from contact precautions without providing physician all necessary information to make a decision. This deficient practice has the potential to affect all 101 residents identified on the resident census list provided by the Administrator on 09/20/16. If the facility does not maintain appropriate infection control practices, then residents are likely to be exposed to disease and infection which can affect their health and safety. The findings are: A. Record review of the facility's Infection Control Policy and Procedure Manual: Isolation- Initiating Transmission-Based Precautions revised August 2012 revealed When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks etc) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware that they must first see a nurse to obtain additional information about the situation before entering the room. c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. B. On 09/20/16 at 8:32 pm during observation, there was a precaution cart sitting outside room [ROOM NUMBER] (R #4's room). No sign on door. One dirty glove on floor and two dirty/previously worn gowns balled up on top of the cart. C. On 09/20/16 at 8:36 pm during interview with Certified Nurse Aide (CNA) #9 who was walking down the hallway, when asked about the cart, she stated I'm not sure. That's North unit. CNA confirmed she is working on the South Unit. D. On 09/20/16 at 8:37 pm during interview with CNA #8, He confirmed that R #4 is on isolation precautions for MRSA for the last month. When asked what isolation precautions are, he stated We (staff) have to wear gloves, masks and gown anytime we go into the room. When asked how someone would know if someone is on precautions, he stated There should be a sign to see the nurse before entering the room. E. On 09/20/16 at 8:42 pm during observation, CNA #8 walked by the cart in front of R #4's room and picked up the dirty gowns and glove and placed in a red biohazard bag. F. On 09/20/16 at 8:49 pm during observation, there is a sign laying on top of the cart that reads: Please see nurse before entering. The sign is only visible if standing directly in front of the cart. G. On 09/20/16 at 9:09 pm during an interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #2, DON stated resident in room [ROOM NUMBER] (R #4) has a [DIAGNOSES REDACTED].#2 stated It's (procedure) contact isolation, so you need gowns and gloves to go into the room. H. On 09/20/16 at 9:11 pm during observation outside of room [ROOM NUMBER], the isolation cart is empty of isolation gowns. There was also no a sign on the door alerting staff/visitors about the isolation precautions. I. On 09/20/16 at 09:13 pm during observation and interview LPN #2 verified there is not a sign on the residents door stating There was a sign on the door, it must have fallen off, she further verified the cart outside the resident room [ROOM NUMBER] is empty of isolation gowns. LPN #2 stated (Name of R #4) has a wound on her knee, that has been diagnosed with [REDACTED].#2 was observed walking down the hall and returning with cloth patient gowns from the linen room stating I guess we are out of the paper gowns; I will ask (name of DON). J. On 09/20/16 at 09:22 pm during observation LPN #2 applied cloth gown and gloves then knocked and opened door of room [ROOM NUMBER] she did not go in, spoke to R #4 from the hallway. Resident stated she needed help. LPN #2 walked away down hall stating I will get the CNA and did not return. K. On 09/20/16 at 09:25 pm during interview with LPN #1 she stated she had not been educated or updated in the last three months in reference to residents with infections and was not taking care of the resident in room [ROOM NUMBER]. LPN #1 stated I think the isolation is MRSA, not sure. L. On 09/20/16 at 9:22 pm during observation CNA #7 entered R #4's room, wearing an untied paper gown and was pushing a large (55 gallon container) gray container with a red biohazard bag inside. CNA #7 applied gloves while in the room and placed the container in the bathroom. CNA #7 asked if R # 4 needed help, R #4 asked for water. CNA # 7 took R #4's water pitcher, left the room with her gloves and gown on. CNA #7 while in the hallway removed her gown and gloves and tossed both in the Nourishment room trash can. Prior to entering R #4's room, she put on another gown and gloves and placed the pitcher on the table. CNA #7 then removed her gown and gloves, tossing both in the gray container which she had placed in the bathroom. In a separate trash container in the bathroom there was a red biohazard bag with items inside. M. On 09/20/16 at 9:28 pm during interview with CNA # 7, she confirmed that there was a red biohazard bag in the bathroom trash can. N. On 09/20/16 at 10:34 pm during observation and interview, in room [ROOM NUMBER], there is a red biohazard bag in the bathroom trashcan mixed with regular trash. CNA #7 confirmed the red bag should be in a red bin instead of the regular trashcan. O. On 09/20/16 at 9:47 pm during interview with CNA #8, when asked how would he know if a resident was on precautions, he stated that usually there is a sign to see the nurse on the door. CNA #8 confirmed that there was no sign currently on R #4's room door (room [ROOM NUMBER]). CNA #8 stated that before entering the room to answer a call light, he would put gloves on and gown up. He confirmed that different CNAs gown up depending upon what they are doing. When asked about the gowns that were on top of the cart earlier, he confirmed that those gowns were dirty/previously worn. P. On 09/20/16 at 10:24 pm during observation of room [ROOM NUMBER], there is no sign visible on door, identifying that R #4 is on precautions or instructing others to see the nurse before entering the room. Q. On 09/20/16 at 10:40 pm during interview with R #4 and observation, when asked if everyone who comes into her room is wearing a gown and gloves, she stated Not everyone. Sometimes people do. R. On 09/20/16 at 11:05 pm during interview with the DON after the IJ was called, he stated that R #4's wound is self contained and that everything (wound care) is done at the wound clinic. DON confirmed that the expectation is that staff would still treat the precaution as a precaution and gown up. S. On 09/21/16 at 9:45 am during interview with RN #4, she confirmed that the physician was contacted this morning (09/21/16) and that R #4 was removed from contact isolation. RN #4 confirmed that the resident was out of her room and moving around on the unit. T. Record review of the Physician order [REDACTED]. U. On 09/21/16 at 9:51 am during interview with Medical Doctor #1, she confirmed that R #4 is having her wound dressing changed at the wound clinic and her Jackson Pratt (JP) drain (medical device used as a post operative drain for collecting bodily fluids from surgical sites) emptied at the facility. MD #1 stated that she saw the wound on the 14th (September 2016) and there was copious (abundant) drainage. V. On 09/21/16 at 10:00 am during observation of R #4's wound, RN #4 removed the knee brace from R #4's left leg. There was a green stain along both sides of the foam knee immobilizer aligned with the wound. The wound was draining through the side of the adhesive dressing. There was a foul odor. When asked about the drainage, RN #4 stated It's probably food. RN #4 confirmed that dressing changes are only done at the wound clinic. W. On 09/21/16 at 11:56 am during observation interview with the Wound Care Clinic Nurse (WCCN), she confirmed that R #4 was last seen at the Wound Clinic on the 12th (September 2016). WCCN removed the dressing for R #4 and there was a purulent (consisting of pus) soaked 4 x 4 (4 by 4 inch) wound dressing. As the WCCN cleansed the wound, it continued to consist of purulent drainage. X. On 09/21/16 at 11:59 am during interview with the Wound Care Medical Doctor (MD) #3 when asked if R #4 should be on precautions, he stated Yes, she needs to be on contact precautions, has to take her antibiotics and have her dressing changed. Y. Record review of the Medication Administration Record (MAR) for R #4 dated 09/01/16 to 09/21/16 revealed that Doxcycline (antibiotic) was to be administered twice daily, however the medication was circled as not given on 09/20/16 at 8:00 pm and 09/21/16 at 8:00 am. Z. On 09/21/16 at 2:29 pm during interview with the Assistant Director of Nursing (ADON), she confirmed that R #4 missed 2 doses of antibiotics and she was unsure why. AA. On 09/21/16 at 4:25 pm during interview with MD #2, he stated that he has been on call for MD #5 and the nurse called him this morning and told him that R #4 had finished her antibiotics and healed and asked if she (R #4) could be taken off contact precautions. MD #2 confirmed that he has never seen R #4 before but he relies upon the nurses to update him and usually trusts their judgement. When informed about the condition of R #4's wound and that she has missed antibiotic treatment, MD #2 stated that R #4 needed to be put back on contact precautions. BB. Record review of the CDC (Center for Disease Control) Guideline for Isolation Precautions: Table 2 provided by DON as the document the facility follows for precautions . Document reveals Skin or wound with Infection of MRSA Contact Precautions.

Based on observation, record review and interview, the facility failed to provide the necessary care and services to attain the highest practical physical well being for 1 (R #4) of 1 (R #4) resident reviewed for infection control by: 1. Not providing wound care treatment. 2. Not ensuring that R #4 was being administered her antibiotic medication. 3. Not identifying a change in condition for R #4 4. Not providing accurate information to the physician when requesting that R #4 be taken off contact isolation precautions. This deficient practice likely resulted in R #4's wound worsening and a delay in necessary treatment to promote healing. The findings are: A. On 09/20/16 at 09:13 pm during interview, Licensed Practical Nurse (LPN) #2 stated (Name of R #4) has a wound on her knee, that has been diagnosed with [REDACTED]. B. On 09/20/16 at 11:05 pm, during interview with the Director of Nursing (DON), he stated that R #4's wound is self contained and that everything (wound care) is done at the wound clinic. C. On 09/21/16 at 9:45 am, during interview with Registered Nurse (RN) #4, she confirmed that the physician was contacted this morning (09/21/16) and that R #4 was removed from contact isolation. RN #4 confirmed that the resident was out of her room and moving around on the unit. D. Record review of the Physician order [REDACTED]. E. On 09/21/16 at 9:51 am, during interview with Medical Doctor (MD) #1, she confirmed that R #4 is having her wound dressing changed at the wound clinic and her Jackson Pratt (JP) drain (medical device used as a post operative drain for collecting bodily fluids from surgical sites) emptied at the facility. MD #1 stated that she saw the wound on the 14th (September 2016) and there was copious (abundant) drainage. F. On 09/21/16 at 10:00 am, during observation of R #4's wound, RN #4 removed the knee brace from R #4's left leg. There was a green stain along both sides of the foam knee immobilizer aligned with the wound. The wound was draining through the side of the adhesive dressing. There was a foul odor. When asked about the drainage, RN #4 stated It's probably food. RN #4 confirmed that dressing changes are only done at the wound clinic. G. On 09/21/16 at 11:48 am at the Local Hospital's Wound Clinic, during observation, R #4 was dropped off at the clinic by the facility van and no facility staff had accompanied her to the clinic. R #4 appeared confused and kept dropping her cell phone. H. On 09/21/16 at 11:56 am, during observation and interview with the Wound Care Clinic Nurse (WCCN), she confirmed that R #4 was last seen at the Wound Clinic on the 12th (September 2016). WCCN removed the dressing for R #4 and there was a purulent (consisting of pus) soaked 4 x 4 (4 by 4 inch) wound dressing. As the WCCN cleansed the wound, it continued to consist of purulent drainage. WCCN stated regarding R #4, (She's) Not acting the same. She has a decreased level of consciousness (LOC) today. It might be from the pain medications. I. On 09/21/16 at 11:59 am during interview with the Wound Care Medical Doctor (MD) #3, when asked if R #4 should be on precautions, he stated Yes, she needs to be on contact precautions, has to take her antibiotics and have her dressing changed. J. Record review of the Medication Administration Record [REDACTED]. K. On 09/21/16 at 2:29 pm, during interview with the Assistant Director of Nursing (ADON), she confirmed that R #4 missed 2 doses of antibiotics and she was unsure why. L. On 09/21/16 at 2:43 pm, during interview with Physical Therapy Assistant (PTA) #1 states R #4's behavior has declined. He stated 3 times awareness (3 times orientation questioning) is screwed up. Her LOC has changed significantly over the last few days. I had her on the bike (on 09/21/16) and she was reaching for stuff in the air that wasn't there. She has really declined in the last two days. I think it is the pain meds (medication). M. On 09/21/16 at 2:50 pm, during interview, Certified Nurse Aide (CNA) #6 stated that R #4 is not the same demeanor as she has been. N. Record review of R#4's Medication Administration Record [REDACTED]. O. On 09/21/16 at 3:03 pm, during interview with Certified Medication Aide (CMA) #1, she confirmed that R #4 had not received any pain medication since 09/19/16. P. On 09/21/16 at 3:38 pm, during interview with the Van Driver, he stated that he has transported R #4 many times to the wound clinic, however on this day (09/21/16) he stated She was kind of out of it when I took her. She was not talkative. She was not herself. Definitely, I did not know what medications she was on. She acted like if she was on medication. Q. On 09/21/16 at 4:25 pm, during interview with MD #2, he stated that he has been on call for MD #5 and the nurse (RN #4) called him this morning and told him that R #4 had finished her antibiotics and healed and asked if she (R #4) could be taken off contact precautions. MD #2 confirmed that he has never seen R #4 before, but he relies upon the nurses to update him and usually trusts their judgement. When informed about the condition of R #4's wound and that she has missed antibiotic treatment, MD #2 stated that R #4 needed to be put back on contact precautions. MD #2 confirmed that he had also not been informed about R #4's change in condition.

Based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well being of 1 (R #1) of 5 (R #1-5) residents reviewed for falls by: 1. Not physically assessing R #1 for injury after he was found on the floor in his room. 2. Not immediately initiating Neurological checks for R #1 after he was found on the floor. 3. Not promptly identifying that R #1's change in condition (no longer able to self ambulate) and expressions of pain, indicated need for more immediate interventions. 4. Not providing sufficient pain relief. R #1 was demonstrating signs of pain starting at 5:30 am and it was documented as being unrelieved pain up until his transfer to the hospital at 2 pm. This deficient practice likely resulted in R #1 experiencing unnecessary pain and discomfort from a [MEDICAL CONDITION] for 16 hours after he was found on the floor in his room to when he was eventually transferred to the hospital. The findings are: A. Record review of the State Agency Incident Report dated 03/07/16 revealed that on 03/01/16 R #1 was found on the floor beside his bed which is a normal care planned event for this resident. Resident placed in the (sic) without any concerns or noting of discomfort. Upon getting up in the morning, resident displayed discomfort. Assessment was completed 03/02/16 based upon facial (sic) scale. An order was obtained to send the resident out for an x-ray and evaluation. Facility notified days later of a [MEDICAL CONDITION] hip. B. Record review of the Care Plan for R #1 revealed Risk for injury r/t falls AEB (as evidenced by) ambulates adlib (as wants) without assist. The care plan did not identify that R #1 would ever sit or lay on the floor. C. On 04/14/16 at 1:03 pm during interview with Licensed Practical Nurse (LPN) #2, regarding R #1 she stated I was his primary nurse for the majority of his stay at he facility. He walked all over. Towards the end he was very stable. Regarding R #1 being found on the floor, she stated I was very surprised. It was very unusual. Very out of the normal for him. He never fell and had no history of falls. They told me he was laying on the ground. The nurse said it was a behavior. His roommate regularly laid on the ground. LPN #2 confirmed that she had never seen R #1 lay on the ground before. She stated I was blown away that the night nurse said that (laying on the ground) was a normal behavior for him. I guess maybe she didn't know him well enough. I don't know what kind of assessment was done cause I wasn't there. I would have gone down there and did a head to toe assessment. Checked joints, checked range of motion for abnormalities, checked his arms and watch for grimacing. I would have checked him seriously. I would have got the Assists (Certified Nurse Aides) to get him up and see if he was weight bearing and written an incidence report. I would have called the doctor and send him out (to the hospital). D. On 04/15/16 at 9:18 am during interview with CNA #2 who first discovered R #1 laying on the floor on the evening of 03/01/16, she stated He (R #1) was on the floor. He was laying on his right side. He was laying in the middle of the room close to his dresser. I figured that he got up and he went down (fell ). CNA #2 described that R #1 would wander around and would sometimes get out of bed after he was laid down in the evening. When asked if she had ever seen R #1 sit or lay on the floor before, she stated I don't think I ever saw him on the floor. CNA #2 stated that R #1's roommate liked to lay on the floor but she had never seen R #1 do that before. CNA #2 confirmed that she thought R #1 had fallen. She stated I got the nurse at that time. She just went in there and saw him and that was it. When asked if the nurse assessed R #1, she stated I don't remember seeing that. CNA #2 described that she and her co-worker helped R #1 up and laid him in bed. She stated I helped him get up in the morning. He was hurting. That was like around between 5:30 am and 6:00 am. He couldn't stand up. We noticed that something was wrong. He was not the man we knew before. We put him in the wheelchair and took him to the dining room and he was trying to get up and it hurt him. You could see the expression on his face. He try to get up a couple times and it hurt him so he stayed in the wheelchair. CNA #2 stated that she informed the nurse and She (Nurse) said that was a behavior. She figured that there was nothing wrong with him. I could see that he was in pain. I don't know if she gave him medicine or not. I left around between 6:00 and 6:30 am. He was in the dining room. E. Record review of a hand written note addressed to the former Director of Nursing by CNA #2 stated (name of R #1) at ALZ (Alzheimer's unit) was on the floor @ 950 pm (03/01/16). I reported it to the nurse. We got him up in bed he had a good night but this morning he was hurting on his right hip. I did report it to the nurse. I also told the CNA's this morning (03/02/16). F. On 04/15/16 at 10:12 am during interview with CNA #3, she stated that she worked with R #1 on the day shift of 03/02/16. She confirmed that she was informed by CNA #2 that R #1 had a fall and he was complaining of pain in his right leg. CNA #3 stated that R #1 could not bare any weight. CNA #3 stated that she informed the day nurse, Registered Nurse (RN) #1 and she assessed him. CNA #3 stated that they started vitals right away. She stated He was in a wheelchair and then we put him in bed. He was sleepy when we try to turn him. He kept making faces (indicating that he was in pain). We did not get him up for lunch. G. On 04/14/16 at 1:27 pm during interview with RN #1, she stated From what I recall, the nurse (Night Nurse, RN #2) said it was a behavior and he (R #1) was found often on the floor. I asked where was he, how was he positioned. She (RN #1) said it wasn ' t ' witnessed. I said, 'I think that would be considered a fall.' She thinks it a behavior so she wasn ' t ' going to call (it a fall) for any reason. She said when they (CNAs) put him in bed, he was fine. As I took over shift, at 6:45/7:15 am, I did my own assessment and neuors (neurological checks). He had anxiety, and I gave him anxiety medication. I was reassessing him. The CNAs said that (resident laying on the floor) wasn ' t ' a behavior. I kept assessing him and they took him over to breakfast. There was no abnormalities. His face wasn ' t ' grimaced in pain. However we assessed him again, when the CNAs took him from breakfast to his room. I assessed him, I did notice a difference. One leg was more towards his chest, he touched his leg and grimaced in pain. I gave pain medication and notified the doctor. He was aware there was a possible fall. He told me to keep assessing. I called the doctor again and got an order for [REDACTED]. (Name of Physician Assistant (PA) #1) came in and I asked him to look at the patient (R #1). He said to send him out. H. On 04/15/15, the Corporate Nurse confirmed that R #1's Medication Administration Record [REDACTED]. I. On 04/15/15 at 9:43 am during interview with PA #1 he stated regarding R #1, I was told that he (R #1) doesn't want to get out of bed. I went to evaluate him right away. When I saw him, he was in pain. I had just barely touched his hip and he was wincing. He couldn't communicate very well cause of dementia. His right leg was rotated out and shortened. I said 'He's broke his hip and needs to go to the hospital.' It was pretty apparent that he had broken his hip. I didn't need an X-ray to tell me if he had broken his hip. I just knew he needed to go to the hospital right away. PA #1 confirmed that the ambulance came for R #1 at about 2 pm on 03/02/16 and R #1 was transferred to the hospital. J. Record review of the physician's orders [REDACTED]. 1. Rsd (resident) winced in px (pain). Facial expression of px 7/10 when r (right) leg elevated. X-ray to pelvis, r hip, r femur, r, knee, r ankle. 2. X-ray canceled to r leg. Send Rsd to (Name of local hospital) via ambulance due to mechanical fall. Rsd c/o (complaint of) px unrelieved by px medication. K. On 04/14/15 at 9:44 am during interview with R #1's wife, she stated that as a result of the fall, R #1 got pneumonia and he passed away. She stated that after the emergency surgery to repair his hip, he couldn't fight the pneumonia. She said He suffered tremendously for 20 days. The doctor said the fall was the cause of his death. L. Record review of the Departmental Notes revealed no documentation from RN #2 regarding R #1 being found on the floor or if any assessments were initiated or completed. M. On 04/14/16 at 2:06 pm during interview with Corporate Nurse (CN), she confirmed that all unwitnessed falls have to have neuro checks started immediately. She stated From what I can gather, (Name of RN #2) did nothing. It makes it very hard when they (staff) don't follow protocol. CN confirmed that RN #2 did not start neuro checks on the evening of 03/01/16 and the early morning of 03/02/16 for R #1 and she should have. CN also confirmed that RN #2 no longer works for the facility. N. Record review of the Neurological Checks Assessment Form dated 03/02/16 revealed Neurochecks were documented by RN #1 as R #1 having stupurous (decreased responsiveness) consciousness and inability to move extremities at 6 am, 7 am, 8 am, 9 am, 1 pm, 5 pm, 9 pm and 1 am (03/03/16). O. On 04/15/16 at 11:21 am during interview with CN, she confirmed that neuro checks were inaccurately documented for R #1 after he had already been transferred to the hospital.

Based on observation, record review and interviews, the following was discovered. 1. A couple of residents were placed on contact precautions, however besides the presence of the medical cart outside the door, there was no notice/signage instructing other residents or visitors that they should take precautions before entering the room. 2. Centers for Disease Control and Prevention (CDC) approved cleaning products were not being used for a resident that staff was informed has [DIAGNOSES REDACTED]. (Clostridium difficile). 3. Paper products were not being used for residents on contact precautions. 4. The dish machine was not at the appropriate temperature to sanitize the dishes. This resulted in Immediate Jeopardy being called on 01/26/16 at 12:35 pm. The Administrator was notified at this time. A Plan of Removal was received and and rejected on 01/26/16 at 4:55 pm, 5:13 pm and 6:50 pm. A fourth Plan of Removal was received and approved on 01/26/16 at 7:08 pm. The scope and severity was decreased from a Level 4, L to a Level 2, F The Plan of Removal included: 1. Staff training within the kitchen regarding dish machine procedures/temperatures. 2. Frequent testing of the dish machine temperature. 3. Plumbers to re-route hot water line to regulate fluctuating temperatures. 4. Staff inservice regarding isolation protocol, hand washing, cleaning rooms with residents on isolation, and infection control process. 5. Infections for January will be identified and placed on Infection Report Form. Based on record review and interview, the facility failed to establish and maintain an Infection Control Program designed to provide safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection by: 1. Not accurately tracking resident infections and using the information to investigate, control and prevent infections in the facility. 2. Not appropriately notifying residents and visitors when a resident is on isolation precautions to prevent other residents and visitors from contracting the infection/disease. 3. Not using appropriate cleaning products approved by the CDC when cleaning rooms of someone diagnosed with [REDACTED]. 4. Not using paper products for meal service to prevent cross contamination. 5. Not ensuring the catheter drainage bag of R #6 remained off of the floor. This deficient practice is likely to affect all 109 residents on the Resident census list provided by the Administrator on 01/15/16. If proper infection control practices are not maintained, residents are likely to be exposed to disease causing organisms resulting in infection. The findings are Findings related to infection control program: A. On 01/26/16 at 10:00 am during interview with Staff Development Coordinator (SDC), regarding the facility infection control program, she stated The information is collected by the ADONs (Assistant Director of Nursing) and passed onto me and I place it in certain categories. SDC stated that she then passes the information onto the Administrator. When asked about isolation precautions, she stated We have been asking that before entering the room to see Nursing staff and visitors so they would know what measures to be taken before entering the room. SDC confirmed that guests should be notified immediately by the Charge Nurse. SDC confirmed that she only started 2 weeks ago and she has seen problems however the Administrator and Director of Nursing are trying to fix them. B. On 01/26/16 at 11:33 am, during interview with the Administrator, he stated (Name of SDC) started with us on the 11th of this month (January 2016). Prior to that it was the ADONs in the building. Directly, I have not had involvement (with infection control program). When asked what the ADONs did, he stated They were to gather the infections and collaborate them and put them in a report for the DON (Director of Nursing) and Corporate. Don't know what happens after all the information is put together. When asked if there were any residents on contact precautions, he responded Yes. She (R #40) is on contact isolation and staff is instructed to follow regime of contact isolations. C. Record review of the Monthly Infection Control Analysis Dated August 2015 to November 2015 revealed the following infection rate percentage for the month: August 2015: 5% September 2015: 4 % October 2015: 5% November 2015: 23% D. On 01/26/16 at 2:45 pm during interview with the Nurse Specialist (NS) after reviewing the facility Infection Control sheets from October to November 2015, she confirmed that the facility has not been appropriately tracking the community and nosocomial (contracted within the facility) infections together, therefore their tracking sheets are inaccurate. Finding related to precaution signage: Findings related to R #40: E. Record review of Physician telephone orders for R #40 dated 01/22/16 revealed Stool for culture and parasite, ua (urinalysis) and .C. Diff. F. On 01/24/16 at 8:45 am during observation and interview, there was a medical cart (containing precaution supplies, ie gown, gloves, mask) outside R #40's room. During interview with the CNA (Certified Nurse Aide) scheduler, when asked why there was a medical cart outside R #40's door, she stated, We have positive confirmation of C.diff (Clostridium difficile). G. On 01/24/16 at 8:55 am during interview with the Director of Nursing (DON), when asked why there wasn't a sign on the door warning that isolation precautions were necessary, the DON responded, It would be a HIPAA (Health Information Portability and Accountability Act) violation to put something on the door. Corporate says that with the cart outside the door that alerts visitors that something is going on with the resident. H. On 01/24/16 at 9:01 am, during interview with LPN #1 when asked if the facility puts a caution sign on the door, he responded, We used to put a sign on the door that read, 'PLEASE SEE NURSE BEFORE ENTERING.' LPN #1 confirmed that they were instructed not to do that anymore. I. On 01/25/16 at 10:10 am, during interview with Certified Nurse Aide (CNA) #11, when asked how she knows if there is a resident with an infection in a room, she stated, There's a cart outside the door with the gloves, mask and gown and there's a sign on the door saying you have to ask the nurse before you go into the room. J. On 01/25/16 at 10:19 am during observation, there was no signage on R #40's door indicating that there was a precaution. K. On 01/25/16 at 10:26 am, during interview with R #86 when asked how he would know if there was an infection in the building, he stated, Well, there would be a sign outside the door and the cart in front of that room. When asked if there were any infections in the buildings at that time, he responded, No, because you would see the notice. L. On 01/25/16 at 10:28 am during interview with an Anonymous Volunteer, when asked how they would know if someone had contact precautions, s/he stated Well I would expect someone to tell me. When you go to the hospital, they let you know that you have to put on a gown and gloves and a mask. M. On 01/26/16 at 11:43 am during interview with the Director of Nursing (DON) when asked what is isolation protocol, she stated Corporate said to no longer put out the note. They felt it was a HIPAA violation. Findings related to R #153: N. On 01/15/16 at 10:32 pm during observation, a medical cart (containing precaution supplies, ie gown, gloves, mask) was observed outside R #153 door. There was no notice/signage indicating that there was isolation precaution or that residents, visitors or staff should be cautious before entering the room. O. Record review of the Department Notes For R #153 revealed: 01/18/16 D/C (discharge) isolation. P. On 01/23/16 at 12:50 pm during observation and interview, a medical cart was observed outside R #153 door. There was no notice/signage indicating that there was isolation precaution or that residents, visitors or staff should be cautious before entering the room. The Regional Nurse (RN), when asked if there should be a sign on the door indicating that there was a precaution for R #153 and the RN confirmed that there should be. Q. On 01/26/16 at 10:38 am during interview with Registered Nurse (RN) #2, she confirmed that R #153 had MRSA (Methicillin resistant Staphylococcus aureus) in his lungs and he was on isolation and contact precautions. RN #2 stated that staff and visitors who were going to be within 3 feet of him, needed to mask, gown and gloves and there would be a cart outside the door. RN #2 also confirmed that there should be a sign on the door for anyone who wanted to enter, to see the nurse. R. On 01/26/16 at 11:43 am during interview with the Director of Nursing (DON) when asked what is isolation protocol, she stated Corporate said to no longer put out the note (signage). They felt it was a HIPAA violation. S. On 01/29/16 at 5:04 pm during interview with Licensed Practical Nurse (LPN) #3 when asked if a resident has MRSA what type of precautions does the facility employ, she responded that they are placed on contact precautions and the infection control cart is placed outside the door, staff is informed through report at change of shift and a sign is placed on the door alerting anyone before going in to see the nurse. T. Record review of the Infection Control Policy and Procedure Manual: MRSA- Management of recurrent skin and soft tissue revised 2011 revealed Using CDC recommended cleaners appropriate for surface being cleaned. Findings related to cleaning products: U. On 01/26/16 at 10:19 am, during observation and interview, R #40's room was observed to have carpet. During interview with Housekeeper (HK) #1 when asked what type of product is used for cleaning a room which has isolation precautions, she indicated that she is using Airx75 Antibacterial cleaning. V. On 01/26/16 during interview and through email communication with the CDC regarding appropriate cleaning products necessary to clean a room in which a resident has [DIAGNOSES REDACTED], they indicated, C. diff can be transmitted both by direct contact with the organism during patient/resident care activities and indirectly by contact with contaminated surfaces. [DIAGNOSES REDACTED] is a spore-forming organism that requires disinfectants capable of destroying the spore. Not all disinfectants have these properties; therefore, we recommend using one of the EPA-registered disinfectants found on their website. The product used at the facility (Airx75) was not on the list. Other precautions listed by the CDC included, Carpeting and rugs can harbor microorganisms and be difficult to clean and disinfect. Smooth, hard surface floor coverings are easier to maintain. Similarly, furniture selections in resident care areas should be selected based on their compatibility with cleaning agents and ease of use. Findings related to changing gloves: W. On 01/23/16 at 9:00 am during an observation of the dish room and interview with Dietary Aide (DA) #1. DA #1 was observed loading the dish machine with dirty dishes and then proceeded to put away the clean dishes without changing his gloves or washing his hands. He stated, I guess I should change my gloves. Findings related to Dish machine temperature: X. On 01/22/16 at 9:05 am during an observation of dish machine it was observed to be at 115 degrees Fahrenheit. Y. On 01/22/16 at 9:10 am during an interview with the Dietary Manager (DM), he stated. The hot water has been off and on for a couple of days now we have not gotten it to go up to 120 degrees. We have been monitoring the temperature. We have had this problem for a few months now. I have talked to maintenance about it several times. Z. On 01/26/20 at 8:18 am during an interview with he DM, he stated. The water temperature is now at 121 degrees. It fluctuates and is not stable. I don't know how long it will stay at that temperature. AA. 01/26/16 at 8:50 am during an observation of the dish machine and an interview with the DM, he stated Dish machine is running between 115 degrees and 118 degrees. When asked if there are any residents on precautions, the DM confirmed that there are no residents on precautions that would require the use of paper products. DM stated, To my knowledge, we have never had anyone on paper precautions. Findings related to catheter bag: AA. On 01/20/16 from 2:50 and 3:10 pm, during an observation, R #6 was sitting in a wheelchair in a common hallway with the resident's catheter drainage bag hanging from the underside of the wheelchair. The lower portion of the catheter drainage bag was resting directly on the floor without a barrier covering the drainage bag. BB. Record review of the Policy and Procedure on Urinary Catheter Care - section infection control dated October 2010 revealed, Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, record review and interviews, the following was discovered. 1. Medication pass at the facility is taking 3-5 hours, which in the evening is resulting in residents being woken up for evening medication pass, which at times the resident will refuse those medications. 2. Residents dependent on insulin are not having their blood sugars checked as ordered, and are not receiving insulin as ordered. 3. A couple of residents were placed on contact precautions, however besides the presence of the medical cart outside the door, there was no notice/signage instructing other residents or visitors that they should take precautions before entering the room. 4. Centers for Disease Control and Prevention (CDC) approved cleaning products were not being used for a resident that staff was informed has [DIAGNOSES REDACTED]. ([MEDICAL CONDITION]). 5. Paper products were not being used for residents on contact precautions. 6. The dish machine was not at the appropriate temperature to sanitize the dishes. This resulted in Immediate Jeopardy being called on 01/26/16 at 12:35 pm. The Administrator was notified at this time. A Plan of Removal was received and and rejected on 01/26/16 at 4:55 pm, 5:13 pm and 6:50 pm. A fourth Plan of Removal was received and approved on 01/26/16 at 7:08 pm. The scope and severity was reduced from Level 4, L to a Level 2, F. The Plan of Removal included: 1. Facility will identify med pass process for all shifts and adjust medication administration times under physician direction. 2. Consider availability of contract staff to replace current agency staff. 3. Staff inservice with current licensed staff regarding passing medications timely. 4. Residents will be identified who need blood sugars and insulin will be administered timely. 5. Monitoring timely medication pass daily for 3 days and weekly. 6. Pharmacy consultant will provide on-site medication pass audit on 01/27/16 and ongoing. 7. Staff training within the kitchen regarding dish machine procedures/temperatures. 8. Frequent testing of the dish machine temperature. 9. Plumbers to re-route hot water line to regulate fluctuating temperatures. 10. Staff inservice regarding isolation protocol, hand washing, cleaning rooms with residents on isolation, and infection control process. 11. Infections for January will be identified and placed on Infection Report Form. Based upon observation, record review and interview, the facility failed to be administered in a manner that enables it to maintain the highest practicable physical, mental and psychosocial well-being of each resident by: 1. Not accurately tracking resident infections and using the information to investigate, control and prevent infections in the facility. 2. Not appropriately notifying residents and visitors when a resident is on isolation precautions to prevent other residents and visitors from contracting the infection/disease. 3. Not ensuring that residents are receiving medication within their scheduled time frames. 4. Not ensuring that insulin dependent resident are receiving their blood sugar checks and insulin as ordered. 5. Not ensuring that residents are treated with respect and dignity. 6. Not maintaining a positive work and living environment 7. Offering temporary employment to a Certified Nurse Aide (CNA) from a sister facility that had been terminated from this facility for abuse making him ineligible for re-hire. 8. Not keeping track of resident and resident family member grievances including how they were resolved. This deficient practice is likely to affect all 109 residents identified on the census list provided by the Administrator on 01/15/16. The findings are: Reference F225 Reference F241 Reference F244 Reference F309 Reference F333 Reference F441 Surveyor: Velarde, Ben

Based on record review, observation and interview, the facility failed to ensure that residents are free of any significant medication errors by not: 1.) checking residents Capillary Blood Glucose (CBG) levels as ordered by the treating physician, and 2.) administering medications and insulin as ordered by the treating physician, and within the scheduled time frame. This deficient practice is likely to affect all 8 residents (R #14, 20, 40, 67, 157, 174, 176 and 182) that are insulin dependent. If nursing staff is not checking residents CBGs and administering their insulin as ordered, then residents are likely to experience medication ineffectiveness resulting in the need for medical intervention and unmonitored elevated CBGs without timely intervention has the potential to result in kidney damage and [MEDICAL CONDITION]. The findings are: A. On 01/22/16 at 10:30 am during observation Licensed Practical Nurse (LPN) #3 was passing medications . She confirmed that she was passing the morning medications. She stated that she starts passing medications after report at about 6:30 am or 7:00 am. She confirmed that she stops medication pass during breakfast so that she can monitor residents for potential choking and then resumes medication pass after breakfast until about about 10:00 or 10:30 am. At that point, LPN #3 states that she starts with the 12:00 pm medications because she will again have to go to the dining room for lunch, and when lunch is over then she can finish the medications. She states the facility used to have medication aids but no longer does so she has no help with the medications and still is expected to go stand in the dining room during meal times. She stated that the nurses on the floor don't have any help from the new administration. She stated that the new administration tells us what has to be done regardless if there is enough staff or not. She states Many staff have left, the new administration is very different, unsupportive and doesn't care if the staff stays or leaves. She stated There is a lot of agency staff and they come and go. Never the same ones. If something happens we just get yelled at or written up. The ADON (Assistant Director of Nursing) used to always be on the floors and asking us if we were ok or needed help. But they left. B. On 01/22/16 at 12:00 pm, Registered Nurse (RN) #5 was charting in the Medication Administration Record [REDACTED]. Then I continue with the noon medications until about 2:00 or 3:00 pm, as sometimes the residents aren't in their room and some residents take quite a few medications. C. 01/22/16 at 7:00 pm, during observation RN#6 is passing medications. When asked what medications she is passing she stated she is finishing the dinner time medications and starting the 8:00 pm and bedtime medications. When asked how long it takes her or until what time does she pass medications, she replied she will be passing medications until about 11:00 pm. She stated that Some residents don't have a picture in their MAR. I have to find someone to identify the resident for me. Sometimes even if they have a picture it's an old one. Also now everytime a resident requests a pain medication or has one scheduled I have to go find another nurse to sign the Narcotic sign out sheet with me, something must have happened, I've never seen or heard of that before. Finding for R #182 D. Record review of the Medication Administration Record [REDACTED]. The scheduled times are 6:30 am, 11:30 am and 4:30 pm as ordered by the physician. E. Record review of the meal times provided by the Administrator on 01/15/16 revealed breakfast is served between 7:40 am and 8:30 am, depending upon the dining room location, lunch is served between 11:40 am and 12:30 pm depending upon the dining room and dinner is served between 4:40 pm to 5:30 pm depending upon the dining room. F. Record review of the Diabetic Monitoring Flow Sheet for R #182 dated 01/01/16 through 01/23/16 revealed CBG was checked and insulin was administered at the following times: 1. 01/01/16 at 5:30 am, CBG was 234 and 5 units of [MEDICATION NAME]was given. 2. 01/02/16 at 11:30 am, CBG was 225 and at 4:30 pm CBG was 244. There was no record of insulin administration for both times. 3. 01/03/16 at 5:30 am, CBG was 132. CBG was not documented for the 11:30 am and 4:30 pm schedule. There was no record of insulin administration for the entire day. 4. 01/04/16 at 5:30 am, CBG was 184. There was no record of insulin administration. At 4:30 pm CBG was 284. There was no record of insulin administration. 5. 01/05/16 at 5:30 am, CBG was 203. There was no record of insulin administration. At 11:30 am, CBG 240. There was no record of insulin administration 6. 01/06/15 at 5:30 am, CBG was 187. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. 7. 01/07/16 at 5:30 am, CBG was 237. There was no record of insulin administration. At 4:30 pm, CBG was 242. There was no record of insulin administration. 8. 01/08/16 at 5:00 am, CBG was 142. There was no record of insulin administration. At 11:30 am there was no record of CBG or insulin administration. 9. 01/09/16 at 5:30 am, CBG was 157 and 5 units [MEDICATION NAME]was given. At 4:30 pm CBG was 133. There was no record of insulin administration. 10. 01/10/16 at 5:00 am, CBG was 243. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. 11. 01/11/16 at 5:30 am, CBG was 203. There was no record of insulin administration. At 11:30 am and 4:30 pm there was no record CBG or insulin administration. 12. 01/12/16 at 5:30 am, CBG was 211. There was no record of insulin administration. 13. 01/13/16 at 5:30 am, CBG was 191. There was no record of insulin administration. At 11:30 am, CBG was 220. There was no record of insulin administration. At 4:30 pm, CBG was 175. There was no record of insulin administration. 14. 01/14/16 at 5:00 am, CBG was 168. There was no record of insulin administration 15. 01/15/16 at 5:00 am, CBG was 186. There was no record of insulin administration. At 11:30 am there was no record of CBG or insulin administration. At 4:00 pm, CBG was 231. There was no record of insulin administration. 16. 01/16/16 at 6:00 am, CBG was 231. There was no record of insulin administration. At 11:30 am, CBG was 244. There was no record of insulin administration. At 4:00 pm, CBG was 256. There was no record of insulin administration. 17. 01/17/16 at 5:30 am, CBG was 189. There was no record of insulin administration. 18. 01/18/16 at 5:30 am, CBG was 213. There was no record of insulin administration. 19. 01/19/16 at 5:30 am, CBG was 190. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. 20. 01/20/16 at 5:30 am, CBG was 182. There was no record of insulin administration 21. 01/21/16 at 5:00 am, CBG was 210. There was no record of insulin administration. 22. 01/22/16 at 5:00 am, CBG was 189. There was no record of insulin administration. At 11:30 am, was CBG 218. There was no record of insulin administration. At 10:00 pm, CBG was 144. There was no record of insulin administration. 23. 01/23/16 at 6:00 am, CBG was 257. There was no record of insulin administration. G. On 01/25/16 at 2:56 pm, during interview with LPN #3 regarding R #182's missing CBG results and insulin administration documentation. She replied that If it's on Sundays (Name of R #182) goes with her son to church then out to eat, and she is not here for the 11:30 am CBG and the insulin injection. When asked if R #182's CBG will be checked again, she replied Well they should check her when she arrives back to the facility. I then asked who checks the 6:30 am CBG, she replied that the night shift does before they leave at 6:00 am. When asked when the 6:30 am insulin is given, she replied that the Night shift nurse does it when she (nurse) checks the CBG. LPN #3 then grabbed a flyer taped to the desk. H. Record review of flyer dated 09/04/15 indicated Effective immediately all CBG's will be done at 6:00 am. I. On 01/25/16 at 3:10 pm, during interview with RN #2, regarding the 6:30 am CBG and insulin administration, she acknowledged that the night shift is checking the CBG, however she stated that They should be done at 6:30 am not 5:00 am or 5:30 am because it's too early to give insulin coverage at that time. J. On 01/25/16 at 4:13 pm, during interview with RN #8, she stated that the night shift checks the CBG's and day shift gives the insulin. I know there's a lot of holes in the MAR. I do mine (CBG checks and insulin administration) but I can't speak for the rest. It looks scary, I know. If you look most of that mess is when agency staff was working. Findings for R #67: K. Record review of the MAR indicated [REDACTED] 1. [MEDICATION NAME] 100 units/ml for CBG 1-150 0 units, 151-350 give 4 units, higher than 351 give 6 units, higher than 400 call the doctor (Page 1) 2. [MEDICATION NAME] sliding scale for CBG 131-170 give 1 unit, 171-210 give 2 units, 211-250 give 3 units, 251-290 give 4 units, 291-330 give 5 units, 331-370 give 6 units, if higher than 370 call the doctor (Page 5). L. On 01/26/2016 at 8:54 am during interview with LPN #1 regarding the 2 sliding scale Insulin orders on the MAR for R #67, he confirmed there are 2 sliding scales on the MAR, he stated the one on page 1 is the correct one, the one on page 5 is old from when R #67 first got to the facility. He stated that regarding all the holes (blank spaces) in the MAR, we have a lot of agency nurses they don't do things the right way. The Director of Nurses (DON) has been made aware, apparently she is trying to figure out a way to makes things easier and so things work the way they should. When asked who checks the 6:30 am CBG, he replied the night shift checks the CBG and we give the insulin if they need it right before breakfast. If its an agency nurse at night then another agency nurse in the morning they probably don't know what to do. A lot of them don't know the residents, and were given no training or orientation. M. Record review of the Diabetic Monitoring Flow Sheet dated 01/01/16 through 01/26/16 revealed the CBG was checked and insulin was administered at the following times: 1. 01/01/16 at 5:30 am, CBG was 94. At 11:30 am, CBG was 164. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 2. 01/02/16 at 5:30 am, CBG was 188. There was no record of insulin administration. At 11:30 am and at 4:30 pm there was no record of CBG or insulin administration. 3. 01/03/16 at 5:30 am, CBG was 135. At 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 4. 01/04/16 at 5:00 am ,CBG was 129. At 11:30 am CBG was 251. There was no record of insulin administration. At 11:50 pm CBG was 225. There was no record of insulin administration. 5. 01/05/16 at 6:00 am, CBG was 171. There was no record of insulin administration. At 11:30 am there was no record of CBG or insulin administration. 5. 01/06/16 at 11:30 am there was no record of CBG or insulin administration. At 10:00 pm, CBG was 230. There was no record of insulin administration. 6. 01/07/16 5:40 am, CBG was 203. There was no record of insulin administration. At 11:30 am there is no record of CBG or insulin administration. At 9:30 pm, CBG 189. There is no record of insulin administration. 7. 01/08/16 at 8:00 pm there is no record of CBG or insulin administration. 8. 01/09/16 at 5:30 am, CBG was 127. At 11:30 am there was no record of CBG or insulin administration. At 4:30 pm, CBG was 205. There was no record of insulin administration. At 8:00 pm CBG, was 195. There was no record of insulin administration. 9. 01/10/16 at 11:30 am CBG was 154. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. 10. 01/11/16 at 5:30 am, CBG was 110. At 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 11. 01/12/16 at 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 12. 01/13/16 at 6:30 am there was no record of CBG or insulin administration. At 8:00 pm CBG, was 204. Resident refused insulin was documented. 13. 01/14/16 at 5:30 am CBG, was 123. At 11:30 am and 4:30 pm there was no record of CBG or insulin administration. At 8:00 pm, CBG was 204. Resident refused insulin was documented. 14. 01/15/16 at 8:00 pm there was no record of CBG or insulin administration. 15. 01/16/16 at 5:30 am CBG was 150. At 10:00 pm, CBG was 222. Resident refused insulin was documented. 16. 01/17/16 at 5:00 am, CBG was 165. There was no record of insulin administration. At 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 17. 01/18/16 at 4:30 pm, CBG was 200. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 18. 01/19/16 at 5:30 am and at 11:30 am there was no record of CBG or insulin administration. 19. 01/21/16 at 5:00 am CBG was 135. At 11:30 am there was no record of CBG or insulin administration. At 8:00 pm, CBG was 202. There was no record of insulin administration. 20. 01/22/16 at 6:30 am there was no record of CBG or insulin administration. At 10:30 pm ,CBG 177. Resident refused insulin was documented. 21. 01/23/16 at 6:00 am, CBG was 176. Resident refused insulin was documented. At 5:20 pm, CBG was 168. Resident refused insulin documented. At 8:00 pm there was no record of CBG or insulin administration. 22. 01/24/16 at 4:30 pm, there is no record of CBG or insulin administration. At 11:00 pm, CBG was 262 and 2 units of [MEDICATION NAME]was given per residents request was documented. 23. 01/25/16 at 5:00 am, CBG was 82. Recommend soda was documented. At 12:00 pm, CBG was 179. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. N. On 01/26/2016 at 9:00 am during interview with LPN #1, when asked regarding R#67's refusal of insulin coverage at bedtime, he stated that The new nurses and the agency nurses are still passing medications at 11:00 pm and 11:30 pm at times and (Name of R #67) knows it's too late because he is very aware of how he feels when his blood sugar is low and he knows his blood sugar will drop quickly so he refuses it because its already over 3 hours late. O. On 01/26/16 at 9:30 am during interview with R #67 when asked if he knew the times he is to have the insulin given to him, he stated I do but I don't think some of the Nurses do. I asked him if he is ever awakened late at night to check his CBG and offered the insulin at that time. He stated that The night nurse does come in sometimes close to midnight and I refuse the insulin because it will drop my sugar too much as I won't have anything to eat until breakfast. I know when I am low and I will not take the insulin. P. On 01/26/16 at 1:28 pm, during interview with R #67, he stated The staff wakes me up at 6:00 am to test my blood sugar before giving insulin. R #67 confirmed that he always has dry mouth. Finding for R #176: Q. Record review of the MAR indicated [REDACTED]. Scheduled at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm as ordered by the physician. R. Record review of the Diabetic Monitoring Flow Sheet dated 01/17/16 through 01/26/16 for R #176 revealed CBG was checked and insulin was administered at the following times: 1. 01/18/16 at 6:00 am, CBG was 193. There was no record of insulin administration. 2. 01/19/16 at 5:30 am, CBG was 163 and 1 unit [MEDICATION NAME]was given. 3. 01/21/16 at 6:00 am, CBG was 226. There was no record of insulin administration. 4. 01/23/16 at 5:30 am, CBG was 167. There was no record of Insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 5. 01/25/16 at 8:00 pm, CBG was 177. There was no record of insulin administration. S. On 01/26/16 at 11:15 am, during interview with R #176, he stated that he gets insulin 3 times a day. When asked if he is ever woken up to receive medication, he stated Yes, they wake me up in the evening every time I get medication. I tell them how thirsty I am but nobody cares. Findings for R #20: T. Record review of the MAR indicated [REDACTED]. U. Record review of the Diabetic Monitoring Flow Sheet dated 01/01/16 through 01/22/16 revealed CBG was checked and insulin was administered at the following times: 1. 01/01/16 at 5:30 am, CBG was 212 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 2. 01/02/16 at 5:30 am, CBG was 222 and 4 units [MEDICATION NAME]was given. At 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 3. 01/03/16 at 5:30 am, CBG was 221 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 4. 01/04/16 at 8:00 am, CBG was 409 and 6 units [MEDICATION NAME]was given. At 11:30 am and 8:00 pm there was no record of CBG or insulin administration. 5. 01/05/16 at 5:30 am, CBG was 176 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 6. 01/06/16 at 4:30 pm and at 8:00 pm there was no record of CBG or insulin administration. 7. 01/07/16 at 8:00 pm there was no record of CBG or insulin administration. 8. 01/08/16 at 5:00 am, CBG was 254 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 9. 01/09/16 at 8:00 pm there was no record of CBG or insulin administration. 10. 01/10/16 at 5:00 am, CBG was 184 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 11. 01/11/16 at 5:30 am, CBG was 292. There was no record of insulin administration. At 11:30 am there was no record of CBG or insulin administration. At 4:30 pm, CBG was 203. There was no record of insulin administration. 12. 01/12/16 at 6:00 am, CBG was 221. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 13. 01/13/16 at 5:30 am, CBG was 229. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 14. 01/14/16 at 5:30 am CBG was 285. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 15. 01/15/16 at 5:00 am, CBG was 229 and 4 units [MEDICATION NAME]was given. At 11:30 am and at 8:00 pm there was no record of CBG or insulin administration. 16. 01/16/16 at 8:00 pm, there was no record of CBG or insulin administration. 17. 01/17/16 at 5:30 am, CBG was 285 and 4 units [MEDICATION NAME]was given. At 8:00 pm there was no record of CBG or insulin administration. 18. 01/18/16 at 5:30 am, CBG was 229. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 19. 01/19/16 at 6:30 am there was no record of CBG or insulin administration. At 4:30 pm and at 8:00 pm there was no record of CBG or insulin administration. 20. 01/20/16 at 5:30 am, CBG was 191. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 21. 01/21/16 at 5:30 am, CBG was 264. There was no record of insulin administration. At 8:00 pm the was no record of CBG or insulin administration. 22. 01/22/16 at 5:30 am, CBG was 277 and 4 units [MEDICATION NAME]was given. V. On 01/26/16 at 11:07 am, during interview with R #20 when asked if she has ever refused her medication because it was too late or she was sleeping, she stated Yes. I've received it late. R #20 stated that she has experienced thirst, confusion, blurred vision and increased urination. Findings for R #157: W. Record review of the MAR indicated [REDACTED]. Scheduled at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm as ordered by the physician. X. Record review of the Diabetic Monitoring Flow Sheet dated 01/11/16 through 01/26/16 for R#157 revealed CBG was checked and insulin was administered at the following times: 1. 01/11/16 at 5:30 am, CBG was 131. At 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 2. 01/12/16 at 5:30 am, CBG was 155. There was no record of insulin administration. At 11:00 am, CBG was 151. There was no record of insulin administration. At 4:30 pm CBG 196. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration 3. 01/13/16 5:30 am, CBG 166. There was no record of insulin administration. At 11:30 am, CBG 174. There was no record of insulin administration. At 4:30 pm, CBG was 208. There was no record of insulin administration. At 8:00 pm there was no record of CBG or insulin administration. 4. 01/14/16 at 5:30 am CBG was 249. There was no record of insulin administration. 5. 01/15/16 5:30 am, CBG was 147. 6. 01/16/16 5:00 am, CBG was 114. At 8:00 pm there was no record of CBG or insulin administration. 7. 01/17/16 at 6:30 am there was no record of CBG or insulin administration. 8. 01/18/16 at 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 9. 01/19/16 at 5:30 am CBG was 141. At 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 10. 01/23/16 at 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 11. 01/25/16 at 5:45 am, CBG was 187. There was no record of insulin administration. At 9:00 pm CBG was 303 and 6 units [MEDICATION NAME]given. 12. 01/26/16 at 5:30 am CBG was 206. There was no record of insulin administration. Findings for R #40: Y. Record review of the Diabetic Flow Sheet dated 01/01/16 through 01/25/16 for R#40 read [MEDICATION NAME] 100 units per milliliter, CBG before meals and bedtime for CBG 0-150 0 units, 151-300 4 units, 301-350 6 units, higher than 350 call physician. Scheduled at 6:30 am, 11:30 am, 4:30 pm and 8:30 pm as ordered by the physician. Z. Record review of the Diabetic Monitoring Flow Sheet dated 12/27/15 through 01/23/16 revealed CBG was checked and insulin was administered at the following times: 1. 12/28/15 at 8:30 pm there was no record of CBG or insulin administration. 2. 12/29/15 at 5:30 am, CBG was 136. At 4:30 pm there was no record of CBG or insulin administration. 3. 12/30/15 at 5:30 am, CBG was 150. At 11:30 am, 4:30 pm and 8:30 pm there was no record of CBG or insulin administration. 4. 12/31/15 at 5:30 am, CBG was 121. At 8:00 pm there was no record of CBG or insulin administration. 5. 01/01/16 at 5:30 am, CBG was 133. 6. 01/04/16 at 5:30 am, CBG was 163. There was no record of insulin administration. At 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 7. 01/05/16 at 5:30 am, CBG was 170 and 4 units [MEDICATION NAME]was given. At 11:30 am, 4:30 pm and 8:30 pm there was no record of CBG or insulin administration. 8. 01/06/16 at 6:30 am there was no record of CBG or insulin administration. At 12:00 pm, CBG was 152. There was no record of insulin administration. At 8:30 pm there was no record of CBG or insulin administration. 9. 01/07/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 10. 01/08/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 11. 01/09/16 at 6:30 am there was no record of CBG or insulin administration. At 4:30 pm and 8:30 pm there was no record of CBG or insulin administration. 12. 01/10/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 13. 01/11/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 14. 01/12/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 15. 01/13/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 16. 01/14/16 at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm there was no record of CBG or insulin administration. 17. 01/16/16 at 8:00 pm there was no record of CBG or insulin administration. 18. 01/17/16 at 6:30 am there was no record of CBG or insulin administration. 19. 01/18/16 at 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 20. 01/19/16 5:30 am, CBG was 129. At 8:00 pm there was no record of CBG or insulin administration. AA. On 01/26/16 at 11:13 am during interview with R #40, she confirmed that her blood sugar is only checked 2 times a day. R #40 also confirmed that she has experienced thirst, confusion once in a while and increased urination. Findings for R #174: BB. Record review of Diabetic Flow Sheet dated 01/01/16 to 01/25/16 for R #174 read [MEDICATION NAME] 100 units per milliliter, CBG before meals if CBG 0-150 no insulin, 151-300 given 4 units, if over 300 give 6 units. The following dates and times documented on the Diabetic Monitoring Flow Sheet are not as ordered by the physician: CC. Record review of the Diabetic Monitoring Flow Sheet dated 01/04/16 to 01/25/16 revealed CBG was checked and insulin was administered at the following times: 1. 01/04/16 at 5:00 am, CBG was 293 and 4 units [MEDICATION NAME]given. At 11:30 am there was no record of CBG or insulin administration. At 5:00 pm CBG was 342. There was no record of insulin administration. 2. 01/05/16 at 5:00 am, CBG was 176 and 4 units [MEDICATION NAME]given. 3. 01/06/16 There was no record of CBG or insulin administration was recorded for this date. 4. 01/07/16 There was no record of CBG or insulin administration was recorded for this date. 5. 01/08/16 There was no record of CBG or insulin administration was recorded for this date. 6. 01/09/16 at 5:30 am, CBG was 184. There was no record of insulin administration. At 11:30 am and 4:30 pm there was no record of CBG or insulin administration. 7. 01/10/16 There was no record of CBG or insulin administration was recorded for this date. 8. 01/11/16 at 6:00 am, CBG was 292. There was no record of insulin administration. At 11:30 am there was no record of CBG or insulin administration. At 4:30 pm CBG was 201. There was no record of insulin administration. 9. 01/13/16 at 6:30 am there was no record of CBG or insulin administration. 10. 01/16/16 at 5:30 am, CBG was 223 and 4 units [MEDICATION NAME]was given. 11. 01/17/16 at 5:30 am, CBG was 233 and 4 units [MEDICATION NAME]was given. 12. 01/19/16 at 5:20 am, CBG was 248 and 4 units [MEDICATION NAME]was given. 13. 01/21/16 at 5:30 am, CBG was 114. 14. 01/22/16 at 5:30 am, CBG was 105. 15. 01/23/16 at 6:30 am there was no record of CBG or insulin administration. 16. 01/24/16 at 6:30 am there was no record of CBG or insulin administration. At 4:30 pm there was no record of CBG or insulin administration DD. On 01/26/16 at 11;51 am during interview with R #174, she confirmed that staff wake her up to give her her evening medication. R #174 also confirmed that she has dry mouth all the time and gets very thirsty. Findings for R #14: EE. Record review of the MAR indicated [REDACTED]. Scheduled at 6:30 am, 11:30 am, 4:30 pm and 8:00 pm as ordered by the physician. FF. Record review of the Diabetic Monitoring Flow Sheet dated 01/19/16 through 01/25/16 revealed CBG was checked and insulin was administered at the following times: 1. 01/19/16 at 8:00 pm there was no record of CBG or insulin administration. 2. 01/20/16 at 6:00 am, CBG was 138. There was no record of insulin administration. At 11:30 am, CBG was 221. There was no record of insulin administration. At 4:30 pm there was no record of CBG or insulin administration. 3. 01/21/16 at 4:30 pm, CBG was 137. There is no record of insulin administration. 4. 01/22/16 at 6:00 am, CBG was 147. There was no record of insulin administration. 5. 01/24/16 at 5:45 am, CBG was 97. 6. 01/25/16 at 5:45 am ,CBG was 153. There was no record of insulin administration. At 4:30 pm CBG was 304. There was no record of insulin administration. 7. 01/26/16 at 5:30 am, CBG 147. There was no record of insulin administration. GG. On 01/22/16 at 10:57 am, during interview with Registered Nurse (RN) #11 confirmed that Nurses do not write in the Medication Administration Record [REDACTED]. RN #11 confirmed that medications should be administered within a 2 hour window of when it is ordered, one hour before or one hour after scheduled time. HH. On 1/25/16 at 4:40 pm, during interview with Pharmacist #1 (RX1) when asked what are the risks to the residents if medications are not being administered at the times scheduled, on time or at the same times each day. She replied that With most medications the staff has a 2 hour window when passing medications. I asked her how long the medication pass should take. She replied Again it shouldn't take longer than 2 hours as you have one hour before the scheduled time and one hour after. I asked what about the capillary blood glucose (CBG) checks and insulin administration. She replied I know this is taking the staff longer now as they used to have med techs and now they don't but I've talked to them about this and those CBG's should be checked right before going to eat, maybe they can start at 6:00 am but 5:30 am and 5:00 am is way too early. She also stated There shouldn't be all those holes in the MAR, I know they have a lot of agency nurses, but somebody needs to be checking that, and monitoring the residents for hypo (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) as well as other potential side effects depending on the medications the residents are taking. When asked for some medications that should be administered as scheduled, at the same times every day if there are any that if not given consistently could have a negative outcome for the residents. She replied, Well defiantly Insulin, as well as blood pressure medication, [MEDICAL CONDITION] medication, mood or [MEDICAL CONDITION] medications, pain medications and even antibiotics and sleeping meds as the goal is to maintain effectiveness, consistent levels, pain control etc and minimize the potential ill effects if not being consistent with the administration times. But definitely med pass should not be taking 4 and 5 hours. II. On 01/26/2016 at 9:51 am during interview with Medical Director (MD) #1 regarding the CBG's and insulin not being administered as ordered or documented, CBG's not being done at 6:30 am, instead it's being done by the night shift before they

Based on record review and interview, the facility failed to promote care with dignity and respect for 11 (R # 20, 86, 89, 99, 104, 144, 148, 153, 173, 174 and 181) of 11 (R # 20, 86, 89, 99, 104, 144, 148, 153, 173, 174 and 181) residents reviewed during random observation by: 1. Waking R #104, 174 and 181 to see if they need changing or to give medication. 2. Not ensuring that R # 60, 89, 153 and 173 were not exposed to other residents or passerbyers from the hallways. 3. R #144 and R #174 having to wait for assistance to the toilet resulting in his soiling himself. 4. R #20, 86, 99, 148 and 174 having to wait for assistance, medications and/or meals. This deficient practice likely resulted in residents feeling embarrassed, ashamed, and as if their feelings and preferences and unimportant don't matter to the facility staff. The findings are: A. On 01/21/16 at 3:10 pm during interview with Anonymous Staff (AS), s/he stated that the Activities Director (AD) was pushing R #179 in her wheelchair down the hall from an activity, and the AD said She (R #179) stinks and R #179 responded No, I don't. Findings related to waking residents: B. On 01/21/16 at 3:10 pm during interview with Anonymous Staff, s/he stated that R #181 was woken up in the middle of the night by a CNA to see if he was wet. AS described that this CNA (unidentified) picked up his shirt, pulled down his pants and untied his brief to see if he was wet. C. On 01/21/16 at 4:07 pm during interview with R #181, when asked if he is ever woken in the night by staff, he confirmed he had been. R #181 stated that a female night CNA (unidentified) has come into his room while he is sleeping, pull his covers down, and untied his pajama pants to see if he is wet. R #181 confirmed that this has happened twice at about 3 am in the morning. R #181 stated, I don't even wet the bed. I don't know why they (staff) do that. D. On 01/22/16 at 9:53 am during interview with R #104, when asked if she is ever woken to get her medication, she stated I have [MEDICAL CONDITION]. The regular doctors prescription is at 6(pm) but I get the drops until 10:30 pm to 12 am. Several times they have said they have given them to me in my sleep. R #104 confirmed that they wake her up to give her medication and take her vitals. R #104 said I have asked the doctor to change the prescription for day time (because of being woken up), but he said it's best to have them (eye drops) at bedtime. Findings related to having to wait for assistance/meals: E. On 01/21/16 at 2:50 pm during interview with R #144, he described that he needs assistance from staff to go to the restroom, taking off the belt, pulling pants down, and have staff spot me incase my knees buckle. When asked if staff respond to his call light, he stated It depends. They usually get here. If I have to go to the bathroom, I know now that I have to give them (staff) time before it's urgent (Need to go to the bathroom). R #144 confirmed that he has had a couple accidents before from having to wait too long. R #144 said, I knew they were understaffed and a lot of staff called in. Either shift blames the other. I tried to retain my right to be dignified. To soil myself doesn't make me feel too good. I wrestle with that. F. On 01/22/16 at 8:21am, during observation and interview, the room tray cart was sitting in the hallway. R #20, 99 and 148 were sitting at a table in the tv room. R #20 stated that they had been waiting for 15-20 minutes for breakfast. When asked if food is ever cold, R #20 responded Sometimes. Scrambled eggs are cold all the time. R #148 confirmed that they have been waiting for the breakfast trays since 8:00 am. G. On 01/22/16 at 8:21 am during interview with R #148, she stated Agency staff are slow in passing out meds (medication). I get sleeping pills but they don't come until 11:00 pm at night. I'm usually in bed since 9 (pm). R #148 also stated that she is unable to wheel herself back to her room, and the other night she had to wait an hour after dinner to get back to her room because there wasn't enough staff. R #148 stated This is a nursing home and they are not staffed adequately. No matter what you do here, you have to wait. H. On 01/22/16 at 8:32 am during interview with an Anonymous Resident (AR), s/he stated If you complain too much they will fire back. They (staff) will be unpleasant, and not answer your call light. They (staff) heard me talking to other residents, complaining in general and they started treating me different. They either like you or they don't like you. AR stated s/he she has seen other residents not be treated well or have to wait a long time. AR was unable to identify the specific residents or staff mentioned. I. On 01/22/16 at 8:38 am during interview with another AR, s/he stated They're (staff) favorite excuse is 'Give me a minute' and when they say that you know they aren't going to show up. It's very frustrating. It's a nursing home, don't expect too much. I asked (Name of local hospital) if they can keep me longer, cause I knew I wouldn't get the right care I needed here. J. On 01/22/16 at 8:40 am during observation and interview, CNA #8 served R #99 her breakfast tray. At 8:46 am R #20 and R #148 were served their breakfast trays. CNA stated that trays are suppose to be passed out at 8:20 am however I am a little behind, cause 2 CNAs called in and I am helping them. K. On 01/22/16 at 8:47 am during interview with R #86, when asked if he ever has to wait for assistance, R #86 stated Getting medications. Mostly at night but in the day time too. Usually my night pills. I didn't get them until almost 10 o clock. L. On 01/22/16 at 3:19 pm during interview with R #174, she stated We don't get good healthcare. The food here is not great. They don't have enough help. I don't know if it's cause the CNAs don't get enough help. I don't know if they are quitting. Everybody knows it here (that things are bad). What they are bringing in is agency care. Some of them are ok. Some of them are rude. Some of them we (residents) have to wait (for assistance). We get our medications late in the evenings. We can't get help (transfer to bed) until after 8 o cock. We have to wait on the showers. They say to us, 'It's not 7 o clock.' (to get help in bed). We have to wait for CNAs (from night shift) to get in. I can't get in (bed) myself. Everyone (CNAs) says, 'I need help' and it has to be 2 people (to transfer R #174). We come out of the dining room and we have to stay sitting. Atleast 12 hours in the wheelchair. Since I've had surgery on my spine I can't stay in my chair that long. My back is hurting. I press the call light and had to wait. When we (residents) have to use the restroom, they say 'Wait, wait.' Yes, sometimes I pee in my pants. I feel frustrated. I just want to leave this place and go somewhere else. They have to give our medications at 8 o clock but they don't give them until late. R #174 confirmed that she is woken up to be given medication and to be changed. Findings related to be exposed: M. On 01/27/16 at 9:49 am, on 01/28/16 at 8:43 am, and on 01/28/16 at 3:38 pm, R #60 was observed laying in bed with his hospital gown pulled up, exposing his briefs. This could be viewed from the hallway by passerbyers. N. On 01/22/16 at 3:16 pm and on 01/25/16 at 9:44 am during observation, R #89 was sitting in her room in her wheelchair moving towards the open door, with her pajama gown pulled up to her pelvis, exposing her legs and thighs. This was visible to passerbyes. O. On 01/21/16 at 10:30 am during an observation for the preparation of wound care CNA #8 positioned R #153 in bed then walked out of the residents room, leaving the door to the resident's room open. From the common hallway, R #153 was observed to be laying in bed with his pants down to his ankles and the resident's brief visible to passerbyes. P. On 01/22/16 at 8:29 am to 8:40 am during observation, R #173 was laying down in bed with his hospital gown on and bare buttocks facing towards the hallway. The door to resident's room was open. The Administrator was observed to walk by the resident's room twice during this time. Q. On 01/22/16 at 8:40 am, the Regional Nurse Specialist confirmed the above observation and closed R #173's room door.

Based on record review and interview, the facility failed to honor resident's rights for 1 (R #113) of 1 (R #113) resident reviewed during a complaint investigation by inappropriately placing a wander gurard on R #113 for 76 days without an order preventing him from being able to leave the facility and threatening to discharge R #113 if he didn't comply with the placement of the wander guard. If residents are being intimidated to comply with facility rules, then staff are violating residents' rights to have a choice in how they wish to live their lives which could result in feelings of frustration, fear, humiliation and depression. The findings are: A. Record review of Ombudsman Notes dated 11/25/15 revealed Meeting yesterday (11/24/15) with resident, his daughter, tribal officials, Administrator, DON (Director of Nursing), SSD (Social Services Director) and MDS Coordinator. Resident has not been assessed to lack capacity. Resident leaves facility and usually walks to where his daughter works, several blocks from (Name of facility). Administrator states that they need to discharge him because he does not follow policy by signing out, and therefore they cannot guarantee his safety. Resident states that he cannot always sign out because the sign out book is not always present at the front desk (Ombudsman confirms that book is not always there). Since 11/03/15 resident has been wearing a wander guard on his right leg due for his own safety per Administrator. There was no physician's order for a wander guard and the daughter/POA (Power of attorney) had not been notified that a wander guard was in place until the day of the meeting (11/24/15). B. Record review of Face Sheet dated 11/03/15 for R #113 reveals R #113 is his own responsible party. C. On 01/25/16 at 2:54 pm during interview with Social Services Director (SSD), she stated that regarding R #113, I have know this man (R #113) for about 7 years. He walks all over. That has always been his routine. It is care planned. When the new team (Administration) came, they thought of it as a liability. SSD confirmed that R #113 walks to his daughter's work which is a few blocks away and also goes next door (hotel) to play cards with the housekeepers. One day he went out and it was kind of cold, he was wearing a jacket. They got very concerned and put him on the wander guard. We had a meeting with his daughter and tribe (11/24/15). He stayed with the wander guard until I could get 2 doctors to say he was competent. That he could make his own decisions and was aware of the risk. He has medicaid so it was hard (to find physicians). SSD confirmed that he never had an order for [REDACTED]. D. Record review of the Physician orders revealed during October 2015 and November 2015 revealed there was no order for a wander guard. 1. A Physician order dated 11/24/15 revealed Keep wander guard in place until psych (psychiatric) consult to evaluate need for wander guard related to flight risk and personal safety. 2. A Physician order dated 01/18/16 revealed D/C (discharge) wander guard r/t (related to) results of competency evals (evaluations). E. On 01/26/16 10:47 am during an interview with the Corporate Nurse Specialist she stated. We do not have an order for [REDACTED]. F. On 01/26/16 11:27 am during an interview with Administrator when asked when the wander guard was placed on R #113, he stated that it was after he (Administrator) was hired (10/15/15) and before the Care Plan meeting in November (11/24/15). When asked for the reason the wander guard was placed on R #113, he stated There was concern of him going out in inclement weather and whether or not he was able to make those decisions. Administrator confirmed that at the Care Conference on 11/24/15, there was a request for some evaluations to be done. It was agreed that the wander guard would be removed once the competency assessment was completed and it was decided that he was capable of making his own decisions. When asked if a wander guard could be put on a resident without a physician's order, he stated It should not be. G. On 01/26/16 1:19 am during interview with Clinical Psychologist, she stated. I was asked by the facility if I could perform a competency test on R #113. I tested R #113 with a higher cognitive test and the results indicated he was cognitive and able to make rational decisions. I then submitted the diagnostic evaluation to the facility. H. On 01/27/16 10:24 am during an interview with R #113 he stated They put that thing (wander guard) on me so I wouldn't leave the building. A buzzer would sound when I would want to leave the building, It made me feel bad cause I could not leave the building. It was a nuisance to me every time I walked by the front door the buzzer would sound. It felt like I was in jail. I did not do anything else so they would not punish me any more. I am not such a bad boy. I don't want that thing on me again. I try to obey. I know how to follow instructions. I. On 01/25/16 to 01/29/16 during an interview with Medical Doctor (MD) #1, he confirmed that he never gave an order to put the wander guard on R #113. MD #1 confirmed that he was not informed that R #113 had a wander guard until after the care conference meeting (11/24/15).

Based on observation, interview and record review the facility failed to implement the care plan and follow physician orders [REDACTED].#3, 41, 45, 75, 172 and 175) of 10 ( R #3, 31, 41, 43, 45, 75, 81, 87, 172 and 175) residents reviewed for pressure ulcers and during random observation during meal service. If the facility is not implementing the care plan and following physician's orders [REDACTED]. The findings are: Findings related to pressure ulcers for R #3: A. Record review of the wound and skin status report dated 01/20/16 revealed the resident was noted to have two unstageable pressure ulcers; one located on the left ankle and the other located on the left side of her foot. Both of these pressure ulcers were noted to have been identified on 11/19/15 and were not present upon the resident's admission to the facility. The resident was also noted to have two other unstageable pressure ulcers to her right foot; one located on the lateral (outside) aspect of the heel and the other on the lateral aspect of the foot. Both of these pressure ulcers were noted to have been identified on 01/13/16 and were not present upon the resident's admission to the facility. Treatment to include Waffle boots on when in bed and while up for off loading. Order Sherpa for suhioning to BIL feet to be applied at foot of bed and in chair if applicable. Apply when order is received then discontinue waffle boot. B. Record review of Physician order [REDACTED]. Apply to foot of bed, et wc (wheelchair) if appropriate. Apply when received then DC waffle boots. C. On 01/19/16 from 8:48 am to 9:32 am, during an observation, R #3, was reclining in a geri-chair (a type of wheelchair) in the common area next to the nurses' station. The resident had one waffle boot on her left foot with no waffle boot present on the resident's right foot. Three separate times during the observation the resident had her ankles crossed, with the outer aspect of the right ankle pressed up against the inner aspect of the left ankle. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. D. On 01/19/16 from 9:52 am to 10:53 am, R #3 was reclining in a geri-chair in the common area next to the nurses' station. The resident had one waffle boot on her left foot with no waffle boot present on the resident's right foot. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. E. On 01/21/16 from 9:19 am to 10:28, R #3 was reclined in the geri chair in the common area next to the nurses' station. The resident did not have waffle boots placed on either feet and both of the resident's heels were set directly on the foot rest of the geri-chair. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. F. On 01/21/16 at 3:46 pm, during an interview with the resident she was asked if she had the strength to reposition herself on her own and stated, No, I can't do anything thing on my own, I'm helpless, they (staff members) have to do everything for me. G. On 01/21/16 at 3:47 pm, during an interview and observation with the wound care nurse Registered Nurse (RN) #11 she was asked if the resident should be wearing waffle boots on both of her feet while she rests in the geri-chair and stated, Yes. RN #11 confirmed that eventhough the resident cannot reposition herself, she frequently shifts while in the chair and the waffle boot often get removed. During an observation, RN #11 began performing wound care to the resident's pressure ulcers on her feet. When RN #11 removed the residents right sock, no wound dressing was present over the resident's pressure ulcer located closest to the ankle. RN #11 confirmed the resident should have had a dressing covering the pressure ulcer to protect it. H. On 01/22/16 at 8:55 am, R #3 was reclining in a geri-chair in the common area next to the nurses' station. The resident had waffle boots placed on both feet but the waffle boot on the right foot was deflated. The resident did not have a cushion/pillow to relieve the pressure off of her feet/heels I. On 01/22/16 at 3:07 pm R #3 was reclined in the geri chair in the common area next to the nurses' station. The resident did not have waffle boots placed on either feet. The resident had her ankles crossed, with the outer aspect of the right ankle pressed up against the inner aspect of the left ankle. The resident did not have a cushion/pillow to relieve the pressure off of her feet/heels. J. On 01/26/16 at 10:37 am during observation, R #3 was laying in her geri-chair in the television (TV) room. Her heels were resting on a Sherpa pad. K. On 01/27/16 at 9:08am during observation, R #3 was laying in her geri chair in the TV room. There was no boots or no sherpa pad under heels. L. On 01/27/16 at 10:37 am during observation, R #3 was laying in her geri chair in the TV room, the sherpa pad was under R #3's calves, however her heels were resting directly on the chair. M. On 01/28/16 at 8:52 am during observation, R #3 was laying in her geri chair in the TV room. R #3's heels were laying on the chair. No boots or sherpa pad under her feet. N. On 01/29/16 at 9:25 am during observation, R #3 was laying in her geri chair in the TV room, the sherpa pad was on the floor. R #3's heels were laying on the chair. O. On 01/29/16 at 2:16 pm, during observation, R #3 was laying in her geri chair in the tv room. The sherpa pad was half way off the chair, and no pad was under her heels. Findings related to Meal tickets: Findings for R #41: P. Record review of monthly weight report for R #41 dated 12/29/15 revealed 1.21% weight loss in 1 month, 16.62% weight loss in 3 months, 12.83% weight loss in 6 months. Q. Record review of lunch meal ticket dated 01/29/16 revealed Mighty shakes (high calorie nutritional supplement) TID (Three times a day) w/meals, soups with every meal. R. On 01/29/16 at 12:27 pm during observation of lunch meal, R #41 was not given a mighty shake and she was not served any soup. S. On 01/29/16 at 12:31pm during an interview with the Dietary Manager (DM), he confirmed R #41 should be served a shake TID and she was not given a shake and soup for lunch. Findings for R #44: T. Record review of weight report dated 12/29/15 revealed a 1 month weight loss of 6.60%, 3 month weight loss of 9.98% and a 6 month weight loss of 13.92%. U. Record review of lunch meal ticket reveals, regular diet, high protein snacks between meals at HS (night) 2.0 med pass (high calorie supplement) 90 ml (milliter) tid w/meals. V. On 01/29/16 at 12:33 pm during an observation of the lunch meal, R #44 was not served the med pass as ordered on his tray ticket. W. On 01/29/16 at 12:36 pm DM state, R #44 should be getting his med pass with meals and that comes out of the kitchen if it is on the meal ticket. DM confirmed that R #44 was not served med pass for lunch. Findings for R #75: X. Record review of monthly weight report dated 12/29/15 reveals a 4.66% weight loss in 1 month, a 4.95% weight loss in 3 months and 9.65% in 6 months. Y. On 01/29/16 at 12:35 pm during an observation of lunch meal, R #75 was served a mighty shake that was partially frozen. The shake carton was tipped upside down on a cup, and minimally pouring out. Z. On 01/29/15 at 12:36 pm during an interview with DM, he stated. We just took them (mighty shakes) out to thaw we usually don't serve them like that, but they will thaw out that is why they (CNA's) are letting it drip into the glass. Findings for R #172: AA. Record review of monthly weight report dated 12/29/15 revealed 1.16% weight loss in 1 month, 1.16% weight loss in 3 months and 2.75% weight loss in 6 months. BB. Record review of lunch meal ticket dated 01/29/16 revealed, no knife on tray, sandwich of choice, soup of choice. CC. On 01/29/16 at 12:28 pm during observation of lunch meal, R #172's lunch consisted of beef enchiladas, parslied carrots, charro beans, corn torilla, sugar cookie. There was a knife on her tray, no sandwich or soup were observed on her plate. DD. On 01/29/16 at 12:28 during interview Social Services Director, she confirmed she should not have a knife and she did not have soup or a sandwich on her tray. Findings for R #179: EE. Record review of care plan dated 03/03/15 for R #179 revealed Regular CCD (Consistent Carbohydrate Diet for diabetics). To provide diet as ordered. FF. Record review of lunch meal ticket dated 01/29/16 revealed Renal diet. Beef Patty , LS (low sodium) Brown gravy, Parslied carrots, rice, corn tortilla, sugar cookie, milk and soup for Lunch. GG. On 01/29/16 at 12:29 during observation of lunch meal, R #179 was observed to be eating red chilies enchiladas and beans and carrots. There was no soup in front of R #179. HH. On 01/29/16 at 12:30 pm during interview Dietary Manager (DM) confirmed R #179 is non compliant with her renal diet, however, R #179 should be getting soup for lunch.

Based on observation, interview and record review the facility failed to ensure that 1 (R #3) of 5 (R #3, 31, 43, 81 & 87) residents reviewed for pressure ulcers received the necessary services to prevent the development of new pressure ulcers by: 1. Not monitoring the condition of the resident's feet. 2. Not providing appropriate pressure relieving cushioning while the resident was resting in a geri-chair (a type of wheelchair). 3. No ensuring one of the resident's pressure ulcers was covered with an appropriate wound dressing. This deficient pact likely resulted in the resident developing multiple avoidable pressure ulcers. The findings are. A. Record review of the physician's orders [REDACTED]. This order was noted to be performed on a daily basis. B. Record review of the treatment administration record dated 11/01/15 to 11/30/15 revealed no indication that daily foot checks were performed during the entire month. Under the section where daily foot checks were to be performed at 8:00 am was a strickthrough note that was re-written to be performed PRN (as needed). C. Record review of the wound and skin status report dated 01/20/16 revealed the resident was noted to have two unstageable pressure ulcers; one located on the left ankle and the other located on the left side of her foot. Both of these pressure ulcers were noted to have been identified on 11/19/15 and were not present upon the resident's admission to the facility. The resident was also noted to have two other unstageable pressure ulcers to her right foot; one located on the lateral (outside) aspect of the heel and the other on the lateral aspect of the foot. Both of these pressure ulcers were noted to have been identified on 01/13/16 and were not present upon the resident's admission to the facility. Treatment to include Waffle boots on when in bed and while up for off loading. Order Sherpa for suhioning to BIL feet to be applied at foot of bed and in chair if applicable. Apply when order is received then discontinue waffle boot. D. Record review of Physician order [REDACTED]. Apply to foot of bed, et wc (wheelchair) if appropriate. Apply when received then DC waffle boots. E. On 01/19/16 from 8:48 am to 9:32 am, during an observation, R #3, was reclining in a geri-chair (a type of wheelchair) in the common area next to the nurses' station. The resident had one waffle boot on her left foot with no waffle boot present on the resident's right foot. Three separate times during the observation the resident had her ankles crossed, with the outer aspect of the right ankle pressed up against the inner aspect of the left ankle. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. F. On 01/19/16 from 9:52 am to 10:53 am, R #3 was reclining in a geri-chair in the common area next to the nurses' station. The resident had one waffle boot on her left foot with no waffle boot present on the resident's right foot. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. G. On 01/21/16 from 9:19 am to 10:28 R #3 was reclined in the geri chair in the common area next to the nurses' station. The resident did not have waffle boots placed on either feet and both of the resident's heels were set directly on the foot rest of the geri-chair. During the observation the resident was not offered to reposition or a cushion/pillow to relieve the pressure off of her feet/heels. H. On 01/21/16 at 3:46 pm, during an interview with the resident she was asked if she had the strength to reposition herself on her own and stated, No, I can't do anything thing on my own, I'm helpless, they (staff members) have to do everything for me. I. On 01/21/16 at 3:47 pm, during an interview and observation with the wound care nurse Registered Nurse, (RN) #11 she was asked if the resident should be wearing waffle boots on both of her feet while she rests in the geri-chair and stated, Yes. RN #11 confirmed that eventhough the resident cannot reposition herself, she frequently shifts while in the chair and the waffle boot often get removed. During an observation, RN #11 began performing wound care to the resident's pressure ulcers on her feet. When RN #11 removed the residents right sock, no wound dressing was present over the resident's pressure ulcer located closest to the ankle. RN #11 confirmed the resident should have had a dressing covering the pressure ulcer to protect it. J. On 01/22/16 at 8:55 am, R #3 was reclining in a geri-chair in the common area next to the nurses' station. The resident had waffle boots placed on both feet but the waffle boot on the right foot was deflated. The resident did not have a cushion/pillow to relieve the pressure off of her feet/heels K. On 01/22/16 at 3:07 pm R #3 was reclined in the geri chair in the common area next to the nurses' station. The resident did not have waffle boots placed on either feet. The resident had her ankles crossed, with the outer aspect of the right ankle pressed up against the inner aspect of the left ankle. The resident did not have a cushion/pillow to relieve the pressure off of her feet/heels. L. On 01/26/16 at 10:37 am during observation, R #3 was laying in her geri-chair in the television (TV) room. Her heels were resting on a Sherpa pad. M. On 01/27/16 at 9:08am during observation, R #3 was laying in her geri chair in the TV room. There was no boots or no sherpa pad under heels. N. On 01/27/16 at 10:37 am during observation, R #3 was laying in her geri chair in the TV room, the sherpa pad was under R #3's calves, however her heels were resting directly on the chair. O. On 01/28/16 at 8:52 am during observation, R #3 was laying in her geri chair in the TV room. R #3's heels were laying on the chair. No boots or sherpa pad under her feet. P. On 01/29/16 at 9:25 am during observation, R #3 was laying in her geri chair in the TV room, the sherpa pad was on the floor. R #3's heels were laying on the chair. Q. On 01/29/16 at 2:16 pm, during observation, R #3 was laying in her geri chair in the tv room. The sherpa pad was half way off the chair, and no pad was under her heels.

Based on record review and interview, the facility failed to prevent the development of infection in a pressure ulcer for 1 (R #127) of 4 (R #12, 42, 87 & 127) residents with pressure ulcers by: 1. Not providing adequate intervention to prevent R #127 from picking at her rectal area and then removing/picking at her wound/pressure ulcer dressing. 2. Not providing a detailed evalutation of the resident's pressure ulcer with each dressing change or at least weekly. This deficient practice is likely to have resulted in R #127 developing an Eschericha coli (a bacteria commonly found in fecal matter) infection in the pressure ulcer on her right hip. The finding are: Not providing adequate intervention for R#127 A. Record review of the care plan dated 09/02/14 revealed that the resident was noted as having the following problem areas, "Self Care Deficit AEB (as evidenced by): resident has [DIAGNOSES REDACTED]." B. Record review of the wound clinic notes dated 12/02/14, 12/09/14, 12/12/14, 12/16/14 and 12/19/14 revealed that the resident was identified as having a stage four pressure ulcer to the right hip. C. Record review of the Wound Assessment Report dated 12/02/14 revealed that the resident's pressure ulcer was identified as being infected. D. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident was identified as being severely impaired with regard to making decisions about her tasks of daily life and had continuous difficulty with inattention. E. Record review of Departmental Notes dated 12/18/14 at 1:56 pm revealed the resident was identified to have a significant change in wound status as necrotic (dead) tissue was noted to be present in the wound. F. Record review of the departmental notes dated 12/22/14 at 6:35 pm revealed the resident's pressure ulcer was identified as being re-infected. G. On 12/31/14 at 3:54 pm during an interview with Certified Nursing Assistant (CNA) #1 she confirmed that while she cared for the resident she was aware of the fact the resident exhibited a behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked how long the resident had been displaying this behavior CNA stated, "A while, maybe a month or a month and a half." When asked, as a CNA, what she did to prevent the resident from picking at her wound she stated, "I tried to clip her nails, but she didn't let me and we would try to brush her nails in the shower but she wouldn't let us. She wore pants and we wound tuck her shirt into her pants so she couldn't get to it but she would still lift up her shirt and get into it and pick." When asked if she ever redirected the resident to not pick at her wound she stated, "Yeah, I would walk in and she would usually do it in bed, but I would tell her not to because it would get infected." When asked if redirecting the resident to not pick at her wound was successful she stated, "Sometimes, she would remember for a while but then she would forget and go right back to it." When asked what other interventions she tried she stated, "We just tried to keep telling not to do it." H. On 01/02/15 at 10:56 am during an interview, Licensed Practical Nurse (LPN) #1 confirmed that while he cared for the resident he was aware of the fact the resident exhibited a behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked if redirecting the resident was effective he stated, "It was for a time. She would stop for two or three days but then she would go right back to digging. So kind of, but it wasn't completely effective." When asked what steps were taken after redirection didn't work he stated, "Well we couldn't put a glove on her or anything like that because that would be a restraint. We sent her to the wound clinic but really we couldn't do much else. I don't know of any other intervention we could have done." During the interview LPN #1 confirmed that he did not try placing a glove on the resident's hand. I. On 01/02/15 at 11:57 am during an interview with the Acting Director of Nursing (ADON), she confirmed that she was aware of the resident's behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked what interventions were set in place to prevent this behavior she stated, "We tried to keep her on her side and keep her comfortable and the wound clinic said to rotate her and keep her on her side. PT (physical therapy) got her a wider wheelchair." When asked if there were any other interventions the facility tried to prevent the resident from picking at her wound she stated, "We would try to redirect her but it was difficult and she would forget." When asked if the facility had considered placing a glove on the resident's hand she stated, "(Name of LPN #1) tried that." When asked if the facility had considered placing the president on one-to-one status to prevent her from picking at her wound she stated, "No, not that." Not providing a detailed evaluation J. Record review of the Treatment Administration Record, nursing and HIgh Nursing Facility (HNF) notes dated 12/18/14 to 12/23/14 revealed the resident was documented as having a dressing change treatment to the pressure ulcer on her right hip performed on eight separate occasions. There was no indication that a complete evaluation of the pressure ulcer was performed and included the following: 1. Location and staging. 2. Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining (erosion) or tunneling/sinus tract (openings underneath the skin). 3. Exudate (fluids that drain out of the body) if present: type (such as purulent (pus like)/serous (water like)), color, odor and approximate amount. 4. Pain, if present: nature and frequency (e.g., whether episodic or continuous). 5. Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (tissue death) (slough (shedding dead tissue) or eschar (dead tissue that is scab like)); and 6. Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration (softening)) as appropriate. K. On 01/02/15 at 11:57 am during an interview with ADON when asked how often nursing staff are expected to evaluate the wound of residents with pressure ulcers she stated, "Every shift, at least daily." L. Record review of the History and Physical dated 12/23/14 revealed the resident was diagnosed with [REDACTED]. A notation read, "This is most likely related to the infected decubitus ulcer of the right greater trochanter (hip bone)." M. Record review of laboratory wound culture results dated 12/27/14 revealed the resident had Eschericha coli (a bacteria commonly found in fecal matter) growth in her pressure ulcer along with mixed types of microorganisms found on the skin.

Based on record review and interview, the facility failed to accurately assess 3 (R #48, 155 & 189) of 9 (R #1, 48, 127, 139, 155, 156, 174, 188 & 189) reviewed for nutrition, pressure ulcers and resident's rights by 1. Not accurately assessing R #48 for being a smoking risk. If residents are not accurately assessed for their smoking risks, then resident's plan of care and treatment may not reflect the resident's actual risk when smoking putting the resident and other resident's in the facility at risk. 2. Not ensuring the Minimum Data Set (MDS) was accurate for R #189. If a residents MDS is not accurate, the resident's plan or care may not reflect the resident's actual health concerns. 3. Not performing Braden skin assessments (a tool to assess pressure ulcer risk) as needed for R #155. If residents at high risk of developing pressure ulcers do not receive Braden risk assessment frequently enough, staff may not implement enough preventative measures to ensure residents do not develop pressure ulcers. The findings are: Findings for R #48: A. Record review of Physician order [REDACTED]. B. Record review of the Safe Smoking (MDS) data set [DATE] and 11/11/14 revealed that R #48 does not exhibit poor smoking awareness and does not require interventions like supervision when smoking. C. Record review of the Smoking Warning for (name of R #48) dated 08/19/14 revealed that R #48 has been smoking inside her room and that oxygen is present in R #48's room which poses a safety risk and violates the facilities smoking policy. D. Record review of Departmental Notes for R #48 revealed: 1. 11/12/14 "Res also cont's (continues) to smoke in her room with the O2 on, notified (name of Physician Assistant #1) who had a conversation with res (resident) and wrote n/o (order) to d/c (discharge) res if she cont's to smoke in her room and cont's to refuse care from staff. Res understands. 2. 11/16/14 "Also found to be smoking in room x (times) 2 this evening." E. On 11/12/14 at 2:28 pm during observation of R #48's room, there was an oxygen tank at the foot of R #48's bed. F. On 11/18/14 at 1:59 pm during observation of R #48's room, there was an oxygen tank at the foot of R #48's bed. G. On 11/14/14 at 3:29 pm during interview with R #48, she stated that she got caught smoking and staff put her cigarettes up front (nurse's station). She stated that she is dependent on other residents to provide her cigarettes. H. On 11/17/14 at 10:53 am during interview with R #48, she confirmed that she has been getting cigarettes from other residents and picking up the butts from the ground. I. On 11/18/14 at 10:57 am during interview with the SSD, she stated "She has been told what the consequences are in graphic terms. Apparently she has been smoking in there (her room) at night." J. On 11/18/14 at 3:50 pm during interview with the Administrator, he stated "More than a month ago. It has been known that she smokes in her room. There was an extra smoke alarm put in her room. I informed staff if she smokes in her room, I need to be called. The first time I was notified. She smoked in her room again. We had a care conference with her. On Saturday, she was found smoking and staff took the cigarettes and lighter and then an hour later she was found smoking again. We looked at pretty much everything we can do to help her recognize the unsafe behaviors. Obviously with oxygen, it is much more severe. We feel pretty strongly that she is not (going to stop smoking in her room). We are looking at, is there a safe place to discharge her or help her be aware of what is happening." Findings for R #189 K. Record review of the History and Physical dated 10/30/14 revealed that R #189 has celiac disease (condition in the intestines in which a person cannot digest gluten). L. Record review of the Physician order [REDACTED]." M. Record review of the Minimum Data Set (MDS), Section K: Swallowing/Nutritional Status dated 11/15/14 did not indicate that R #189 is ordered a therapeutic diet. N. On 11/18/14 at 2:10 pm during interview with the Dietary Manager (DM), he stated that R #189 is on a therapeutic diet and MDS was coded incorrectly. O. On 11/18/14 at 2:39 pm during interview with Minimum Data Set (MDS) Coordinator #1 she confirmed that the MDS was coded incorrectly and it should reflect R #189's current diet. Findings for R #155 P. Record review of the Policy and Procedure on Skin Systems dated August 2014 revealed, "A Braden risk assessments will be completed on admission, weekly for four weeks, with changes of condition and then on a quarterly basis." Q. Record review of the Wound Healing Progress Report dated 05/28/14 revealed that R #155 was admitted to the facility with a stage 2 pressure ulcer to the right buttock on 05/28/14. R. Record review of the Risk History Report for R #155 revealed the only Braden risk assessment the resident received was dated 06/23/14. S. On 11/18/14 at 10:24 am, during an interview with the Staff Development Coordinator/Licence Practical Nurse she confirmed the only Braden risk assessment in the medical record for R #155 was dated 06/23/14. T. On 11/20/14 at 2:33 pm during an interview with Registered Nurse #1, when asked how often Braden skin assessments should be performed when a resident is first admitted she stated, "If they (residents) are a new admission, it (Braden assessment) is part of the assessment process and after that, it is then completed quarterly."

The facility failed to ensure that residents were free from accident hazards by knowing that R #48 on several occasions had been smoking in her room in the presence of oxygen, and despite several failed efforts to encourage R #48 to stop smoking in her room, the facility did not remove the oxygen hazard. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 11/18/14 at 4:50 pm. The facility Administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 11/18/14 at 6:39 pm. Based on the plan, interventions included: 1. Resident #48's oxygen order was discontinued and the equipment was removed from the resident's room. In the event that resident #48 requires oxygen at some future time she will receive 1:1 (one-to one). supervision. Resident is on a supervised smoking schedule and smoking materials are kept in medication cart. 2. All smokers have received an updated Safe Smoking Assessment. Unsafe smokers have been placed on a supervised smoking schedule and smoking materials have been removed. All smokers will be reassessed quarterly and upon change of condition. 3. All smokers are being reeducated regarding the facility smoking policy, removal of oxygen from any smoking area, and safe smoking practices including, but not limited to, not sharing smoking materials. 4. Staff have received in-service education regarding: a. Resident #48's oxygen discharge order b. Identifying smokers at potential risk for unsafe smoking c. Removing oxygen from any area where smoking is occurring d. In the event that smoking occurs within the facility, the smoker is considered unsafe, smoking materials are removed, the resident is placed on 15 minute checks or, if the resident requires oxygen, 1:1 (one-to-one) supervision e. Smoking supervision for unsafe smokers, including smoking equipment, times, and prevention of unsafe smoking conditions. Based on the Plan of Removal and observation, the IJ was lifted. This resulted in the scope and severity being reduced from a L to Level 2, Scope F. Based on record review, interview and observation, the facility failed to ensure that residents are free from accidents for all 118 residents, listed on the facility census list provided by the Administrator on 11/12/14, by knowing that R #48 on several occasions had been smoking in her room in the presence of oxygen, and despite several failed efforts to encourage R #48 to stop smoking in her room, the facility did not remove the oxygen hazard. This deficient practice is likely to result in an increase risk of a fire igniting which will burn faster and hotter, putting all residents and staff in the facility in danger. The findings are: A. Record review of Physician order [REDACTED]. B. Record review of the Safe Smoking (MDS) data set [DATE] and 11/11/14 revealed that R #48 does not exhibit poor smoking awareness and does not require interventions like supervision when smoking. C. Record review of the Smoking Warning for (name of R #48) dated 08/19/14 revealed that R #48 has been smoking inside her room and that oxygen is present in R #48's room which poses a safety risk and violates the facilities smoking policy. D. Record review of Departmental Notes for R #48 revealed: 1. 11/12/14 "Res also cont's (continues) to smoke in her room with the O2 on, notified (name of Physician Assistant #1) who had a conversation with res (resident) and wrote n/o (order) to d/c (discharge) res if she cont's to smoke in her room and cont's to refuse care from staff. Res understands. 2. 11/16/14 "Also found to be smoking in room x (times) 2 this evening." E. On 11/12/14 at 2:28 pm during observation of R #48's room, there was an oxygen tank at the foot of R #48's bed. F. On 11/18/14 at 1:59 pm during observation of R #48's room, there was an oxygen tank at the foot of R #48's bed. G. On 11/14/14 at 3:29 pm during interview with R #48, she stated that she got caught smoking and staff put her cigarettes up front (nurse's station). She stated that she is dependent on other residents to provide her cigarettes. H. On 11/17/14 at 10:53 am during interview with R #48, she confirmed that she has been getting cigarettes from other residents and picking up the butts from the ground. I. On 11/18/14 at 10:57 am during interview with the Social Services Director (SSD), she stated, "She has been told what the consequences are in graphic terms. Apparently she has been smoking in there (her room) at night." J. On 11/18/14 at 3:50 pm during interview with the Administrator, he stated, "More than a month ago. It has been known that she smokes in her room. There was an extra smoke alarm put in her room. I informed staff if she smokes in her room, I need to be called. The first time I was notified. She smoked in her room again. We had a care conference with her. On Saturday, she was found smoking and staff took the cigarettes and lighter and then an hour later she was found smoking again. We looked at pretty much everything we can do to help her recognize the unsafe behaviors. Obviously with oxygen, it is much more severe. We feel pretty strongly that she is not (going to stop smoking in her room). We are looking at, is there a safe place to discharge her or help her be aware of what is happening."

Based on observation, record review and interview, the facility failed to implement the Care Plan and follow Physician's orders for 5 (R #48, 54, 74, 107 and 122) of 11 (R #44, 48, 54, 74, 81, 84, 107, 122, 139, 189 an 190) residents reviewed for call light functioning, tube feeding, unnecessary medication and at random observation by: 1. Staff not providing R #48 access to her own cigarettes. If residents' personal belongings are withheld from them by staff then staff are violating residents' rights to have a choice in how they wish to live their lives which could result in feelings of frustration, humiliation and depression. 2. Not providing break through pain medication for R #48. This deficient practice likely resulted in R #48 experiencing multiple incidences of unrelieved pain. 3. Not ensuring that call lights in residents rooms are functioning and within resident's reach for R #74, 107 and 122. If call lights are not within reach for residents and/or not functioning, this is likely to result in residents being unable to request assistance, such as needing help with transferring, after falling or other acute distress. 4. Not performing oral care for R #54. If residents who cannot perform oral care for themselves do not receive adequate oral care they can experience dry mouth, discomfort, and oral infections. The findings are: Findings for R #48 related to resident's rights: A. Record review of the Care Plan for R #48 dated 08/25/14 revealed "Resident is a smoker, often smokes in the facility (appears to not be a safe smoker, all smoking equipment has been removed from resident and she must now get equipment from nurse and return after smoking due to poor safety awareness.)" B. On 11/14/14 at 3:29 pm during interview with R #48, she stated that she got caught smoking and staff put her cigarettes up front (nurse's station). She stated that she doesn't have access to her cigarettes and she is dependent on other residents to provide her cigarettes. C. On 11/14/14 at 3:52 pm during interview with Licensed Practical Nurse (LPN) #2 and observation, LPN #2 stated that R #48 was caught two times with the cigarettes in her room. He stated that he went in her room with the doctor to tell her that if she continued to smoke in her room, she would be discharged . LPN #2 continued to say that he went in her room and took her cigarettes (2 packs). LPN #2 pulled 2 packs of cigarettes from a drawer at the nurse's station. When asked if R #48 gave the cigarettes to him, he stated, "No, I just took them." LPN #2 confirmed that the cigarettes were the resident's and purchased by the resident. LPN #2 confirmed that R #48 does not have access to her cigarettes. LPN #2 also continued to say that the hospital told her that she can't smoke. "I went and took them from her." LPN #2 confirmed that the resident gets cigarettes from other residents on the unit. When asked if there was a doctor's order to take her cigarettes, he stated, "No order. Verbal order from the hospital. Due to her just having surgery she shouldn't be smoking." D. On 11/17/14 at 10:55 am during interview with Assistant Director of Nursing (ADON) #2, she confirmed that R #48's cigarettes have been locked in pharmacy and resident does not have access to them. E. On 11/17/14 at 10:53 am during interview with R #48, she confirmed that her cigarettes have not been returned to her and she has been getting cigarettes from other residents and picking up the butts from the ground. F. On 11/17/14 at 1:55 pm during interview with the Social Services Director (SSD) when informed that a nurse said he took R #48's cigarettes from her, she responded, "They cant deny her the cigarettes. She can always get cigarettes from other people." G. On 11/18/14 at 11:34 am during interview with R #48, she confirmed that she hasn't been given her cigarettes. She stated, "There's not much I can do about it. It's upsetting to me. I feel like hell. I'm an old lady. I'm not young. I feel like I'm begging for something that is mine. I'm not hurting anybody." H. On 11/18/14 at 3:50 pm during interview with the Administrator, when informed that R #48's cigarettes were taken from her, he stated, "From my knowledge, they are being kept in the cart and given to her when she goes out to smoke. My understanding was that she could ask for them and that was my directive as well." Findings for R #48 related to pain medication: I. Record review of (name of Medical Facility) Transfer Orders for R #48 dated 11/11/14 revealed R #39 had "repair of right femur fracture" with orders for [MEDICATION NAME] (pain reliever) 5 milligrams (mg) and [MEDICATION NAME] (pain reliever) 50 mg every 6 hours for pain. Handwritten note on Order dated 11/12/14 revealed "Please make sure all these orders are completed." J. Record review of Physician Orders for R #48 dated 08/12/14 revealed "[MEDICATION NAME] 50 mg 1 tablet PO (by mouth) Q (every) 6H (hours) PRN (as needed) Pain." K. Record review of Departmental Notes for R #48 revealed: 1. 11/13/14, "Resident verbally abusive with nurse when she can not get her pain meds due to timing of last given. 2. 11/16/14, "Requested pain medication before 6 hrs (hours) as ordered, Began to yell out, 'What the f*** is wrong with this place? Do I have to suck a (name of male genitalia) to get my medicine?' This type of behavior and language has also become NFR (normal for resident) if meds (medication) not given when requested. Returned later and asked for pain medication again. Did administer to resident who was then pleasant and cooperative." L. Record review of the Medication Administration Record [REDACTED]. M. Record review of the Refusal of Medication or treatment for [REDACTED]. N. Record review of the PRN Flowsheet for [MEDICATION NAME] and Other Medications for R #48 dated 11/16/14 at 9:00 am, 11/17/14 at 12:00 am and 2:00 pm revealed that R #48 rated her pain one hour after she received [MEDICATION NAME] 5 mg as a 4-5 (on a 1-10 pain intensity scale). O. On 11/12/14 at 2:44 pm during interview and observation of R #48, she was moaning in pain and grabbing her right hip. R #39 stated that she recently had hip surgery and was in pain. R #39 stated she could get pain medication at 3:00 pm. P. On 11/14/14 at 3:26 pm during interview with R #48, when asked when she receives her pain medication she responded "Every 6 hours." R #48 stated that she writes down the time in a notebook so she can keep track of when she can ask for it again. Q. On 11/19/14 at 9:38 am during interview with Licensed Practical Nurse (LPN) #2 when asked about pain medication available to R #48, he stated that resident can have [MEDICATION NAME] 5 mg and [MEDICATION NAME] 50 mg every 6 hours. He explained that if resident's pain level is more than a 9 or 8 (on the 1-10 pain assessment scale, 10 being the worse) then she is given [MEDICATION NAME]. LPN #2 confirmed that R #48 has not received [MEDICATION NAME]. When asked if resident ever requests more pain medication, he stated "Sometimes. Especially if she sees a new nurse on the floor, she'll say she didn't get it. She'll try and get more." When asked what if resident continues to complain of pain, he stated "Then we would give her the [MEDICATION NAME] after 3 hours for break through pain." R. On 11/19/14 at 9:45 during interview with R #48, when asked about her pain, she stated "I'm having it right now. It is high cause I was outside moving around." When asked if she could ask for pain medication, she stated that she had to wait until 12:30 pm which would be 6 hours. R #48 confirmed that there have been times in which she requested pain medication and wasn't provided it because it hadn't been 6 hours. S. On 11/19/14 at 10:40 am during interview with Certified Nurse Aid (CNA) #3 when asked if R #48 ever complains of pain, she stated "She does have pain. Yesterday when I was working with her she asked for pain medicine. She was in bed. I asked if she needed anything and she said pain meds,"Yesterday she asked 3 times. but I think she (nurse) kept forgetting. I told her that I had let the nurse know." When asked if resident has ever not been provided pain medication cause it wasn't time, she responded, "There was one time she was asking for it a lot but it wasn't time to give it." T. On 11/19/14 at 10:43 am during interview with Physician Assistant (PA) #1 when asked if R #48 could receive [MEDICATION NAME] and [MEDICATION NAME] at the same time, he responded "She can get those at the same time. It would be better not to. Wait at least 20 to 30 minutes." When asked if pain assessment of 5 is acceptable, he responded "We would want it better than that." U. On 11/19/14 at 11:26 am during interview and observation with R #48, she stated that on a pain scale 1-10, reasonable amount of pain would be 1 or 2. Resident pressed call light button to ask for more pain medication. V. On 11/19/14 at 11:30 am during observation, CNA #3 informed LPN #2 that R #48 wanted pain medication. W. On 11/19/14 at 1:39 pm during interview with R #48, she confirmed that she was provided pain medication at 12:30 pm. Findings for R #107: X. Record review of Care Plan for R #107 dated 02/20/12 revealed, "Call bell in reach." Y. On 11/19/14 at 2:02 pm during observation of R #107's room, R #107 was in bed and the call light cord was not within his reach. Findings for R #74 and R #122: Z. Record review of Care Plan for R #122 dated 12/27/13 revealed, "Call bell in reach." AA. Record review of Care Plan for R #74 dated 01/14/12 revealed, "Call bell in reach." BB. On 11/19/14 at 1:52 pm during observation of R #122 and #74's room, R #122 and R #74 were in bed and the call light was not within their reach. R #122's call light cord was pulled from wall and not functioning. CC. On 11/19/14 at 1:52 pm during interview with Licensed Practical Nurse (LPN) #2 she stated, "They don't know how to use them and sometimes it's dangerous for them cause they play with them." LPN confirmed that R #74's and R #122's call light was not within R #74's and R #122's reach. Findings for Resident #54 DD. On 11/14/14 at 11:09 am during an interview with family member of Resident #54, she confirmed that when she has visited Resident #54 that she has observed him with dried mucous in and around his mouth as well as having an oral sore. EE. On 11/14/14 at 11:56 am Resident #54 was observed sitting in his wheelchair. He had dried mucous on his lips, teeth and in his mouth. FF. On 11/17/14 at 1:44 pm during interview with Registered Nurse #2 he confirmed that when certified nursing assistants perform oral care, they should be documenting it in Accunurse (electronic charting system). GG. Record review of the Flow Sheet for Resident #54 dated 11/01/14-11/17/14 revealed no documentation of oral care. HH. Record review of the History and Physical dated 05/22/14 revealed Resident #54 was diagnosed with [REDACTED]. II. Record review of Care Plan dated 05/16/14 revealed that Resident #54 had the following problem areas: 1. Resident is unable to make daily decisions for care, relies on staff for all activities of daily living (ADLs). Approach for this problem area included provide cueing, prompting, and assist for personal care as needed 2. Is at risk for complications associated with tube feed. Approach for this problem area included mouth care every shift. JJ. Record review of the Mouth Care Policy and Procedure dated October 2010 revealed the following: The purposes of this procedure are to keep the residents lips and oral tissues moist, to cleanse and freshen the residents mouth, and to prevent infections of the mouth. The following information should be recorded in the residents medical record: the date and time the mouth care was provided. The name and title of the individual(s) who provided the mouth care. All assessment data obtained concerning the residents mouth. The certified nursing assistant should report to the licensed nurse to record in the medical record.

Based on record review, interview and observation the facility failed to provide necessary pain relief for 1 (R #48) of 5 (R #48, 81, 84, 189 and 190) residents reviewed for unnecessary medication by not providing R #48 with available pain medication for break through pain. This deficient practice likely resulted in R #48 experiencing multiple incidences of unrelieved pain. The findings are: A. Record review of (name of Medical Facility) Transfer Orders for R #48 dated 11/11/14 revealed R #39 had "repair of right femur fracture" with orders for [MEDICATION NAME] (pain reliever) 5 milligrams (mg) and [MEDICATION NAME] (pain reliever) 50 mg every 6 hours for pain. Handwritten note on Order dated 11/12/14 revealed "Please make sure all these orders are completed." B. Record review of Physician order [REDACTED]." C. Record review of Departmental Notes for R #48 revealed: 1. 11/13/14 "Resident verbally abusive with nurse when she can not get her pain meds due to timing of last given. 2. 11/16/14 "Requested pain medication before 6 hrs (hours) as ordered, Began to yell out, 'What the f*** is wrong with this place? Do I have to suck a (name of male genitalia) to get my medicine?' This type of behavior and language has also become NFR (normal for resident) if meds (medication) not given when requested. Returned later and asked for pain medication again. Did administer to resident who was then pleasant and cooperative." D. Record review of the Medication Administration Record [REDACTED]. E. Record review of the Refusal of Medication or treatment for [REDACTED]. F. Record review of the PRN Flowsheet for [MEDICATION NAME] and Other Medications for R #48 dated 11/16/14 at 9:00 am, 11/17/14 at 12:00 am and 2:00 pm revealed that R #48 rated her pain one hour after she received [MEDICATION NAME] 5 mg as a 4-5 (on a 1-10 pain intensity scale). G. On 11/12/14 at 2:44 pm during interview and observation of R #48, she was moaning in pain and grabbing her right hip. R #39 stated that she recently had hip surgery and was in pain. R #39 stated she could get pain medication at 3:00 pm. H. On 11/14/14 at 3:26 pm during interview with R #48, when asked when she receives her pain medication she responded "Every 6 hours." R #48 stated that she writes down the time in a notebook so she can keep track of when she can ask for it again. I. On 11/19/14 at 9:38 am during interview with Licensed Practical Nurse (LPN) #2 when asked about pain medication available to R #48, he stated that resident can have [MEDICATION NAME] 5 mg and [MEDICATION NAME] 50 mg every 6 hours. He explained that if resident's pain level is more than a 9 or 8 (on the 1-10 pain assessment scale, 10 being the worse) then she is given [MEDICATION NAME]. LPN #2 confirmed that R #48 has not received [MEDICATION NAME]. When asked if resident ever requests more pain medication, he stated "Sometimes. Especially if she sees a new nurse on the floor, she'll say she didn't get it. She'll try and get more." When asked what if resident continues to complain of pain, he stated "Then we would give her the [MEDICATION NAME] after 3 hours for break through pain." J. On 11/19/14 at 9:45 during interview with R #48, when asked about her pain, she stated "I'm having it right now. It is high cause I was outside moving around." When asked if she could ask for pain medication, she stated that she had to wait until 12:30 pm which would be 6 hours. R #48 confirmed that there have been times in which she requested pain medication and wasn't provided it because it hadn't been 6 hours. K. On 11/19/14 at 10:40 am during interview with Certified Nurse Aid (CNA) #3 when asked if R #48 ever complains of pain, she stated "She does have pain. Yesterday when I was working with her she asked for pain medicine. She was in bed. I asked if she needed anything and she said pain meds, "Yesterday she asked 3 times. but I think she (nurse) kept forgetting. I told her that I had let the nurse know." When asked if resident has ever not been provided pain medication cause it wasn't time, she responded "There was one time she was asking for it a lot but it wasn't time to give it." L. On 11/19/14 at 10:43 am during interview with Physician Assistant (PA) #1 when asked if R #48 could receive [MEDICATION NAME] and [MEDICATION NAME] at the same time, he responded "She can get those at the same time. It would be better not to. Wait at least 20 to 30 minutes." When asked if pain assessment of 5 is acceptable, he responded "We would want it better than that." M. On 11/19/14 at 11:26 am during interview and observation with R #48, she stated that on a pain scale 1-10, reasonable amount of pain would be 1 or 2. Resident pressed call light button to ask for more pain medication. N. On 11/19/14 at 11:30 am during observation, CNA #3 informed LPN #2 that R #48 wanted pain medication. O. On 11/19/14 at 1:39 pm during interview with R #48, she confirmed that she was provided pain medication at 12:30 pm.

Based on record review and interview, the facility failed to uphold resident's rights for 1 (R #48) of 1 (R #48) resident reviewed for Resident's Rights by taking R #48's cigarettes and not allowing her access to them and threatening to discharge R #48 to a homeless shelter or psychiatric hospital if she didn't comply with smoking rules. If residents' personal belongings are withheld from them by staff and residents are being intimidated to comply with facility rules, then staff are violating residents' rights to have a choice in how they wish to live their lives which could result in feelings of frustration, fear, humiliation and depression. The findings are: A. Record review of Physician order [REDACTED]. Pt states she understands." B. On 11/14/14 at 3:29 pm during interview with R #48, she stated that she got caught smoking and staff put her cigarettes up front (nurse's station). She stated that she doesn't have access to her cigarettes and she is dependent on other residents to provide her cigarettes. C. On 11/14/14 at 3:49 pm during interview with Assistant Director of Nursing (ADON) #2, when asked about resident smoking in her room, she responded, "They were going to give her a 30 day notice if she continued. We are trying to get her in her group home, but she had her fracture. (Name of Medical Director) has a psych hospital. He thought if he couldn't get her to the group home that they could get her in the psych hospital cause she does have psych issues." D. On 11/14/14 at 3:52 pm during interview with Licensed Practical Nurse (LPN) #2 and observation, LPN #2 stated that R #48 was caught two times with the cigarettes in her room. He stated that he went in her room with the doctor to tell her that if she continued to smoke in her room, she would be discharged . LPN #2 continued to say that he went in her room and took her cigarettes (2 packs). LPN #2 pulled 2 packs of cigarettes from a drawer at the nurse's station. When asked if R #48 gave the cigarettes to him, he stated, "No, I just took them." LPN #2 confirmed that the cigarettes were the resident's and purchased by the resident. LPN #2 confirmed that R #48 does not have access to her cigarettes. LPN #2 also continued to say that the hospital told her that she can't smoke. "I went and took them from her." LPN #2 confirmed that the resident gets cigarettes from other residents on the unit. When asked if there was a doctor's order to take her cigarettes, he stated, "No order. Verbal order from the hospital. Due to her just having surgery she shouldn't be smoking." E. On 11/17/14 at 10:55 am during interview with ADON #2, she confirmed that R #48's cigarettes have been locked in pharmacy and resident does not have access to them. F. On 11/17/14 at 10:53 am during interview with R #48, she confirmed that her cigarettes have not been returned to her and she has been getting cigarettes from other residents and picking up the butts from the ground. G. On 11/17/14 at 1:55 pm during interview with the Social Services Director (SSD) when informed that a nurse said he took R #48's cigarettes from her, she responded, "They cant deny her the cigarettes. She can always get cigarettes from other people." SSD confirmed that Physician Assistant (PA) #1 told R #48 once that she didn't belong here (facility) and he was going to discharge her to a shelter. H. On 11/18/14 at 10:21 am, during interview with PA #1 stated, "We are going to send her to the psych hospital. She puts the other resident in danger. It isn't her I'm worried about. I found a lighter in her room last week. I told if she lit up within the facility that I would send her to the homeless shelter or a psych hospital. I think we need to send her to a psychiatric hospital because of her hip. She has a very treatable psychiatric condition." PA #1 stated that resident has untreated [MEDICAL CONDITION]. When asked what symptoms of [MEDICAL CONDITION] R #48 exhibits, he stated, "She kicked me out of her room. She wouldn't let me exam her." I. On 11/18/14 at 10:57 am during interview with the SSD, she stated, "She has been told what the consequences are in graphic terms. Apparently she has been smoking in there at night. I talked with her yesterday and she was very angry. Part of that was a defense mechanism. She's been threatened by the (name of PA #1). I told her I had no plans to send her to a shelter cause it's unsafe and they won't accept her." J. On 11/18/14 at 11:34 am during interview with R #48, she confirmed that she hasn't been given her cigarettes. She stated, "There's not much I can do about it. It's upsetting to me. I feel like hell. I'm an old lady. I'm not young. I feel like I'm begging for something that is mine. I'm not hurting anybody." K. On 11/18/14 at 3:50 pm during interview with the Administrator, when informed that R #48's cigarettes were taken from her, he stated, "From my knowledge, they are being kept in the cart and given to her when she goes out to smoke. My understanding was that she could ask for them and that was my directive as well." When asked if he had seen PA #1's order to discharge R #48, he confirmed that he had and stated "That is inappropriate."

2 Based on record review and interview, the facility failed to prevent the development of infection in a pressure ulcer for 1 (R #127) of 4 (R #12, 42, 87 & 127) residents with pressure ulcers by: 1. Not providing adequate intervention to prevent R #127 from picking at her rectal area and then removing/picking at her wound/pressure ulcer dressing. 2. Not providing a detailed evalutation of the resident's pressure ulcer with each dressing change or at least weekly. This deficient practice is likely to have resulted in R #127 developing an Eschericha coli (a bacteria commonly found in fecal matter) infection in the pressure ulcer on her right hip. The finding are: Not providing adequate intervention for R#127 A. Record review of the care plan dated 09/02/14 revealed that the resident was noted as having the following problem areas, Self Care Deficit AEB (as evidenced by): resident has [DIAGNOSES REDACTED]. B. Record review of the wound clinic notes dated 12/02/14, 12/09/14, 12/12/14, 12/16/14 and 12/19/14 revealed that the resident was identified as having a stage four pressure ulcer to the right hip. C. Record review of the Wound Assessment Report dated 12/02/14 revealed that the resident's pressure ulcer was identified as being infected. D. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident was identified as being severely impaired with regard to making decisions about her tasks of daily life and had continuous difficulty with inattention. E. Record review of Departmental Notes dated 12/18/14 at 1:56 pm revealed the resident was identified to have a significant change in wound status as necrotic (dead) tissue was noted to be present in the wound. F. Record review of the departmental notes dated 12/22/14 at 6:35 pm revealed the resident's pressure ulcer was identified as being re-infected. G. On 12/31/14 at 3:54 pm during an interview with Certified Nursing Assistant (CNA) #1 she confirmed that while she cared for the resident she was aware of the fact the resident exhibited a behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked how long the resident had been displaying this behavior CNA stated, A while, maybe a month or a month and a half. When asked, as a CNA, what she did to prevent the resident from picking at her wound she stated, I tried to clip her nails, but she didn't let me and we would try to brush her nails in the shower but she wouldn't let us. She wore pants and we wound tuck her shirt into her pants so she couldn't get to it but she would still lift up her shirt and get into it and pick. When asked if she ever redirected the resident to not pick at her wound she stated, Yeah, I would walk in and she would usually do it in bed, but I would tell her not to because it would get infected. When asked if redirecting the resident to not pick at her wound was successful she stated, Sometimes, she would remember for a while but then she would forget and go right back to it. When asked what other interventions she tried she stated, We just tried to keep telling not to do it. H. On 01/02/15 at 10:56 am during an interview, Licensed Practical Nurse (LPN) #1 confirmed that while he cared for the resident he was aware of the fact the resident exhibited a behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked if redirecting the resident was effective he stated, It was for a time. She would stop for two or three days but then she would go right back to digging. So kind of, but it wasn't completely effective. When asked what steps were taken after redirection didn't work he stated, Well we couldn't put a glove on her or anything like that because that would be a restraint. We sent her to the wound clinic but really we couldn't do much else. I don't know of any other intervention we could have done. During the interview LPN #1 confirmed that he did not try placing a glove on the resident's hand. I. On 01/02/15 at 11:57 am during an interview with the Acting Director of Nursing (ADON), she confirmed that she was aware of the resident's behavior of picking at her rectal area with her hands, removing the dressing to the pressure ulcer on her right hip and picking at the wound itself. When asked what interventions were set in place to prevent this behavior she stated, We tried to keep her on her side and keep her comfortable and the wound clinic said to rotate her and keep her on her side. PT (physical therapy) got her a wider wheelchair. When asked if there were any other interventions the facility tried to prevent the resident from picking at her wound she stated, We would try to redirect her but it was difficult and she would forget. When asked if the facility had considered placing a glove on the resident's hand she stated, (Name of LPN #1) tried that. When asked if the facility had considered placing the president on one-to-one status to prevent her from picking at her wound she stated, No, not that. Not providing a detailed evaluation J. Record review of the Treatment Administration Record, nursing and HIgh Nursing Facility (HNF) notes dated 12/18/14 to 12/23/14 revealed the resident was documented as having a dressing change treatment to the pressure ulcer on her right hip performed on eight separate occasions. There was no indication that a complete evaluation of the pressure ulcer was performed and included the following: 1. Location and staging. 2. Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining (erosion) or tunneling/sinus tract (openings underneath the skin). 3. Exudate (fluids that drain out of the body) if present: type (such as purulent (pus like)/serous (water like)), color, odor and approximate amount. 4. Pain, if present: nature and frequency (e.g., whether episodic or continuous). 5. Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (tissue death) (slough (shedding dead tissue) or eschar (dead tissue that is scab like)); and 6. Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration (softening)) as appropriate. K. On 01/02/15 at 11:57 am during an interview with ADON when asked how often nursing staff are expected to evaluate the wound of residents with pressure ulcers she stated, Every shift, at least daily. L. Record review of the History and Physical dated 12/23/14 revealed the resident was diagnosed with [REDACTED]. A notation read, This is most likely related to the infected decubitus ulcer of the right greater trochanter (hip bone). M. Record review of laboratory wound culture results dated 12/27/14 revealed the resident had Eschericha coli (a bacteria commonly found in fecal matter) growth in her pressure ulcer along with mixed types of microorganisms found on the skin.

Based on record review and interviews, the facility failed to investigate, immediately report and do a follow-up investigation for 1 of 6 sampled residents (#1) who sustained a dislocated hip (injury of unknown origin). This injury resulted in Resident #1 having to go to the emergency room (ER) for treatment. This deficient practice had the potential to affect 117 residents who resided at the facility. The findings are: A. On 11/16/10 at 9:45 am, during an interview, Resident #1's granddaughter stated that when she visited the resident on 07/10/10, she could hear her grandfather yelling as she walked down the hallway. When she entered his room she stated, "He was in bed and his left foot was turned out." She asked the staff if he had fallen and they told her no. She asked for her grandfather to be transported to the emergency room (ER) to be evaluated. She stated at the ER, hospital staff told her that Resident #1 had a dislocated hip and "it had to be popped back into place." B. On 11/16/10, review of Resident #1's chart revealed a nurse's note dated 07/10/10 at 2:30 pm. The note indicated, "Resident's son and granddaughter into visit with him. Per son 'he's C/O (complaining of) pain to his hip & it looks twisted.' Went to assess resident's L (left) leg/hip appears out of place. Touched leg/foot, resident states 'it hurts too much don't move it.'" The signature on the note belonged to Licensed Practical Nurse #1, who no longer works at the facility. C. On 11/16/10 at 1:10 pm, during an interview, the Director of Nursing (DON) stated, "I don't remember being told anything about this incident." D. On 11/16/10 at 2:05 pm, during an interview, the Administrator stated, "I'm the abuse coordinator for the building and this is a reportable incident but it was not reported to me." The Administrator confirmed that they failed to investigate, report, and do a follow-up investigation. E. On 11/16/10 at 3:05 pm, during an interview, Certified Nursing Assistant #1 stated, "The resident was on a low bed, had a tabs alarm with a fall mat and was always on the floor and never wanted to be in the bed, and that is all I know." F. On 11/16/10 at 4:30 pm, during an interview, Physical Therapist #1 stated, "When the resident first came into the facility we were walking him and after he went to the ER he was placed on bedrest."