Every finding on record at Chesapeake Health and Rehabilitation Center

Based on observations, record review, interview, and facility policy review, the facility failed to notify the physician/practitioner regarding significant changes identified on Abnormal Involuntary Movement Scale (AIMS) assessments beginning on 02/18/26 and continuing through 05/19/26 for one of one resident (Resident (R)1). This deficient practice had the potential to result in delayed evaluation and treatment of medication-related adverse effects, worsening involuntary movements, progression of tardive dyskinesia symptoms, functional decline, and decreased quality of life. (Cross Reference F756) Findings include: Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR). indicated the resident was admitted to the facility on [DATE]. Review of R1's Care Plan located under the Care Plan tab of the EMR, dated 05/04/23, indicated that the resident was at risk for adverse reactions related to the use of an antipsychotic for a diagnosis of dementia with behaviors. The care plan was then updated on 11/09/24 and directed staff to monitor for adverse reactions and to notify the physician, if indicated. Review of a document provided by the facility for R1 titled, Order Listing Report, dated 08/15/25, revealed the resident was ordered risperidone one milligram (mg) to be administered by mouth two times a day for mood disorder related to a dementia diagnosis with other behavioral disturbances. Review R1's AIMS – Abnormal Involuntary Movement Scale dated 09/19/25, located under the Assmnt (Assessment) tab of the EMR indicated the resident was assessed and was identified for difficulty with balance but did not have tremors and/or tongue rolling. Review of R1AIMS – Abnormal Involuntary Movement Scale dated 02/18/26, located under the Assmnt tab of the EMR, indicated the resident now had tremors identified in her hands, leg movement, moderate mouth smacking, had mild tongue movement with her tongue in and out of her mouth, and her movements occurred while in bed. Review of R1's encounter Progress Notes located under the Prog (Progress) Note tab of the EMR, dated 03/06/26,indicated psychiatric Nurse Practitioner (NP)1 documented that the resident was seen while she was in bed. Per progress notes, the resident presented with no acute behavioral symptoms. NP1 documented that the resident was calm and had no tardive dyskinesia (involuntary and erratic movement, lip smacking, or tongue movement caused by long term use of an antipsychotic). Review of R1AIMS – Abnormal Involuntary Movement Scale dated 05/19/26, located under the Assmnt tab of the EMR, indicated the resident had constant right leg movement along with tapping of her foot, constant rolling of her tongue inside and outside of her mouth, the tongue now had moderate movement during this assessment. The resident was not identified with tremors in her hands and arms, and the assessment indicated the resident had no tremors while in bed. Review of R1's order note Progress Notes located under the Prog Note tab of the EMR, dated 05/28/26, indicated the resident's risperidone was reduced to 0.5 mg to be administered by mouth every morning and at bedtime to do a gradual dose reduction for adjunct to depression. Review of R1's encounter Progress Notes located under the Prog Note of the EMR, dated 05/29/26, indicated NP1 last saw the resident on 03/06/26 and that the resident was seen while she was in bed. Per progress notes, the resident presented with no acute behavioral symptoms. NP1 documented that the resident was calm and had no tardive dyskinesia. Review of R1's clinical record failed to identify if nursing notified NP1 of the increase in the resident's tremors and tongue movement, from 02/18/26 forward. During an interview on 08/17/26 at 10:28 AM, R1 was observed with tremors in both arms and hands. R1 stated she did not have Parkinson's disease. An attempt was made to further interview the resident but that was unsuccessful. During an observation on 08/17/26 at 11:33 AM R1 was being pushed in her wheelchair by staff. R1 had tremors of her right hand/arm and her right leg/foot. During an interview on 08/17/26 at 11:36 AM, Licensed Practical Nurse (LPN)3 who was a charge nurse, was asked how long R1 had tremors. LPN3 stated that the resident did not have a diagnosis of Parkinson's disease. LPN3 stated the process for a resident who was on an antipsychotic was to have a quarterly AIMS. LPN3 stated R1 was scheduled for her next AIMS on 08/19/26. During an interview on 08/19/26 at 8:50 AM, NP1 stated he reduced the risperidone from 1 mg three times a day to 0.5 mg twice a day. NP1 stated that her not having a gradual dose reduction in six months prompted him to make the reduction. NP1 stated it was nine months since the last gradual dose reduction for R1. NP1 stated if the resident had tremors this was one of the long-term side effects of taking an antipsychotic and would see the resident on 08/20/26. NP1 stated he depended on the facility to notify him if there were any changes in a resident. During an interview on 08/19/26 at 9:54 AM, LPN1/Unit Manager stated the AIMS assessments were previously completed by the MDS Coordinator but currently the completion of the AIMS assessments was done by the Unit Managers. LPN1 stated if there was a change in the AIMS status for a resident, the medical provider would be notified. During this interview, LPN1 reviewed the EMR for R1, and confirmed that the resident had no identified tremors or tongue movement on the 09/15/25 AIMS assessment. LPN1 stated that the resident sustained a change in her condition on 02/18/26 and then again on 05/19/26, since R1 had tremors and tongue movement. LPN1 stated there was a communication book to the medical directors and confirmed that there was no corresponding note in this notebook regarding LPN1 stated she had observed R1's tremors and noted that the tremors were not reflected in NP1's progress notes. LPN1 stated NP1 did not make any changes to the resident's medications from 02/18/26. LPN1 stated she went back in the EMR and there were no notes regarding R1's tremors from NP1. LPN1 began R1's AIMS assessment at 10:00 AM. R1's right leg began to move rapidly, and the resident was then observed to roll her tongue in her mouth. When the resident raised both arms, there were no tremors in both arms. R1's right leg continued to move. After this, R1 began to have tremors in both arms. LPN1 verified this observation. During an interview on 08/20/26 at 9:25 AM, the Director of Nursing (DON) stated the AIMS assessments were to be completed monthly, and the medical provider should be alerted to the change in the resident's AIMS. The Divisional Director was present during this interview. During an interview on 08/20/26 at 10:47 AM, NP1 confirmed that he assessed R1 this morning and the resident now has a diagnosis of Tardive Dyskinesia. NP1 stated he was not aware of the resident's change in status with the tremors and tongue rolling. NP1 stated that because the resident was receiving an antipsychotic medication he would need to further assess the resident and set up a plan for the care of the resident. Review of a facility policy titled Significant Change of Condition dated 01/29/24 indicated . A licensed nurse will assess the patient for signs and symptoms of a change in condition.Notify the provider and document in the Progress Note.

Based on interview, record review, and policy review, the facility failed to ensure the Consultant Pharmacist identified and reported a medication regimen irregularity for one of one sampled resident (R1) reviewed for unnecessary medications. R1 developed abnormal involuntary movements, including tremors and tongue-rolling movements, while receiving risperidone, an antipsychotic medication. Despite Abnormal Involuntary Movement Scale (AIMS) assessments documenting a change in condition, the Consultant Pharmacist did not make a recommendation or notify facility staff of a potential medication-related irregularity. This deficient practice had the potential for delayed evaluation and intervention, worsening involuntary movements, progression of medication-related adverse effects, and decreased quality of life.Findings include: Review of R1's admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] of the electronic medical record (EMR). Review of a document provided by the facility for R1 titled Order Listing Report dated 08/15/25, revealed the resident was ordered risperidone 1 milligram (mg) to be administered by mouth three times a day for mood disorder related to a dementia diagnosis with other behavioral disturbances. Review R1's AIMS – Abnormal Involuntary Movement Scale, dated 09/19/25, located under the Assmnt (Assessment) tab indicated the resident was assessed and was identified for difficulty with balance but did not have tremors and/or tongue rolling. Review of a document provided by the facility titled Psychotropic & Sedative/Hypnotic Utilization by Resident from 02/01/26 through 07/31/26 indicated the resident was on risperidone. These documents indicated that the last AIMS Assessment was reviewed from 09/2025. There was no evidence that the Consultant Pharmacist identified the new tremors and tongue movement from the 02/18/26 and the 05/19/26 AIMS assessments. The Consultant Pharmacist did not document any findings as medication-related irregularity. Review of R1AIMS – Abnormal Involuntary Movement Scale dated 02/18/26, of the EMR, indicated the resident now had tremors identified in her hands, leg movement, moderate mouth smacking, had mild tongue movement with her tongue in and out of her mouth, and her movements occurred while in bed. Review of R1AIMS – Abnormal Involuntary Movement Scale dated 05/19/26, of the EMR, indicated the resident had constant right leg movement along with tapping of her foot, constant rolling of her tongue inside and outside of her mouth, the tongue now had moderate movement during this assessment. The resident was not identified with tremors in her hands and arms, and the assessment indicated the resident had no tremors while in bed. Review of R1's order note Progress Notes located under the Prog Note tab dated 05/28/26 indicated the resident's risperidone was reduced to 0.5 mg to be administered by mouth every morning and at bedtime to do a gradual dose reduction for adjunct to depression. During an interview at 08/20/26 at 8:30 AM, the Consultant Pharmacist stated she was aware of the newly identified tremors and tongue movement for R1 from the AIMS assessment completed on 02/18/26. The Consultant Pharmacist stated she did not make any recommendations to the medical provider since everything was being done and provided the current gradual dose reduction completed in 05/2026. The Consultant Pharmacist stated that the facility could request an interim medication review if there were associated concerns with R1 medications. During an interview on 08/202/6 at 9:25 AM, the Director of Nursing (DON) stated the Consultant Pharmacist's responsibilities were to notify the facility for any irregularities. The DON stated she never saw R1 with tremors or tongue rolling. The DON stated that if the pharmacist saw a change in the condition of a resident, she was to be notified. The Regional Director was present during this interview. Review of a facility policy titled Medication Regimen Review dated 01/29/24 indicated . When the consultant pharmacist identifies an irregularity that requires immediate or urgent action, the pharmacist will notify the Director of Nursing and assigned nurse the time the irregularity is identified.

Based on observations, resident/staff and RP (responsible party) interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for seven of 70 residents, Residents #17, #195, #66, #145, #190, #88 and #134.The findings include: 1. The facility staff failed to provide ADL (activities of daily living) specifically bathing, incontinence care, dressing, oral hygiene and personal hygiene for a dependent resident, Resident #17 (R17). R17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CKD (chronic kidney disease) and bipolar disorder. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 3/30/26, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting, hygiene and meals. A review of the comprehensive care plan dated 4/24/23 revealed, FOCUS: Resident requires assistance with ADLs related to advanced age, chronic health conditions, fatigue, malaise, DM and CKD. The resident is incontinent of bladder and frequently incontinent of bowels. She has a diagnosis of overactive bladder. INTERVENTIONS: Provide toileting hygiene as needed for incontinent episodes. Lift sheet for turning and repositioning while in bed. A review of the March, April and May 2026 ADL documentation revealed missing evidence of bathing, incontinence care, dressing, oral hygiene and personal hygiene on 3/5, 3/17, 3/21, 3/31, 4/3, 4/12, 4/18, 4/23, 4/24, 4/25, 4/27, 4/30, 5/15 and 5/18. An interview was conducted on 5/17/26 at approximately 11:50 AM with RP for R17. Asked about the care R17 receives, RP stated, overall it is okay, but they do not change her briefs often enough and it is because they are short staffed. An interview was conducted on 5/17/26 at 4:45 PM with CNA (certified nursing assistant) #2. Asked where their care is documented, CNA #2 stated, the care is documented in PCC (point click care). Asked what is indicated if there are blanks in the documentation, CNA #2 stated, if there are blanks, then it was not documented and was not done. An interview was conducted on 5/18/26 at 11:00 AM with CNA #1, when asked where their care is documented, CNA #1 stated, there is documentation in the computer in PCC. Asked what blanks in the documentation indicates, CNA #1 stated that the care was not provided. On 5/20/26 at 3:00 PM, the administrator and the director of nursing were made aware of the findings. A review of the facility's Nursing Care & Services policy revealed, Nursing staff will provide nursing care and services following current standards of practice recognized by state boards of nursing as informed by national nursing organizations and by hiring individuals who graduate from an approved nursing school and/or nurse aide curriculum and have or will have successfully passed a licensing and/or certification examination. The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skill & Techniques by [NAME], [NAME], and Ostendorff, as a reference for nursing services and skills not otherwise provided in the Policies and Procedures Manuals. No further information was provided prior to exit. 2. The facility staff failed to provide ADL (activities of daily living) specifically bathing, incontinence care, dressing, oral hygiene and personal hygiene for a dependent resident, Resident #195 (R195). R195 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CVA (cerebrovascular accident) and dementia. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 11/25/25, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for locomotion/transfer/dressing/toileting, hygiene and meals. A review of the comprehensive care plan dated 11/22/25 revealed, FOCUS: Resident requires assistance with ADLs relate to weakness, impaired mobility and cognition related to recent hip fracture and dementia. The resident is incontinent of bladder and frequently incontinent of bowels. INTERVENTIONS: Provide toileting hygiene as needed for incontinent episodes. Check and change briefs frequently as needed. Provides assistance in feeding for meals. A review of the November and December 2025 ADL documentation revealed missing evidence of bathing, incontinence care, dressing, oral hygiene and personal hygiene on 11/25, 11/28, 11/30, 12/7, 12/8, 12/9, 12/10, 12/13, 12/16, 12/20 and 12/22. An interview was conducted on 5/17/26 at 4:45 PM with CNA (certified nursing assistant) #2. Asked where their care is documented, CNA #2 stated, the care is documented in PCC (point click care). Asked what is indicated if there are blanks in the documentation, CNA #2 stated, if there are blanks, then it was not documented and was not done. An interview was conducted on 5/18/26 at 11:00 AM with CNA #1, when asked where their care is documented, CNA #1 stated, there is documentation in the computer in PCC. Asked what blanks in the documentation indicates, CNA #1 stated that the care was not provided. On 5/20/26 at 3:00 PM, the administrator and the director of nursing were made aware of the findings. No further information was provided prior to exit. 3. For Resident #66 (R66), the facility staff failed to provide showers and incontinence care/toileting assistance on dates in February, March, April and May 2026. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 4/15/2026, the resident was assessed as being severely impaired for making daily decisions, being dependent for toileting and showering/bathing and always incontinent of bowel and bladder. On 5/18/2026 at 9:26 AM, an interview was conducted with R66's responsible party who stated that they had voiced concerns to facility staff regarding R66 being left soiled for extended periods and not receiving showers in the past. She stated that she felt it was due to short-staffing and felt that the certified nursing assistants (CNA) could not get to every resident timely when they had more than 20 residents to take care of. She stated that she used to come in and shower R66 herself but could not do this anymore and had to rely on the staff to do it. Review of the ADL (activities of daily living) documentation for R66 from 2/1-2/28/2026 failed to evidence incontinence care provided on day shift on 2/10/26, 2/11/26, 2/19/26, 2/23/26, and 2/28/26, on evening shift on 2/10/26 and 2/27/26 and on night shift on 2/15/26 and 2/28/26. It failed to evidence a shower provided on 2/13/26, 2/20/26 and 2/27/26. Review of the ADL documentation for R66 from 3/1-3/31/2026 failed to evidence incontinence care provided on day shift on 3/8/26 and 3/30/26, on evening shift on 3/23/26, and on night shift on 3/6/26, 3/14/26, 3/16/26, 3/27/26 and 3/31/26. It further failed to evidence a shower provided on 3/3/26, 3/13/26, 3/17/26, 3/27/26 and 3/31/26. Review of the ADL documentation for R66 from 4/1-4/30/2026 failed to evidence incontinence care provided on day shift on 4/3/26, 4/6/26, 4/10/26, 4/11/26, 4/17/26, 4/18/26, 4/23/26, 4/26/26 and 4/27/26, on evening shift on 4/9/26, 4/10/26, and 4/18/26, and on night shift on 4/11/26, 4/25/26, 4/26/26 and 4/30/26. It further failed to evidence a shower provided on 4/3/26, 4/7/26, 4/14/26, 4/17/26, 4/21/26 and 4/28/26. Review of the ADL documentation for R66 from 5/1-5/31/2026 failed to evidence incontinence care provided on day shift on 5/5/26, 5/9/26, 5/10/26 and 5/16/26, and on night shift on 5/8/26 and 5/10/26. It further failed to provide evidence of a shower provided on 5/1/26 and 5/5/26. The comprehensive care plan for R66 documented in part, Long Term Care: [Name of R66] requires assistance with ADLS relate to advanced age, cognitive impairment, inability to perform ADLs, weakness . Created on: 07/21/2024. Revision on: 12/17/2025. It further documented, [Name of R66] is incontinent of bladder and bowels and is dependent on staff for toileting hygiene. Created on: 03/02/2024. Revision on: 12/17/2025. Under Interventions it documented in part, provide toileting hygiene with brief changes. Date Initiated: 03/02/2024 . On 5/18/2026 at 5:40 AM, an interview was conducted with CNA #1 who stated, Staffing is bad, there were only two of us last night and with each of us having 25 residents, we are unable to complete all the incontinence care that is needed. The CNAs try hard to get it done; it just is not possible. On 5/18/26 at 6:25 AM an interview was conducted with CNA #4, who stated that they were working overtime due to short staffing and with only two CNAs on the unit they were unable to complete the work. On 5/20/2026 at 10:36 AM, an interview was conducted with licensed practical nurse (LPN) #2, unit manager who stated that she had spoken with R66's family in the past regarding concerns of the resident being left soiled and showers. She stated that as far as she knew R66 received their showers and the family had come in to give R66 showers in the past but had not been able to lately. LPN #2 stated that R66 did not refuse care but required two staff for all care due to stiffness. On 5/20/2026 at 12:12 PM, an interview was conducted with CNA #6 who stated that they evidenced the care they provided by their documentation in the medical record. She stated that showers were twice a week and given according to a schedule. CNA #6 stated that they evidenced incontinence care and showers by the documentation in the medical record. On 5/20/2026 at 3:59 PM, an interview was conducted with CNA #9 who stated that incontinence care was provided every two hours and as needed to residents. She stated that showers were given twice a week according to a schedule. She stated that R66 was scheduled for showers on Mondays on her shift and she never refused care. CNA #9 stated that the evidence of the showers provided was in the medical record documentation. On 5/21/2026 at 11:05 AM, the Administrator and Director of Nursing were made aware of the concern. No further information was provided prior to exit. 4. For Resident #145 (R145), the facility staff failed to provide fingernail care. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date of 5/6/2026, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were moderately impaired for making daily decisions. The assessment documented R145 having impairment in the upper and lower extremity on one side and being dependent for personal hygiene, bathing and showering. On 5/17/2026 at 3:33 PM, an observation was made of R145 in their room. R145 was observed to not have use of the right arm due to paralysis and limited range of motion to the fingers of the left hand. The fingernails were observed to be approximately 1/4 inch long and uneven with visible debris underneath. An interview was attempted with R145 at that time, due to their diagnoses R145 communicated by gestures, nodding and closed ended questions. R145 shook their head No when asked if staff trimmed their fingernails for them. Additional observations on 5/17/2026 at 1:52 PM, 3:02 PM, 5/18/2026 at 10:25 AM and 5/19/2026 at 9:42 AM revealed the same as described above. The comprehensive care plan for R145 documented in part, Long Term Care: [Name of R145] requires assistance with ADLS relate to right hemiparesis. Resident executes his right to refuses to wear splints. Created on: 07/27/2023. Revision on: 11/06/2025. On 5/19/2026 at 9:20 AM, an interview was conducted with licensed practical nurse (LPN) #7, unit manager, who stated that fingernail care was done daily by the CNAs (certified nursing assistants) during bathing. She stated that staff trimmed the nails as needed but every residents nails were looked at on Sundays to catch up. LPN #7 observed R145's fingernails and stated that they were long and untrimmed and needed trimming. R145 nodded Yes when LPN #7 asked if they could trim their nails and gestured that he also wanted to be shaved. On 5/20/2026 at 12:12 PM, an interview was conducted with CNA #6 who stated that they cleaned residents nails daily during ADL care and trim them as needed. She stated that the fingernails should be assessed every day. On 5/20/2026 at 3:03 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 5. For Resident #190 (R190), the facility staff failed to provide showers on dates in September and October 2025. On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 9/18/2025, the resident was assessed as having impairment in the upper extremity on both sides and being dependent for showering/bathing. Review of the ADL (activities of daily living) documentation for R190 from 9/1-9/30/2025 failed to evidence a shower provided on 9/16/2025 and 9/25/26. Review of the ADL documentation for R190 from 10/1-10/31/2025 failed to evidence a shower provided on 10/2/26. The comprehensive care plan for R190 documented in part, The resident has an ADL self-care performance deficit r/t Impaired balance, Limited Mobility, Stroke. Created on: 05/25/2018. Revision on: 10/16/2025. Under Interventions it documented in part, AM Routine: assist/provide ADL care as needed. Date Initiated: 05/10/2019. Created on: 05/29/2018. Revision on: 10/16/2025 . On 5/20/2026 at 10:36 AM, an interview was conducted with licensed practical nurse (LPN) #2, unit manager who stated that showers were given twice a week according to a schedule they kept on each unit split up between each shift. On 5/20/2026 at 12:12 PM, an interview was conducted with CNA #6 who stated that they evidenced the care they provided by their documentation in the medical record. She stated that showers were twice a week and given according to a schedule. On 5/20/2026 at 3:59 PM, an interview was conducted with CNA #9 who stated that showers were given twice a week according to a schedule. She stated that the evidence of the showers provided was in the medical record documentation. On 5/20/2026 at 3:03 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 6. The facility staff failed to provide grooming and hygiene care for a dependent resident before a scheduled outside appointment for (Resident #88), in the survey sample. Resident #88 was originally admitted to the facility on [DATE]. The current diagnoses included; Type 2 Diabetes Mellitus with diabetic chronic kidney disease, anemia, heart failure, and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/16/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were moderately impaired. A synopsis of an event dated 4/22/26 revealed that Resident #88 had a scheduled morning outside appointment and was transported via stretcher by a transport provider. Resident #88 was not appropriately groomed or dressed for this appointment and was transported to the appointment in an undignified manner. A review of section GG (Functional Abilities and Goals) dated 4/16/26 of Resident #88's Minimum Data Set (MDS) coded the resident as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands(excludes baths, showers, and oral hygiene). A review of Resident #88's nurses note dated 4/22/26 at 2:26 PM read: LOA to MD appt per order. Left facility approximately 7:10am and returned approximately 1:30pm via stretcher transport. No acute distress/discomfort noted upon returning. No additional areas of skin impairments noted. An interview was conducted on 5/20/26 at 10:20 AM with Licensed Practical Nurse (LPN) #6. LPN #6 stated that on the morning of 4/22/26, the 11 PM – 7AM shift did not get Resident #88 ready for her scheduled outside appointment. LPN #6 also stated that she had a conversation with Resident #88's daughter and it was discussed that Resident #88 went to the appointment in a gown and was not groomed. LPN #6 further stated that the 11 PM – 7AM staff should have had Resident #88 ready for the appointment and confirmed that Resident #88 was not dressed or groomed appropriately for the scheduled outside appointment. An interview was conducted on 5/20/26 at 10:55 AM with the Unit 2 Nursing Manager. The Unit 2 Nursing Manager stated that Resident should have been appropriately groomed and dressed for the scheduled outside appointment on 4/22/26. The Unit 2 Nursing Manger also stated that it was the responsibility of the 11 PM – 7 AM shift to have Resident #88 ready for the outside appointment on 4/22/26. On 5/20/26 at approximately 6:05 p.m., a final interview was conducted with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information. 7. The facility's staff failed to provide activities of daily living for Resident #134. Resident #134 was admitted to the facility on [DATE]. The residents' diagnoses included dementia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 05/06/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 1 out of 15. This indicated that Resident #134's cognitive abilities for daily decision-making were severely impaired. In section GG0130 Self-Care, the resident was coded as dependent for eating, oral care, toileting hygiene, showers, personal hygiene, upper- and lower-body dressing, and putting on and taking off footwear. On 5/17/2026 at 11:39 AM, Resident #134 was observed in bed, and the pancake call bell was not within reach. The resident had a large amount of chin hair and long, dirty, and chipped fingernails. The longest fingernails were approximately 2.25 inches beyond the fingertips. Food was observed on the resident's clothing and in the bed. On 5/18/26 at approximately 2:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated that the staff had clipped and cleaned all the residents' nails. On 5/21/2026 at 2:30 PM, a final interview was conducted with the Administrator, Director of Nursing, the Regional [NAME] President of Operations, and the Regional Director of Clinical Services. They voiced no concerns regarding the above information.

Based on staff interview and clinical record review, the facility staff failed to maintain dignity by not providing appropriate grooming or clothing before a scheduled outside appointment for 1 of 70 residents (Resident #88), in the survey sample.The findings included: Resident #88 was originally admitted to the facility on [DATE]. The current diagnoses included; Type 2 Diabetes Mellitus with diabetic chronic kidney disease, anemia, heart failure, and peripheral vascular disease.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/16/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were moderately impaired.A synopsis of an event dated 4/22/26 revealed that Resident #88 had a scheduled morning outside appointment and was transported via stretcher by a transport provider. Resident #88 was not appropriately groomed or dressed for this appointment and was transported to the appointment in an undignified manner.A review of section GG (Functional Abilities and Goals) dated 4/16/26 of Resident #88's Minimum Data Set (MDS) coded the resident as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands(excludes baths, showers, and oral hygiene). A review of Resident #88's nurses note dated 4/22/26 at 2:26 PM read: LOA to MD appt per order. Left facility approximately 7:10am and returned approximately 1:30pm via stretcher transport. No acute distress/discomfort noted upon returning. No additional areas of skin impairments noted.An interview was conducted on 5/20/26 at 10:20 AM with Licensed Practical Nurse (LPN) #6. LPN #6 stated that on the morning of 4/22/26, the 11 PM - 7AM shift did not get Resident #88 ready for her scheduled outside appointment. LPN #6 also stated that she had a conversation with Resident #88's daughter and it was discussed that Resident #88 went to the appointment in a gown and was not groomed. LPN #6 further stated that the 11 PM - 7AM staff should have had Resident #88 ready for the appointment and confirmed that Resident #88 was not dressed or groomed appropriately for the scheduled outside appointment. An interview was conducted on 5/20/26 at 10:55 AM with the Unit 2 Nursing Manager. The Unit 2 Nursing Manager stated that Resident should have been appropriately groomed and dressed for the scheduled outside appointment on 4/22/26. The Unit 2 Nursing Manger also stated that it was the responsibility of the 11 PM - 7 AM shift to have Resident #88 ready for the outside appointment on 4/22/26.On 5/20/26 at approximately 6:05 p.m., a final interview was conducted with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 70 residents in the survey sample, Residents #136. The findings include:For Resident #136 (R136), the facility staff failed to keep the catheter collection bag (1) off the floor. R136 was admitted to the facility with diagnoses that included but were not limited to obstructive uropathy (2). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/27/2026, R136 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R136 was severely impaired of cognition for making daily decisions. Section H Bladder and Bowel code R136 as having an indwelling catheter. On 05/17/2026 at approximately 1:00 p.m. an observation of R136's catheter collection bag revealed the bottom of the bag was resting on the floor. On 05/17/2026 at approximately 3:30 p.m. an observation of R136's catheter collection bag revealed the bottom of the bag was resting on the floor. The physician's order for R136 documented in part, Foley catheter (3) 16 French (4), 10cc (cubic centimeters). Order Date 3/20/2025. On 11/12/2025 at approximately 11:08 a.m. an interview was conducted with the Uniit Manager for Unit One regarding th eplacement of a residemt's catheter collect bag. She staed that the bag should be kept off the floor for infection control purposes. After informed of the observations described above she stated that the catheter collection bag should not have been resting on the floor. The facility's policy Urunary Catheterizations documented in part, 7. Ensure drainage bags are not touching the floor. On 05/21/2026 at approximately 8:43 a.m. the Administrator and Director of Nursing were made aware of the above findings. No further information was provided prior to exit. References:(1) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (2) A condition in which the flow of urine is blocked. This causes the urine to back up and injure one or both kidneys. This information was obtained from the website: https://medlineplus.gov/ency/article/000507.htm. (3) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm. (4) Refers to the size of the catheter, with higher numbers indicating larger sizes. This information was obtained from the website: https://balumed.com/en/medical-dictionary/16-french-foley-catheter.

Based on family interviews, staff interviews, and a clinical record review, the facility staff failed to ensure residents received two person assistance during care and bed mobility per care plan and the bed mobility assessment binder to prevent accidents for one (1) of six (6) residents in the survey sample, Resident #1 which resulted in a fall with major injuries. The findings included: Resident #1 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The resident died in the facility on [DATE]. The diagnoses included metastatic cancer, heart failure, renal insufficiency and malnutrition. The quarterly Minimum Data Set (MD) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were moderately impaired. A review of the Resident's care plan revealed an intervention dated [DATE] which indicated the resident required two-person assistance with bed mobility; also, the information in the bed mobility book included an intervention that stated the resident required two-person assistance with bed mobility. On [DATE] at approximately 9:26 AM an interview was conducted with the resident's Power-of-attorney (POA). The POA stated on [DATE] at approximately 10:45 PM she received a call from a nurse at the facility stating Resident #1 experienced a fall during care. The POA stated she requested the resident be transferred to the hospital for further evaluation. On [DATE] at 11:03 AM an interview was also conducted with Family Member (FM) #3. FM stated because the resident's condition was declining so he decided to stay with her at the facility as much as possible and sometimes almost 24 hours per day to monitor her care and do what he could. FM #3 stated after meeting with the administrative staff concerning the resident's care, he was informed that the resident should receive care every two hours by two persons. FM #3 stated most of the time when staff came to render care there was only one person and he would explain that he was informed care was to be rendered by two people and the staff would go out and return 30 minutes later or more with a second person. FM #3 further stated on [DATE] at approximately 10:00 PM, Certified Nursing Assistant (CNA) #4 entered the resident's room to render care and he reminded her that the administrative staff told him that the resident's care was to be provided by two persons. FM #3 stated he thought she would get another person as all others had done but she did not. FM #3 stated that CNA #4 told him it was time for her to get off and there was no one else available to help her, therefore she proceeded to render the resident's care alone. FM #3 stated CNA #4 was in a hurry and she snatched the sheet and the resident fell from the bed to the floor hitting the floor like a ton of bricks. FM #3 stated CNA #4 ran out the room to get help and returned with of 6 or 7 other people. He stated the 6 -7 staff members were unable to lift the resident off the floor therefore after approximately 30 minutes they used the lift to successfully get the resident off of the floor. FM #3 stated the resident complained of great pain and was transferred to the hospital. A review of the hospital's discharge summary dated [DATE] at 12:37 PM read that Resident #1 was admitted to the hospital on [DATE] after a fall from the bed in the nursing facility resulting in a head contusion, a subdural hematoma and a displace or dislocated left knee joint prothesis was later identified. An interview was conducted with CNA #4 on [DATE] at 4:40 PM. CNA #4 stated she had worked with the resident before, but she was not working on her normal assignment for she normally worked a different unit. CNA #4 stated prior to assuming care for the Resident #1 she failed to review the bed mobility binder so she would know how much assistance was required during care/bed mobility. CNA #4 also stated that the CNA she received report from did not inform her that the resident was to have two people assistance with care/bed mobility. CNA #4 stated Family Member #3 called for assistance to change the resident and she went in alone to provide care. CNA #4 stated she positioned the resident on her right side and she placed one hand on the resident and was using the other hand to open the brief, when the resident rolled off the bed on to the floor. An interview was also conducted with the Director of Nursing (DON) on [DATE] at 11:30 AM. The DON stated after a review she identified the resident had experienced nine falls since admission to the facility and eight of the falls were a result of poor decision making (self transfers) by the resident and the ninth falls was a result of staff no utilizing two people when rendering care/bed mobility. The DON stated the Interdisciplinary team developed a four point Performance Improvement Plan on [DATE] when they identified the resident's fall was a result of not following the two person assistance plan. A review of the Resident's care plan revealed an intervention dated [DATE] which stated the resident required two person assistance with bed mobility. The Facility's Action Plan dated [DATE] indicated the following: 1. Staff failed to follow two persons bed mobility that was put in place. 2. Resident was sent to the emergency department for evaluation and treatment. CNA was re-educated on two persons bed mobility with another staff member. QAPI meeting. 3. Education of nursing staff as it relates to residents as it relates to two persons bed mobility. 4. Weekly audits conducted by Nurse Managers times four weeks the weekly thereafter. CNA education ongoing. An onsite review of the Facility's Performance Improvement Plan was validated through resident observations during bed mobility, staff interviews, and resident record reviews on [DATE] and [DATE]. Residents who were assessed and required two-person assistance with care were validated through assessments, care plans, and random observations. The survey sample was expanded to ensure no other resident that were assessed to require two person assistance experienced a fall secondary to not having two persons assistance with care/bed mobility. Four random residents were observed to received two person assistance as care planned. The random observations results were 100%. Three CNAs were interviewed to determine how they identified resident's who required two person assistance with bed mobility with 100% accurate responses. Four resident bed mobility status were reviewed in the binder for bed mobility status with 100% compliance validated by the care plan. The survey sample was expanded to ensure the Facility's Action Plan had been implemented. No new deficient practices in the area of F689 were identified during the onsite review, thus Past-Non Compliance (G) PNC was issued to the facility dated [DATE]. On [DATE] at approximately 5:47 PM a final interview was conducted with the Administrator, the DON and the Nurse Consultant. The above information was reviewed and the Facility's administration offered no further comments.

Based on a family interview, staff interviews, a clinical record review, and review of facility documents, the facility staff failed to ensure the Power-of-attorney (POA) and/or a designated representative was notified of the identification of a sacral pressure ulcer on [DATE] and of the deterioration of the same sacral pressure on [DATE] for 1 of 15 residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The resident died in the facility on [DATE]. The diagnoses included metastatic cancer, heart failure, renal insufficiency and malnutrition. The quarterly Minimum Data Set (MD) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were moderately impaired. On [DATE] at approximately 9:00 AM an interview was conducted with the resident's POA. The POA stated she was unaware that the resident had a huge pressure ulcer to her sacrum until she was admitted to the hospital on [DATE] and the hospital's staff allowed her to view the pressure ulcer. The POA further stated she was frequently in the facility as well as the resident's son and the facility's staff failed to notify either of them of the pressure ulcer. A review of the clinical record revealed on [DATE] at 19:02 a skin observation identified a Stage 2 sacral pressure ulcer which was covered with a border gauze. No measurements or tissue type was identified on this skin observation document. On [DATE] a wound assessment was conducted by the contracted wound assessor. The sacral pressure ulcer was confirmed to be a stage 2 and it measured 6 centimeters by 2 centimeters and presented with 100 percent (%) epithelial tissue. Another wound assessment was conducted on [DATE] by the contracted wound assessor. This assessment revealed the sacral pressure ulcer had worsened and it was determined to be unstageable because of a depth of 0.2 cm and it contained ,d+[DATE]% slough (dead tissue, which needs to be removed for healing to take place). An interview was conducted with the wound care nurse on [DATE] at approximately 3:41 PM. The wound care nurse stated the above-mentioned pressure ulcer documentation was accurate. The wound care nurse further stated it is the responsibility of the charge nurse or Unit Manager to notify the POA and/or other designated representative of changes in the resident. The wound care nurse stated after the contracted wound assessor leaves the facility a report is forwarded to the facility to be reviewed by the Unit Managers, the Director of Nursing and her of all findings during the wound care rounds. An interview was also conducted with the DON on [DATE] at approximately 11:30 AM. The DON stated the wound care assessment information is used to update the care plan, review during meetings and to develop action plans. The DON stated after a review of Resident #1's clinical record she was unable to identify documentation that the POA and/or a designated representative was notified of the initial sacral pressure ulcer observation on [DATE] or of the deterioration identified on [DATE]. On [DATE] at approximately 5:47 PM a final interview was conducted with the Administrator, the DON and the Nurse Consultant. The above information was reviewed and the Facility's administration offered no further comments.

Based on a family interview, staff interviews, clinical record review, and review of documents provided by the family, the facility's staff failed to ensure Resident #2 received total assistance of two or more people during care/bed mobility and the needed assistive device (a 47-inch wide bariatric bed) was in use to prevent a fall on [DATE] which resulted in multiple blunt force injuries which contributed to the resident's death resulting in immediate jeopardy. The findings included: Resident # 2 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #2 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #2's diagnoses included atherosclerosis, hypertensive cardiovascular disease, dementia, CHF, COPD, Diabetes type 2, strokes with right hemiparesis, hypothyroidism, atrial fibrillation, and severe obesity. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision-making were moderately impaired. In section G (Functional Status) the resident was coded as requiring total care of two or more people with bathing, personal hygiene, dressing, toileting, bed mobility and transfers, and supervision after set-up with eating. Locomotion was coded as occurring only once or twice. A review of a nurse's note dated [DATE] at 4:51 AM read that CNA #1 was in the process of changing Resident #2 and the resident was pulling herself over too much to the side of the bed and fell off. According to the nurse's note, the resident sustained an abrasion underneath her left eye, a laceration on the left side of her mouth, and a skin tear on her left forearm. There were new orders on the Hospital's After-visit summary dated [DATE]: Ice to swollen areas, Tylenol as needed for discomfort, and Norco for severe pain if the Tylenol was not adequate. Dermabond had been applied to the superficial lacerations. Dermabond instructions were supplied, gauze as needed if further bleeding from the dental socket, and return if there were further problems. An interview was conducted with the Responsible Party (RP) of Resident #2 on [DATE] at 1:59 PM. The RP stated that the room Resident #2 resided in was being renovated starting [DATE] or [DATE] therefore, Resident #2 was moved from Unit One to Unit Four. The RP stated she received a call from the facility on [DATE] stating that the resident had fallen from the bed during care. The RP stated she came to the facility to visit Resident #2 after she returned from the hospital, and she was groggy because she had received Vicodin (a narcotic pain medication) at the hospital therefore, the resident was unable to tell her specifics relating to the fall. The RP stated as a result of the fall, Resident #2 sustained lacerations and abrasions under the left eye and to both hands and arms, a left upper lip laceration, and expelled a left upper tooth, as well as left hip pain with leg swelling. During the interview with the RP on [DATE] at 1:59 PM, the RP stated while visiting with Resident #2 on [DATE], she noticed that the Resident had no personal items in the room on Unit Four, therefore, she went to Unit One to obtain some of the Resident's items. She discovered that the bariatric bed with the low air loss mattress on it was still in the room on Unit One and the bed the Resident was utilizing and had fallen from earlier that day, on Unit Four, was a standard bed. The RP stated after she alerted the Facility's staff of the bed concerns, they placed Resident #2 on the appropriate bed (Bariatric bed). The RP stated she was later told by the Administrator and Director of Nursing (DON) that a certified nursing assistant (CNA) #1 was changing the Resident alone when she fell from the bed and that the Resident required two-person assistance when care was being rendered. The RP also stated that the Administrator and Director of Nursing (DON) informed her that the Resident should have been on the bariatric bed at the time of the fall on [DATE] and they had made an error. On [DATE], a comparison was made to determine the differences between the two beds by the Administrator. The results revealed that the bed the Resident was on at the time of the fall was 35 inches wide and the bariatric bed the Resident normally reclined on which held a low air loss mattress was 47 inches wide. A difference of 12 inches in width. An interview was conducted with Certified Nursing Assistant (CNA) #1 on [DATE] at 4:12 PM. CNA #1 stated the Resident's fall on [DATE] happened so fast. She stated she was using a pull sheet to pull the resident to her, and then roll the resident away from her, but the Resident jerked while holding the side rail. CNA #1 stated the jerk action and the resident's weight caused the resident to fall from the bed to the floor with her (CNA #1) landing on top of the resident. CNA #1 stated she was working with the resident alone because there was no alert that she required the care of two or more people, and she was unaware that the Resident was not on the appropriate bed. CNA #1 stated the resident hit her head on the nightstand when she fell , and she remained conscious. CNA #1 also stated she rang the call bell and yelled for help and the licensed nurse came into the resident's room. CNA #1 stated after the licensed nurse observed the scene, she called 911 and the Emergency Medical Technicians (EMT) got the resident off the floor. CNA #1 stated the Facility staff nor the EMTs used a Hoyer (mechanical lift brand name) lift to move the Resident. The resident was transported to a local hospital by EMTs on [DATE] at approximately 4:51 AM and returned to the facility on [DATE] at approximately 12:49 PM. A late entry nurse's note dated [DATE] at approximately 5:49 PM read: 9:03 AM the nurse (RN 1) was notified by CNA #2 that the Resident was complaining of pain. RN #1 entered the Resident's room to medicate her with one dose of Oxycodone. The resident was educated that if the pain did not cease immediately to notify the nurse. CNA #2 was on duty and informed RN #1 that she was a regular staff member in the resident's hall and that she would make repeated checks on her to ensure that she was okay. At approximately 10:20 AM, CNA #2 notified this nurse that the resident was not alert and appeared to be having difficulty breathing. RN #1 entered the room and observed the same and informed CNA #2 to contact the DON, the ADON, and all clinical staff to come and assist. Once all hands were on deck, increased oxygen was given, vital signs were taken and the staff were able to get an oxygen level of 97% and a heart rate of 57 beats per minute, although the resident's heart rate was very weak. The Resident was unresponsive and observed to have Cheyne-Stokes breathing, 911 was called immediately after the vital signs were taken. RN #1 called the [resident's representative name] and left a non-detailed message requesting that she contact this nurse on her personal cellular device. At 10:38 AM emergency Medical Services (EMS) and the local police department arrived. EMS was escorted to the resident's room, and they began their assessment, the resident was still having difficulty breathing, they applied the Ambu air bag to assist the resident with taking in more air. The nurse witnessed EMS start CPR. They performed 30 minutes of unsuccessful manipulations of CPR. The lead EMS notified nursing and present staff that they were pronouncing the time of death at 11:10 a.m. This nurse contacted the [resident representative] again from her cellular device and left a message requesting a call back at 11:20 am. A review of the autopsy report dated [DATE] at 9:00 AM indicated the following: 1. External Wounds: a right forehead purple bruise, right upper cheek curved abrasion, and bruising to the jawline extending to the corner of the mouth, posterior right forearm two red abrasions with bruising, posterior medial right hand is an abrasion with slough. 2. Multiple Blunt Force Injuries: a recent left femoral fracture with surrounding soft tissue hemorrhage. A left posterior 1st and 2nd rib fractures with hemorrhage. Bruising and abrasions to the face with a recently absent left upper incisor, right forearm, and left hand. Subgaleal hematoma, right scalp (Subgaleal hematomas (SGHs) result from the accumulation of blood in the subgaleal space after a minor head trauma; radial or tangential forces applied to the scalp during minor trauma can cause hemorrhage in the subgaleal space.) The autopsy report stated the multiple blunt force injuries contributed to her death and documented the cause of death accident. On [DATE] at approximately 4:05 p.m., an interview was conducted with the Nurse Consultant. The Nurse Consultant stated the Facility staff developed an Action plan secondary to Resident #2's fall. She stated the Facility's staff determined during their investigation that the resident should had two staff members during care, but only one was present at the time of the fall and they determined that the proper bed (Bariatric) was not in use at the time of the fall on [DATE]. The Nurse Consultant stated the Action plan dated [DATE] provided staff education and put in place options to consider prior to moving a Resident from one unit to another. The Nurse Consultant also stated the fall and the Action plan were reviewed in the Quality Assurance Meeting on the same day and the audits were completed to validate that no further incidents were identified related to a failure of not using bariatric beds or two-person assistance when required. The Facility's Action Plan dated [DATE] indicated the following: Resident fell during provision of care. For Residents requiring two-person assistance - 1. CNAs and Nurses were educated on the provision of two-person assistance, and review tasks. This will be monitored by printing the task listing report weekly. 2. Audit completed to identify to identify those needing two-person assistance. This will be monitored by printing the device list and monitoring the presence of devices for all. 3. Audit of care plans completed to ensure the need for two-person assistance for bed mobility is included in the proper care plan. This will be monitored by random observation of the provision of care for bed mobility weekly to ensure the proper number of staff is providing care. 4. Remove the two-person assist signs from rooms (focus on use of the task listing). This will be monitored by random monitoring of documentation for bed mobility to ensure documentation reflects accurate provision of care. 5. Print Task Listing for bed mobility and keep it at the nurse's station for staff to review and identify those needing two-person assistance. The resident moved to a different room without the proper-sized bed and her belongings. Residents requiring a room change are at risk- Obtain a listing of residents moved within the past 30 days. This will be monitored by the Unit managers (UM) checking the Resident orders and care plan after room changes are done. The UM should compare the Resident and environment to ensure that proper bed and belongings are present. 2. Visually check Residents to ensure that the proper bed is in place and belongings are in the current room. 3. Educate staff that room changes from unit to unit will be avoided if possible. An onsite review of the Facility's Action plan was validated via resident and staff interviews, resident observations, and resident record reviews. All residents who were assessed to require Bariatric beds had a Bariatric bed and a care plan for the use of the Bariatric bed. Residents who were assessed and required two-person assistance with care were validated through assessments, care plans, and random observations. The survey sample was expanded to ensure the Facility's Action Plan had been implemented. No new deficient practices in the area of F689 were identified during the onsite review, thus Immediate Jeopardy (IJ) PNC was issued to the facility dated [DATE]. A final interview was conducted with the Administrator, the Assistant Administrator, the Director of Nursing, and the Nurse Consultant on [DATE] at approximately 5:00 PM regarding the above information and was informed that the incident resulted in Immediate Jeopardy-J PNC. The facility's staff had no additional information to offer and voiced no further concerns.

Based on observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to provide necessary care and service to prevent deterioration for 1 of 58 resident's (Resident #92) who had stage IV pressure ulcer to the coccyx. The coccyx pressure ulcer on admission to the facility measured length 9.96 centimeters by width 3.89 centimeters by depth 0.30 centimeters and on 12/2/21 the coccyx pressure ulcer measured 16.00 centimeters by 7.66 centimeters by 2.0 centimeters with a tunneling at six o'clock measuring 5.50 centimeters, and it presented malodorous with heavy drainage which constituted harm. For 2 of 11 residents with facility acquired pressure ulcers in a survey sample of 58 residents, the facility staff failed to initially identify them prior to an advanced stage. Resident #65's right lateral ankle pressure ulcer was initially identified by the facility staff as a stage III with 40% granulation tissue and 60% slough/eschar. For Resident #90, the facility staff initially identified a left heel pressure ulcer as unstageable on 12/7/21, which constituted harm. The findings included: 1. Resident #92 was originally admitted to the facility 11/1/21 after an acute care hospital stay and has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/7/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #92's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, transfers, and toileting, extensive assistance of one person with personal hygiene, bathing, and dressing, limited assistance of one person with locomotion, and supervision after set-up with eating. On 12/7/21 at approximately 3:45 p.m., an interview was conducted with Resident #92. The resident stated the wound care Nurse Practitioner (NP) was disappointed with the condition of the coccyx pressure ulcer because it showed significant deterioration during the 12/2/21 assessment but it was worse on 12/7/21, even with the ordered change in the treatment on 12/2/21. The resident also stated the wound care NP instructed him on 12/2/21 to ensure the staff repositioned him frequently and provided incontinence care timely to prevent further wound deterioration. The resident further stated the suprapubic catheter eliminated most moisture but as a result of [CONDITION(S)] he was unaware of when or if he had a bowel movement. The resident also stated he is able to assist the staff when he is positioned and can hold on to the bed rail while care is rendered. Review of the Braden Scale for Predicting Pressure Sore Risk revealed the resident had a potential for pressure ulcer development secondary to sensory loss, for he was unable to feel pain or discomfort in 1 to 2 extremities, chairfastness; for his ability to walk was severely limited or non-existent, unable to bear weight and/or must be assisted into a chair or wheelchair, limitations in mobility; makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently and friction and shear; requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. The resident score 15 on the Braden Predictor which classified him as At Risk. A moderate risk was 13-14, high risk 10-21 and a very high risk was 9 or below. Review of Resident #92's current care plan dated 11/16/21 read; the resident has pressure ulcers (Coccyx, heels) or potential for pressure ulcer development related to decreased functional mobility. The goal read; the resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions included; monitor nutritional status. Provide supplements as ordered, monitor intake and record and position resident as needed. The clinical record revealed Resident #92 had no weekly skin assessments or wound care evaluation between 11/9/21 and 11/24/21, recommendation offered by the wound care NP were not instituted from 11/4/21 through 12/2/21 and there was no evidence the the facility staff informed the NP of the not carrying out the recommendation, and wound care treatments were not documented as completed on the Treatment Administration Record for the following days; 11/2/21, 11/3/21, 11/21/21, 11/23/21, 12/3/21 and 12/8/21 and a Certified Nursing Assistant was given the responsibility to round with the wound care NP and write verbal orders to be transcribed into nurse documentation and recommendations for orders to treat wounds. The wound care NP Wound Tissue Analytics document of the coccyx pressure ulcer recommended a Specialty bed, ensure compliance with turning and elevate the legs regularly. Observations were make of the Resident #92 in bed 12/7/21 at approximately 3:45 p.m., 12/8/21 at approximately 11:55 a.m., 12/9/21 at approximately 1:35 p.m., 12/10/21 at approximately 2:40 p.m. and 12/13/21 at approximately 5:15 p.m. During each of the observations the resident's legs were not elevated as recommended. Review of the Clinical Record revealed the following documentation: The nurse's weekly skin evaluation dated 11/1/21 listed a stage IV sacral pressure ulcer present on admission to the facility without measurements or description. A Wound Tissue Analytics document dated 11/2/21, which stated Resident #92 was admitted to the facility with a stage IV coccyx pressure ulcer measuring length 9.96 centimeters by width 3.89 centimeters by depth 0.30 centimeters and presented with 20 percent granulation tissue and 80 percent eschar, no odor and moderate serosanguious drainage. The treatment was cleanse with normal saline and [MEDICATION(S)] and silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. The weekly skin evaluation dated 11/8/21 listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. There wasn't a wound care NP note until 11/9/21. A Wound Tissue Analytics document dated 11/9/21, revealed the coccyx pressure ulcer had stalled. It measured 7.51 centimeters by 9.43 centimeters by depth 0.20 centimeters and presented with 50% granulation tissue and 50% eschar, no odor and moderate serosanguious drainage. The treatment was cleanse with Dakins and Dakins moist to dry and silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. There was no further weekly skin evaluations between 11/8/21 and 11/19/21. There was no weekly wound assessments between 11/9/21 and 11/24/21. The weekly skin evaluation dated 11/19/21 listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. There wasn't a new wound care NP note until 11/24/21. A Wound Tissue Analytics document dated 11/24/21, revealed the coccyx pressure ulcer was worsening. It measured 15.23 centimeters by 7.79 centimeters by depth 0.30 centimeters and presented with 30% granulation tissue and 70% eschar, no odor and moderate serosanguious drainage. The treatment remained cleanse with Dakins and Dakins moist to dry and a silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. The weekly skin evaluation dated 11/27/21, listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. A Wound Tissue Analytics document dated 12/2/21, revealed the coccyx pressure ulcer was worsening. It measured 16.00 centimeters by 7.66 centimeters by depth 2.00 centimeters, and a tunneling at six o'clock measuring 5.50 centimeters and the coccyx pressure ulcer presented with 30% granulation tissue and 70% eschar, malodorous, and with heavy serosanguious drainage. The treatment remained cleanse with Dakins and Santyl and a super- absorbent dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. A Wound assessment dated [DATE], revealed the coccyx pressure ulcer was worsening. It measured 16.16 centimeters by 7.71 centimeters by depth 2.00 centimeters, and a tunneling at six o'clock measuring 5.50 centimeters and the coccyx pressure ulcer presented with 10% granulation tissue and 90% eschar, malodorous, and with heavy purulent drainage. The treatment remained cleanse with Dakins and Santyl and a super-absorbent dressing. An amended note written by the wound care NP dated 12/8/21 read; discussed possible debridement of the sacral wound as well as needing to send the resident out to have surgical debridement done. This was tried by me (NP) on Tuesday but the eschar was too adherent to the wound bed. Will look at attempting debridement when rounding on 12/14/21 if the eschar is loosen enough by the Santyl. The next weekly skin evaluation was dated 12/12/21, and listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. Review of the Treatment Administration Record revealed the following orders for the coccyx pressure ulcer: 11/1/21 - 11/2/21;cleanse sacral area with dermal wound cleanser, pat dry. Apply hydrogel and cover with a dry dressing daily and as needed if soiled, every day shift. This order was discontinued 11/2/21. 11/2/21 - 11/3/21; there were no treatment orders for the coccyx or sacral pressure ulcer. 11/4/21 - 11/24/21; cleanse coccyx with dermal wound cleanser, apply honey fiber and cover with a silicone dressing daily, every day shift. This order was discontinued 11/24/21. The wound care NP recommendations dated 11/9/21 read; cleanse the coccyx with Dakin's and use of Dakin's moist-to-dry dressings was never instituted. 11/24/21 - 12/2/21; cleanse coccyx with dermal wound cleanser, apply honey fiber and cover with a silicone dressing every two days, day shift. This order was discontinued 12/2/21. The wound care NP recommendations dated 11/24/21 read; cleanse the coccyx with Dakin's and use of Dakin's moist-to-dry dressings was never instituted. 12/2/21- 12/10/21; cleanse the coccyx with Dakin's solution, apply Santyl ointment, cover with a super-absorbent dressing every day shift. This order was discontinued 12/10/21. 12/10/21 - current ; cleanse the coccyx with dermal wound cleanser, pack with Dakin's soaked gauze, cover with an ABD pad and secure with tape. On 12/10/21 at approximately 2:40 p.m., an observation was made of Resident #92's coccyx pressure ulcer during wound care performed by Licensed Practical Nurse (LPN) #14 assisted by LPN #15. LPN #14 removed a old dressing fully saturated with dark green foul smelling drainage. The odor was so overwhelming it permeated the room and hallway outside the door. The coccyx wound presented as a butterfly shape covering greater than 50% of both sides of the coccyx. The tissue was totally black and green and leathery with a red outline of the entire wound. Above the coccyx are was a deep tunneling area with a flap of skin in the very center and a large amount of dark green drainage flowed from it. LPN #14 cleaned the dark leathery portion of the wound with Dakin's solution, applied Santyl ointment and two thick foam dressing which covered the leathery portion of the wound but barely the tunneled area. The tunneled area wasn't cleaned, neither was Santyl or other treatment applied inside the tunneled wound. After wound care on 12/10/21 at approximately 2:55 p.m., an interview was conducted with LPN #14. LPN #14 stated this was the first time she had provided the coccyx wound care for Resident #92 therefore; she was unable to provide any information on the wound's prior state. LPN #14 stated she didn't see the tunneling area above the dark leathery tissue and she didn't think about where the large amount of drainage had come from. LPN #14 did acknowledge the foul odor of the wound. An interview was also conducted with LPN #15 on 12/10/21 at approximately 3:00 p.m. LPN #15 stated she was the fulltime day shift nurse for Resident #92 and she completed the coccyx wound care regularly. LPN #15 stated the wound presented with more drainage than she had seen before and she stated the odor was more offensive. LPN #15 stated she wasn't aware of the tunneling area above the dark leathery tissue and she had never performed a treatment to the tunneling area. An interview was also conducted with the Unit Manager on 12/10/21 at approximately 3:05 p.m. The Unit Manager stated she had been working in the position for five days and she had not had the opportunity to observed Resident #92's coccyx pressure ulcer or read information provided by the wound care NP but she would notify the NP of the state of the coccyx pressure ulcer. The Unit Manager also stated LPN #6 had previously provided oversight to the unit and she may have some additional information regarding Resident #92's coccyx pressure ulcer. An interview was conducted with LPN #6 on 12/10/21 at approximately 3:25 p.m. LPN #6 stated sometimes she assisted the wound care NP with rounds and other times other nurses or a Certified Nursing Assistant (CNA) rounded with the NP. LPN #6 stated during the rounds the NP gives verbal orders and they are written down and passed on to the nurses on the unit for documentation purposes and even when the CNA rounded with the NP that was the procedure and they simple destroy the notes after they are recorded the information in the clinical record. LPN #6 also stated most of the time when treatment orders are changed it can take up to two days to get the newly ordered products in the facility to begin use. On 12/13/21 at approximately 12:15 p.m., an interview was conducted with CNA #4. CNA #4 stated she worked frequently with Resident #92 and the resident always had a good attitude, was compliant with care, remained positioned when positioned although he favored the sitting position because he enjoyed watching sports on television and using his phone. CNA #4 stated the resident was incontinent of bowels and required staff to provide incontinence care for bowel movements. On 12/13/21 at approximately 12:20 p.m., an interview was conducted with CNA #5. CNA #5 stated she had worked a few times with Resident #92 while orientating to the position. She stated she had assisted to provide care for the resident that morning and found him to be very pleasant, and attempted to assisted with his care as much as he was capable. On 12/14/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. *Dakin solution is a strong topical antiseptic widely used to clean infected wounds, ulcers, and [CONDITION(S)].[6] Full strength Dakin's solution is usually diluted in water, depending on its intended use. A 0.5% solution of hypochlorite (containing approximately 5000 ppm free chlorine) is used for disinfecting areas contaminated with bodily fluids, including large blood spills (after the area has been cleaned with a detergent). Dilute Dakin's solution (0.05% to 0.025%) can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections (https://www.ncbi.nlm.nih.gov/books/NBK 6/) This information was obtained 12/17/21. The information below was obtained on 12/17/21 from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar6_pu_woundassesst.pdf *Eschar. Cornified or dried out dead tissue. *Tunneling. Tracts extending out from the wound. *A Stage IV Pressure Ulcer: Definition o Full thickness tissue loss with exposed bone, tendon, or muscle - Slough or eschar may be present. o Often include undermining and tunneling Description o The depth of a stage IV pressure ulcer varies by anatomical location. - The bridge of the nose, ear, occiput, and malleolus do not have adipose subcutaneous tissue and stage IV ulcers can be shallow. o Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making [CONDITION(S)] or osteitis likely to occur. o Exposed bone/tendon is visible or directly palpable. *An Unstageable Pressure ulcer: Definition o 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. Description o Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a Stage III or IV. o Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. 2. The facility staff failed to identify Resident #65's right lateral ankle pressure ulcer prior to it being found at an advanced stage resulting in harm. The pressure injury was found as a stage III with 40% granulation tissue and 60% slough/eschar. Resident #65 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 10/22/21 coded Resident #65 a 06 out of a possible score of 15 indicating severe cognitive impairment. The MDS coded Resident #65 requiring total dependence of two with bathing, bed mobility, toilet use, hygiene and dressing, extensive assistance of one with transfer and eating for Activities of Daily Living care. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #65 with impairment on both sides to her upper and lower extremity. Resident #65 was coded as having no mood, rejection of care or behavioral problems. The MDS with an ARD of 10/22/21 under section M (Skin Condition - M0100) was coded for the using a Formal Assessment Instrument/tool (e.g., Braden, Norton or other) for the determination of Pressure Ulcer Risk. Under section (M0150) for Risk of Pressure Ulcers coded Resident #65 at risk for developing pressure ulcers and under section (M1200) for skin and treatments was coded for having pressure reducing device bed, turning/repositioning program and pressure ulcer care. Resident #65's care plan with a created date of 06/23/21 identified the resident with the potential for skin impairment and actual skin impairment to the left heel, left outer ankle, right lateral foot and left buttocks. The goal set for the resident by the staff was that the resident will have no evidence of skin impairment through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to keep skin clean and dry, lotion dry skin, moisture barrier cream as needed for protection of skin and weekly skin assessment. Resident #65's care plan with a revision date of 11/16/21 identified the resident with another pressure ulcer located to the right outer ankle. Some of the interventions/approaches the staff would use to accomplish this goal is for Healing Partners to provide skin/wound care as needed, turn and reposition, wedge foam, air loss mattress and wound care as ordered. A Braden Risk Assessment Report was completed on 10/20/21; resident scored a 10 indicating high risk for the development of pressure ulcers. Sensory perception is the ability to respond meaningfully to pressure-related discomfort. Resident #65 is very limited with sensory perception and only responds to painful stimuli and cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Activity (degree of physical activity) is chair fast, Mobility is completely immobile (does not make even slight changes in body or extremity position without assistance) and Friction & Shear with a problem requiring moderate to maximum assistance in moving, frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contractures or agitation leads to almost constant friction. Review of Resident #65's bi-weekly skin assessments were reviewed from 06/23/21 through 11/02/21 with no skin issues to the right lateral ankle until identified at an advance stage (stage III) by the Wound Specialist (NP) on 11/02/21. The Wound Care Specialist/Nurse Practitioner documented the following on a Tissue Analytics Form: -11/02/21 at 9:11 a.m., a new Stage III pressure ulcer was identified to right lateral ankle measuring 1.75 cm x 2.03 cm with 40% granulation tissue and 60% slough/eschar (dead) tissue with a moderate amount of serosanquinous drainage with unattached edges. The stage III pressure ulcer was documented as facility acquired. A treatment started to apply Honey Fiber to wound bed and wrap with kling/kerlix daily. -11/11/21 -stage III pressure ulcer to right lateral ankle measuring 1.91 cm x 1.94 cm with 10% granulation tissue and 90% slough/eschar with scant amount of serosanquinous drainage. Wound status documented as improving. A new treatment was started for [MEDICATION(S)] three times daily, wrap with kling/kerlix. - 11/23/21 - Stage III pressure ulcer to right lateral ankle measuring 3.29 cm x 3.33 cm with 100% slough/eschar with scant amount of serosanquinous drainage with attached edges. Wound status documented as stable. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Offloading heels by wearing foot protectors and frequent positioning. Dressing is [MEDICATION(S)] with Kling/Kerlix. -11/30/21 - Stage III pressure ulcer to right lateral ankle measuring 3.05 cm x 2.65 cm with 40% granulation and 60% slough/eschar with moderate amount of serosanquinous drainage and bleeding also present from wound bed with unattached edges. Wound status documented as worsening. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Treatment changed to Honey fiber - apply to wound bed daily and wrap with kling/kerlix. -12/14/21 - Stage III pressure ulcer to right lateral ankle measuring 3.68 cm x 2.88 cm with moderate amount of sersanquinous drainage and bleeding also present from wound bed with unattached edges. Wound status documented as worsening but without odor. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Treatment changed to Collagen Ag daily. The current treatment as of 12/09/21 is to cleanse right lateral ankle with normal saline, pat dry, apply [MEDICATION(S)], cover with gauze and wrap with kerlix. On 12/09/21 at approximately 12:20 p.m., wound care observation was conducted with License Practical Nurse (LPN) #1. Resident #65 was lying in bed, positioned on her right side lying on an alternating low air loss pressure mattress. LPN #1 perform wound care with the assistance of another nurse. Prior to starting wound care to the Resident #65, LPN #1 washed her hands x 31 seconds, used hand sanitizer and donned a new pair of gloves. The LPN removed the dressing from the resident's right lateral ankle wound with a large amount of sersanquinous drainage present on dressing removed. The right lateral ankle wound bed noted with red granulation and yellow tissue present; no odor present. LPN #1 removed her gloves, applied hand sanitizer then applied a new pair of gloves. The wound was cleansed with normal saline in a circular motion x 2, gloves removed, hand sanitizer applied, new gloves applied, Manuk-ahd honey coated dressing applied to wound bed, covered with gauze and wrapped with kling. A phone interview was conducted with the Wound Specialist/Nurse Practitioner (NP) on 12/10/21 at approximately 1:16 p.m. When asked if the staff had informed her prior to performing wound care to Resident #65 on 11/02/21 that the resident had a stage III to her right lateral ankle, she replied, No. The NP stated, While providing routine wound care with the assistance of a nurse on 11/02/21, I observed a new stage III pressure ulcer to the right lateral ankle. The NP said the wound had been there then for a while due to the fact that the wound bed had some granulation tissue present as well as slough and eschar. Review of Resident #65's clinical record revealed a weekly skin evaluation entered by LPN #1 on 11/02/21 at approximately 3:03 p.m. The document included the following: wound to right outer ankle. An interview was conducted with LPN #1 on 12/13/21 at approximately 10:14 a.m. When asked if she identified the pressure ulcer on Resident #65 on 11/02/21, she replied, It was found on 11/02/21 by the NP. She said the NP need assistance with positioning Resident #65 and while positioning the resident, the NP found the pressure ulcer to the resident's right outer ankle. LPN stated, I do the resident's wounds often and to be perfectly honest, I never say the wound the right outer ankle until it was identified by the NP on 11/02/21. A debriefing was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. When asked, At what stage do you expect for the nurses to first identify a pressure ulcer she replied, They should be found when there is a difference in the color of their skin; at a stage I. Definitions *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). * Stage 3 Pressure Injury: Full-thickness skin loss - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). *Low air loss mattress is an alternating pressure mattress systems are designed to heal and prevent bedsores (http://www.medicalairmattress.com/deluxe.html). *MANUK-Ahd is a honey impregnated super absorbent gelling fiber dressing that maintains a balanced moist environment conducive to wound healing. Dressing properties cause honey to gel with wound fluid and allows for easy removal. Benefits from using Manuk-ahd honey gel include the following: easily conforms to any wound type, gels with exudate, high strength and integrity, super absorbent for moderate to heavy exuding wounds, high sugar levels in the honey results in osmotic pressure, promoting autolytic debridement and wound odor reduction (https://www.woundsource.com/product/manukahd-lite). 3.The facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of a pressure ulcer that was initially identified at an advanced stage, resulting in harm. Resident #90 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has been discharged multiple times from the facility to the community. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/04/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #90 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) of the admission MDS, the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. Requires one person assist with locomotion on and off the unit and with eating. Requiring total dependence of one person with bathing. The admission MDS in section M (Skin Conditions) M0100 Determination of Pressure Ulcer/Injury Risk: Section A reads: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. =Yes. Section B reads: Formal assessment instrument/tool (e.g., Braden, Norton, or other) = Yes. Section C reads: Clinical assessment= Yes. M0150 Risk of Pressure Ulcers/Injuries. Is this resident at risk of developing pressure ulcers/injuries? =Yes. M0210. Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries stage 1 or higher? = Yes. M0300 (Current number of unhealed pressure ulcers at each stage. G. unstageable deep tissue: Suspected deep tissue injury. Number of unstageable pressure ulcers suspected with deep tissue injury: 1. Number of unstageables present on admission: 1 M -Number of venous and arterial ulcers: 1 M1040-Other ulcers, wounds and skin problems: None M1200-Skin and Ulcer Treatments: Pressure reducing device for chair, Pressure reducing device for bed, Pressure ulcer care and application of dressings to feet. The MDS above only list Skin problems before the new unstageable ulcer on the left heel was identified. Braden Scale for Predicting Pressure Ulcers dated 11/02/16. Score is 16. SCORING: AT RISK 15-18. MODERATE RISK 13-14. HIGH RISK 10-12. VERY HIGH RISK 9 or below. The care plan dated 11/15/21 reads: Focus-The resident has an ADL self-care performance deficit r/t Activity Intolerance. Goals: The resident will improve current level of function in ADLs through the review date. Interventions: Staff to assist with ADL's (Activity of Daily Living) as needed. Provide sponge bath when a full bath or shower cannot be tolerated. A review of the MDS and Care Plan reveal no refusals for bed baths or bathing The Self Care assessment dated on 11/03/21 indicated that the Resident was dependent on staff to put on and take off footwear. The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. The care plan dated 11/15/21 reads: Focus-Actual skin impairment r/t limited mobility, muscle weakness, and DM (Diabetes Mellitus) II, admitted with surgical incision to Right hip with staples, skin tears to Right lower leg, and Right Forearm, and skin breakdown to Right lateral ankle and Right buttock. Goals: Resident will have no evidence of skin impairment through next review. Keep skin clean and dry. Lotion to dry skin. Moisture barrier cream as needed for protection of skin. Pericare with incontinence episodes. Pressure reduction mattress. Treatments to all areas as ordered. Notify MD as needed. Weekly Skin Assessment. A review of the ADL (Activity of Daily Living) sheet note dated 12/13/21 reads: Resident prefers bed baths and is scheduled for baths/showers on [TRUNCATED]

Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to provide the necessary care and services to 1 of 58 residents (Resident #170) for the prevention and complication of a Urinary Tract Infection ([CONDITION(S)]) and [CONDITION(S)]. The facility staff failed to notify the physician or Physician Assistant (PA) when orders were given for a UA with C&S, and that they were never obtained, over five days. The resident became unresponsive, with oxygen saturation levels of 83% (normal=95-100%), and was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #170 was originally admitted the nursing facility on 12/13/17. The resident was discharged to the local hospital on 10/17/21 and did not return to the nursing facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 07/22/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 13 of 15 indicating no cognitive impairment. Resident #170 was coded total dependence of two with dressing, total dependence of one with bathing and toilet use, extensive assistance of two with bed mobility and supervision with one assist with hygiene for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan with a created date on 05/11/18 and a revision date of 10/17/21 identified Resident #170 at risk for [CONDITION(S)] related to has history of [CONDITION(S)]'s. The goal set for the resident by the staff was that the resident's [CONDITION(S)] will resolve without complications by the review date. One of the interventions/approaches the staff would use to accomplish this goal is monitor/document/report to MD as needed for signs and symptoms of [CONDITION(S)]: frequency urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status and behavioral changes. On 10/11/21, Physician Assistant (PA) progress revealed the following information: Resident #170 is being seen today possible [CONDITION(S)] symptoms per nursing staff. Per nursing, there are concerns that the resident may have a [CONDITION(S)] and states his catheter was recently removed by urology. Resident was recently sent to the emergency room (ER) for hematuria and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Under general information revealed the following: incontinent of bowel and bladder, penile discharge present and with no visible hematuria in his brief. The PA wrote to obtain UA with C&S if symptoms develop. On 10/13/21, PA progress note dated 10/13/21 revealed the following information: Resident #170 is being seen today for evaluation of hematuria and confusion per nursing staff. Resident has a significant history of recurring [CONDITION(S)]'s and recently had catheter removed per urology order. Under general information revealed the following: report hematuria with confusion; change from baseline. The PA wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of Resident #170's clinical record did not reveal lab results for UA with C&S after being ordered on 10/13/21. On 12/09/21 at approximately 5:29 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said if the nurse was not able to obtain the urine specimen as ordered by the physician, PA or Nurse Practitioner (NP) then the nurse should have communicated to oncoming shift that Resident #170 still needed to have urine obtain for a UA with C&S. She said if the nurses were still not able to obtain the urine then the physician, PA or NP should have been notified and to possibly get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the nurse's should have been monitoring the resident for s/s of [CONDITION(S)] and a change in condition and to notify the physician, NP or PA right away if such symptoms occurred and to document in the information in the resident's clinical record. On 12/09/21 at approximately 5:40 p.m., an interview was conducted with the Medical Director. He said if the nurses were not able to obtain the labs as ordered for UA with C&S, myself the NP or PA should have been notified. The Medical Director was informed by the surveyor that the resident was having signs of [CONDITION(S)] to include confusion and hematuria. He stated, If the resident was having signs of [CONDITION(S)] and the staff were not able to obtain the labs as ordered, an order would have been given to straight Cath to obtain the urine specimen. He said the resident could have been treated prophylactically with antibiotics until the C&S was received. License Practical Nurse (LPN) #9 documented in the resident's nurses note on 10/13/21 at approximately 3:13 p.m., that the resident was informed several times during the shift a urine sample has been ordered. The resident replied several times I don't have to go yet. The urine sample was not collected on the 7-3 shift. The nurses note did not indicate the NP/PA or physician were made aware the UA with C&S was not obtained as ordered. An interview was conducted with the LPN #9 on 12/10/21 at approximately 11:17 a.m. The LPN stated, The 11-7 shift reported off to me that Resident #170 need a UA with C&S. The nurse said she was not able to obtain the urine specimen so it was passed on the oncoming nurse for the 3-11 shift on 10/13/21. On 12/10/21 at approximately 11:25 a.m., a phone interview was conducted with LPN #10. The LPN was assigned to provide care and services to Resident #170 on 10/13/21 (3-11 shift). The LPN stated, I don't recall ever being told in report that Resident #170 need a urine sample but I know for sure, I did not obtain a urine specimen from Resident #170. Review of Resident #170's clinical record revealed the following documentation entered on 10/17/21 at approximately 3:22 p.m. Resident #170 noted with altered mental status, unresponsiveness with oxygen saturation at 83% on room air. A new order was obtained to send to the ER for evaluation and treatment. Resident #170 was admitted to the hospital and placed in Intensive Care Unit (ICU), the resident did not return to the nursing facility. Review of the hospital records revealed the following: Resident #170 presented in the emergency room (ER) on 10/17/21 from (name of nursing facility) for further evaluation due to Altered Mental Status (AMS). The 911 transport revealed the following: Resident #170 was transferred from (name of nursing home) where he was found unresponsive and hypoxic. The resident was placed on non-breather mask and transported to the ER. On the evaluation work-up at (name of hospital), in the ER Resident #170 was awake but sluggish and continues on non-breather mask. Upon arrival to the hospital, the ER records indicated Resident #170's body temperature @ 88 degrees F (hypothermia - low body temperature) with a [NAME] and warming lights. The white blood count was 16,000, urinalysis with large leukocyte esterase, positive nitrites and WBC too numerous to count with 4+ bacteria. The ER records indicated the resident was admitted to Intensive Care Unit (ICU). Intravenous Fluids (IV), IV antibiotic ([MEDICATION(S)] and [MEDICATION(S)]) was started. The resident was diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A debriefing was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m., Resident #170's issues was presented again. The facility did not present any further information about the findings. Definitions -Urinary tract infection occurs when there is compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, [CONDITION(S)] is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov). -[CONDITION(S)] is a serious medical condition. It's caused by an overwhelming immune response to infection. The body releases immune chemicals into the blood to combat the infection. Those chemicals trigger widespread inflammation, which leads to blood clots and leaky blood vessels. As a result, blood flow is impaired, and that deprives organs of nutrients and oxygen and leads to organ damage. In severe cases, one or more organs fail. In the worst cases, blood pressure drops, the heart weakens, and the patient spirals toward septic shock (https://www.nigms.nih.gov/education/Documents/[CONDITION(S)].pdf). -Severe [CONDITION(S)] symptoms may include but not limited to organ failure, such as kidney (renal dysfunction resulting in less urine) low platelet count and change in mental status, pain in the lower abdomen and blood in the urine. Systolic pressure is equal to or less than 100 millimeters of mercury (mmhg) and abnormal white blood cell count (either too high or too low). In some cases, [CONDITION(S)] may turn into septic shock, which is a drastic drop in blood pressure that can increase the risk of death. Signs of septic shock include but not limited to: needing medication to maintain systolic blood pressure equal to or greater than 64 mmHG and high levels of lactic acid in your blood, which means your cells aren't using oxygen in the right way. To prevent urosepsis, get treated as soon as possible. The longer you delay treating [CONDITION(S)], the more likely to develop urosepsis, septic shock, renal failure and death (https://webmd.com). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a [CONDITION(S)] (http://www.webmd.com/a-to-z-guides/urine-culture). -Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Oxygen saturation levels are considered normal between 95-100%. Levels that fall to 88% or lower, seek immediate attention (medlineplus.gov).

Based on observation, record review and staff interview, the facility staff failed to provide care and services to one resident (Resident #28) during wound care treatment to promote dignity and respect and failed to remind and assist 3 Residents (#146, #132 and #103) to vote in the November 2021 general election in the survey sample of 58 residents. The findings included: 1.Resident #28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident received wound treatment on 12/08/21 from Licence Practical Nurse (LPN) LPN #11. Resident #28 was assessed having a Basis Interview of Mental Status (BIMS) score of (7) seven. A Quarterly Minimum Data Set (MDS) dated [DATE] indicated this resident had ADL (activities of daily living) deficits in self care, physical mobility, and maintaining adequate nutritional status. A revised care plan dated 10/23/21 indicated: Potential for skin impairment and or pressure ulcer: Goal: Resident will have no evidence of skin impairment; interventions- keep skin clean and dry. Moisture barrier cream as needed for protection of skin. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/08/21 at 1:15 P.M. LPN #11 was observed to provided wound care to the right heel of Resident #28. After removal of old dressing and applying the new wound care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Following the wound dressing disposal and washing of hands, LPN #11 asked how she had performed. LPN #11 was reminded that she wrote the date of the dressing change on the resident. LPN #11 stated, yes I did. I should not have done that. 2. The facility staff failed to remind and assist Resident #146, to vote in the November 2021 general election. Resident #146 was originally admitted to the facility 7/12/18. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/15/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #146's cognitive abilities for daily decision making were intact. On 12/7/21 at approximately 4:00 p.m., an interview was conducted with the Resident Council group. During this interview Resident #146 stated she didn't get to vote in the November 2021 election and it was her desire to vote. The resident stated no one talked about the upcoming election or asked if she wanted or needed assistance to obtain an absentee ballot. 3. The facility staff failed to remind and assist Resident #132, to vote in the November 2021 general election. Resident #132 was originally admitted to the facility 12/22/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were intact. On 12/7/21 at approximately 4:00 p.m., an interview was conducted with the Resident Council group. During this interview Resident #132 stated she didn't get to vote in the November 2021 election and she has always voted. The resident stated no one talked about the upcoming election or asked if she wanted or needed assistance to participate in the November 2021 election. 4. The facility staff failed to remind and assist Resident #103, to vote in the November 2021 general election. Resident #103 was originally admitted to the facility 12/27/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/7/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #103's cognitive abilities for daily decision making were intact. On 12/7/21 at approximately 4:00 p.m., an interview was conducted with the Resident Council group. During this interview Resident #146 stated he didn't get to vote in the November 2021 election and he would have liked to vote. The resident stated no one talked about the upcoming election or asked if he desired an absentee ballot. On 12/9/21 at approximately 3:10 p.m., an interview was conducted with the Discharge Planner. The Discharge Planner stated it is her duty to manage all voting activities but she aware it included talking with the residents and assisting those not registered or in need of obtaining application and absentee ballots. The Discharge Planner stated she assisted all ballots addressed to residents to ensure they were received and returned to the local registration office. The Discharge Planner stated going forward she would ensure all activities related to voting are carried out. On 12/14/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. No additional information was offered.

Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure residents were afforded the opportunity to formulate advance directives, and the advance directive was maintained in the clinical record, readily accessible to the direct care staff to convey upon transfer to the emergency medical personnel and/or the hospital for 5 of 58 residents (123, 55, 77, 146 and 170), in the survey sample The findings include: 1. Resident #123 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #123's cognitive abilities for daily decision making were severely impaired. A review of the Resident #123's clinical record didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other but; a scanned DO NOT RESUSCITATE (DNR) form dated [DATE], was in noticed in miscellaneous records. This form read as follows; I, the undersigned, state that I have a [NAME] fide physician/patient relationship with the patient named above. I have certified in the patient's medical record that he/she or a person authorized to consent on the patient's behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. I further certify: The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signatures of the physician and patient were on the document.) The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It read verified from medical records only. There was no evidence of a discussion with the resident and/or responsible party neither was there evidence the NP provided information to the resident and/or responsible party regarding his right to refuse medical or surgical treatment or to formulate an advance directive. The clinical record further evidenced a nurse's note dated [DATE] at 2:36 p.m., which read; per nurse KB copies of the Medication Administration Record/Treatment Administration Record and the bed hold policy were faxed to the hospital. There was no evidence the DNR form or an advance directive was conveyed to the hospital along with the other documents. An interview was conducted with the Unit Manager UM) for Resident #123's unit on [DATE] at approximately 4:40 p.m., she wasn't sure where to locate an advance directive for she had only been the UM for five days but she was aware of how important such a document would be to the direct care staff during a life threatening emergency. An interview was conducted with the Admission's Director on [DATE] at approximately 4:50 p.m. The Admission's Director stated if the documents are sent from the hospital with other medical records she makes them available to nursing but it is nursing responsible to discuss advance directives with the resident and/or their responsible party. On [DATE] at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated they be putting together a training plan relating to Advance Directives. 2. Resident #55 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact A review of the Resident #55's clinical record didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical treatments, feeding restrictions, organ donation, autopsy request or other but; a scanned document dated [DATE] from the Palliative Medicine team read; Advance Directives: The Palliative Care Interdisciplinary Team has updated the Navigator with Health Care Agent and any associated documents. Medical Power of Attorney, Living Will, Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no POLST form on file for this patient. No Advance Directive, Surrogate Decision Maker, son (name) awaiting contact. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence information was provided to the resident and/or responsible party regarding his right to refuse medical or surgical treatment or to formulate an advance directive and the person-centered care plan didn't contain information on advance directives. The clinical record further evidenced a nurse's note dated [DATE] at 10:36 p.m., which read; Writer spoke with 5 east nurse to get an update on the resident. The nurse stated the resident was having an esophagogastroduodenoscopy (EGD) procedure completed and afterwards he would be admitted for bleeding. The progress note further stated the Family was notified and the Care plan goals and bed hold policy was faxed over to hospital. There was no evidence advance directives were conveyed to the hospital along with the above documents. An interview was conducted with the Unit Manager UM) for Resident #55's unit on [DATE] at approximately 4:40 p.m., she wasn't sure where to locate an advance directive for she had only been the UM for five days but she was aware of how important such a document would be to the direct care staff during a life threatening emergency. An interview was conducted with the Admission's Director on [DATE] at approximately 4:50 p.m. The Admission's Director stated if the documents are sent from the hospital with other medical records she makes them available to nursing but it is nursing responsible to discuss advance directives with the resident and/or their responsible party. On [DATE] at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Director of Nursing stated they be putting together a training plan relating to Advance Directives. 3. The facility staff failed to provide Resident #77 with the opportunity to formulate an advance directive. Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having a Basic Interview for Mental Status (BIMS) score of 9. Resident #77 was coded as having Activities of Daily Living (ADL's) deficits in mobility, and at risk for falls. A revised care plan dated [DATE] indicated: Focus: Nutrition Risk r/t Recent hospitalization , chewing/swallowing difficulty with mechanically altered diet in place. A review of the clinical records did not indicate Resident #77 was provided with the opportunity to develop an advance directive. During an interview on [DATE] at 3:00 P.M. with the Director of Nursing (DON) she was asked if Resident #77 had an advance directive. The DON stated no, Resident #77 had not formulated an advance directive. 4. The facility staff failed to provide Resident #146 with the opportunity to formulate an advance directive. Resident #146 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS dated [DATE] assessed resident as having a BIMS score of 15. Resident #146 was coded as having ADL deficits with balance, and limited physical mobility. A revised care plan dated [DATE] indicated: Focus: Resident is/has potential to be physically aggressive r/t irritability and anger issues. A review of the clinical records did not indicate Resident #146 was provided with the opportunity to develop an advance directive. During an interview on [DATE] at 3:10 P.M. with the Director of Nursing (DON) she was asked if Resident #77 had an advance directive. The DON stated no, Resident #146 had not formulated an advance directive. 5. The facility staff failed to ensure that Resident #170's Advanced Directive/DNR was sent upon transfer/discharge to the hospital on [DATE]. Resident #170 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) a 13 of 15 indicating no cognitive impairment. Review of Resident #170's Order Summary for [DATE] revealed the following order: Do not resuscitate (DNR) effective as of [DATE]. On [DATE] at approximately 3:22 p.m., an eINTERACT change in condition document was completed by License Practical Nurse (LPN) #2. The document revealed the following information: send Resident #170 to the hospital due to being unresponsive, experiencing shortness of breath, labored or rapid breathing and oxygen saturation at 83% on room air. The clinical record did not show evidence that Resident #170's Advanced Directive/Do Not Resuscitate (DNR) was sent with him when transferred to the hospital. A nurse's note entered by LPN #2 on [DATE] (,d+[DATE]) shift at approximately 9:45 p.m., revealed the following: (name of hospital) Emergency Department (ER) physician called and spoke with LPN #2. The physician requested for Resident #170's DNR form to be faxed to the ER department. The note further revealed that Resident #170's DNR form was faxed to the hospital as requested by the ER physician. An interview was conducted with LPN #2 on [DATE] at approximately 11:11 a.m., who stated, I was not assigned to Resident #170 but did assist with his transfer to the hospital on [DATE]. When asked if the Resident's Advance Directive or DNR form was sent with the resident when he was transferred to the hospital on [DATE], she replied, No, the DNR form was sent later after being requested by the ER physician. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on [DATE] at approximately 12:35 p.m. The DON said the expectation is for the resident's Advance Directive/DNR form to be sent with the resident when is transferred to the hospital. The facility's policy titled Advance Directive with an effective date [DATE]. 1. A copy of the Center's policies governing the implementation of self-determination of rights is present upon admission by the Admission Office and the Notification/Acknowledgement Form verifying all communication regarding advance directives is to be placed in the Medical Record at the time of admission. 2. Upon admission a licensed nurse must immediately review the advance medical directive documents provided. If the Living Will specifies or declares the withholding of Cardiopulmonary resuscitation (CPR) or specifies that they do not want to be resuscitated, a license nurse must immediately notify the attending physician an secure a valid DNR.

Based on complaint investigation, staff interviews, facility document review, and clinical record review, the facility staff failed to notify the physician and resident's representative of missed laboratory services for 3 residents (Resident #13, Resident #17 and Resident #170), and they failed to notify one representative of a change in condition for one resident (Resident #167), a closed record resident in the survey sample of 58 residents. The findings included: 1. The facility staff failed to notify the physician and resident representative of missed blood work ordered on 11/01/21 for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) for Resident #13. Resident #13 was originally admitted the nursing facility on 07/27/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 08/29/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 03 of 15 indicating severe cognitive impairment. Resident #13 was coded total dependence of one with bathing, extensive assistance of one with transfer, dressing, hygiene, bed mobility and toilet use and supervision with setup with eating for Activities of Daily Living (ADL) care. Review of Resident #13's clinical record revealed the following order dated 11/01/21: labs for CBC and BMP every Tuesday for 3 weeks. During the review of Resident #13's clinical record on 12/08/21 did not reveal lab results for CBC and BMP for 11/02/21 or 11/16/21. On the same day, the Director of Nursing stated she was not able to locate in the clinical record lab results for the CBC or BMP for the two dates mentioned above. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The DON was asked if the physician and the resident's representative should have been notified of the missed labs for CBC and BMP, the DON stated, Yes. 2. The facility staff failed to notify the physician and resident representative of missed blood work ordered on 11/24/21 for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) for Resident #17. Resident #17 was admitted the nursing facility on 09/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 09/10/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 15 of 15 indicating no cognitive impairment. Resident #17 was coded supervision with limited assistance of one with transfer, dressing, hygiene, bed mobility and toilet use and supervision with eating and bathing Activities of Daily Living (ADL) care. Review of Resident #17's clinical record revealed the following order dated 11/24/21: labs for CBC with diff and BMP to be drawn on 11/26/21. During the review of Resident #17's clinical record on 12/08/21 did not reveal lab results for CBC with diff and BMP. On the same day, the Director of Nursing stated she was not able to locate in the clinical record lab results for the CBC with diff and BMP for 11/26/21. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The DON was asked if the physician and the resident's representative should have been notified of the missed labs for CBC with diff and BMP, the DON stated, Yes. Definitions: -CBC is a blood test that measures the number and types of cells in your blood. This helps doctor's check on your overall health. The tests can also help to diagnose diseases and conditions such as [CONDITION(S)], infections, clotting problems, blood cancers, and immune system disorders (https://medlineplus.gov/bloodcounttests.html). -BMP is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP includes tests for the following: Glucose, a type of sugar and your body's main source of energy (https://medlineplus.gov/lab-tests/basic-metabolic-panel-bmp). -Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a [CONDITION(S)] (http://www.webmd.com/a-to-z-guides/urine-culture). -Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture). - Urinary Tract Infection ([CONDITION(S)]) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney (http://www.cdc.gov/HAI/ca_uti/[CONDITION(S)].html). 3. The facility staff failed to notify the physician and resident representative of missed lab work for UA/C&S ordered on 10/13/21 for Resident #170. Resident #170 was admitted the nursing facility on 09/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 07/22/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 13 of 15 indicating no cognitive impairment. Resident #170 was coded total dependence of two with dressing, total dependence of one with bathing and toilet use, supervision with one assist with hygiene with Activities of Daily Living (ADL) care. The MDS coded the resident as always incontinent of bladder and bowel. Review of Resident #170's clinical record revealed the following order dated 10/13/21: obtain labs for UA with C&S for hematuria. During the review of Resident #170's clinical record on 12/09/21 did not reveal lab results for UA with C&S. On the same day, the Regional Director of Clinical Services stated she was not able to locate in the clinical record lab results for the UA with C&S. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The DON was asked if the physician and the resident's representative should have been notified of the missed UA with C&S, the DON stated, Yes. 4. The facility staff failed to notify the Resident Representative of an open area found on Resident #167's chest. Resident #167 was originally admitted to the facility 06/15/21 and discharged on [DATE] to an acute care hospital. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as moderately impaired for daily decision making. In section G(Physical functioning) the resident was coded as requiring extensive assistance with bed mobility and eating. Requires total dependence with transfers, locomotion on the unit, dressing, toilet use and personal hygiene. Requiring total care with bathing. A review of the TAR (Treatment Authorization Record) reads: dressing changes to chest daily, clean with dermal wound cleanser apply Xeroform and cover with dry dressing every day shift for chest abrasion -Order Date 06/22/2021 5:14 PM -D/C (discontinue) Date 06/26/2021 12:04 PM. (Resident received wound care treatment as ordered). A review of the weekly skin assessment dated [DATE] reveal that Resident #167's skin is intact. A review of the weekly skin assessment dated [DATE] reveal that Resident #167 has an abrasion on his chest. Measuring 7.4 cm (Length) x 7.0 cm (Width). Note reads: Pt. (Patient) has open area to chest, appears to be from him rubbing on his chest with his hand. MD notified. Date acquired: 6/20/21. A review of progress notes dated 6/20/2021 at 22:14 (10:14 PM) Reads: Open area to pt. (patient) chest noted, appears to be a stage 2 from pt. rubbing his hand repeatedly across his chest. Area was cleaned and dried and dressing placed over area. Note placed in communication book asking provider to assess and give treatment order. Pt. wife notified. On 12/10/21 at approximately, 3:00 PM an interview was conducted with the DON (Director of Nursing) concerning Resident #167. She stated, The nurse documented that she notified the family but she didn't. She said she got busy and forgot to call the RP (Responsible Party). A copy of an Employee Corrective Action was received from the DON concerning LPN #4 dated 7/01/21. It reads: A resident was found with a wound, you charted that the family was updated. Family was in for a visit, noticed the wound and was upset that nobody had notified them. When speaking to you about the documentation you stated that you meant to update the family but did not. On 12/14/21 at approximately 10:35 AM an interview was conducted with LPN #4 concerning Resident #167 concerning an area found on his chest. She stated, He was anxious when he came from the hospital. I worked the 3-11 shift. He kept rubbing his hand across his chest a lot. The doctor was notified and a treatment was put in for it. It looked pink like the top layer of skin came off. I asked her to assess the area to make sure we were providing the correct treatment. I found the area. He didn't come in with it. The family was notified the following day but I didn't personally notify them. I found it late at night. I was going to notify her but it was late and I forgot to go back and change my note. I think I said that provider and RP were notified. But I only notified the provider by putting a note in the communication book. I should have gone back and fixed my note. On 12/14/2021 at approximately 3:10 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. COMPLAINT DEFICIENCY

Based on observation, resident interview and staff interviews the facility staff failed to provide reasonable care for the protection of residents' property from loss and to return laundry in a timely manner for 3 of 58 residents (Resident #50, Resident #90 and Resident #138) in the survey sample. The findings included; 1.The facility staff failed to return Residents laundry in a timely manner and protect Resident's laundry from loss. Resident #50 was originally admitted to the facility 05/14/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Non-displaced Fracture and Obesity. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/11/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #50 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring supervision of one person assistance with bed mobility, transfers and toilet use. Resident is independent with no set-up help or assistance with walking in the room or corridor. Independent with locomotion on and off the unit. Requires extensive assistance of one person with dressing. Requires independence set-up help only with eating. The care plan dated 6/02/21 reads: The resident has an ADL self-care performance deficit r/t Limited Mobility, Limited ROM, Musculoskeletal impairment, fractures. Goal: The resident will improve current level of function in ADLs through the review date. Interventions: Assist with all ADL's as needed. On 12/08/21 at approximately 11:55 AM during the initial tour an interview was conducted with Resident #50 concerning personal belongings. She stated, My laundry has been in the laundry for over two months. They say the laundry is behind and the washer stays broken. I had to go out and buy clothes because I didn't have any. I'm missing 6 pairs of sweats, 5 T- shirts and underwear. I did get a pair of sweats back yesterday (12/07/21). I gave the receipt to the administrator yesterday. My name is written in my clothes. On 12/09/21 at approximately, 12:54 PM an interview was conducted with the administrator concerning missing personal belongings for Resident #50. He stated, I just received this receipt from her on yesterday for lost clothing. I will reimburse her $56.24. Received an invoice from the facility administrator on 12/09/21 at 4:00 PM. It reads: Please send payment of $58.24 to Resident #50 for reimbursement of missing clothing. 2. The facility staff failed to return Residents laundry in a timely manner and protect Resident's laundry from loss. Resident #90 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has been discharged multiple times from the facility to the community. The current diagnoses included; Fracture of unspecified part, History of falling and an unstageable ulcer of the left heel. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/04/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #90 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. Requires one person assist with locomotion on and off the unit and with eating. Requiring total dependence of one person with bathing. The care plan dated 11/15/21 reads: Focus-The resident has an ADL self-care performance deficit r/t Activity Intolerance. Goals: The resident will improve current level of function in ADLs through the review date. Interventions: Staff to assist with ADL's (Activity of Daily Living) as needed. Provide sponge bath when a full bath or shower cannot be tolerated. On 12/08/21 at approximately 5:36 PM an interview was conducted with Resident #90 concerning missing clothing. He stated, I had three shirts, three pair pants washed 4 four weeks ago on a Wednesday and I haven't gotten them back. I told everybody. They said they'd call. My name was written in these clothes. 3. The facility staff failed to return Residents laundry in a timely manner and protect Resident's laundry from loss. Resident #138 was originally admitted to the facility 02/07/2021 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Chronic Pain Syndrome and Pain Unspecified. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/12/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #138 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as independent set-up help only with transfers, walking in the room, locomotion on and off the unit, eating and bathing. Requiring supervision after set-up help only with dressing and personal hygiene. Requiring supervision one person physical assistance with toileting. On 12/08/21 at approximately 3:37 PM an interview was conducted with Resident #138 concerning missing laundry. She stated, I'm missing pieces of laundry (Clothing). Several shirts and pants. I notified the administrator. I gave him a copy of my receipts in early November. On 12/09/21 at approximately 4:00 PM the facility administrator presented the surveyor with a handwritten list of missing clothing that he received from the resident. The administrator also presented surveyor with an invoice dated 12/09/21 reading: Please send payment of $97.48 to Resident #138 for reimbursement of missing clothes. On 12/13/21 at approximately 1:00 PM an interview was conducted with Laundry Aide (OSM/Other Staff Member) #3 concerning missed clothing on the above residents. She stated, I talked to him (Resident #90). I've been looking for his clothes and nothing is back there anymore. I was down and washer and dryer and worked by myself for two weeks. Today I found a white shirt and PJ's (Pajama Bottoms) He said he didn't want us to do his laundry anymore. I pulled Resident #138's clothes, washed and dried them separately. I haven't seen any of her items. The other attendant has her (Resident #50). Surveyor asked to speak with the other attendant in question but was not able to speak with her. On 12/14/2021 at approximately 3:10 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on clinical record review, staff interviews and facility record review, the facility staff failed to recognize, assess and intervene (to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #123). The findings included: Resident #123 was originally admitted to the facility 9/28/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/4/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #123's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person with bed mobility, dressing, and toileting, limited assistance of one person with walking and locomotion, supervision of one person after set-up with eating and personal hygiene. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/2/21 order was discontinued on 12/10/21 when a new order was received for daily weights related to congestive heart failure one time a day related to acute diastolic congestive heart failure. Notify the Physician/Nurse Practitioner of a weight gain of 2 pounds in one day or 5 pounds in one week. The POS also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's diet order dated 11/5/21 read, Heart Healthy Diabetic diet, Level 7 - Regular texture, Regular Liquids consistency. The current care plan had a problem dated 11/5/21 which read; The resident has Congestive Heart Failure. The goal read; The resident will have clear lung sounds, heart rate and rhythm within normal limits through the review date and the resident will be free of peripheral [CONDITION(S)] through the review date. The interventions included; encourage proper/ordered diet. Give cardiac medications as ordered. Monitor for [CONDITION(S)]. Oxygen at 2 liters per minute via nasal cannula. Vital signs as ordered. Report abnormal findings as needed. Weights as ordered. An interview was conducted with Resident #2's spouse on 12/7/21 at approximately 2:35 p.m. The spouse stated there was concern with the meals the resident receives because of the disease processes of diabetes and heart failure. The spouse stated the resident currently had great [CONDITION(S)] to the legs and there was facial [CONDITION(S)] and she thought the resident was receiving [MEDICATION(S)] (a diuretic) daily, was to be weighed daily and should be receiving a low carbohydrate (carb) and low salt diet because of his medical conditions. On 12/7/21 at approximately 2:38 p.m., Resident #92 stated there was tightness of his chest and he was short of breath. On 12/7/21 at approximately 2:45 p.m., an observation was made of the resident legs; the left was with plus 4 swelling and the right with plus 3 swelling. Both legs presented tight and shiny. Review of the oxygen concentrator revealed the resident was receiving 2 liters of oxygen at that time. Review of the clinical record revealed the [MEDICATION(S)] was discontinued during the resident's last hospitalization but the order for a daily weight was active. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The weight obtained ranged from 236.6 to 222.8 then to 229.1, with no documented notification to the responsible party or practitioner. From 12/1/21 through 12/9/21 no weights were documented. On 12/10/21 a weight of 199.1, was obtained and a new order was given for daily weight on 12/10/21. No weight was obtained on 12/11/21, the 12/12/21 weight was 228 (there was no documentation the practitioner or family was notified of the 29 pound weight gain), the 12/13/21 weight was documented as not applicable, and the 12/14/21 weight was recorded as 228.1. All recorded weights after administration of the diuretic on 12/9/21 were greater than the pre-diuretic weight of 199.1, with no notifications documented. On 12/9/21 at approximately 4:40 p.m., an interview was conducted with the Unit Manager (UM) for the Unit Resident #123 resided on. The above information was shared with the UM and she stated an assessment would be made of the resident's status and the practitioner would be made know if there were negative findings. On 12/10/21 at approximately 11:40 a.m., the UM stated a significant change in condition was documented 12/9/21 on behalf of Resident #123 for the resident presented with new or worsening [CONDITION(S)]. The UM stated a one time dose of [MEDICATION(S)] was administered 12/9/21, a venous Doppler examination to bilateral lower extremities was ordered and the resident was followed-up by the in house provider that day. The Nurse Practitioner's documentation revealed the following; Chief Complaint/ Nature of Presenting Problem: left lower extremity swelling, congestive heart failure and shining bilateral lower extremities, the resident had chronic congestive heart failure; start [MEDICATION(S)] 2 milligrams daily and obtain a BMP & Complete Blood Count (CBC) with differential on 12/13/21. On 12/14/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Consultant stated when the weights indicated a discrepancy another weight should have been obtained and the practitioner should have been notified of the [CONDITION(S)] had it been observed. No additional information was offered. Heart failure signs and symptoms may include: Shortness of breath with activity or when lying down, fatigue and weakness, swelling in the legs, ankles and feet, rapid or irregular heartbeat, swelling of the belly area (abdomen), very rapid weight gain from fluid buildup . (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc- 142). The above information was obtained 12/17/21.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to treat, monitor and manage pain for 1 of 58 residents (Resident #138), in the survey sample. The findings included: Resident #138 was originally admitted to the facility 02/07/2021 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/12/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #138 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as independent set-up help only with transfers, walking in the room, locomotion on and off the unit, eating and bathing. Requiring supervision after set-up help only with dressing and personal hygiene. Requiring supervision one person physical assistance with toileting. In section J J0100 (Pain Management, dated 11/12/21) the resident was coded as Received scheduled pain medication regimen? Yes. Received PRN pain medications or was offered and declined? No. Received non-medication intervention for pain? No. J0200. Should Pain Assessment Interview be conducted? Yes. J0300. Pain Presence. Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes. J0400. Pain Frequency. Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly. J0500. Pain Effect on Function. Ask resident: Over the past 5 days, has pain made it hard for you to sleep at night? Yes. The care plan dated 11/12/21 reads: Focus: Pain. Goal: Resident will have no/decreased complaints of pain through next review. Interventions: Attempt non-pharmacological interventions as needed. Interventions utilized before use of PRN pain medication (reposition, dim lights, locate to calm environment, diversional activities). Medicate as ordered. Notify MD for pain not relieved with medication or with new complaints of pain. Premedicate in anticipation of painful procedures. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] All Narcotic Pain medication Refills to come from Doctor's office every shift for Pain Management. Active 08/24/2021. [MEDICATION(S)] Capsule 6 MG Give 1 capsule by mouth three times a day for back spasms per Pain management center Phone Active 11/18/2021. Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain Verbal Active 02/07/2021. Tylenol with [MEDICATION(S)] #4 Tablet 300-60 MG (Acetaminophen-[MEDICATION(S)]) Give 1 tablet by mouth three times a day for back pain per doctor pain management center Verbal Active 03/04/2021. The MAR (Medication Administration Record) reads: All Narcotic Pain medication Refills to come from Doctor's office every shift for (Evening and Night) Pain Management -Order Date 08/24/2021 1337. Initialed by staff from 12/01/21-12/14/21. [MEDICATION(S)] Capsule 6 MG Give 1 capsule by mouth three times a day for back spasms per Pain management center -Order Date11/18/2021 1336 Tylenol with [MEDICATION(S)] #4 Tablet 300-60 MG (Acetaminophen [MEDICATION(S)]) Give 1 tablet by mouth three times a day for back pain per Doctors pain management center -Order Date 03/04/2021 0857 (8:57 AM). According to the [DATE] doses of Tylenol with [MEDICATION(S)] #4 Tablets 300-60 MG were not administered. The chart code indicating 9 was written = Other/See Progress Notes. Missed doses on the following days: 12/13/21 missed doses at 1300 (1:00 PM) and 1700 (5:00 PM) and on 12/14/21 missed doses at 0900 (9:00 AM), 1300 (1:00 PM) and 1700 (5:00 PM). Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain -Order Date 02/07/2021 0954 (9:54 AM). No doses of as needed Tylenol 325 MG was given per MAR. [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 8 hours for pain for 2 Days DC when Tylenol #3 arrives -Order Date 12/14/2021 1054 (10:54 AM) -D/C Date 12/15/2021 0045 (12:45 AM). The First dose of [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth one time only for pain for 1 Day -Order Date 12/14/2021 9:15 AM. Was administered at 10:20 AM. The Second dose of [MEDICATION(S)] 5-325 MG was administered on 12/14/21 at 4:00 PM. A review of nursing notes reveal the following on 12/13/2021 at 14:32 (2:32 PM) concerning Resident #138's pain medication. Called patients MD, it was on automated message so left the message regarding her being positive of COVID and a request to refill her (acetaminophen-[MEDICATION(S)]). Per LPN #7. On 12/08/21 at approximately 3:44 PM a telephone interview was conducted with Resident #138 concerning her pain medication. I didn't receive Tylenol # 4 from a nurse. On 12/14/21 at 8:28 AM a follow up phone call was made to resident #138. She states she's having pain in her lower back. When asked to rate her pain level she stated. I'm an 8 out of 10. I've been out of Tylenol #4 since Yesterday. A review of the MAR (Medication Administration Record) reveal that resident did not receive her scheduled Tylenol #4 at 1300 (1:00 PM) and 1700 (5:00 PM). On 12/14/21 at approximately 9:05 AM surveyor spoke to the DON (Director of Nursing) concerning Resident not receiving her pain medications. She was asked to contact the said surveyor after investigating the pain medication concerns. On 12/14/21 at 9:10 AM an interview was conducted with LPN #7 (via telephone/LPN #7 states she's not working today) concerning Resident #138's Tylenol #4. She stated, She gets that from her pain doctor. We don't order for her. I tried calling him. There was an automatic voice message. The resident told me to call the office. I told LPN #6 (Unit Manager) about it. She's aware. I haven't given any replacements for her. She said that she was fine. I had no idea that I had to order it. That doctor will send the medication. I asked her if she wanted a Tylenol. She wasn't in any pain yesterday. On 12/14/21 at 9:50 AM., an interview was conducted with the DON concerning Resident #138. She stated, She is out of the medication but the nurse at the pain office said her physician did not sign the script. The physician was out and didn't sign her script. It did not fax to pharmacy but faxing it this morning. She received [MEDICATION(S)] this morning. The surveyor asked, what she received on yesterday as a substitute for her Tylenol #4. She stated, I think she has a prn (as needed) order for Tylenol but did not receive it. It was ordered this morning. Someone should have followed up but the nurse said she received the script and sent to it to Pharma script on yesterday but the physician didn't sign it. When medications run low we would fax the script to the pharmacy. When running low, renew the medication. The pain doctor is notified. I would have had the nurse follow up. I did call Pharma script to add it to the Omnicell (Drug Dispensing System). On 12/14/21 at approximately 12:30 PM a telephone interview was conducted with The Pharmacist at Pharmascript (OSM #1/Director of Quality and Pharmacist). Concerning Resident #138. She stated, Currently, Omnicell now list Tylenol#4. This was added as of today. The request is to add Tylenol #4 to their Omnicell which was added today 12/14/21. The original script is from October 22, 2021. We had a prescription on file based on the dispensing timeline we dispensed on 12/01/21 for 30 tablets a 10 day supply. The next was refilled on 12/14/21 today. There was quantity remaining. Meaning they could have called to request another supply. We need an original valid prescription on file. Set up to dispense 30 tablets at a time. 12/01/21 should have been active only a 10 day supply, if they needed more there was quantity remaining to get more from us. They should order more. Let me call you back. The next fill after 12/01/21 is today. 12/14/21 at approximately, 12:45 PM a phone call was make to LPN #6 concerning Resident #138. She stated, She follows pain management our NP (Nurse Practitioner) don't do anything here for narcotics. We have to actually call the doctor's office, then he faxes the script into pharmacy. Normally we do 3-5 days because pharmacy won't refill if over 5 days. I told her (LPN #7) to call the doctor's office. I didn't know anything until the evening. The said surveyor asked LPN #6 if the facility's Omnicell had Tylenol #4 available. She stated, No it doesn't. If we had known that the NP could supply it we would have her pain medication if I had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Doctor's office had the script because we called. He wasn't available to sign off until today. Every week I will personally look at her supply and reorder it (Tylenol #4) as it goes. We will stock it in our Omnicell. On 12/14/21 at approximately 1:05 PM a returned phone call was received from the Pharmacist (OSM #1). She stated, We did have a prescription on file that could have been refilled on 12/01/21. We didn't have a refill request until today. We had a valid prescription on file. They could have called us or went through point click care. We will sit up refresher courses for them so they could know how to request from us. On 12/14/21 at approximately 3:00 PM a phone call was received from Resident #138. She stated, they gave me pain medications this morning and they said my pain medication is not in. My pain still an 8 out of 10. The [MEDICATION(S)] brought my pain down to a 5. I was hurting bad. I take Tylenol 4 plus Terzanidine together. I don't know how often I'm supposed to take the [MEDICATION(S)]. No policies were available per facility staff. On 12/14/2021 at approximately 3:10 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Consultant stated, We thought we had to obtain a new prescription.

Based on record review, resident interview and staff interviews, the facility staff failed to procure narcotics timely for one resident (Resident #138) in a survey sample of 58 residents. The findings included: Resident #138 was originally admitted to the facility 02/07/2021 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Chronic Pain Syndrome and Pain Unspecified. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/12/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #138 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as independent set-up help only with transfers, walking in the room, locomotion on and off the unit, eating and bathing. Requiring supervision after set-up help only with dressing and personal hygiene. Requiring supervision one person physical assistance with toileting. In section J J0100 (Pain Management, dated 11/12/21) the resident was coded as Received scheduled pain medication regimen? Yes. Received PRN pain medications or was offered and declined? No. Received non-medication intervention for pain? No. J0200. Should Pain Assessment Interview be conducted? Yes. J0300. Pain Presence. Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes. J0400. Pain Frequency. Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly. J0500. Pain Effect on Function. Ask resident: Over the past 5 days, has pain made it hard for you to sleep at night? Yes. The care plan dated 11/12/21 reads: Focus: Pain. Goal: Resident will have no/decreased complaints of pain through next review. Interventions: Attempt non-pharmacological interventions as needed. Interventions utilized before use of PRN pain medication (reposition, dim lights, locate to calm environment, diversional activities). Medicate as ordered. Notify MD for pain not relieved with medication or with new complaints of pain. Premedicate in anticipation of painful procedures. The POS (Physician Order Summary) reads: All Narcotic Pain medication Refills to come from Doctor's office every shift for Pain Management. Active 08/24/2021. [MEDICATION(S)] Capsule 6 MG Give 1 capsule by mouth three times a day for back spasms per Pain management center Phone Active 11/18/2021. Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain Verbal Active 02/07/2021. Tylenol with [MEDICATION(S)] #4 Tablet 300-60 MG (Acetaminophen-[MEDICATION(S)]) Give 1 tablet by mouth three times a day for back pain per doctor pain management center Verbal Active 03/04/2021. The MAR (Medication Administration Record) reads: All Narcotic Pain medication Refills to come from Doctor's office every shift for (Evening and Night) Pain Management -Order Date 08/24/2021 1337. Initialed by staff from 12/01/21-12/14/21. [MEDICATION(S)] Capsule 6 MG Give 1 capsule by mouth three times a day for back spasms per Pain management center -Order Date11/18/2021 1336 (1:36 PM). Tylenol with [MEDICATION(S)] #4 Tablet 300-60 MG (Acetaminophen [MEDICATION(S)]) Give 1 tablet by mouth three times a day for back pain per Doctors pain management center -Order Date 03/04/2021 8:57 AM). According to the [DATE] doses of Tylenol with [MEDICATION(S)] #4 Tablets 300-60 MG were not administered. The chart code indicating 9 was written = Other/See Progress Notes. Missed doses on the following days: 12/13/21 missed doses at 1300 (1:00 PM) and 1700 (5:00 PM) and on 12/14/21 missed doses at 0900 (9:00 AM), 1300 (1:00 PM) and 1700 (5:00 PM). Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain -Order Date 02/07/2021 0954 (9:54 AM). No doses of as needed Tylenol 325 MG was given per the MAR. [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 8 hours for pain for 2 Days DC when Tylenol #3 arrives -Order Date 12/14/2021 1054 (10:54 AM) -D/C Date 12/15/2021 0045 (12:45 AM). The First dose of [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth one time only for pain for 1 Day -Order Date 12/14/2021 9:15 AM. Was administered at 10:20 AM. The Second dose of [MEDICATION(S)] 5-325 MG was administered on 12/14/21 at 4:00 PM. A review of nursing notes reveal the following on 12/13/2021 at 14:32 (2:32 PM) concerning Resident #138's pain medication. Called patients MD (Medical Doctor), it was on automated message so left the message regarding her being positive of COVID and a request to refill her (acetaminophen-[MEDICATION(S)]). Per LPN #7. On 12/08/21 at approximately 3:44 PM a telephone interview was conducted with Resident #138 concerning her pain medication. I didn't receive Tylenol #4 from a nurse. On 12/14/21 at 8:28 AM a follow up phone call was made to resident #138. She states she's having pain in her lower back. When asked to rate her pain level she stated. I'm an 8 out of 10. I've been out of Tylenol #4 since Yesterday. A review of the MAR (Medication Administration Record) reveal that resident did not receive her scheduled Tylenol #4 at 1300 (1:00 PM) and 1700 (5:00 PM). On 12/14/21 at approximately 9:05 AM surveyor spoke to the DON (Director of Nursing) concerning Resident not receiving her pain medications. She was asked to contact the said surveyor after investigating the pain medication concerns. On 12/14/21 at 9:10 AM an interview was conducted with LPN #7 (via telephone/LPN #7 states she's not working today) concerning Resident #138's Tylenol #4. She stated, She gets that from her pain doctor. We don't order for her. I tried calling him. There was an automatic voice message. The resident told me to call the office. I told LPN #6 (Unit Manager) about it. She's aware. I haven't given any replacements for her. She said that she was fine. I had no idea that I had to order it. That doctor will send the medication. I asked her if she wanted a Tylenol. She wasn't in any pain yesterday. On 12/14/21 at 9:50 AM., an interview was conducted with the DON concerning Resident #138. She stated, She is out of the medication but the nurse at the pain office said her physician did not sign the script. The physician was out and didn't sign her script. It did not fax to pharmacy but faxing it this morning. She received [MEDICATION(S)] this morning. The surveyor asked, what she received on yesterday as a substitute for her Tylenol #4. She stated, I think she has a prn (as needed) order for Tylenol but did not receive it. It was ordered this morning. Someone should have followed up but the nurse said she received the script and sent to it to Pharma script on yesterday but the physician didn't sign it. When medications run low we would fax the script to the pharmacy. When running low, renew the medication. The pain doctor is notified. I would have had the nurse follow up. I did call Pharma script to add it to the Omnicell (Drug Dispensing System). On 12/14/21 at approximately 12:30 PM a telephone interview was conducted with The Pharmacist at Pharmascript (OSM #1/Director of Quality and Pharmacist). Concerning Resident #138. She stated, Currently, Omnicell now list Tylenol#4. This was added as of today. The request is to add Tylenol #4 to their Omnicell which was added today 12/14/21. The original script is from October 22, 2021. We had a prescription on file based on the dispensing timeline we dispensed on 12/01/21 for 30 tablets a 10 day supply. The next was refilled on 12/14/21 today. There was quantity remaining. Meaning they could have called to request another supply. We need an original valid prescription on file. Set up to dispense 30 tablets at a time. 12/01/21 should have been active only a 10 day supply, if they needed more there was quantity remaining to get more from us. They should order more. Let me call you back. The next fill after 12/01/21 is today. 12/14/21 at approximately, 12:45 PM a phone call was make to LPN #6 concerning Resident #138. She stated, She follows pain management our NP (Nurse Practitioner) don't do anything here for narcotics. We have to actually call the doctor's office, then he faxes the script into pharmacy. Normally we do 3-5 days because pharmacy won't refill if over 5 days. I told her (LPN #7) to call the doctor's office. I didn't know anything until the evening. The said surveyor asked LPN #6 if the facility's Omnicell had Tylenol #4 available. She stated, No it doesn't. If we had known that the NP could supply it we would have her pain medication if I had an order for it. The NP had to issue a verbal order on the phone to pharmacy so they could issue a code. The Doctor's office had the script because we called. He wasn't available to sign off until today. Every week I will personally look at her supply and reorder it (Tylenol #4) as it goes. We will stock it in our Omnicell. On 12/14/21 at approximately 1:05 PM a returned phone call was received from the Pharmacist (OSM #1). She stated, We did have a prescription on file that could have been refilled on 12/01/21. We didn't have a refill request until today. We had a valid prescription on file. They could have called us or went through point click care. We will sit up refresher courses for them so they could know how to request from us. On 12/14/21 at approximately 3:00 PM a phone call was received from Resident #138. She stated, they gave me pain medications this morning and they said my pain medication is not in. My pain still an 8 out of 10. The [MEDICATION(S)] brought my pain down to a 5. I was hurting bad. I take Tylenol #4 plus Terzanidine together. I don't know how often I'm supposed to take the [MEDICATION(S)]. No policies were available per facility staff. On 12/14/2021 at approximately 3:10 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Consultant stated, We thought we had to obtain a new prescription.

Based on resident interview, clinical record review, and staff interviews, the facility staff failed to ensure the resident was free from significant medication error (the staff failed to administer the intravenous (IV) antibiotic ([MEDICATION(S)] 2 grams IV every 8 hours) as ordered from 11/16/21 through 12/2/21 for 1 of 58 residents (#55), in the survey sample The findings include: Resident #55 was originally admitted to the facility 10/14/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/18/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with bed mobility, transfers, dressing, eating, toileting, and personal hygiene and limited assistance of one person with walking and locomotion. An interview was conducted with Resident #55 on 12/8/21 at approximately 12:15 p.m. Resident #55 stated one day he woke up one day with a painful left upper arm, draining from a hole in it and he had no idea how it occurred. The resident stated he was hospitalized and received surgery related to the left upper arm and after leaving the hospital and returning to the rehabilitation facility, he was to receive IV antibiotics but he didn't start receiving them until last Friday, 12/3/21. A review of the Resident #55's discharge records from the local hospital to the rehabilitation facility included the following orders written on a document from the Infectious Disease practitioner's office; [MEDICATION(S)] 2 grams IV every 8 hours. Stop date-12/11/21. Indication- High grade MSSA Bacteremia. Peripherally inserted central catheter (PICC) line care per protocol (10 milliliters (ml) flush with normal saline pre and post infusion. 3 ml [MEDICATION(S)] flush (10 units/ml) post infusion or every 24 hours). Discontinue PICC line after completion of antibiotic. If the patient has a port -use 5 ml (100 units/ml) [MEDICATION(S)]. Port care per protocol. The following blood test were requested; Complete Blood Count (CBC) with differential, Comprehensive Metabolic Panel (CMP), Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) every week while on the IV antibiotic. Lab results to be faxed to (number). Follow-up in Infectious Disease office 12/2/21 at 1440. Office address. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record provided no evidence regarding the IV antibiotic administration or information informing the resident/responsible party or Practitioner of the delay in beginning the IV therapy. A review of miscellaneous documents revealed an appointment with the Infectious Disease practitioner dated 12/2/21. The document revealed the visit was related to the infection of the left humerus; hospital stay 11/9/21 through 11/16/21, IV [MEDICATION(S)] day 19, End of the IV therapy will be 12/11/21. A large left upper extremity abscess, unclear how he obtained wounds to the left arm, unless due to pressure measuring 27 by 7 by 3.8 centimeters and mixed attenuation with fluid, gas and enhancing periphery, no destructive lesion of bone, no definite joint involvement. Bacteremia of the left upper arm likely to the abscess. The progress note further read; the resident unfortunately has not been on IV [MEDICATION(S)] since discharged from the hospital at which time he was on day 4 of a planned 28 day. The Practitioner further stated the rehabilitation facility was contacted and the nurse confirmed the resident had not been on antibiotic since admission to the facility. The progress note further read; a follow-up call was made to the Case Manager at the hospital who stated the order was indeed entered and confirmed the order was the rehabilitation facility had received the order. The Practitioner's decided to restart the antibiotic therapy and provided the order to the rehabilitation facility. An interview was conducted with the Director of Nursing on 12/8/21 at approximately 2:20 p.m. The Director of Nursing stated the primary admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing provided a document dated 12/3/21, acknowledging the medication error. A plan wasn't developed to help prevent further admission medication errors. On 12/14/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. No additional information was offered.

Based on staff interviews, clinical record review and the facility's policy, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. The facility staff failed to obtain Resident #13's blood work ordered on 11/01/21 for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP). Resident #13 was originally admitted the nursing facility on 07/27/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 08/29/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 03 of 15 indicating severe cognitive impairment. Resident #13 was coded total dependence of one with bathing, extensive assistance of one with transfer, dressing, hygiene, bed mobility and toilet use and supervision with setup with eating for Activities of Daily Living (ADL) care. Review of Resident #13's clinical record revealed the following order dated 11/01/21: labs for CBC and BMP every Tuesday for 3 weeks. During the review of Resident #13's clinical record on 12/08/21 did not reveal lab results for CBC and BMP for 11/02/21 or 11/16/21. On the same day, the Director of Nursing stated she was not able to locate in the clinical record lab results for the CBC or BMP for 11/02/21 or 11/16/21. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The above findings were presented again; no further information was provided prior to exit. 2. The facility staff failed to obtain Resident #17's blood work ordered on 11/24/21 for CBC and BMP. Resident #17 was admitted the nursing facility on 09/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 09/10/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 15 of 15 indicating no cognitive impairment. Resident #17 was coded supervision with limited assistance of one with transfer, dressing, hygiene, bed mobility and toilet use and supervision with eating and bathing Activities of Daily Living (ADL) care. Review of Resident #17's clinical record revealed the following order dated 11/24/21: labs for CBC with diff and BMP to be drawn on 11/26/21. During the review of Resident #17's clinical record on 12/08/21 did not reveal lab results for CBC with diff and BMP. On the same day, the Director of Nursing stated she was not able to locate in the clinical record lab results for the CBC with diff and BMP. A debriefing was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The above findings were presented again; no further information was provided prior to exit. 3. The facility staff failed to obtain lab work for UA with C&S ordered on 10/13/21. Resident #170 was admitted the nursing facility on 09/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 07/22/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 13 of 15 indicating no cognitive impairment. Resident #170 was coded total dependence of two with dressing, total dependence of one with bathing and toilet use, supervision with one assist with hygiene with Activities of Daily Living (ADL) care. The MDS coded the resident as always incontinent of bladder and bowel. Review of Resident #170's clinical record revealed the following order dated 10/13/21: obtain labs for UA with C&S for hematuria. During the review of Resident #170's clinical record on 12/09/21 did not reveal lab results for UA & C/S. On the same day, the Regional Director of Clinical Services stated she was not able to locate in the clinical record lab results for the UA with C&S. The Regional Director said the physician and responsible party should have been notified of the missed UA with C&S. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. The DON was asked if the physician and the resident's representative should have been notified of the missed UA with C&S, the DON stated, Yes. The facility's policy titled: Laboratory/Diagnostic Testing with an effective date of 11/01/19. Policy: Laboratory, radiology and other diagnostic services are provided to the Center by way of written contractual agreements. The contracted service vendor is to provide services to the Center that ensure safe and effective patient testing and timely delivery of laboratory, radiology and other diagnostics testing results. -Procedure: 1. A licensed nurse will obtain laboratory, radiology, or other diagnostic services to meet the needs of its patients as ordered the physician or physician extender. 2. A license nurse will monitor and track all physician or physician extender ordered laboratory, radiology, and other diagnostic tests; ensure that tests are complete as ordered and communicate results to the physician in a timely manner. Definitions: 1. CBC is a blood test that measures the number and types of cells in your blood. This helps doctor's check on your overall health. The tests can also help to diagnose diseases and conditions such as [CONDITION(S)], infections, clotting problems, blood cancers, and immune system disorders (https://medlineplus.gov/bloodcounttests.html). 2. BMP is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP includes tests for the following: Glucose, a type of sugar and your body's main source of energy (https://medlineplus.gov/lab-tests/basic-metabolic-panel-bmp). 3. Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a [CONDITION(S)] (http://www.webmd.com/a-to-z-guides/urine-culture). 4. Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture). 5. Urinary Tract Infection ([CONDITION(S)]) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney (http://www.cdc.gov/HAI/ca_uti/[CONDITION(S)].html).

Based on resident interview, family interview, staff interview, and clinical record review, the facility staff failed to accommodate the resident's foods preferences to meet nutritional needs for 1 of 58 residents (Resident #123), in the survey sample. The findings included: Resident #123 was originally admitted to the facility 9/28/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; diabetes, heart failure, , [CONDITION(S)] and status post left great toe amputation. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/4/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #123's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person with bed mobility, dressing, and toileting, limited assistance of one person with walking and locomotion, supervision of one person after set-up with eating and personal hygiene. The resident's diet order dated 11/5/21 read, Heart Healthy Diabetic diet, Level 7 - Regular texture, Regular Liquids consistency. The current care plan had a problem dated 11/29/21 which read; Nutrition Risk related to a recent hospitalization , diagnosis diabetes, heart failure, and a surgical wound with need for a therapeutic diet. The goal read; The resident will maintain adequate nutritional status as evidenced by no significant weight change by next review. The interventions included; provide and serve diet as ordered. Monitor intake and record every meal. Weekly weights. An interview was conducted with Resident #2's spouse on 12/7/21 at approximately 2:35 p.m. The spouse stated there was concern with the meals the resident receives related to his disease processes of diabetes and heart failure. The spouse stated the resident currently had great [CONDITION(S)] to the legs he should be receiving a low carbohydrate (carb) low salt diet because of his medical conditions. The spouse further stated the resident receives too many carbs and his meals often are the same as the roommate's meal. The stated spouse also stated the lunch meal served that day was Salisbury steak with gravy (there is too much gravy served) rice and corn (too many carbs) and a roll (another high carb food). The spouse stated the resident is served green vegetables (low carbs) about twice weekly. On 12/7/21 at approximately 2:45 p.m., an observation was made of the resident legs; the left was with plus 4 swelling and the right with plus 3 swelling. Both legs appeared tight and were shiny. On 12/8/21 at approximately 2:00 p.m., an interview was conducted with the District Dining Services Manager (DDSM) regarding responsibilities for obtaining resident likes/dislikes, preferences, substitutions, and variation between the regular diet and specialty diet for Resident #123. The DDSM stated it is the Culinary Services Manager's (CSM) responsible to obtain the above information from the resident and/or resident representative with in twenty-four hours of admission but; the resident was missed because of the weekend admission. The DDSM stated the the CSM had received disciplinary action regarding the oversight and an interview had been conducted and the dietary card updated with likes/dislikes and preferences. On 12/14/21 at approximately 5:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on a complaint investigation, staff and complainant interview and facility documentation review, the facility staff failed to promptly notify the physician for 1 of 4 residents (Resident #4) in the survey sample a change of condition, specifically of consistent elevations in blood sugars; as a result Resident #4 was admitted to the ICU (intensive care unit) with a [DIAGNOSES REDACTED]. The findings include: Resident #4 was admitted to the nursing facility on 11/1/19 with [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Resident #4 was not in the facility long enough to have a completed Minimum Data Set (MDS) assessment. The Admission Assessment/Screening dated 11/1/19 indicated the resident was alert and oriented times person, place, time (day, month, year) and situation. The assessment indicated the resident's cognition was intact with no deficits, able to understand others and was understood by them. The 48 hour care plan dated 11/1/19 identified one of the resident's focus areas was diabetes mellitus. The goal set by the staff for the resident was that there would be no complications related to diabetes and some of the interventions the staff would implement to prevent complications included: administer diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. Other interventions were to monitor/document/report PRN (as needed) any signs and symptoms of [MEDICAL CONDITION] (increase blood sugar levels) that may include diminished mental status, abdominal pain and muscle cramps. Resident #4 had the following physician orders [REDACTED]. Accuchecks finger stick blood sugar (FSBS), is one method of blood glucose monitoring before (AC) meals (breakfast, lunch and dinner) and hour of sleep (HS). -Humalog KwikPen solution per-injector 100 unit/ml (milliliter) (Insulin [MEDICATION NAME]) inject subQ the following sliding scale (as a result of FSBS readings obtained AC and HS): 0-60=give 0 (no) units of Humalog insulin and follow [DIAGNOSES REDACTED] orders; 61-149=give 0 units of Humalog insulin; 150-200=give 2 units of Humalog insulin; 201-250=give 4 units of Humalog insulin; 251-300=give 6 units of Humalog insulin; 301-350=give 8 units of Humalog insulin; 351-400=give 10 units of Humalog insulin; 401 and above=give 10 units of Humalog insulin and recheck the blood sugar in one hour. Notify the MD (medical doctor). The following Medication Administration Record [REDACTED] -11/2/19 (Saturday) FSBS AC at 4:00 p.m.=401 with 10 units of Humalog insulin administered subQ. There was no record of a recheck of the resident's blood sugar in one hour nor was it recorded that the MD was called per orders. The Licensed Practical Nurse (LPN) #1, who obtained this FSBS and was assigned to the resident during this time, was not available for interview and no longer employed by the facility. -11/2/19 FSBS HS at 9:00 p.m.=401 with 10 units of Humalog insulin administered subQ. There was no record of a recheck of the resident's blood sugar in one hour nor was it recorded that the MD was called per orders. LPN #1 who obtained this FSBS was the same aforementioned nurse. -11/3/19 FSBS at 6:30 a.m.=460 with 10 units of Humalog insulin administered subQ. The nurse's notes indicated that LPN #2 made a call to the on call service and left a message to inform them of the results of the FSBS. The message log that was presented to the surveyor by the Medical Director on 11/13/19 at 2:15 p.m. indicated the on- call service returned the call at 6:45 a.m., but they were left on hold and spoke to no one, thus this elevated blood sugar was not addressed. -11/3/19 FSBS at 12:00 p.m. (lunch time) was reading *HI as well as the rechecked FSBS at 1:30 p.m. The nurse's notes indicated LPN #2 called the on call, left a message and was awaiting a call back. The message logs presented by the Medical Director did did not evidence any calls to them at that time, and said because they were not made aware there was no opportunity to address them with any further orders. The Medical Director also confirmed that there were no calls made to the on call service on 11/2/19 at 4:00 p.m. or 9:00 p.m. which would have enabled the on call provider to address the elevated blood sugars early on prior to the critical stages of her condition on 11/3/19. *HI FSBS readings via accucheck means the FSBS level was in the Critical Range above 600 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 71/). Lack of prompt notification resulted in Resident #4 being transferred to the local Emergency Department (ED) on 11/3/19 at 3:53 p.m., admitted to ICU with a [DIAGNOSES REDACTED]. The hospital records indicated Resident #4 presented in the local Emergency Department (ED) on 11/3/19 at 4:14 p.m. with high blood sugars with complaints of nausea, vomiting and abdominal pain. The patient reported she was not getting insulin administered when I needed it. The resident's serum (blood) glucose level was 724 (74-106=normal). The urine glucose level was 250 (negative=normal), [MEDICATION NAME] were 40 (negative=normal). The resident was admitted to the hospital and diagnosed with [REDACTED]. The hospital history and physical (H&P) dated 11/3/19 indicated the resident was accompanied by her daughter and she herself called ambulance services to transport her mom to the hospital because she states, I just knew she was in DK[NAME] The daughter reiterated, as evidenced in the H&P that there were issues with the patient receiving her insulin in a timely manner. The hospital H&P indicated the resident had nausea, vomiting, abdominal pain, felt fatigued and lethargic. The H&P also indicated the resident was being admitted to the ICU and treated with a life threatening illness. *DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called [MEDICATION NAME]. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose), a major source of energy for your muscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called [MEDICATION NAME], eventually leading to DKA if untreated. Untreated diabetic ketoacidosis can lead to unconsciousness and death. The warning signs and symptoms (S&S) of DKA can develop quickly, sometimes within 24 hours and include: Excessive thirst Frequent urination *Nausea and vomiting (Resident #4's S&S) *Abdominal pain (Resident #4's S&S) *Weakness or fatigue (Resident #4's S&S) Shortness of breath Fruity-scented breath Confusion *High blood sugar level ([MEDICAL CONDITION]) (Resident #4's S&S) *High [MEDICATION NAME] levels in the urine (Resident #4's S&S) Seek emergency care if: Blood sugar levels are consistently higher than 300 milligrams per deciliter (mg/dL) and you have multiple signs and symptoms of diabetic ketoacidosis. Without enough insulin, your body can't use sugar properly for energy. This prompts the release of hormones that break down fat as fuel, which produces acids known as [MEDICATION NAME]. Excess [MEDICATION NAME] build up in the blood and eventually spill over into the urine. Diabetic ketoacidosis can be triggered by a problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering DK[NAME] The risk of diabetic ketoacidosis is highest with type 1 diabetes. Complications of DKA include abnormal electrolytes that can affect the brain (swelling) heart, muscles and nerves (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc- 551). The facility's policy ad procedures titled Significant Change in Condition dated 2/1/15, indicated assessment of a significant change in condition shall be reported to the primary physician. Potentially life threatening conditions require nursing assessment skills and expertise to determine whether a patient should be transferred to an acute care setting. The decision shall be made by a licensed nurse when the patient's condition is so acute that time does not permit waiting for physician's response. On 11/14/19 at 3:45 p.m., a debriefing was conducted with the Administrator, DON and Corporate Nurse. An opportunity was provided for further questions and/or clarification. No further information was provided prior to survey exit. Complaint Deficiency.

Based on a complaint investigation, staff and complainant interviews and facility documentation interviews, the facility staff failed to effectively monitor and provide treatment for [REDACTED].#4) in the survey sample which resulted in a hospital admission to the intensive care unit (ICU) with blood sugar level of 724 (74-106 mg/dl (milligrams/deciliter)=normal) and [DIAGNOSES REDACTED]. The findings include: Resident #4 was admitted to the nursing facility on 11/1/19 with [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Resident #4 was not in the facility long enough to have a completed Minimum Data Set (MDS) assessment. The Admission Assessment/Screening dated 11/1/19 indicated the resident was alert and oriented times person, place, time (day, month, year) and situation. The assessment indicated the resident's cognition was intact with no deficits and she was able to understand others and was understood by them. The 48 hour care plan dated 11/01/19 identified one of the resident's focus areas was diabetes mellitus. The goal set by the staff for the resident was that there would be no complications related to diabetes and some of the interventions the staff would implement to prevent complications included administered diabetes medication as ordered by the doctor and monitor/document for side effects and effectiveness. Other interventions were to monitor/document/report PRN (as needed) any signs and symptoms of [MEDICAL CONDITION] (increase blood sugar levels) that may include diminished mental status, abdominal pain and muscle cramps. Resident #4 had the following physician orders [REDACTED]. -Accuchecks finger stick blood sugar (FSBS), which is one method of blood glucose monitoring before (AC) meals (breakfast, lunch and dinner) and hour of sleep (HS). -Humalog KwikPen solution per-injector 100 unit/ml (Insulin [MEDICATION NAME]) inject 5 units subcutaneously (subQ) (under the skin-into the fat layer between the skin and the muscle) before meals for DM which was a scheduled standing order. -[MEDICATION NAME] solution pen-injector 100 unit/ml (insulin [MEDICATION NAME]) inject 18 units subQ at bedtime/HS. -Humalog KwikPen solution per-injector 100 unit/ml (Insulin [MEDICATION NAME]) inject subQ the following sliding scale (as a result of FSBS readings obtained AC and HS): 0-60=give 0 (no) units of Humalog insulin and follow [DIAGNOSES REDACTED] orders; 61-149=give 0 units of Humalog insulin; 150-200=give 2 units of Humalog insulin; 201-250=give 4 units of Humalog insulin; 251-300=give 6 units of Humalog insulin; 301-350=give 8 units of Humalog insulin; 351-400=give 10 units of Humalog insulin; 401 and above=give 10 units of Humalog insulin and recheck the blood sugar in one hour. Notify the MD (medical doctor). The following Medication Administration Record [REDACTED] -11/2/19 (Saturday) FSBS AC at 4:00 p.m.=401 with 10 units of Humalog insulin administered subQ. There was no record of a recheck of the resident's blood sugar in one hour nor was it recorded that the MD called per orders. The Licensed Practical Nurse (LPN) #1 who obtained this FSBS and was assigned to the resident during this time, was not available for interview and no longer employed by the facility. -11/2/19 FSBS HS at 9:00 p.m.=401 with 10 units of Humalog insulin administered subQ. There was no record of a recheck of the resident's blood sugar in one hour nor was it recorded that the MD was called per orders. LPN #1 who obtained this FSBS was the same aforementioned nurse. -11/3/19 (Sunday) FSBS AC at 6:30 a.m.=460 with 10 units of Humalog insulin administered based on the sliding scale and the scheduled 5 units of Humalog subQ as evidenced on the MAR. The notes indicated LPN #2 left a message with the on call doctor about the 460 FSBS. The nurse's notes indicated LPN #2 rechecked Resident #4's blood sugar at 7:34 a.m. which was 596 and called the on-call (service) again and left another message. The notes indicated at 8:30 a.m., LPN #2 checked the blood sugar which was now 597 and gave 10 units of Humalog (without a physician's orders [REDACTED]. The notes indicated she received a call back at 9:50 a.m. and spoke to the on call service nurse who had a question and LPN#2 placed the on call nurse on hold and upon retrieval of the call, it was noted the on call nurse had hung up. LPN #2 called the on call nurse back. After conferring with the on call doctor, the on call nurse made a return call to the nursing unit and gave orders to LPN #2 to start sliding scale Humalog AC and HS. There was no notation in the nurse's notes that LPN #2 informed or questioned the on call nurse that the resident was already on AC and HS sliding scale and that this order would not address/treat the escalating blood sugars; nor was there any notation what information was given to the on call nurse by LPN #2. -The nurse's notes indicated the FSBS AC on 11/3/19 at 12:00 p.m. read HI and rechecked to also read HI. This HI reading meant the FSBS level was in the Critical Rangeabove 600 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 71/). LPN #2 noted she gave the scheduled 5 units of Humalog, as well as 10 units of Humalog per the sliding scale of 401 or greater, and placed a call to the on call doctor at 1:30 p.m., awaiting a call back. The nurse's notes indicated at 2:53 p.m., the FSBS still read HI and I just keep calling (the on-call service). The nurse's notes indicated the resident's daughter called and was told by LPN #2 that she was waiting on a call from the physician and that the daughter wanted to send the resident to the hospital. The nurse's notes indicated I called 911 so daughter would not take mother to the hospital in her car. I explained the ambulance can get her there faster. Continued to monitor and resident was in no distress. There were no further nurse's notes regarding EMT arrival and/or departure from the nursing facility. After this surveyor reviewed the nurse's notes and Medication Administration Record [REDACTED]#2 that she was having difficulty with call backs from the on call service about elevated FSBSs, duplicated sliding scale orders for AC and HS, as well as lack of emergent intervention until the resident's daughter called to request the resident be sent out for evaluation. The ADON stated she was not sure why LPN #2 did not call her Unit Manager, herself, or the DON based on the resident's elevated FSBSs and her indication that she was having problems with call backs from the on call service. The ADON stated that LPN#1 and LPN #2 were new hires but were not new nurses with many years of nursing experience. On 11/12/19 at 11:45 a.m., Unit III Manager stated Resident #4 was admitted on [DATE] for therapy. She said when she orients nurses to the unit, she gives them her phone number to call her for any problems, and could not understand why LPN #2 did not call her for help with Resident #4 or to inform her she was having problems with return messages from the on call service. She stated, If (LPN #2's name) was having such difficulty contacting the physician and the sugars were steadily rising, she should have called 911 earlier and catch up with the physician afterwards. She also stated she was not aware of the duplicate sliding scale order for FSBS AC and HS at 9:50 a.m. which would have not done anything to treat the elevated blood sugars. The Unit III manager was not aware that the 11/2/19 6:00 p.m. or 9:00 p.m. FSBS's of 401 were not rechecked after an hour or the physician notified. On 11/12/19 at approximately 5:00 p.m., the aforementioned issues were brought to the attention of the DON and Corporate nurse. They stated during orientation all nursing staff were made aware of the unit manager's phone numbers, as well as the DON, ADON and Administrator's personal cell phone numbers. They agreed that LPN #2 failed to recheck the blood sugars on 11/2/19 and follow orders to notify the physician. They also stated they could not understand the difficulties in contacting the physician on 11/3/19 as indicated in the nurse's notes by LPN #2 because the physician's are usually prompt with return calls. It was also brought to their attention, based on the duplication in orders, Resident #4 was never treated for [REDACTED]. An appointment was set to meet with the Medical Director who was most of the facility resident's attending physician 11/13/19 around 2:00 p.m., who would present the call logs for 11/2-3/19. The Medical Director was interviewed on 11/13/19 at approximately 2:15 p.m. The corporate nurse was present during the interview. The Medical Director stated once a call is made to the on call service, the nurse takes the message and relays it to the physician on call, give the information to her and the on call nurse calls back with a response from the on call physician with any orders. He said all incoming calls are recorded and phone time stamped, the on call LPN puts in the nature of the call and scans it to send through a secure email. He stated for urgent issues, which was Resident #4's situation, the facility calls the on call, the LPN records the nature of the call and tiger text the provider and the provider responds to the LPN via tiger text. He said the LPN uses the company cell phone number to call the facility with a turn around time of one hour. The Medical Director stated for life threatening emergency issues, 911 should be called and notification to the on call as time permits. The message logs the Medical Director presented to this surveyor reflected the following: -No incoming calls from LPN #1 on 11/2/19 at 4:00 p.m. or 9:00 p.m. -On 11/3/19 at 6:45 a.m. noted that a call was made from the on call service to Unit III as a result of an incoming call at 6:30 am, but they were left on hold, spoke to no one -On 11/3/19 at 7:25 a.m., a call from LPN #2 on Unit III indicated Resident #4's FSBS was 593, the resident was asymptomatic and that she gave 10 units of Humalog insulin. LPN #2 indicated she would recheck the blood sugar and call back in one hour. -On 11/3/19 at 8:35 a.m., a call from LPN #2 indicated FSBS was 597. The log indicated LPN #2 relayed to the on call nurse that the resident gets 5 units of Humalog insulin Q (every) 6 am and Q HS, sliding scale only Q HS and [MEDICATION NAME] 18 units Q HS. This message to be forwarded to the provider. -The log also indicated a call had been made to Unit III on 11/3/19 at 9:45 am and they were placed on hold and spoke to no one. -On 11/3/19 at 10:00 a.m., the on call nurse speaks to LPN #2 to inform her the message was relayed to the provider and she would receive a call in a few minutes. -On 11/3/19 at 10:08 a.m., a call to Unit III resulted in no answer with no one picking up. -On 11/3/19 at 10:16 a.m., a call to Unit III resulted in orders given to LPN #2 to change sliding scale to AC and HS. -There was no call registered to the (on call) service nurse on 11/3/19 at 1:30 p.m. by LPN #2 as she indicated in her nurse's notes that she made at that time. -On 11/3/19 at 3:06 p.m., the log indicated LPN #2 called the (on call) nurse that the blood sugars were reading HI and the (on call) nurse text the provider this information on 11/3/19 at 3:15 p.m. On 11/3/19 at 3:29 p.m., the provider ask the (on call) nurse if the resident was symptomatic and were vital signs okay? There is not indication that the provider got the information if the resident was stable. On 11/3/19 at 3:38 p.m., the (on call) nurse responds that Family just took her to the ER. The Medical Director presented to this surveyor a copy of the text on 11/13/19 at 10:16 a.m. that the provider received- BS=597 got Humalog 5 units every 6 am and HS, sliding scale only for every HS, [MEDICATION NAME] 18 units every HS. Orders given to LPN #2 were to Change sliding scale to AC and HS. The Medical Director stated, Either the information about the resident's current insulin orders were read incorrectly to the on call nurse, or the on call nurse interpreted them incorrectly. Bottom line, the resident was already on sliding scale AC and HS, so the resident did not receive orders that would have helped bring her blood sugar levels down. The Medical Director also said if the LPN thought the response times were too slow she could have escalated to a higher level by calling the DON or Administrator. The Corporate Nurse stated, When the sugars kept going up, I wonder why she did not access the RN nurses in the facility and if she thought she was not getting through to the on call service, she could have called the DON, ADON, Unit Manager or Administrator. During the above interview, the Medical Director stated five years ago, based on hurricane preparations, he devised an On Call Protocol that worked so well, he requested they be posted at every nurse's station, visible to all nurses. The protocol addressed instructions for non-urgent issues, life threatening emergency issues and urgent issues. He stated Resident #4 would have fallen in the category for urgent issues with the following instructions: -Call (phone number to the on call service) and choose the correct prompt for your facility and you will be connected directly to our on-call LPN's cell phones (we have eliminated our previous answering service to reduce delays). -You may reach his/her voicemail if she is on the phone with another facility. Please leave a detailed message including your name, facility, unit/call back number, reason for your call and we will return your call promptly. -Our on call provider should return your call approximately within 1 hour. Please call our on-call LPN again if you don't receive a call back from our provider within 1 hour. -Please contact our on-call supervisor at (phone number) if you don't receive a call within 15-20 minutes of your second attempt. -Please notify your DON/Administrator to contact the facility's medical director if our on-call supervisor can't be reached to address your concerns. On 11/13/19 at 3:27 p.m., an interview was conducted with LPN#2. She stated she tried to call the physician's on call service after the 6:30 a.m. FSBS of 460, after the 7:34 a.m. rechecked FSBS of 596 and did not receive a call back until 9:50 a.m. at which time the on call nurse asked her to check to see how much insulin the resident was on, and when she came back to the phone, the on call nurse had hung up on her. She stated when she called the on call nurse back, the nurse told her she had to relay the information to the physician and she would return the call to her. LPN #2 stated the on call nurse relayed the order from the physician to start sliding scale Humalog AC and HS. When asked by this surveyor if she questioned the order in that the resident was already on Humalog AC and HS, she stated,Oh, is there something wrong with the order? I don't see what is wrong with the order. LPN#2 did not recognize, until brought to her attention by the surveyor, that she had not obtained any further insulin orders that would have a positive effect at lowering the resident's blood sugars. The LPN further stated the FSBS read HI at 12:00 p.m. and she placed a call to the on call doctor at 1:30 p.m., with no return call from the on call service, and at 2:53 p.m. when the FSBS read HI again. She stated that she was continuously calling the on call service and they were not calling her back. She said, The daughter called and said the resident called her to tell her she felt sick. I told her I was waiting for the on call to call me back, but she said she wanted (Resident #4's name) to go to the hospital, so I called 911 so the daughter would not take her in her car. During the aforementioned interview with LPN #2, she was asked by this surveyor if she was having such great difficulty contacting the physician and/or needed further guidance, could she have called her nurse manager, the Registered Nurse (RN) supervisor who was in the building at the time, the Director of Nursing (DON), the ADON or the Administrator. The LPN responded she did not get the Unit III Manager's phone number until later, after the issues with Resident #4. She stated she could not disturb the RN supervisor because she was on another unit and she currently did not know the phone numbers of the DON, ADON or the Administrator and she did not currently know where to find them. Random checks for the On Call Protocol was conducted on each of the four units: -On 11/14/19 at 10:50 a.m., Unit I did not have the On Call Protocol posted at the nurse's station, but LPN #3 stated she had the protocol memorized and was able to verbalized the protocol. She also stated she has not had a problem contacting the on call even on the weekends. She stated she could not speak for a newly hired employee although she felt during orientation, they should be made aware. She stated if she had any concerns regarding the resident's declining health, she would call the unit manager or DON and if the situation became dire, she would not delay, but call 911 and contact the physician later. -On 11/14/19 at 11:00 a.m., Unit II did not have the On Call Protocol visible at the nurse's station. LPN #4 said, I have seen it before, but I don't know where I saw it. Maybe it is in the Big Blue Book. After a 20 minute search, LPN #4 found the protocol taped behind other documents. She said if she assessed the resident to be in trouble, even without a call back from the physician, she would definitely consult with another nurse, possibly call the DON and 911. -On 11/14/19 at 11:15 a.m., Unit III LPN #5 stated she worked for the facility for [AGE] years and it was usually the same physician and the number was posted at the nurse's station, but she said never saw a document titled On Call Protocol. She stated, It may be in the little black book, but it was not found. She said she could call the nursing supervisor, ADON or DON if she was unsure of what she should do in case a resident was becoming gravely ill and check with the doctor later. -On 11/14/19 at 11:30 a.m., the On Call Protocol was clearly visible in a sheet protector posted at the nurse's station near the telephone. A Unit IV LPN (#6) stated, If the physician or Nurse Practitioner (NP) is not in the building, I would call the on call service, leave a message for a return call, check with the nurse supervisor, and if the situation worsens, I would call 911. The Administrator, DON, ADON and all Unit Manager's personal cell phone numbers were posted on the inside door cabinet or in the nursing office area on all four units. On 11/14/19, at 1:55 p.m., neither LPN #1 or LPN #2's (both hired 9/9/19) orientation Skills Competency Validation Record could be located. LPN #1 had a Medication Pass Observation check sheet document, but LPN #2's could not be located. The DON and Corporate Nurse said all of the aforementioned orientation Skills Competency Validation Record and Medication Pass Observation must be filled out before completing orientation. They stated the medication pass observation check off document was also completed on an annual basis. The New Hire Orientation Agenda for the Nursing Department was reviewed that indicated on day 1 nurse's were introduced to their departments. The DON and Corporate Nurse stated that new hires are with a mentor for 5 days to check off all skill competency areas and could be extended if necessary. They stated they were sure the nurse's were oriented during this time on the On Call Protocol and where to find all the administrative cell phone numbers. The hospital records indicated Resident #4 presented in the local Emergency Department (ED) on 11/3/19 at 4:14 p.m. with high blood sugars with complaints of nausea, vomiting and abdominal pain. The patient reported she was not getting insulin administered when I needed it. The resident's serum (blood) glucose level was 724 (74-106=normal). The urine glucose level was 250 (elevated), [MEDICATION NAME] were 40 (abnormal). The resident was admitted to the hospital and diagnosed with [REDACTED]. The hospital history and physical (H&P) dated 11/3/19 indicated the resident was accompanied by her daughter and she herself called ambulance services to transport her mom to the hospital because she states, I just knew she was in DK[NAME] The daughter reiterated, as evidenced in the H&P that there were issues with the patient receiving her insulin in a timely manner. The hospital H&P indicated the resident had nausea, vomiting, abdominal pain, felt fatigued and lethargic. The H&P also indicated the resident was being admitted to the ICU and treated with a life threatening illness. On 11/14/19 at 2:21 p.m., a telephone interview was conducted with the complainant. She stated the resident called her sister who lived in the same city as the nursing facility and stated to her, Please come get me, I am sick and I have been nauseous and throwing up all day. I fell like I am dying. The complainant stated the resident knew when her blood sugars were high and felt she wasn't being administered her insulin correctly. She stated her sister jumped in the car and on the way she called 911, gave them the necessary information, and was assured by them it was an emergent situation and would immediately dispatch the EMTs to the facility. She stated her sister was in the building as the EMTs arrived and she packed up the resident's belongings and accompanied the resident to the ED. When asked if her sister wanted to transport the resident in her car and was told by LPN #2 that she should not because the ambulance can get her there faster, the complainant responded that it was never her sister's intention to take the resident to the hospital in the car; that was why she called 911. During the above interview with the complainant she stated she spoke with the Unit III Manager to complain about the nurse's failure to adequately treat the high blood sugars and that the family was not informed. She stated the Unit III Manager told her she would pass her concerns on to the DON. The complainant stated the DON called her and stated the facility followed protocol and that the nurse called the physician and was waiting for the physician to call back. She stated the DON stated, We did everything right. The complainant stated the Administrator called and stated he looked over everything and felt it was the hospital's fault that they released the resident from the hospital too soon due to her sugars being out of control. The complainant stated she knew for a fact that the resident's blood sugars were manageable when she was discharged from the hospital on [DATE] and that she would always require insulin to treat her type 1 diabetes for the rest of her life. She stated, I felt pushed aside by the Administrator. On 11/14/19 a previous interview was conducted with the Admissions Director at approximately 1:15 p.m. She stated the process to assure the facility can accept and care for a potential admission included completion and review of the Center Admission Alert paperwork. Review of this paperwork indicated the resident was being admitted for skilled services that would include occupational and physical therapy. The Admission's Director stated, Her medicals were reviewed and she was deemed appropriate for skilled services by our facility on 11/1/19. The Department of Police records indicated two 911 calls were made on 11/3/19. The first 911 call was made by the resident's daughter asking that they send the resident out due to blood sugars reading high and the second 911 call was made by the nursing facility. An interview with the Central Records Department indicated, which was corroborated through review of the Service Detail Report, that information about the two calls were merged due to it was going to the same location. On 11/14/19 at 3:45 p.m., a debriefing was conducted with the Administrator, DON and the Corporate Nurse. The Administrator stated although the orientation checklists could not be located for both LPN #1 and #2, he was sure they received proper orientation. An opportunity was provided for further questions and/or clarification. No further information was provided prior to survey exit. *DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called [MEDICATION NAME]. The condition develops when your body can't produce enough insulin. Insulin normally plays a key role in helping sugar (glucose), a major source of energy for your muscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called [MEDICATION NAME], eventually leading to DKA if untreated. Untreated diabetic ketoacidosis can lead to unconsciousness and death. The warning signs and symptoms (S&S) of DKA can develop quickly, sometimes within 24 hours and include: Excessive thirst Frequent urination *Nausea and vomiting (Resident #4's S&S) *Abdominal pain (Resident #4's S&S) *Weakness or fatigue (Resident #4's S&S) Shortness of breath Fruity-scented breath Confusion *High blood sugar level ([MEDICAL CONDITION]) (Resident #4's S&S) *High [MEDICATION NAME] levels in the urine (Resident #4's S&S) Seek emergency care if: Blood sugar levels are consistently higher than 300 milligrams per deciliter (mg/dL) and you have multiple signs and symptoms of diabetic ketoacidosis. Without enough insulin, your body can't use sugar properly for energy. This prompts the release of hormones that break down fat as fuel, which produces acids known as [MEDICATION NAME]. Excess [MEDICATION NAME] build up in the blood and eventually spill over into the urine. Diabetic ketoacidosis can be triggered by a problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering DK[NAME] The risk of diabetic ketoacidosis is highest with type 1 diabetes. Complications of DKA include abnormal electrolytes that can affect the brain (swelling) heart, muscles and nerves (https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc- 551). Complaint Deficiency.

Based on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure 2 residents (Residents #99 & Resident #122) of 63 residents in the survey sample received care, consistent with professional standards of practice, to identify a pressure ulcer prior to an advanced stage constituting harm for Resident #99; and inaccurately assessed and documented a pressure ulcer to the shin for Resident #122. 1. The facility staff failed to identify Resident #99's left heel pressure ulcer prior to it being found at an advanced stage resulting in harm. The pressure ulcer was first identified found as an unstageable with 100% eschar (hard black dead tissue). 2. For Resident #122, the facility staff failed to accurately assess and document an area of [MEDICAL CONDITION] at a surgical incision wound on the right shin. The facility staff inaccurately assessed and documented the area as a stage 3 pressure ulcer. The findings included: 1. Resident #99 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Type II Diabetes and *[MEDICAL CONDITION] Resident #99's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/24/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #99 total dependent of one with toilet use, dressing, personal hygiene and transfer, extensive assistance of two with bed mobility and extensive assistance of one with bathing. Under section M Under section (M0150) at risk for developing pressure ulcers was coded yes. Under section (M1200) for skin and treatments was coded for having pressure reducing device for bed. Resident #99's person-centered comprehensive care plan revised on 06/06/19 documented Resident #99 with pressure ulcer and at risk for further skin impairment due to decreased mobility and incontinence. The goal: will have not further skin impairment through the next review. Some of the intervention/approaches to manage the goal included to provide *keep skin clean and dry, moisture barrier cream as needed for protection of skin, pressure reduction mattress and pressure reduction surface to wheelchair. A Braden Risk Assessment Report was completed on 03/29/19; resident scored a 16 indicating at risk for the development of pressure ulcers. Mobility is very limited; makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Review of Resident #99's Medication Administration Record [REDACTED]. Cleanse with dermal wound cleanser, apply Santyl, cover with dry dressing. On 06/05/19 at approximately 10:35 a.m., a wound care observation was conducted with License Practical Nurse (LPN) #13. Resident #99 was lying in bed, positioned in a supine position (on her back). Prior to starting wound care, LPN #13 washed her hands and donned a pair of gloves. The LPN removed the old dressing from the left heel wound, removed her gloves, used hand sanitizer, and then applied a new pair of gloves. The left heel wound dressing observed with small amount of yellow drainage with no odor. The left heel wound bed observed with yellow slough; no odor present. The wound was cleansed with wound cleanser in a circular motion x 2; gloves removed, hand sanitizer applied, a new pair of gloves applied, Santyl ointment applied to wound bed with a q-tip, covered with 2 x 2 gauze, covered with coversite, gloves removed, hands washed x 32 seconds. Weekly skin and wound-Total Body Skin Assessment was completed on on 05/30/19 by LPN #12. Under the section for number of new wounds was coded for no new wounds. Review of Resident #99's the clinical record written by LPN #5 revealed the following: - 05/31/19 Resident seen by the Podiatrist with LPN #5; Deep Tissue Injury (DTI), to left heel, cleanse with DWC, apply Santyl, cover with dry dressing. -Clinical note dated 6/3/19 included the following: Left heel wound originally found by podiatry and charge nurse on 05/31/19. Left heel originally a DTI but debrided that day on 05/31/19. Orders received on 05/31/19 for Santyl treatment. Wound assessed by unit manager. Wound bed with minimal slough, and predominant granulated tissue, EP and moist. Wound measurement at time of assessment 3.0 cm x 2.0 cm x 0.1 cm, with moderate drainage noted. The clinical note was written by the RN-Clinical Manager on Unit 3. An interview was conducted with the RN-Clinical Manager on Unit 3 on 06/10/19 at approximately 2:09 p.m., who stated, I did not see Resident #99's pressure ulcer to his heel on 05/31/19. The area was found by the podiatrist and LPN #5; you will need to speak with LPN #5 for further details. She stated, I only documented what was told to me by LPN #5. The review of progress note written by the podiatrist on 05/31/19 at 1:06 p.m., revealed the following information: -Black eschar has formed to the left heel (3 cm x 3 cm (centimeter) and necrotic). -Plan: Debride ulcer to left heel with number 10 blade, apply santyl-treated with santyl and dry dressing applied. Skin & Wound Evaluation completed on 06/05/19 included the following: -Type (Pressure) -Stage (Unstageable: Obsured (sic) full-thickness skin and tissue loss). -Due to (Slough and/or eschar) -Location (Left Heel) -Acquired (In-House Acquired) -How long has the wound been present (05/31/19) -Wound Measurements (0.9 cm x 0.8 cm) -Wound bed (Slough) -% Slough (90% of wound filled) An interview was conducted with LPN #5 on 06/10/19 at approximately 2:42 p.m., who assisted the podiatrist with Resident #99 on 05/31/19. The LPN stated, I was holding Resident #99's foot for the podiatrist when I felt something hard to his left heel. She said the podiatrist looked at the area to his heel. The surveyor asked, When did you first realize that Resident #99 had an unstageable wound to his left heel she replied, I did not know Resident #99 had an area to his left heel until I found it on that day (05-31-19) while assisting the podiatrist. A phone interview was conducted with the *podiatrist on 06/07/19 at approximately at 3:45 p.m. The surveyor asked, On 05/31/19, an area was noted on Resident #99's left heel; can you tell me what you observed? The podiatrist said he was doing a follow up assessment on Resident #99 current wounds (arterial) to his left foot with LPN #5 assisting. He said the nurse was holding the resident's left foot in her hand when she asked me to look because she felt something hard on his heel. The podiatry stated, I observed a hard black pressure ulcer to the heel. The surveyor asked, What stage was the pressure ulcer he replied, The pressure ulcer was an unstageable wound because it was covered with hard black eschar that required debridement. He stated, The wound was debrided, the hard covering was removed with a scalpel blade and after the debridement was done, there was still some eschar present. The podiatrist said he started Santyl ointment to continue with the chemical treatment of [REDACTED]. A phone interview was conducted with LPN #12 on 06/10/19 at approximately 5:10 p.m The LPN completed the weekly skin and wound assessment on 05/30/19 that read no new wounds. The LPN stated, I did the resident's skin assessment that day and I did not notice any new areas. The surveyor asked, How long does it take for eschar to develop she replied, It takes a while but it was not there on 05/30/19; that's all I can tell you. An interview was conducted with the Director of Nursing (DON) and Cooperate Nurse on 06/10/19 at approximately 5:35 p.m. The surveyor asked, At what stage do you expect for your nurses to first identify a pressure ulcer she replied, When the skin is red and blanchable but at least by a stage I. A pre-exit meeting was held with the Administrator, Director of Nursing and Cooperate Nurse on 06/10/19 at approximately 8:25 p.m. The facility did not present any further information about the findings at the time of exit. A pressure ulcer prevention policy was requested from the DON and Cooperate Nurse on 06/10/19 at approximately 11:12 a.m. The Cooperate Nurse said the facility does not have a policy on pressure ulcer prevention but did provide a policy on General Wound care/Dressing Changes. The policy was reviewed but did not contain any information on preventing pressure ulcers. Definitions: -Podiatrist is a health professional who [DIAGNOSES REDACTED]. *Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/ 5.htm). *Heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes blood and fluid to back up into the lungs, the buildup of fluid in the feet, ankles and legs - called [MEDICAL CONDITION] (mayoclinic.org). *A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Santyl is used to help the healing [MEDICAL CONDITION] ulcers. [MEDICATION NAME] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts. *Pressure Injury-Deep Tissue (Persistent non-blanchable deep red, maroon or purple discoloration) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). 2. Resident #122 was admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #122's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/03/2019 coded Resident #122 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #122 as requiring limited assistance of 1 for bed mobility, toilet use and personal hygiene, extensive assistance of 1 for transfer and dressing, physical help of 1 in part of bathing activity and independent with set up help only for eating. On 06/05/2019 at approximately 12:00 p.m., review of Resident #122's clinical record revealed the following: Discharge Summary from the hospital revealed Discharge [DIAGNOSES REDACTED]. Skin and Wound Evaluation for Resident #122 dated 04/05/2019 revealed that the resident had a Surgical Incision on the Right Shin closed with Steri-Strips, present on admission. Wound Measurements: Area: 4.9 cm2., Length: 20.8 cm., Width: 0.4 cm. The Braden Scale For Predicting Pressure Sore Risk dated 04/05/2019 revealed a score of 15. Physician order [REDACTED]. Cleanse area with NACL (Sodium Chloride) apply Xeroform and dry dressing. Review of the Nurse Practitioner Progress Note dated 04/30/2019 revealed a note under the History of Present Illness with a date of 04/17/2019, it was documented in part, as follows: Nursing also states that he is having some redness to his incision area. This writer observed his incision where it is very slightly [DIAGNOSES REDACTED]tous but with out any signs and symptoms of infection. Review of the Nurse Practitioner Progress note dated 05/01/2019 revealed the following, it was documented in part, as follows: [AGE] year old white male who is a skilled resident of the facility for right tibial and fibular fracture was reporting pain to therapist for approximately 2 days. Therapist uncover his boot to find out patient had increased [DIAGNOSES REDACTED] to right lower extremity linear open wounds directly from stabilization boot. Patient stabilization boot will be discontinuing, Ortho will be contacted. Patient reports increased pain. Again he is noted with [DIAGNOSES REDACTED] and sloughing to the area where he will be started on Santyl and Keflex. Skin and Wound Evaluation for Resident #122 dated 05/01/2019 revealed information identifying a new Pressure Ulcer-Medical Device Related Pressure Ulcer, *Stage 3: Full-thickness skin loss located on the Right Shin with 100% slough in wound bed It was documented that the Pressure Ulcer was acquired in - house. The question on the form asked, How long has the wound been present? It was answered, New. Wound Measurements were documented as follows: Area: 4.2 cm2., Length: 3.1 cm., Width: 1.9 cm. Wound Pain was documented in part, as follows, Pain Frequency: Intermittent. Medication Administration Record [REDACTED]. Treatment Administration Record revealed that Xeroform Petrolat Patch had a D/C (Discontinue) date of 05/01/2019. Treatment Administration Record revealed an order dated 05/02/2019 and is documented in part, as follows: Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to Right shin topically every evening for wound healing. Clean right shin wound with NS. Apply Santyl and dressing daily. D/C Date 05/07/2019. Review of Nurse Practitioner Progress Note dated 05/07/2019 revealed the following, and is documented in part, as follows, Orthopedic office states that it is okay to keep the boot off at this time. In reassessment of patient's wounds, [DIAGNOSES REDACTED] has lessened and his wounds are not draining but scabbed over. At this time Santyl will be discontinued. Patient did complete Keflex on today. Patient will start [MEDICATION NAME] to linear leg wound. Treatment Administration Record revealed an order dated 05/07/2019 and is documented in part, as follows, [MEDICATION NAME] Zinc Ointment 500 Unit/GM Apply to right leg topically every evening shift for leg wound for 10 days clean with DWC (Dakins Wound Cleanser) and apply [MEDICATION NAME] to right leg wound, kerlix and the ace wrap. Last date treatment documented on kardex dated 05/17/2019. Skin and Wound Evaluation dated 05/08/2019 revealed Pressure Ulcer, Stage 3 on Right Shin had improved. It is documented, Wound Bed - [MEDICATION NAME] - 100% of wound covered, surface intact. Wound Measurements: Area: 1.0 cm2., Length: 1.8 cm., Width: 0.8 cm. Skin and Wound Evaluation dated 05/14/2019 revealed Pressure Ulcer, Stage 3 on Right Shin had improved. It is documented, Wound Bed - [MEDICATION NAME] - 100% of wound covered, surface intact. Wound Measurements: Area: 0.5 cm2., Length: 1.2 cm., Width: 0.6 cm. Review of Care Plan focus created on 05/17/2019 revealed and is documented in part, as follows: The resident has pressure ulcer (R Shin) R/T (Related To) use of fracture boot. Review of Nurse Progress Note dated 05/21/2019 revealed and is documented in part, as follows: Surgical and mechanical device related pressure wound to right shin healed over at time of wound assessment. Tx (Treatment) ordered discontinued. On 06/07/2019 at approximately 9:15 a.m., the unit nurse was asked to show Resident #122's right shin to the surveyor. The surveyor observed a dry, scabbed linear area on the right shin that was the incision site. The nurse pointed to a tan circular area next to the incision site where the pressure ulcer had been before it healed. The Surveyor observed a boot with velcro straps in the residents room. On 06/07/2019 at 9:45 a.m., an interview was conducted with Registered Nurse (RN) #2 Unit Manager concerning the Pressure Ulcer identified on Resident #122's right shin and she was asked, Has Resident #122 had the same boot since admission? RN #2 stated, Yes. RN #2 was asked, Could the boot be removed? RN #2 stated, Yes. RN #2 was asked, When did the staff remove the boot? RN #2 stated, Resident #122 has a surgical incision on the right leg. The staff removed the boot daily, it was taken off for his treatment on 3-11 shift and he did not sleep in it at night. RN #2 was asked, What can you tell me about the Stage 3 pressure ulcer on the right shin? Did he have 1 or 2 areas on the right shin? RN #2 stated, He had 2 areas. He had a incision site and a pressure ulcer from the boot. The boot rubbed a superficial area with slough on his leg. The Nurse Practitioner saw the wound and ordered antibiotics to include Keflex and Santyl and within a week it was healed. RN #2 was asked, Why wasn't the wound identified before it became a Stage 3? RN #2 stated, The nurse may have not cleansed the wound before staging the area. On 06/07/2019 at 11:20 a.m., an interview was conducted with the Nurse Practitioner and she was asked, What can you tell me about the wound on Resident #122's right shin? The Nurse Practitioner stated, Next to the incision line the skin was red, warm to touch. The incision line had scabbed and in the breaks of the incision line it was draining yellow slough. I ordered Santyl and Keflex, monitored a couple times, asked therapy about the boot not being worn for a bit because they thought the wound was from the boot. I diagnosed it as [MEDICAL CONDITION]. On 06/10/2019 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) and the Nurse Consultant. The DON was asked, What caused the wound next to the incision line? The DON stated, Thinking it was [MEDICAL CONDITION], coming from infection. I don't think the nurse assessed it correctly. The DON was asked. Are your nurses trained to assess? The DON stated, Yes. The DON was asked, Do your nurses know how to assess wounds? The DON stated, Yes. The Surveyor stated, The wound was assessed at a Stage 3 when it was identified. The DON was asked, Who assessed the wound? The DON stated, The nurse. The DON was asked, At what stage would you expect the nurses to identify a wound? The DON stated, At a Stage 1. The DON was asked, Do you think the boot caused the wound? The DON stated,Not sure, some of the staff thought so, not sure. Staff documented that the boot caused the wound. On 06/10/2019 at approximately 8:30 p.m. at pre-exit meeting the Administrator, Director of Nursing and Nurse Consultant was informed of the findings. The facility did not present any further information about the finding. *Guidance from www.npuap.org The National Pressure Ulcer Advisory Panel (NPUAP) includes: Stage 3 Pressure Injury (ulcer): Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury

Based on staff interviews, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure 1 of 2 residents in the survey sample, Resident #1, received proper care and treatment during an acute change of condition resulting in hospitalization and subsequent [MEDICAL CONDITION]. The facility staff failed to immediately respond to provide emergency care for Resident #1 who was having difficulty breathing and failed to properly assess for placement and patency of the [MEDICAL CONDITION] (1) airway that resulted in acute [MEDICAL CONDITION] (2) and subsequent hospitalization due to [MEDICAL CONDITION] (3) [MEDICAL CONDITION]. The findings Included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 had a size 6 (brand name) [MEDICAL CONDITION] inserted at the hospital on [DATE]. The initial Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 with a score of 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's mental status and daily decision making skills were intact. Resident #1 was coded for [MEDICAL CONDITION] care, oxygen therapy, and suctioning. Resident #1's Care Plan with a revision date of [DATE] read, in part, as follows: Focus: The resident has a [MEDICAL CONDITION] r/t (related to) stenosis of larynx. One of the goals listed was: The resident will have clear and equal breath sounds bilaterally through the review date. Interventions were listed as: 1. Ensure [MEDICAL CONDITION] ties are secured at all times. 2. Monitor/document respiratory rate, depth, and quality as needed. Keep ambu bag (6) at bedside in case of emergencies. 3. Oxygen [MEDICAL CONDITION] as ordered. 4. Suction as necessary. The physician orders [REDACTED]. Keep ambu bag @ (at) bedside every shift for [MEDICAL CONDITION]. 2. [MEDICAL CONDITION] catheter (7) prn (as needed). Dispose of catheter with each use, as needed for thick secretions. 3.[MEDICAL CONDITION] Q (every) shift. On [DATE] at 00:06 (12:06 am), LPN #1 (Licensed Practical Nurse) documented in the Nurses Progress Notes for Resident #1 as follows: CNA answered residents light around 452 (4:52 pm) resident stated that she was having a hard time breathing got into room at 455 (4:55 pm) resident was unresponsive and started to turn purple called for code and CPR (8) was started resident started turning blue after first cycle that started to resolve and color came back EMS (Emergency Medical Services) came at 500 (5:00 pm) and resident had a pulse in the low 40's (40 beats per minute) rescue breathing continued EMS took over and resident started breathing on her own resident taken to the ER (emergency room ) and family called with no answer resident family made aware when they came to visit resident. admitted for acute resp. (respiratory) failure. The EMS (City Fire Department) record for Resident #1 dated [DATE] included the following documentation: At scene - [DATE] 17:00:18 (5:00 pm) At patient - [DATE] 17:02:00 (5:02 pm) Depart - [DATE] 17:20:01 (5:20 pm) Chief Complaint: [MEDICAL CONDITION] x 10 minutes Primary Impression: Respiratory Arrest Primary Symptom: unresponsive, unconscious Dispatched to 73 y.o. (year-old) female [MEDICAL CONDITION] with CPR in progress. Upon arrival, patient is on bed with CPR board underneath her with CPR in progress and being ventilated with BVM (bag valve mask) via her mouth. Staff stated that she had pushed her call bell button and then was found unresponsive. CPR was stopped and pulses were found at femoral (main artery in thigh) and radial (radial artery in forearm) sites ROSC (return of spontaneous circulation) at 17:03 (5:03 pm), patient [MEDICAL CONDITION] found to be dislodged and had a plug which was cleared and put back into place, defibrillation (9) pads were placed. Patient was ventilated with good compliance [MEDICAL CONDITION] . It was unknown if patient ever lost pulses prior to CPR being initiated by staff. Lung sounds with assisted ventilation (10) reveal diminished with a fine wheeze in all fields . Patient was moved to long spinal board and secured with all straps supine (lying on back) to stretcher. Vitals and physical assessment continued during transport with no change in patient condition upon arrival. Patient turned over to ED/RN (Emergency Department/Registered Nurse) Bed #26 (name of hospital). Vitals: Time: Respiration (number of breaths per minute) 17:06:03 (5:06 pm) 9 assisted (with bag mask) 17:08:01 (5:08 pm) 11 (not assisted, breathing on her own) On [DATE] at 9:18 am, a phone interview was conducted with Paramedic #1 who responded to the code for Resident #1 on [DATE] and completed the EMS (City Fire Department) report. When asked for clarification regarding the placement of the mask on Resident #1, he stated that when they arrived, CPR was in progress, BVM was on her mouth. They took over and when they cut Resident #1's shirt, they found the [MEDICAL CONDITION] on her chest area. It was plugged with mucus, removed the plug and reinserted. Clarified the statement on the report that stated, It was unknown if patient ever lost pulses prior to CPR being initiated by staff and he stated, If I remember it right, we never defibrillated the patient. He stated that pulses were found in about 1.5 minutes. When asked about the [MEDICAL CONDITION] they found on the resident's chest area, he could not tell if it was the inner cannula that got dislodged. He stated that Paramedic #2, who was taking care of the airway at the time, would be able to clarify this question. On [DATE] at 9:41 am, a phone interview was conducted with Paramedic #2 who had also responded to the code for Resident #1 on [DATE]. He stated that when he arrived at the scene, the mask was on Resident #1's mouth. When asked about the [MEDICAL CONDITION] they found, he stated, It was the whole device (with both the inner and outer cannulas{11}) . I actually saw the stoma (12). The observation and statement by the paramedic of the [MEDICAL CONDITION] cannula being found on the resident's chest wall indicated LPN#1 failed to assess the resident's airway ([MEDICAL CONDITION]) for placement and/or obstruction prior to beginning CPR. The Hospital Medical Record for Resident #1 included the following documentation: A. Emergency Department Clinical Record dated [DATE]: Admit: [DATE] Chief Complaint: [MEDICAL CONDITION] History of Present Illness: The patient is a [AGE] year-old female who resides at (name of nursing facility) reportedly presses the call button at 1653 (4:53 pm). The nursing staff there responded to the patient's complaint. Reportedly, then the patient went into [MEDICAL CONDITION] and the medics were summoned upon the medic arrival the patient was blue, CPR was in progress and she was being bagged by bag mask ventilation to the mouth. Upon removal of the patient's shirt the medic noted that [MEDICAL CONDITION] become displaced and it was on her chest wall. It looked to be plugged. [MEDICAL CONDITION] replaced. The patient was bagged up to O2 sats (13) of 100% and transferred here. The patient has been unresponsive since prior to arrival. No significant further history can be obtained because the patient is unresponsive. Past Medical History: Per the patient's chart of subglottic stenosis (14), prior stroke. Resident #1 had a [DIAGNOSES REDACTED]. Using the bag valve mask over the mouth will not be as effective in allowing air pass through the airway compared to attaching it directly to the [MEDICAL CONDITION] which is located below the narrow airway. Diagnoses: [REDACTED]. Acute [MEDICAL CONDITION] 2. Possible [MEDICAL CONDITIONS]. The patient was admitted to the ICU (Intensive Care Unit) in serious condition. B. Procedure Notes signed on [DATE] The EEG (15) is performed on a [AGE] year-old female in the intensive care unit for evaluation of hypoxic [MEDICAL CONDITION] (16) with myoclonic jerks(17) . Impression: This is an abnormal EEG . The abnormal findings are consistent with hypoxic [MEDICAL CONDITION]. C. Palliative Progress Notes dated [DATE]: Acute [MEDICAL CONDITION] in [MEDICAL CONDITION] (patient) with removal of vent support ,[DATE]. Tolerating supplemental O2 (oxygen) with good sats. [MEDICAL CONDITIONS] ,[DATE] above. D. Discharge Summary dated [DATE]: admitted : [DATE] discharge date : [DATE] Initial Presentation - Chief Complaint: The patient is a [AGE] year-old female with history of obstructive sleep apnea, [MEDICAL CONDITION], diabetes, hypertension, [MEDICAL CONDITION], and subglottic stenosis. She was at (name of nursing facility) where it looks like she was being taken care of and her [MEDICAL CONDITION] got displaced. Medics were called who replaced the [MEDICAL CONDITION]. She apparently could not breathe. She was also bagged for a little while and chest compressions were started by the staff in (name of nursing facility). After the EMT (Emergency Medical Technician) came, they put the [MEDICAL CONDITION] back and bagged her and got her sats back to 100%. She initially underwent [MEDICAL CONDITION] for [MEDICAL CONDITION] following a left cerebellar (18) stroke in ,[DATE]. She had admission at (name of hospital) in ,[DATE] where ENT (Eye, Nose and Throat) records state that she was noted to have obstructive tracheal granulation and her [MEDICAL CONDITION] was replaced. She was later in the heart unit until June and underwent dilatation of the subglottic and tracheal stenosis. She had another admission in (name of hospital) in June and had repeat [MEDICAL CONDITION] done by ENT. Discharge Diagnoses: [REDACTED]. Suspect [MEDICAL CONDITION] metabolic [MEDICAL CONDITION](19)/Coma with myoclonic activity at admission. On [DATE] at 3:50 pm, an interview was conducted with CNA#1 who was asked to describe the incident that happened on [DATE] when Resident #1 was having difficulty breathing. She stated that she saw Resident #1's call bell on and she responded. The resident was complaining of having complications of breathing, saying with her lips that she was having a hard time breathing and notified LPN#1. When asked where LPN #1 was, she replied, I don't remember where my nurse was. CNA#1 was asked a few more questions and was not able to provide additional information. She repeatedly stated, I don't remember. On [DATE] at 4:30 pm, an interview was conducted with the Staff Development Coordinator and when asked what type of training had been provided for staff on care of residents with [MEDICAL CONDITION], she stated, We have [MEDICAL CONDITION] and suctioning [MEDICAL CONDITION] care in the past but not this year that I know of. When asked how she would respond if a resident with a [MEDICAL CONDITION] has difficulty breathing, she replied, Just take out the inner cannula, there might be a mucus plug. A bag (ambu) is kept in the room, give them extra air. On [DATE] at 3:48 pm, an interview was conducted with LPN#1. The nurse was asked to describe the incident that happened on [DATE] involving Resident #1 and he stated, I was just doing my med pass in a room with another resident. I came out of the room and was coming down the hall when I saw her (Resident #1) light on. I went to her (Resident #1) room. I thought she was asleep, I tapped her to wake her up and she was not responsive. I saw she wasn't moving and noticed her nail beds were blue. I yelled out the door to call a Code Blue, somebody called a code. I went back to the room to start CPR. I saw her face looked pale and I noticed she wasn't breathing. I hooked up the ambu bag to the concentrator (20) and put it on her trach. Other nurses came to the room . I didn't check the pulse, I got one of the other nurses to check pulse. I guess she didn't have a pulse. They started chest compressions. EMS came and they took over. They saw the monitor and stopped chest compressions. LPN #1 was asked to verify if he checked the resident for a pulse prior to initiating CPR, he stated, Not that I can remember. No. When asked if the mask was on the mouth, he stated, There was no way that we could have bagged her without the trach. When she left the building, she still had a trach. LPN #1 was asked what he would do if [MEDICAL CONDITION] dislodged, he replied, We [MEDICAL CONDITION] bedside, a smaller trach. She had one taped on the pole with ambu bag . I never had an experience in putting it back. If he had to do it, he stated, I would put the neck back, not force it in and it should go right in. LPN #1 stated that he did not have training on emergency care of a [MEDICAL CONDITION] patient. The paramedics' report of finding the dislodged cannula under the resident's clothing was shared at this time. LPN#1 stated that the paramedics were wrong, the [MEDICAL CONDITION] was never out, it may be the inner cannula. He stated that Resident#1 had a history of [REDACTED]. The surveyor reviewed with LPN #1 his documentation in the Nurses Progress Notes. These notes were inconsistent with the response during the aforementioned interview. LPN#1 documented on [DATE] at 12:06 am that CNA #1 reported to him at 4:52 pm that Resident #1 was having a hard time breathing; he did not respond until 4:55 pm to check on Resident #1. LPN#1 stated that he did not recall what he was doing prior to being notified by CNA#1. He stated, I must have been doing something when she told me about the resident having difficulty breathing . I completed a task before I responded to the report. When asked what he should have done in this situation, he replied, . I could have responded right away. On [DATE] at 3:35 pm, a phone interview was conducted with LPN #2 and when asked to describe what happened on [DATE] involving Resident #1 she stated, It was called overhead. I walked as fast as I could. I participated in CPR and left when EMS arrived. LPN #2 was asked to provide more detailed information and she stated, I started with chest compressions. LPN #1 was there. He was standing over her bed, trying to put ambu bag on [MEDICAL CONDITION]. I didn't think he started compressions. I went to the other side of the bed, we put a CPR board and started CPR. I did compressions. I did about 3 rounds and got tired and someone took over. I assisted with bagging. When asked where the mask was on Resident #1 during CPR, she replied, I didn't remember. I think the resident'[MEDICAL CONDITION] in place . I think the mouth, whatever was situated with mask. LPN#2 also stated that the resident had a gown on when she was doing chest compressions, partially unsnapped. When asked if she checked for a pulse, she replied, After about 2 minutes, I checked the groin on the left side. She was a large lady, I didn't feel the pulse. LPN #2 was asked if she had training on emergency care for dislodged [MEDICAL CONDITION], she stated that she did not have training but had worked with trachs in the past and able to replace dislodged trachs. On [DATE] at 2:30 pm, an interview was conducted with LPN #3 who was asked to describe the incident that occurred on [DATE] involving Resident #1 and provided the following statement, I went on Unit 1 and the nurse with me was LPN #1. LPN#1 was doing chest compressions. I came in with crash cart. LPN #2 was hooking up oxygen and helped hooked 100% oxygen. I gave her (LPN #2) the ambu bag so she could connect it to the trach. I hooked up the suction machine. She had frothy stuff coming out of her mouth. EMS came, hooked up to cardiac monitor and one of them said she had a pulse. LPN #1 stayed with EMS, the other nurses left the room. LPN #3 was asked where the ambu bag was attached to during CPR, she replied, [MEDICAL CONDITION]. when they have a trach, they breathe through their trach. She stated that the resident looked dusky. She also stated that the resident had her top on during CPR and you could see her sternum. According to LPN #3, she had lots of experience with trachs and was able to reinsert dislodged trachs in the past. On [DATE] at 1:30 pm, an interview was conducted with LPN #4 (Supervisor) and was asked to describe the incident that occurred on [DATE] involving Resident #1. She stated, I think she coded. When Code Blue is called, all licensed nurses respond. Three nurses had already started CPR and the crash cart was in the room. LPN #1 was doing chest compressions, LPN#2 was bagging directly to the trach, and LPN #3 was setting up the suction machine. LPN#4 did the documentation during CPR on a piece of paper towel and gave the information to LPN #1 who was assigned to the resident. LPN #1 did the documentation in the chart. LPN #4 was asked if the [MEDICAL CONDITION] was in place during CPR and she replied, [MEDICAL CONDITION] there . they did not call me about any concerns with dislodged trach. She stated that EMS got there fairly quick and they took over. Paramedics said she (Resident #1) had a pulse once the monitor was hooked up. I can't remember if she had started breathing. LPN #4 was asked what she would expect nurses do if the [MEDICAL CONDITION] gets dislodged and she replied, Every patient usually has an [MEDICAL CONDITION] the bedside and an ambu bag. Protocol is to use a smaller size. If unable get a smaller size, then we will try to get oxygen in them and transfer, send the person out. LPN #4 was asked about her expectations when a nurse receives a report that a [MEDICAL CONDITION] resident is having difficulty breathing and she replied, Lock the cart, go down and check immediately. I mean ABC's (Airway, Breathing, Circulation). On [DATE] at 11:40 am, an interview was conducted with the DON (Director of Nursing) and provided her a summary describing LPN #1's failure to respond immediately to a change in condition that required a nursing assessment and immediate implementation of emergency care. When asked what her expected response of the nurse would have been, she stated, I would have expected him (LPN #1) to respond immediately . push the button to lock the cart . Stop what you're doing and see what's going on . Visually look at her and see if she is not getting air, touch and check if cold and clammy, if in distress, check the trach, suction and take the inner cannula out and clear. If the resident becomes unconscious, start CPR . Let's suction her first . You don't want to waste time . That's basic nursing . The paramedics' report of finding the dislodged cannula under the resident's clothing was shared at this time. The DON was asked if nurses have been trained on emergency care for residents with [MEDICAL CONDITION], she replied, Every nurse we hire, we ask if they have ever [MEDICAL CONDITION]. She stated [MEDICAL CONDITION] procedure and emergency care for [MEDICAL CONDITION] patient were not included in their current skills validation list and will be added. She also mentioned that they will start staff training on the topic today. On [DATE] at 1:30 pm, the DON provided a copy of the action plan for staff training and read as follows: Education on emergency care of a patient with a [MEDICAL CONDITION] and response time for respiratory distress will begin today, [DATE] and will include, but not limited to, the ABC's of emergency care. This will be provided to licensed nurses by the SDC (Staff Development Coordinator) and unit managers. Routine and emergency care education will be provided to newly hired licensed nurses at the time of orientation and to current licensed nurses as needed when newly admitted patients enter the facility. The DON also provided a copy of the plan of action for staff training on emergency equipment for [MEDICAL CONDITION] that will be kept at the bedside at all times. The DON was asked if she understood the concerns identified with the emergency care provided by LPN #1 for Resident #1 during a change in condition, she replied, Yes, I do. She stated, First, delay in response. He (LPN #1) should stop immediately and stop what he was doing. Second, not assessing (the [MEDICAL CONDITION]) for obstruction and emergency care . find out why can't she breathe. She stated, He (LPN#1) got excited and just started CPR. The facility policy and procedure for Cardio-Pulmonary Resuscitation (CPR) provided by the DON on [DATE] read, in part, as follows: Policy: Staff certified in Cardio-Pulmonary Resuscitation (CPR) will initiate CPR as a resuscitation procedure to restore breathing and or heartbeat if any patient is found to be in cardiopulmonary arrest, EXCEPT where the patient's physician has specifically and appropriately documented a DNR (Do Not Resuscitate) order in the patient's permanent medical record. Procedure: . 2. Establish responsiveness . 3. If there is no valid DNR order on the chart . begin the immediate activation of an emergency call to 911. 4. Initiate CPR following certified CPR guidelines 6. A licensed nurse will document in Nurses Notes the condition and circumstances of initiating CPR, the duration and events of the procedure, and outcome of the situation. The facility policy and procedure for [MEDICAL CONDITION] Care provided by the DON on [DATE] did not include a procedure for provision of emergency care when resident has a change of condition related to [MEDICAL CONDITION], i.e., dislodged [MEDICAL CONDITION], difficulty breathing, etc. On [DATE], the DON provided copies of CPR cards of 11 nurses and found that 5 out of 11 nurses had expired CPR cards. Two (2) of the 5 nurses with expired CPR cards were LPN #1, who performed CPR on Resident #1 and LPN #3, who assisted with setting up the suction machine. LPN#1 had completed the CPR/AED for Professional Rescuers and Health Care Providers conducted by American Red Cross on [DATE]. This is valid for 2 years. LPN #3 had completed the same class on [DATE]. On [DATE] at 11:40 am, an interview was conducted with the DON and was asked regarding the nurses' expired CPR cards and she replied, We have a policy that if you're doing CPR, you must be certified. As a professional, you have to keep CPR card current. On [DATE] at 2:00 pm, the Administrator, DON and Regional Nurse Consultant were made aware of these findings. No additional information was presented prior to exit. COMPLAINT DEFICIENCY (1) [MEDICAL CONDITION] - a surgically made hole that goes through the front of your neck and into your trachea or windpipe. (Reference: https://www.nhlbi.nih.gov/health/health-topics/topics/trach) (2) Acute [MEDICAL CONDITION] - a sudden inability of the lungs to maintain normal respiratory function. The condition may be caused by an obstruction in the airways or by failure of the lungs to exchange gases in the alveoli. (Reference: http://medicaldictionary.thefreedictionary.com/acute+respiratory+failure) (3) [MEDICAL CONDITION] - Anoxia is a condition characterized by an absence of oxygen supply to an organ or a tissue. (Referencehttp://medical-dictionary.thefreedictionary.com/anoxia) (4) Stenosis of larynx - narrowing or stricture of any or all areas of the larynx*; may be congenital or acquired. (Reference: http://medical-dictionary.thefreedictionary.com/laryngeal+stenosis) (4) Larynx - The organ of voice production. (Reference: http://medical-dictionary.thefreedictionary.com/larynx) (5) [MEDICAL CONDITION] - diminished availability of oxygen to the body tissues. (Reference: http://medical-dictionary.thefreedictionary.com/[MEDICAL CONDITION]) (6) Ambu bag - used for an artificial-respiration device consisting of a bag that is squeezed by hand. (Reference: merriam-webster.com) (7) Catheter (suction) - A catheter used to remove mucus and other secretions from the upper airway, trachea, and main bronchi. (Reference: http://medical-dictionary.thefreedictionary.com/suction+catheter) (8) CPR stands for CardioPulmonary Resuscitation. It is an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped. This may happen after an electric shock, drowning, or [MEDICAL CONDITION]. CPR involves: · Rescue breathing, which provides oxygen to a person's lungs. · Chest compressions, which keep the person's blood circulating. Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue CPR until the person's heartbeat and breathing return, or trained medical help arrives. Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6 minutes later. (Reference: https://medlineplus.gov/ency/article/ 3.htm) The resuscitation flowchart for a [MEDICAL CONDITION] patient read, in part, as follows: (Reference: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/[MEDICAL CONDITION]/) ASSESS AIRWAY: Look: for breathing movements of the chest. Listen: for breathing sounds from the [MEDICAL CONDITION]. Feel: for air coming from the [MEDICAL CONDITION] or nose or mouth. If airway OBSTRUCTED: Suction [MEDICAL CONDITION]. Change the patient's inner cannula tube if one present. Extend the patient's neck slightly with a small towel rolled under the shoulders. If the [MEDICAL CONDITION] is still blocked or dislodged: remove and re-insert a new tube. If unable to re-cannulate, try again using a smaller size tube . (9) Defibrillation - to arrest the fibrillation of (heart muscle) by applying electric shock across the chest, thus depolarizing the heart cells and allowing normal rhythm to return.(Reference:http://www.dictionary.com/browse/defibrillation?&o= 4&s=t) (10) Assisted Ventilation - The maintenance of breathing by artificial means. (Reference: http://www.thefreedictionary.com/respiratory+ventilation) (11) Cannula - a tube for insertion into a vessel, duct, or cavity. (Reference: http://medical-dictionary.thefreedictionary.com/cannula) (12) Stoma - a mouth like opening; an incised opening that is kept open for drainage or other purposes. (Reference: http://medical-dictionary.thefreedictionary.com/stoma) (13) O2 sats - oxygen saturation - the amount of oxygen bound to hemoglobin in the blood, expressed as a percentage of the maximal binding capacity. (Reference: http://medical-dictionary.thefreedictionary.com/oxygen+saturation) (14) Subglottic stenosis - is airway narrowing below the vocal folds. Subglottic stenosis causes shortness of breath, especially during times of exertion. When severe, subglottic stenosis, causes noisy breathing during inspiration and expiration. (Reference: http://www.throatdisorder.com/breathing-disorders/subglottic-stenosis). (15) EEG (electroencephalogram) - the record produced by electroencephalography; a tracing of the electric impulses of the brain. (Reference: http://medical-dictionary.thefreedictionary.com/EEG) (16) Hypoxic [MEDICAL CONDITION] - neurological damage due to deprivation of oxygen or blood or of both to the brain for several minutes. (Reference: http://medical-dictionary.thefreedictionary.com/hypoxic+[MEDICAL CONDITION]) (17) Myoclonic jerks - Myoclonic means pertaining to [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is shock like contractions of part of a muscle, an entire muscle, or a group of muscles; usually a manifestation of a convulsive disorder. (Reference: http://medical-dictionary.thefreedictionary.com/[DIAGNOSES REDACTED]) (18) Cerebellar - The part of the brain involved in coordination of movement, walking, and balance. (Reference: http://www.thefreedictionary.com/cerebellum) (19) [MEDICAL CONDITION] Metabolic [MEDICAL CONDITION] - Metabolic [MEDICAL CONDITION] is an alteration of brain function or consciousness due to failure of other internal organs. (Reference: http://medical-dictionary.thefreedictionary.com/metabolic+[MEDICAL CONDITION]) (20) Oxygen Concentrator - an electronic device that removes nitrogen from room air, thus increasing the oxygen concentration; commonly used by patients who require long-term oxygen administration at home. (Reference: http://medical-dictionary.thefreedictionary.com/oxygen+concentrator) Administering Oxygen by Transtracheal Catheter Nursing Action Preparatory Phrase 3. Assess catheter patency. Obstruction is indicated by a decreased Sa02, high pressure in the deliverly tubing, or stimulation of a cough. Rationale 3. Mucus can form on the end of the catheter and restrict oxygen delivery. Lippincott Manula of Nursing Practice - Eight Edition

Based on observation, clinical record review, staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to protect Resident # 5, 1 of 33 residents in the survey sample, from recurrent sexual abuse. Resident # 5 was inappropriately touched on 9/27/11 and again on 4/25/12 by the ex - husband of the resident's roommate . Findings included: Resident # 5, an eighty year old, was re-admitted to the facility on [DATE]. Resident # 5's [DIAGNOSES REDACTED].# 5 was unable to complete the BIMS (Brief Interview for Mental Status) and was coded as severely impaired in daily decision-making with both short and long range memory problems. Resident # 5 was coded as sometimes understanding others "responding adequately to simple, direct communication only". The resident was coded as demonstrating behaviors including inattention and disorganized thinking. Resident #5 was coded as requiring extensive assistance of at least one staff member in toileting, personal hygiene and bathing. Review of a complaint received from a state adult protection agency, dated 4/30/12, regarding an incident the agency was investigating, revealed concern that the ex-husband of Resident # 5's roommate's had directed sexually inappropriate behavior toward Resident #5, as observed by two staff members. The Agency stated a similar incident had taken place in October, 2011. The representative of the state adult protection agency stated in the complaint that facility staff failed to "adequately implement their policy and procedures for the prohibition of resident abuse". Review of the incident revealed the event occurred in September. A Facility Reported Incident faxed to the State Agency on 9/28/11 revealed a Certified Nursing Assistant (CNA) had witnessed the ex-husband of Resident #5's roommate "lean down to (Resident #5) and said something. She (CNA) then saw him place his fingers at the top of her (Resident #5) blouse and chest area. She (CNA) then said he placed his hands on Resident # 5's face and kissed her. According to the Facility Reported Incident report, the DON (Director of Nursing) questioned the husband "who denied any wrong doing". The ex-husband was asked to leave and police were called. According to the report Resident # 5 was not interviewable. On 5/9/12 at 12 noon, CNA #2 stated on 9/27/11 she was passing out trays. She stated she went into Resident #5's room and the curtain was pulled about three quarters of the way between Resident # 5 and her roommate when she witnessed "a gentleman standing over" Resident #5. She stated the gentleman was kissing the resident on the lips and was fumbling {sic}with the resident's breast which was not "fully exposed". The CNA stated she did not know who the gentleman was so she immediately went to the nurse and reported what she had seen. She said she was told he was the husband of Resident # 5's roommate. When asked what the facility staff did about the incident she said they posted the visitation rules inside the nurses station. When asked, she stated she was not made aware of the second incident on 4/25/12. On 5/9/12 at 3:00 pm LPN (Licensed Practical Nurse) #1 stated on 9/27/11 she was approached by CNA # 2 about what she had just witnessed in Resident # 5's room. The LPN stated she told the CNA that the gentleman in the room was Resident #5's roommate's ex-husband. The LPN stated the CNA reported Resident #5's breast was exposed "enough to tell it was a breast" and that he had kissed her. The LPN stated she went to the front and reported to the DON (Director of Nursing) what had happened. When asked, she stated she tried to make sure the ex-husband and Resident # 5 were not in the room together. She stated she would try to pass by the room on occasion to make sure Resident #5 was not in the room with the ex-husband. The LPN acknowledged there could have been times when Resident # 5 "rolled herself back to the room" while the ex-husband was still there. She stated she was not aware of how long the visitation rules stayed in place. On 5/9/12 at 1:45 pm this surveyor met with the Administrator and DON. The Administrator stated he met with the son after the first incident and told the son his father would not be allowed back into the facility until they were able to investigate the issue. The DON stated the family, physician and police were notified. The DON stated the sister did not believe the ex-husband meant anything by the incident and did not want her sister moved to a different room. The Administrator described the ex-husband as "cognitively good, with some physical health issues". The Administrator stated the ex-husband could drive himself to the facility but acknowledged he was not sure that was safe. The Administrator stated the police questioned the ex-husband who denied the incident. The Administrator stated that following the investigation visitation rules were developed and shared with the ex-husband and son and were posted on 10/7/12. The DON stated they felt the visitation rules had been followed and on 1/2/12 the visitation rules had been lifted at the request of the family. Review of a document dated 10/7/11 entitled "Facility visitation for (name of ex-husband of roommate)" . The visitation plan to monitor and protect Resident #5 following the first incident on 9/28/11 read: "1. Visitation may occur during the hours of 12 noon and 2:00 pm only. 2. (Name of ex-husband of roommate) must call the facility and speak to a staff member on unit one to inform the staff that you will be coming. This will allow for staff to remove (Resident # 5) to a different location. 3. (Name of ex-husband of roommate) will not be permitted to be in (Resident #5's room) if the Resident # 5 is in the room. Any violation of these conditions will immediately cause you to be prohibited from returning to the facility indefinitely." The Unit Manager stated on 5/10/12 at 8:00 am, when asked, the plan following the first incident on 9/27/11, was to remove Resident # 5 from her room and not the roommate and ex-husband because Resident # 5 was "more likely to be out of the room". She stated the CNA would ordinarily provide personal care and then would transport Resident #5 to activities or the nursing station. The Unit Manager stated, following the first incident, although the ex-husband was provided with the visitation rules, a formal monitoring process had not been established. The Unit Manager said there was no documentation of when or if the ex-husband called the unit to say he would visit, or at what time he came or left the unit following the first incident. She stated "sometimes the staff would let you know" when he had called " but not always. Nothing formal.". The Unit Manager stated they did not have anything in place to monitor that he came between 12:00 pm and 2:00 pm. She acknowledged the possibility Resident #5 could have returned at any time to the room during the time when the ex-husband was in the room since the resident could self-ambulate by wheelchair. The Unit Manager stated there was no mechanism, such as planned and systematic rounds to assure that Resident # 5 was not in the room with the ex-husband. She was unable to confirm whether the ex-husband had inappropriately touched the Resident # 5 between the time the visitation rules had been put in place until the 2nd incident occurred on 4/25/12, either before or after the visitation rules were lifted. When asked what would she do in the future to assure Resident # 5 was protected, she stated "I would make sure he came to the nursing station and was escorted to the room and make sure (Resident # 5) was out of the room. She added she would have implemented a more formal monitoring process. The Unit Manager stated there was still no formal implementation for monitoring of visitation process following the second incident. On 5/11/12 at 10:30 am the DON and Administrator would also confirm that there was no formal monitoring process. Review of the facility investigation of the 2nd incident of sexual abuse which reportedly occurred on 4/25/12 revealed two staff members witnessed the ex-husband of Resident #5's roommate kiss Resident # 5 on the mouth and pat her on the hand. According to the investigation, the ex-husband of the roommate again denied that he had kissed the roommate. The facility investigation, as reported to the State Agency, failed to include a similar event occurred on 9/27/12 that resulted in a plan to monitor the visitation between the ex-husband and the roommate primarily directed at the ex-husband not being in the presence of Resident # 5. The Administrator said during an interview on 5/9/12 at 1:45 that following the second incident, he met again with the son and ex-husband and a new visitation plan was developed. Review of a document dated 5/4/12 entitled "Facility visitation for (name of ex-husband of roommate)" . The visitation plan to monitor and protect Resident #5 following the second incident on 4/25/12 read: 1. You (name of ex-husband) must call the unit before you intend to visit (roommate's name). 2. Upon entering the facility you must be accompanied by one of your adult family members who must remain with you at all times during your entire visit. 3. You are not to do anything for her roommate (Resident # 5) or any other female patient and have no physical contact with the roommate (Resident # 5) while visiting. Any violation of these conditions will immediately cause you to be prohibited from returning to the facility permanently" At 5/10/12 at 11:35 am, the representative of the state adult protective services agency, stated the initial report on the 9/27/12 issue had been found "invalid' because the facility reportedly had a plan in place. When the agency received the second report, the representative stated she did not agree with the facility rescinding the visitation requirements because both Resident #5 and her roommate were "incapacitated". She stated "the behavior was inappropriate and felt the ex-husband might be taking advantage of the situation". The representative stated she did not believe the facility had implemented the plan that was set up to prevent further inappropriate behavior. Review of Resident # 5's Care Plan provided by Unit # 1 Manager when asked for the current care plan, indicated the plan had been reviewed on 9/2710 and with review dates that included 12/17/10, 2/24/11; 5/17/11; 8/1/11; 10/18/11 (following the first event) ; 1/2/12 and 4/3/12 and did not include any mention of monitoring or protection of the Resident # 5. On 5/11/12 at 10:30 am the above was discussed with the Director of Nursing, Administrator and Nurse Consultant. The DON was asked how the facility knew when the ex-husband came in to the facility, she stated he would sign in the guest book in the lobby when he arrived. When asked if he then went to the unit, the DON acknowledged she would see the the ex-husband sitting in the lobby in the morning. She stated that she would later observe that he was not in the lobby any longer and assumed he went to the nursing unit. When asked about the monitoring process, to assure the visitation rules were being followed from October 7th, 2011 through January 2nd, 2012 , the DON and Administrator said there was no formal monitoring process in place to assure the behavior had not continued. Based on the above review, no formal plan was implemented to monitor the effectiveness of the visitation rules in preventing another incident of inappropriate sexual behavior. Although the DON stated the facility staff felt the visitation rules had been followed, there was no evidence to conclude that the rules were followed or that they were effective at preventing further incidents of inappropriate sexual behavior. There was no confirmation that the call from the ex husband resulted in any specific and direct behavior on the part of the nurses. There was no confirmation Resident # 5 was protected from additional inappropriate sexual advances either while the visitation rules were in place or after they were lifted on January 2nd, 2012. At the time of the survey, following the 2nd incident, there was no formal plan implemented to monitor the effectiveness of the visitation rules in preventing another incident of inappropriate sexual behavior. There was nothing in place that either assured the ex-husband would call before coming or follow the visitation rule related to being accompanied by a family member. Complaint Deficiency

2. The facility staff failed to consistently float the resident's heels in accordance with physician orders. Resident #8 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent Minimum Data Set (MDS) was a quarterly dated [DATE]. The MDS coded the resident with one un-stageable pressure ulcer with necrotic tissue. She was not coded to reject care. The revised care plan dated [DATE] identified the resident with a right heel ulcer and potential for further skin breakdown. The goal of the staff was that progress would be evident in ,[DATE] weeks. One of the approaches the staff would use to accomplish this goal included "keep bilateral lower extremity floating heels at all times (sic)". Resident #8 had the following current wound clinic/physician's orders [REDACTED]. The following observations were made where the resident's heels were not floated: On [DATE] at 7:00 am Resident #8 was observed in bed asleep with bilateral heels not floated, directly laying on the mattress. On [DATE] from 9:00 am through 10:30 am, the resident was observed in bed. Bilateral heels were not floated. On [DATE] from 9:00 am through 11:00 am, the resident was observed in bed. Her heels were not floated and came in direct contact with mattress. On [DATE] at 11:20 am, assigned CNA #7 assisted by CNA #9 transferred the resident from the bed to the wheelchair. An area of yellow/brown drainage was observed on the bed linens where the resident's right foot rested. CNA #7 said, "I am her full time aide and we do not place anything under her heels while she is in bed; we only use the boots when she gets out of bed into her wheelchair. The wound care clinic knows about that drainage and they do the treatments." On [DATE] at 10:00 am, an interview was conducted with Unit III Manager, Registered Nurse (RN #2). She stated she expected the staff to float the resident's heels at all times to ensure adequate circulation and promote healing to the area using of regular pillows or the Heelz-up (brand name) pillow while in bed when the heel protector boots were not applied. She said the resident's heels were not to touch the mattress at anytime because she already had an existing Stage IV pressure ulcer on the right heel. She stated the wound was assessed un-stageable with eschar upon admission to the nursing facility. A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining & sinus tracts also may be associated with this type of ulcer. When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed. (1994 Agency for Health Care Policy and Research/ AHCPR Guidelines). The Treatment Administration Record (TAR) dated [DATE] through the ,[DATE] shift on [DATE], was signed off by the licensed nurse for each shift indicating the heel protector boots were in place at all times, as well as the Heelz-up pillow. On [DATE] at 1:45 pm, the Director of Nursing (DON), Nurse Consultant (NC)#1, NC #2 and the Unit III Manager stated floating heels meant nothing touched the heels. NC #1 stated, "Ideally the resident should wear the boots to float her heels and it is the most effective treatment so her heels will remain floated. Although the mattress provides some pressure relief, it is the back up. It does not provide heel floatation." On [DATE] at 2:30 pm, Unit III Manager said, "When you (this writer) talked to me on Friday ([DATE]), I had the Heelz-up pillow discontinued that day and we decided to make sure the boots are used at all times to ensure her heels are floated." COMPLAINT DEFICIENCY Based on observation, clinical record review, staff interview, facility document review, and in the course of a complaint investigation, facility staff failed to provide care and services to assess, identity, treat and prevent pressure sores for 2 of 33 residents in the survey sample, Residents #31 and #8. 1. Facility staff failed to identify and provide care and services for 2 Stage III pressure ulcers for Resident # 31 and failed to provide ongoing assessemnt of a wound after it was identified on the resident's ankle. 2. Facilitiy staff f ailed to consistently float Resident #8's heels in accordance with physician orders. Findings included: 1. Failed to provide Resident # 31 with care and services for assessment and treatment of [REDACTED]. The Resident developed 2 Stage III ulcers and 1 Stage II ulcer on the left leg and a Deep Tissue injury to the left heel with subsequent infection and above the knee amputation of leg. Resident #31 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. On [DATE], the resident was transported to the emergency room of an acute care hospital and diagnosed with [REDACTED]. On [DATE] staff identified Resident # 31 had developed 2 Stage III ulcers, 1 Stage II ulcer and a Deep Tissue injury to the left heel. On [DATE] the resident was admitted to the vascular service of an acute care hospital and underwent an above the knee amputation of the left leg. According to Resident # 31's Minimum Data Set (MDS) Assessment, done as a quarterly review with an ARD (Assessment Reference Date) of [DATE] and in effect prior to the [DIAGNOSES REDACTED]. The resident was coded as being totally dependent, requiring the assistance of at least 2 staff for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), bed mobility, toilet use, personal hygiene and bathing. She was assessed as not steady, only able to stabilize with human assistance during surface to surface transfer (between bed and chair or wheelchair). The resident was coded as understanding others and being understood. She was not coded as rejecting care. Review of the MDS Assessments with Assessment Reference dates of [DATE] and [DATE] indicated Resident # 18 was not coded as refusing care. On [DATE] at 3:50 pm, Resident # 31's RP (Responsible Party) requested to speak with a surveyor. The RP stated she was the resident's cousin and attended all medical appointments with the resident. The RP stated she visited the resident on Sunday night, [DATE]. The RP stated she was called by the facility later in the evening and made aware the resident had sustained a fractured femur. She stated Resident # 31 was sent to the Emergency Department of an acute care facility and returned later in the evening with a "stabilizer" on her left leg. The RP stated that Resident # 31's skin under the "stabilizer" began to breakdown over time. According to an entry in the Progress Notes, dated [DATE] 4:09 am, Resident # 31 returned from the ER (Emergency Department) at 3:15 am "with lt (left) knee immobilizer intact. lt foot has 2+ [MEDICAL CONDITION], pedal pulse present ...". On [DATE] at 11:05 am, the UM (Unit Manager) of Unit 2 stated Resident # 31 returned from the ER with an immobilizer on the left leg from above the knee to the ankle. Review of the Clinical Record included an order, dated [DATE], that read "Remove immobilizer (left) leg (every) shift for skin check and then reapply). When asked, the UM stated that on [DATE] she initiated a call to the Physician to get an order to remove the immobilizer every shift. The UM stated "that is the standard..that you remove the immobilizer every shift and check the skin". She stated she was aware that prior to [DATE], some nurses were removing the immobilizer and some were not. The UM stated the [DATE] order for removing the immobilizer did not include removing the compression wrap on the foot and the nurses were not removing the wrap on the foot. The UM, in describing how the skin was assessed when the immobilizer was removed stated : "we opened the immobilizer, and tried to lift her leg. When asked, she stated she did not use a flashlight or mirror to visualize the skin on the back of the leg. She stated the "staff would try to turn her a little and she would yell in pain". The UM stated the resident's leg was very heavy. In an interview at 12:00 noon on ,[DATE], LPN # 7 described how she assessed Resident # 31's left leg: " I removed the straps and looked at the skin on the top of the leg. Then I would try to lift her leg a little. I would try to look under the leg. I usually got someone to help lift (the resident's) leg. But she was in so much pain. She was always in pain. Her leg was very heavy, very difficult to look at underneath. Her leg was broken . Didn't think we should move her much." The LPN stated she believed the immobilizer caused the wounds. She stated the immobilizer "caused moisture". LPN # 7 confirmed, after reviewing the Treatment Administration Record, that her initials were recorded as removing the immobilizer and assessing Resident # 31's skin on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] on the ,[DATE] shift. She stated she had never identified any wounds during that time. According to a Progress Note entry on [DATE] the LPN had identified a blister on the left outer ankle. In an interview at 12:00 noon on ,[DATE], LPN # 10 described how she assessed the left leg: "I unwrapped the straps and leave her leg open (to air). An aide would help". When asked, the LPN stated she would lift the resident's leg, maybe an inch or inch and a half. The LPN stated Resident # 31 would yell as soon "as I touched her leg, I tried not to make her more uncomfortable than she already was". When asked, she stated she did not use a flashlight and she did not feel under the back of the leg. When asked how she would know there was a problem, she stated she "would notice the smell". LPN #10 confirmed, after reviewing the Treatment Administration Record, that her initials were recorded as removing the immobilizer and assessing Resident # 31's skin on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The UM stated on [DATE] at 11:10 am that she did not recall ever looking at wounds for Resident # 31 on weekly wound rounds until after [DATE] when the 4 wounds were identified. When asked how the wounds were all identified on [DATE], the UM stated that the Nurse Consultant was doing skin checks on that day and found that Resident # 31 had 4 Pressure Wounds. On [DATE] the Nurse Consultant confirmed that she had found the wounds and had called the UM to observe the wounds as well. The Nurse Consultant stated the Wound Sheets were initiated at that time. The RP stated at 3:45 pm on [DATE] that during a Physician Visit on [DATE] (the Orthopedic Specialist) Resident # 31 was advised by the Physician, the ulcers on Resident # 31's leg were not going to heal and the resident "needed to go back to the hospital and have the other leg amputated". The RP stated the physician told them "the leg was infected all the way to the bone". The RP stated she discussed her concerns regarding problems with the skin care and the "stabilizer" with the Administrator, and he told her the amputation was from poor circulation. The RP stated the resident had had a procedure in late December, 2011 on the left leg and the resident was told the circulation in the left leg was "good" post the procedure. Review of the resident's clinical record indicated Resident #31 had undergone an Aortogram and Artherectomy for improving blood flow in the left leg on [DATE]. The report of the same date revealed the outcome: "...excellent with no residual stenosis and brisk runoff through the popliteal". Review of the Clinical Record revealed the breakdown of the resident's skin was documented in the progress noted beginning on [DATE] at 11:22 pm. An entry in the Progress Notes by an LPN read " abrasion on the side of the left lower leg". On [DATE] at 8:26 am an entry in the Progress Notes, by a second LPN, indicated the anterior of left leg had "a small area on the lower anterior side". Review of the 24 hour report for [DATE] at 8:26 am revealed an entry that read " ...no open areas... anterior of leg sm(small) area, lower anterior side, no drainage, reddened area will continue to monitor". Review of Resident # 31's Medication Administration/Treatment Records indicated a Physician order [REDACTED]. Apply Santyl Ointment and cover with dry dressing". The skin assessments done on [DATE] and [DATE] confirmed the presence of a wound on the outer part of the left lower leg. On [DATE] an entry in the Progress Notes indicated "treatment was done to ankle area with green foul smelling drainage". There was no indication there was any change in the treatment order or the initiation of an Ulcer and Wound Record from the identification of the wound on [DATE] through [DATE] when the wound was identified as a "new wound". The Wound Nurse confirmed on [DATE] at 10:25 am that she did not have a wound sheet on the left outer ankle wound. She stated it was the nurse's responsibility who identified the wound to start a wound sheet. She stated the wound sheet was the mechanism by which she was aware of a new wound so that she could monitor, measure and make treatment changes. The Wound Nurse was unable to provide the surveyor with evidence that the wound on the outer leg was monitored, assessed or measured. There was no treatment change to the wound noted from the initial physician ordered treatment on [DATE] until an Ulcer and Wound Record, dated [DATE], described the onset of "a new wound" on the left outer leg as a Stage III measuring 4 x [MEDICAL CONDITION], although the wound was described on [DATE] as having "green foul smelling drainage". Review of Resident # 31's clinical record did not did not reveal that any Pressure Ulcer and Wound Records had been initiated until the [DATE] onset of 4 Pressure Ulcers on the left leg and heel. The wounds at that time were described as follows: Stage III Calf 7.5 x 3 (no depth described) with sero-sanguenous drainage and slough Stage III Outer leg 4 x 6.2x .1 with sero-sanguenous drainage and slough Stage II Top of foot 2.6 x 2.5 < 0.1 with sero-sanguenous and granulation Unstageble Heel 4 x 3 x< 0.1 On [DATE] at 3:45 pm the RP stated she accompanied Resident # 31 to the Physician's Office on [DATE] where the Resident was told that she had to have the leg amputated. Review of Resident # 31's Clinical Record revealed a Physician order [REDACTED]. A report, dated [DATE], revealed the Impression : "1. Severe [MEDICAL CONDITION] plaque; 2. Inflo-disease at the left aorto-illiac segment; 3. Left superficial femoral artery stenosis. The changes are in the moderate to severe ischemia range". Review of Resident # 31's Progress Notes and the 24 Hour report does not indicate the resident's left leg was ever assessed for pulse, temperature or color or any other assessment that could indicate progressing ischemia from [DATE] following the fractured femur through discharge on [DATE] when her left leg was amputated. On [DATE] Resident # 31 was admitted to the vascular service of an acute care facility. According to the Vascular Surgery History and Physical, with an admission date of [DATE], "Left leg, non healing ulcers/ (question whether related to ) infection vs abscess vs ischemic disease". Resident # 31 underwent an Above the Knee Amputation and was readmitted to the facility on [DATE]. [DATE] note by Orthopedics confirmed the need for the AKA stating : "followup for [MEDICAL CONDITION] with gangrene of LLE (Left Lower Extremity) resulting in L AKA (Left Above the Knee Amputation)".

Based on observations, clinical record review, staff and resident interview and facility document review, the facility staff failed to ensure the 3 of 33 residents (Residents #31, #32 and #27) in the survey sample received the necessary staff assistance for safe transfers and bed mobility. 1. Resident #31 was not transferred to the bed with two staff in accordance with the comprehensive assessment and care plan, thus she encountered a left leg fracture. 2. Resident #32 was not repositioned in bed by two staff and rolled out of bed. 3. Resident #27's Merry Walker chair was not locked during an observed transfer to bed and a gait belt was not utilized. The findings included: 1. Resident #31 was admitted to the nursing facility on 9/29/09 with [DIAGNOSES REDACTED]. On 2/19/12, the resident was evaluated at the local emergency room (ER) and diagnosed with [REDACTED]. Resident #31's Minimum Data Set (MDS) in effect at the time of the aforementioned ER visit was a quarterly dated 1/12/12. The MDS coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 12 (moderately impaired cognitive performance). The resident was coded to require total assistance from 2 staff for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), bed mobility, toilet use, personal hygiene and bathing. She was assessed as not steady, only able to stabilize with human assistance during surface to surface transfer (between bed and chair or wheelchair). The resident's speech was clear, she had the ability to understand the staff and was understood. She was not coded to reject care (i.e., ADL assistance). The care plan dated and reviewed 1/23/12 identified the resident required the use of a Vanderlift (mechanical lift) to be transferred with two staff assist at all times. The goal of the staff was the resident would not sustain any injuries. The care identified pain related to a recent left femoral and knee fracture on 2/19/12. The Physical Therapy evaluation initial plan of care dated 12/6/11 assessed Resident #31's range of motion, strength, balance, functional transfers and gait analysis. It was documented and determined the resident was dependent on the staff for transfers with the mechanical lift. The Physical Therapist was interviewed on 5/14/12 at 11:10 am. She stated Resident #31 had to "absolutely be transferred with the mechanical lift and two CNA's or nurses for her safety. She was not able to stand, transfer or pivot to assist in the transfer process." An interview was conducted with Resident #31 on 5/11/12 at 4:00 pm while she was in bed. Both legs were observed amputated above the knee. She stated CNA #12 was placing her in bed by himself without the use of the mechanical lift when her left knee/leg hit the metal bed frame, dropping her on the bed. She said, "I heard and felt a crack and then a grinding sound (the resident mimicked a grinding sound with her voice). It was one of the worse pains I've ever had." She further stated that when the incident happened, on the 3/11 shift around 4:00 pm, the only thing CNA #12 said afterwards was "oops". According to the resident, "It was my only good leg and I got up daily before this happened." She also said surgical intervention was not required, but a brace was applied to the left leg. She said she acquired sores from the brace which did not heal and resulted in an above the knee amputation. During an interview with the Director of Nursing (DON) on 5/11/12 at 5:15 pm, she stated CNA #12 improperly transferred Resident #31 and caused injury to the resident. The DON said CNA #12 no longer worked for the nursing facility. She stated the CNA should have used the assistance of another CNA, as well as the mechanical lift to transfer the resident in and out of bed for her safety. Also, the DON said she spoke to CNA #12 on 2/23/12 and informed him he used improper technique during transfer of the resident from the wheelchair to bed, which caused the resident injury and pain. According to the DON, the CNA could not find the lift and did not go to another unit to obtain one; he transferred the resident alone. The DON stated the resident's left leg was stiff, she was unable to bend her knee and her foot turned outward; without a right extremity, she was not able to assist in transfers. In addition to the aforementioned incident, CNA #12 had previously failed to provide Activities of Daily Living (ADL) care for a different resident who required two staff assist for bed mobility and incontinence care, consequentially resulting in a fall out of bed. LPN #4 indicated in a nurse's note dated 2/19/12 at 4:01 pm, Resident #31 stated during chair to bed transfer her knee hit the side of the bed. The note indicated the resident was crying at the time of the nursing assessment. Physician orders [REDACTED]. On 5/14/12 at 11:55 am, an interview was conducted with Licensed Practical Nurse (LPN) #4 who worked the 3/11 shift on 2/19/12. She stated she was told by CNA #11, CNA #12 slammed her leg against the side of the bed during transfer from the wheelchair to the bed. She said, CNA #12 was assigned to provide direct care for the resident on 2/19/12 for the 3/11 shift and should have been the one to report the incident, but did not. LPN #4 stated she immediately assessed the resident, after which she approached CNA #12 and he stated he placed the resident in bed and nothing happened during the transfer. She said he further told her he did not use the assistance of another staff person or the mechanical lift for the transfer. She stated assignments were switched and CNA #12 did not care for the resident the remainder of the 3/11 shift. LPN #4 also said the CNA worked a double, and was not assigned to provide care for R#31 on the 11/7 shift. LPN #4 said she reported the incident to the 4/12 (4:00 pm to 12 midnight) nursing supervisor. The LPN took this writer to the resident's room and before she could point out the part of the metal bed frame that the resident leg hit against, the resident re-told the events of the 2/19/12 incident. She said, "My leg hit the metal part of the bed and I was dropped on the bed. There was a 'crack' and excruciating pain." On 5/14/12 at 12:40 pm, a telephone interview was conducted with CNA #11. She stated she was walking by the room when the resident called out her name as she rang her call bell. She said the resident told her CNA #12 hurt her leg when he placed her in bed. She stated she reported the resident's complaint to LPN#4. She stated, "I have taken care of (Resident #31's name) before and she was and still is a 2 person assist with the Vanderlift." On 5/14/12 at 1:00 pm, a telephone interview was conducted with the 2/19/12 4:00 pm to12:00 midnight (4/12) Registered Nurse (RN #7) shift supervisor. RN #7 stated, she and LPN #4 both examined the resident and based on her complaints of increased pain since the transfer, associated with movement, a mobile x-ray was ordered by the physician. The mobile x-ray revealed an acute fracture involving the left distal femur with associated joint effusion. Nurse's notes dated 2/19/12 at 10:36 pm indicated the physician called regarding the positive knee and femur fracture with new orders to send the resident to the ER for evaluation. The ER report dated 2/19/12 at 12:55 am indicated Resident #31 complained of knee pain and no where else. The report also indicated "one of the nursing home employees, instead of lifting her with the mechanical lift, decided to lift the resident on their own and injured the resident's left leg". Another x-ray was done to re-evaluate the fracture which revealed fracture of the femur. The resident was placed in a knee immobilizer and sent back to the nursing facility. On 5/14/12 at 1:40 pm, a telephone interview was conducted with LPN #12 who worked on 2/19/12 for the 11/7 shift (2/19/12 at 11:00 pm through 2/20/12 at 7:00 am). She stated the resident came back on her shift, as indicated in her nurse's notes, with a knee immobilizer as a result of an acute fracture of the distal femur. An interview was conducted with the resident's Responsible Party on 5/11/12 at 3:50 pm. The RP stated the resident had "had the right leg amputated and the left leg was paralyzed and the foot was turned out". The RP stated she visited Resident # 31 on Sunday Night 2/19/12 who was in a wheelchair. The RP confirmed the date with a calendar she carried with her. The RP stated she was later notified by one of the nurses that "(name of resident)'s leg had been hurt or something and they were doing an X-ray". She was called again and told the leg was fractured but they were going to keep her leg immobilized and "send her to the ER in the morning". She was called once again and told the Physician wanted Resident # 31 sent to the ER that night. When asked about what she was told about what happened the RP stated the resident told her the Certified Nursing Assistant (CNA) could not find the (mechanical lift) so he attempted to put her back in bed by himself and in the process hit her leg on the side of the bed. The RP stated she was told by the (Name of Facility Administrator) that staff would talk to the CNA. The DON later confirmed the CNA had admitted he had not transferred the resident in the right way and he was no longer there. The RP said while in the ER the Physician reported the "bones in the led appeared to be in place and surgery was not necessary". The RP stated when the resident returned from the ER her leg was in a "stabilizer". She stated thereafter, Resident #31's skin started to breakdown. In a Physician visit on 4/3/12 the resident and RP were advised the ulcers on the leg were not going to heal and the resident "needed to go back to the hospital and have the other leg amputated". The RP said the physician told them "the leg was infected all the way to the bone". The RP stated the resident complained of Phantom pain in the leg and had stated to her "Maybe I'm giving up". 3. The facility staff failed to lock the wheels of Resident # 27's seated walker when transferring the resident without assistance and without a gait belt, to and from the bed for incontinence care. Resident # 27 was readmitted to the facility on on 1/6/12. [DIAGNOSES REDACTED]. According to Resident # 27's latest MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 3/8/12 completed as a quarterly review, Resident # 27 was unable to complete the BIMS (Brief Interview for Mental Status) and was coded as severely impaired in daily decision-making demonstrating, behaviors including inattention and disorganized thinking. The resident was coded as displaying both short and long range memory problems. Resident was coded as requiring extensive assistance of at least 1 staff member in transferring between surfaces, including bed to chair. On the previous MDS with an ARD Date of 12/7/11 the resident was coded as requiring the assistance of 2 staff members for transfer. On both MDS Assessments, "Balance during transition from bed to chair " was coded as "Not steady, only able to stabilize with human assistance". On 5/11/12 between 9:45 and 10:15 am this surveyor observed CNA (Certified Nursing Assistant) # 4 providing incontinence care for Resident # 27. The resident was in a seated walker device. The CNA approached Resident # 27, pulled the walker device close to the bed without locking the wheels or telling the resident what she was going to do, and attempted to transfer the resident to the bed by putting her hands under the resident's arms and pivoting her. When the unlocked walker began to slip away, the CNA reseated the resident and again pulled the unlocked walker close to the bed attempting again to lift and pivot the resident without success, as the walker again slipped away. With the wheels still unlocked, the CNA moved the walker to the bed and for the third time, this time holding the resident by the resident's left arm, stood the resident up and pivoted the resident around lifting her as the resident flopped down on the bed. Following the completion of the procedure, the CNA attempted to transfer the resident to the unlocked seated walker which again slipped away. The CNA pulled the walker back in place locking one wheel, pivoting the resident as the resident dropped into the walker. On 5/11/12 at 10:20 am, the CNA, when asked, stated she was not nervous during the observation and did not feel any time pressure. She stated that she performed the procedure as she usually did. At 10:30 am, the Unit Manager stated she would have expected the CNA to lock the seated walker. Review of a facility provided inservice packet entitled "Transfer Techniques (agenda) In-service" provided in March and April 2012, revealed a handout related to gait belt use: Mobility : Transfers. The text read: "When to use (gait belts): During ambulation and transfers for patients requiring standby through full assistance". The education packet did not include anything on locking the wheels on the wheelchair or seated walker. Review of Unit 1's accident log indicated Resident # 27 had a bruise to the left forearm (1/14/12); a skin tear on the right thigh (1/15/12); a fall out of bed (3/4/12); blood noted on calf (3/5/12); bruise on right cheek (3/26/12); fall in room (3/31/12). Review of Resident # 27's Care Plan indicated the resident was "at risk for falls, related to history of falls, ambulated with (seated walker)". On 5/11/12 at 10:30 am the above was discussed with the Director of Nursing, Administrator and Nurse Consultant. COMPLAINT DEFICIENCY 2. the facility staff failed to provide adequate supervision to prevent an injury during a positioning for Resident #32. Resident #32 was to the facility on [DATE] with a readmission on 4/12/12. Resident #32's [DIAGNOSES REDACTED]. Resident #32's Admission Minimum Data Set ((MDS) dated [DATE] coded the resident as having modified independence for cognitive skills for daily decision makings. Resident #23 required total assistance with bed mobility and was coded as a 2 person transfer. Resident #32 was coded as having mobility complications, only to stabilize with extensive assistance during transfer between bed, chair or wheelchair. Resident #6 was coded as not steady, only able to to stabilize with human assistance when moving from seated to standing position. Resident #32 required extensive assistance from staff for all activities of daily living (ADL's). A review of Resident #32's Plan of Care Plan updated thru 5/7/12 evidenced a problem potential for falls with interventions that included: ? two assist for bed mobility, positioning, toileting needs and transfers Review of Resident #32's clinical record evidenced a nursing note dated 7/15/11 at 4:53 PM written by Licensed Practical Nurse (LPN) #5 stated: ? At 6:25 AM, the Certified Nursing Assistant (CNA) #12 called LPN #5 into the resident's room. LPN #5 observed Resident #32 laying on the floor mat beside the bed. CNA #12 reported he was bathing Resident #32 and turned the resident on her side and she rolled out of bed to the floor. LPN #5 notified the Registered Nurse (RN) Supervisor on duty and vital sign machine while CNA #12 stated with Resident #32. After assessment Resident #32 complained the back of her head and right leg was hurting. RN Supervisor and LPN #5 transferred Resident #32 back to the bed. The Nurse Practitioner (NP) was contacted and ordered the resident to be sent to the local hospital emergency room for evaluation. A review of the local hospital emergency room x-ray report on Resident 32's clinical record evidenced there was no evidence of a fracture or internal bleed. A review of the Medication Administration Record on the clinical record evidenced Resident #32 received physician ordered Oxycodone/Apap 4mg/325mg every four hours for pain on 7/15/11 (no time noted) , 7/16/11 (no time noted), 7/18/11 (no time noted), 7/19/12 (no time noted), 7/23/11 (no time noted), 7/24/11 (no time noted), 7/26/11 (no time noted), 7/27/11 (no time noted). A review of facility documentation evidenced a written statement by CNA #12 stated: ? I, CNA #12, was bathing Resident #32 this morning at 6:00 AM, when I bathed her backside and dried it, I attempted to put a diaper on her, before I could put it on her she began to roll out of bed, beginning with her feet and last her head to land on the floor mat provided by the facility for her safety and laid on her backside. The nurse was called soon after. CNA #12 is no longer a facility employee and could not be interviewed. RN # 5 is no longer a facility employee and could not be interviewed During an interview on 5/15/12 at 2:15PM with the Administrator and the Director of Nursing (DON), and Corporate Nurse Consultant, the aforementioned information was shared. The facility staff failed to use the appropriate number staff in accordance with the assessed need for Resident #32 during positioning which resulted in a fall with pain complication to the head and right leg.