Every finding on record at Cheyenne County Village Inc

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 06/16/25 at 08:48 AM, observation in the kitchen revealed the following: In the walk-in refrigerator two pans of uncovered Jello. The two-door silver artic refrigerator had an unzipped bag of yellow square cheese and an unzipped bag with five hamburger patties, which left them open to the air. On 06/16/25 at 08:50 AM, Certified Dietary Manager (CDM) BB verified the above findings and stated everyone has problems zipping the ziplock bags, but staff should make sure the bags are sealed when they are placed in the refrigerator. CDM BB stated that staff should cover food items before placing them in the refrigerator. CDM discarded the above food items in the trash. On 06/17/25 at 10:30 AM, observation during follow-up to the kitchen revealed the following: Both outer sides of the two ovens had numerous different-sized yellow sticky streaks of a sticky substance. The movable island located next to the oven had numerous different-sized streaks of a sticky substance on the back and side. The dish machine log for June 2025 lacked documentation of temperatures on the following days and meals: 06/03/25 - dinner 06/04/25 - breakfast, lunch, and dinner 06/06/25 - breakfast, lunch, and dinner 06/09/25 - dinner 06/10/25 - breakfast and lunch 06/12/25 - lunch and dinner 06/13/25 - breakfast, lunch, and dinner 06/15/25 - breakfast, lunch, and dinner 06/16/25 - dinner A fluorescent ceiling light, approximately 18 inches (in) by 3 feet, located above the right end of the stove, above the prep islander, had a crack in the outer cover at the end, approximately 5 in by 1/4 in wide. On 06/17/25 at 01:15 PM, CDM BB verified the facility kitchen dishwasher was a low-temp dishwasher, verified the lack of temps in the findings above, and stated she expected staff to check dishwasher temperatures every meal. CDM stated she had noticed the crack in the light fixture cover today and would report it to maintenance. The facility's Kitchen Daily, Weekly, and Monthly Cleaning Schedule documents tasks for dietary staff to complete. The facility's Food Receiving and Storage Policy, undated, documented food services or other designated staff would maintain clean and temperature/humidity appropriate food storage areas at all times. All foods stored in the refrigerator or freezer would be covered, labeled, and dated. (use by date). The facility's Sanitization Policy, revised November 2022, documented all utensils, counters, shelves, and equipment would be kept clean, maintained in good repair, and are free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. The policy documented the dishwashing machines would be operated according to the manufacturer's instructions.

The facility had a census of 21 residents. The sample included one resident reviewed for Hospice care. Based on record review and interview, the facility failed to review or revise the care plan for Resident (R) 74 when he was admitted to Hospice care and chose not to have cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating). This deficient practice placed him at risk for staff not honoring his wishes regarding his care. Findings included: - R74's Electronic Medical Record documented diagnoses of thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to clot, sometimes associated with abnormal bleeding), liver cirrhosis (chronic degenerative disease of the liver), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain, anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), and atrial fibrillation (rapid, irregular heart beat). R74's Significant Change Minimum Data Set assessment was closed due to R74's passing. R74's Care Plan, dated [DATE], documented (Specify) Hospice, (Specify) phone number. The plan of care directed staff to contact Hospice with any concerns or changes in conditions that might warrant the need to modify the coordinated care plan, initiated [DATE]. R74's plan of care stated the Hospice care plan and all documentation would be scanned into the facility's computer documentation system, initiated [DATE]. When or if the resident is transferred to the hospital, the resident's choices will be communicated by using advance directives, initiated: [DATE]. R74's plan of care documented CPR would be initiated if the resident's heart or breathing ceases, and resuscitation orders would be part of the medical record, initiated [DATE]. The Provider Note dated [DATE], documented R74 was re-admitted to the facility from the hospital with Hospice or comfort care ordered. On [DATE] at 12:24 PM, Administrative Nurse D stated the resident was given last rites this morning with family present. On [DATE] at 09:36 AM, Certified Nurse Aide (CNA) M stated that staff can check DNR or CPR status in the Kardex for aides, which is right at the top of the page. CNA M was unsure what services Hospice provided. On [DATE] at 03:30 PM, Administrative Nurse D stated she was not sure if Hospice had sent the facility their care plan, and the facility did not have one onsite currently. She stated she had put in the Hospice information on the facility care plan, but the information had disappeared. Administrative Nurse D verified staff should have updated the care plan for DNR. The facility's Hospice Program policy, dated [DATE], stated Hospice would determine the appropriate hospice plan of care as it related to the terminal illness and related conditions. The facility would meet the resident's personal care and nursing needs in coordination with the hospice representative. The facility staff would obtain the most recent hospice plan of care specific to the resident, physician certification and recertification of the terminal illness of the resident, names and contact numbers for hospice personnel involved in the resident's care, the Hospice physician and attending physician orders for the resident. Coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility. The coordinated care plan would reflect the resident's goals and wishes as stated in his/her advance directives and would be revised and updated as necessary to reflect the resident's current status.

The facility had a census of 21 residents. The sample included 12 residents, with three reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to care for Resident (R) 3's catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) in a manner to prevent infection. Findings included: - R3's Electronic Medical Record documented a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. The MDS documented R3 had a urinary catheter and was dependent on staff for toileting, dressing, and mobility. R3's Care Plan, dated 06/08/25, stated R3 had a 16 FR (size) indwelling urinary catheter. The care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. Monitor and document intake and output as per facility policy. Monitor for signs and symptoms of discomfort on urination and frequency. Initiated 01/26/23. R3'S Care Plan, update of 04/01/24, directed staff to utilize personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) gloves and gown before performing any high-contact care activities such as: changing briefs or assisting with toileting, caring for or using an indwelling medical device or urinary catheter, bathing, transferring residents from one position to another, providing hygiene, or changing bed linens. The care plan directed staff to change PPE before caring for another resident to prevent cross-contamination. The Physician Order, dated 07/04/24, directed staff to provide a 16-French (fr) with a 5-10 cc (cubic centimeter) balloon and change the catheter only when clinically necessary. The Physician Order, dated 09/09/24, directed staff to administer Keflex (antibiotic medication) 250 milligrams (mg) every day for urinary tract infection prevention. On 06/17/25 at 09:15 AM, R3 self-propelled her wheelchair to the living room with her catheter bag in a privacy bag under the wheelchair. A section of the catheter tubing was dragged along the floor. On 06/17/25 at 11:33 AM, Certified Nurse Aide (CNA) M wheeled R3 in her wheelchair to the dining room with the catheter tubing sliding on the floor. At 11:35 AM, another CNA wheeled the resident out of the dining room to the weight scale with the tubing dragging on the floor. On 06/17/25 at 01:17 PM, R3 was in her wheelchair in her room, with two to four inches of the catheter tubing on the floor. At 01:30 PM, CNA M washed hands and gloved, but did not don PPE. CNA M set a measuring container on a paper towel on the floor, used an alcohol wipe on the spigot, emptied the catheter bag, wiped the spigot with alcohol again, and placed the catheter bag back into the privacy bag. CNA M measured the urine, emptied it into the toilet. She bagged the container, took it to the soiled utility room, and rinsed it. She placed the container in a bag in the resident's bathroom. At this time, the tubing was not on the floor. CNA M verified that she should have worn PPE. On 06/17/25 at 02:46 PM, Administrative Nurse D verified staff were supposed to wear PPE while providing catheter care and ensure the tubing was off the floor. The facility's Urinary Catheter Care policy, dated August 2022, directed staff to be sure the catheter tubing and drainage bag are kept off the floor.

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required in the treatment cart, when staff failed to place an open date on Resident (R) 7 Humalog insulin vial (a small, glass container that holds a liquid solution of insulin lispro, a fast-acting insulin used to manage blood sugar levels in people with diabetes ) and Lantus pen (a prefilled, disposable injection device containing insulin a long-acting insulin used to manage blood sugar levels in people with diabetes). This placed the resident at risk for receiving an expired and ineffective dose of insulin. Findings included: - On [DATE] at 09:00 AM, observation revealed in the treatment cart R7's undated to when opened Humalog insulin vial and Lantus pen. On [DATE] at 09:00 AM, Licensed Nurse (LN) G verified the above finding and stated staff should date the insulin pen and vial when they open it. On [DATE] at 11:34 AM, Administrative Nurse D stated staff should label and date an insulin pen and vial when they open them. The facility's Insulin Administration Policy, revised [DATE], documented staff were to check the expiration date if drawing from an opened multi-dose vial. If opening a new vial, record the expiration date and time on the vial.

The facility had a census of 21 residents. Based on observation, interview, and record review, the facility failed to use proper infection control practices when they failed to don personal protective equipment (PPE- gloves and gowns) when providing catheter care for Resident (R) 3 and failed to change gloves between soiled and clean areas during incontinent cares for R5. Findings included: - On 06/17/25 at 01:17 PM, R3 was in her wheelchair in her room, with two to four inches of the catheter tubing on the floor. At 01:30 PM, CNA M washed hands and gloved, but did not don PPE. CNA M set a measuring container on a paper towel on the floor, used an alcohol wipe on the spigot, emptied the catheter bag, wiped the spigot with alcohol again, and placed the catheter bag back into the privacy bag. CNA M measured the urine and emptied it into the toilet. She bagged the container, took it to the soiled utility room, and rinsed it. She placed the container in a bag in the resident's bathroom. At this time, the tubing was not on the floor. CNA M verified that she should have worn PPE. On 06/17/25 at 02:46 PM, Administrative Nurse D verified that staff were supposed to wear PPE while providing catheter care and ensure the tubing was off the floor. The facility's Enhanced Barrier Precautions policy, dated December 2024, stated Enhanced Barrier Precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multidrug-resistant organisms (MDROs) during high-contact resident care activities. Enhanced barrier precautions apply when caring for an indwelling device (catheter). - R5's Electronic Medical Record (EMR) documented that R5 had a diagnosis of overactive bladder (a condition characterized by frequent, sudden urges to urinate that can be difficult to control and may lead to involuntary urine leakage). R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R5 had a Brief Interview of Mental Status (BIMS) score of two, which indicated severe cognitive impairment. The MDS documented R5 was dependent with toileting and was frequently incontinent of urine and bowel. R5's Care Plan, revised 05/03/25 care plan-, documented R5 required one staff assistance with toileting. The plan instructed staff to provide R5 perineal (private area) with each incontinent episode. On 06/16/25 at 12:42 PM, observation revealed the resident sat on the toilet, Certified Nurse Aide (CNA) N applied gloves, removed a wet incontinent brief, then with the same soiled placed a new incontinent brief on R5. Continued observation revealed CNA N with the same soiled gloves placed R5's house slippers on, cue and assisted R5 with a gait belt to stand, provided perineal care. CNA N with the same soiled gloves, pulled up the resident's incontinent brief, pants, pulled her shirt bottom over her pants, then removed and discarded gloves. On 06/16/25 at 02:14 PM, CNA N verified she had not changed her gloves after providing perineal care for R5 and stated she should have. On 06/18/25 11:36 AM, Administrative Nurse D stated staff should change gloves whenever they touch something dirty during incontinent care. Upon request, the facility failed to provide a change of gloves during the incontinent care policy.

The facility identified a census of 43 residents with three residents reviewed for pressure ulcers. Based on record review and interview, the facility failed to identify, monitor, and provide appropriate treatments and interventions, to prevent pressure ulcers from worsening and prevent infection for Resident (R) 1. R1 admitted to the facility on [DATE] with a Stage 3 pressure ulcer (full thickness pressure injury extending through the skin into the tissue below) on his coccyx (area at the base of the spine). Nursing staff did not perform consistent wound assessments to include measurements and presence of infection. On [DATE], 81 days after admission, R1's wound had worsened and had foul-smelling yellow drainage. A wound culture recorded R1 had Methicillin-Resistant Staphylococcus Aureus (MRSA-a type of bacteria resistant to many antibiotics) and Escherichia coli (E. coli-bacteria commonly found in the lower intestine that had a potential for causing infections in the urinary tract with inadequate incontinence care) in the wound, and Consultant GG ordered a new treatment and started R1 on an antibiotic, Doxycycline. R1's Electronic Medical Record (EMR) alerted staff that the LiquaCel powder, used in R1's wound treatment, would interfere with the absorption of the antibiotic, but staff did not notify the providers, so no action was taken. On [DATE] a diagnostic scan of R1's abdomen and pelvis revealed sacral osteomyelitis (local or generalized infection of the bone and bone marrow). R1 had new order for intravenous (IV-administered directly into the bloodstream via a vein) and oral antibiotics. The wound consultant team saw R1 on Fridays and gave new orders for daily wound dressing changes. The facility nursing staff did not follow the orders regarding the wound dressing changes as Consultant GG issued multiple warning to staff to ensure the AG rope (used to absorb drainage and promote wound healing) was out of the wound. There were multiple occasions when the wound dressing was not performed as ordered due to unavailable wound supplies. The wound continued to worsen and on [DATE] was recorded as a Stage 4 pressure ulcer (a deep pressure wound that reaches the muscles, ligaments, or even bone) with exposed bone. On [DATE] R1's wound erupted with uncontrollable bleeding and R1 was sent to the local Emergency Department. R1 then transferred to a higher level of care and admitted to the hospital with sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body) and dehydration. R1 died on [DATE]. The facility failure to provide appropriate pressure reducing interventions, failure to consistently monitor R1's wounds and assess and address signs of infection, failure to involve the physician when needed, and failure to provide appropriate wound care services and treatments including ensuring availability of treatment supplies, placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Stage 3 pressure ulcer, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), metastatic lung cancer, hypertension (high blood pressure), and hyperlipidemia (condition of elevated blood lipid levels). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not completed for R1. The MDS documented R1 did not have an altered level of consciousness, disorganized thinking, or inattention. The MDS documented R1 required substantial staff assistance with toileting, bathing, dressing, bed mobility, and transfer. The MDS documented R1 had not received scheduled pain medication, as needed pain medication, or any non-medication interventions for pain. During the pain interview, R1 stated he had the presence of pain, but the rest of the interview was not completed. The MDS documented R1 was at risk for developing pressure ulcers and had a Stage 3 pressure ulcer that was present on admission. The MDS documented R1 received a pressure reducing device for his bed, was not on a turning/repositioning program, did not have nutrition or hydration interventions to manage skin problems, was receiving pressure ulcer care and applications or nonsurgical dressing other than to his feet. The Quarterly MDS, dated [DATE], documented R1 had a Brief Interview for Mental Status score of five which indicated severely impaired cognition. The MDS documented R1 had impairment on both sides of his lower extremities. The MDS documented R1 was dependent on staff for oral hygiene, toileting hygiene, bathing, lower body dressing, putting on and taking off footwear, and personal hygiene. R1 required substantial staff assistance for rolling left to right, sitting to lying, lying to sitting, transfers, and ambulation. The MDS documented R1 had not received scheduled pain medication, as needed pain medication, or any non-medication interventions for pain. During the pain interview, R1 stated he had occasional pain during the look back period that was moderate in strength. The MDS documented R1 was at risk of developing pressure ulcers and currently had a Stage 4 pressure ulcer that was not present on admission. The MDS documented R1 had a pressure reducing device for his bed, a pressure reducing device for his bed, was not on a turning/repositioning program, had nutrition or hydration interventions to manage skin problems, received pressure ulcer care, and had application of ointments/medication other than to his feet. The Nutrition Care Area Assessment (CAA), dated [DATE], documented R1 admitted with a Stage 3 pressure injury to his coccyx and a deep tissue injury to his right heel. On admission R1 reported stabbing pain to his coccyx. The Pressure Ulcer/Injury CAA, dated [DATE], documented R1 had a Stage 3 pressure injury to his coccyx and deep tissue injury to his heel. The CAA documented R1 had bowel incontinence and required extensive assistance with bed mobility. R1 was on a Sizewise (a specialized mattress for pressure relief) mattress and was at risk for unidentified pain. R1's Care Plan directed staff R1 required extensive assistance of one to two staff for bed mobility and staff were to turn/reposition R1 every two hours in bed ([DATE]). R1 required an air mattress on his bed and cushions in his recliner and wheelchair ([DATE]). R1 required weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate ([DATE]). R1 needed to be reminded to turn/reposition at least every two hours ([DATE]). R1 had acute pain related to pressure injury to the sacrum and R1 would verbalize adequate relief of pain. Staff were to monitor and document side effects of pain medication and report to the nurse any changes in usual activity attendance patterns related to signs or symptoms or complaints of pain or discomfort. ([DATE]). The Admitting Hospital Wound Care Note, dated [DATE], documented R1's pressure ulcer was present on admission to the hospital. R1's coccyx wound measured 2.2 centimeters (cm) by 3.7 cm by 0.2 cm, with 60% granulation tissue and 40% slough (dead tissue, usually cream or yellow in color). The Braden Scale for Predicting Pressure Sore Risk, dated [DATE], documented R1's risk score was 15, which indicated at risk. R1's was chairfast, skin was very moist, and noted friction and shear was a potential problem. The Admission Data Collection, dated [DATE], documented R1 had a Stage 3 pressure ulcer but no measurements were taken. A pressure reducing device for R1's bed would be used, R1's heels would be floated, and a turning and repositioning program would be implemented. The Admission Note, dated [DATE], documented R1 admitted on [DATE] at 02:00 PM with the admitting diagnosis of malignant tumor of the lung. R1 was weak but could walk twenty feet. R1's speech and vision were good but R1 was hard of hearing. R1 admitted with a Stage 3 pressure ulcer to his buttock, was a fall risk due to weakness, shown how to use the call light, and educated to wait for assistance to avoid a fall. The Advance Care Planning Note, dated [DATE], documented R1 was at the facility to gain strength after losing weight and strength from chemotherapy. R1 would participate in physical therapy and occupational therapy. R1's goal was to gain weight and strength so he could continue chemotherapy and return home. The Wound Daily Observation Note, dated [DATE], documented R1 had a foam dressing in place. The wound margin was pink and R1 denied pain. The wound did not have any drainage and the wound bed had pink epithelial tissue. The note documented the primary care provider was aware. The Wound Daily Observation Note, dated [DATE], documented R1's foam dressing was intact but had bowel movement in it, so it was removed. The wound was cleansed with normal saline and baby shampoo and rinsed. Skin prep (liquid skin protectant) was applied around the outer skin. Aquacel (a wound dressing) was placed into the wound and a foam dressing placed to cover the wound. The center of the wound was red with active bleeding. The old dressing had a moderate amount of yellow drainage and no odor. R1 denied pain. The wound bed was not assessed. R1's primary care provider was not notified. The Wound Daily Observation, dated [DATE], documented R1's dressing was removed, there was bowel movement in the wound, and the surrounding skin was red. R1 denied pain. The wound had fresh bleeding from the wound. Staff cleansed the wound with normal saline and baby shampoo, rinsed, applied skin prep to the surrounding skin, applied Aquacel, and covered with a foam dressing. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was changed and there was bowel movement in the dressing. The surrounding skin was red. There was no pain noted with the dressing change. A small amount of yellow/red drainage was noted. The wound bed was covered with s. The wound was cleaned with normal saline and baby shampoo, rinsed, skin prep applied to the surrounding skin, Aquacel applied, and covered with a foam dressing. R1's primary care provider was not notified of changes. The Consultant Note, dated [DATE], documented R1 was a new admission with a Stage 3 pressure ulcer to his sacrum (large triangular bone/area between the two hip bones). Consultant HH recommended four ounces of fortified juice at breakfast and an eight-ounce protein shake in the afternoon along with a multivitamin and Vitamin C 500 milligrams (mg) twice a day. R1's estimated calorie needs for healing were 2200 to 2500 calories. The Wound Daily Observation Note, dated [DATE], documented R1's wound treatment was completed per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. No drainage was noted. The wound bed was not assessed. The note lacked notification of the changes to R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented the dressing was changed per R1's primary care provider's order. The skin around the wound was not assessed. No pain was noted during dressing change. Staff were unable to tell if there was drainage as R1 had bowel movement underneath the dressing. The wound bed had granulation (new tissue formed during wound healing). The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was changed per his primary care provider's orders. Skin surrounding the wound was red. R1 had no complaints of pain. A moderate amount of yellow drainage was noted without odor. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 4 cm by 2 cm by 0.5 cm. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was left in place because the dressing did not need changed. Staff documented R1's dressing was clean dry and intact and not changed because it was changed yesterday. (R1's dressing change order directed staff to change R1's dressing daily) The Wound Daily Observation Note, dated [DATE], documented R1's dressing was changed per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. There was yellow drainage with active bleeding and the wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was changed per his primary care providers orders. The skin surrounding the wound was red and staff noted a little old blood on the old dressing. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE] documented a new dressing was applied to R1's wound. The skin surrounding the wound was pink. R1 denied pain. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Skin Observation Tool dated [DATE] documented R1 had a Stage 3 decubitus ulcer (localized skin and tissue injuries that occur when the blood supply to the skin is cut off for more than two to three hours) to his coccyx which measured 3 cm by 1 cm by 0.7 cm. The Nutrition Note, dated [DATE], documented R1 would be receiving six-ounce house supplements with meals. The note included the mid-afternoon supplement shake was going untouched as R1 was always napping. The Wound Daily Observation Note, dated [DATE], documented R1 did not have a dressing to his coccyx. The treatment was done per doctor's orders. The skin surrounding the wound was red. R1 denied pain. No drainage or odor noted. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 2.5 cm by 0.5 cm by 0.4 cm. The Wound Daily Observation Note, date [DATE], documented R1 did not have a dressing in place to his coccyx. A new dressing was applied per doctor's orders. The skin surrounding the wound was red. R1 denied pain. No drainage or odor noted. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented there was a band-aid on R1's wound. The skin surrounding the wound was red. R1 denied pain. The wound bed was red, with no drainage or odor noted. The note included R1's primary care provider did not need to be notified at that time. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 2.5 cm by 0.7 cm by 0.5 cm. The Wound Daily Observation Note, dated [DATE], documented R1 did not have a dressing in place on his coccyx. Treatment to R1's Stage 3 decubitus ulcer done per doctor's orders. The skin surrounding the wound was red, with no drainage or odor noted, and R1 denied pain. The wound bed had some granulation tissue noted. R1's primary care provider was not notified. The Order Note, dated [DATE], documented R1 was to start LiquaCel (a liquid protein supplement) twice a day for wound healing assistance. The Wound Daily Observation Note, dated [DATE], documented R1's dressing to his coccyx was intact. A new dressing was applied per doctor's orders. The skin surrounding the wound was pink. A moderate amount of yellow drainage was noted. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 5 cm by 3 cm. The Wound Daily Observation Note, dated [DATE], documented there was no dressing to R1's coccyx wound. Dressing change was performed per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. There was no drainage or odor noted. The wound bed had granulation tissue. The note lacked notification of R1's primary care provider. The Skin Observation Tool, documented R1's coccyx wound measured 4 cm by 2 cm. The Wound Daily Observation Note, dated [DATE], documented R1 had no dressing to his coccyx. A new dressing was applied per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. The wound bed had granulation tissue and no drainage or odor. The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented R1 had no dressing to his coccyx. Treatment was performed per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. The wound bed had granulation tissue with no drainage or odor noted. The note lacked notification of R1's primary care provider. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound was deep and measured 4 cm by 2 cm. The Wound Daily Observation Note, dated [DATE], documented R1 did not have a dressing to his coccyx. The treatment was done per doctor's orders. The skin surrounding the wound was pink. R1 denied pain. There was no drainage or odor noted. The wound bed had slough. The note lacked notification of R1's primary care provider. The Wound Daily Observation Note, dated [DATE], documented R1 had no dressing in place to his coccyx. The treatment was done per doctor's orders. The skin surrounding the wound was red. R1 denied pain. No drainage or odor was noted. The wound bed was not assessed. R1's primary care provider was not notified. The Skin Observation Tool, dated [DATE], documented R1 had an open sore on his coccyx and was healing slowly. The [DATE] Health Status Note documented R1 felt warm during rounds. R1's temperature was 100.5 degrees Fahrenheit (F) and staff administered 1000 milligrams (mg) of Tylenol (a fever reducing medication) to R1. The Daily Wound Observation Note, dated [DATE], documented R1's dressing was intact and changed. The skin surrounding the wound was pink. There was a moderate amount of thick yellow bloody drainage. The wound bed had slough. The note lacked notification of R1's primary care provider. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 2.5 cm by 0.5 cm with tunneling on the top side that measured 2.5 cm and tunneling on the right side which measured 0.5 cm. The note documented R1 sat in his recliner all day and refused to lay in bed during the day. The note stated the facility faxed R1's primary care provider requesting to send R1 to wound care as R1's wound was tunneling and had heavy drainage. The Daily Wound Observation Note, dated [DATE], documented R1 did not have a dressing in place but the dressing had been changed several times due to drainage. The skin surrounding the wound was red. R1 had pain rated at 8 out of 10, on a zero to ten scale. There was a huge amount of yellow drainage. The wound had 2.5 cm of tunneling at the top of the wound and 0.5 cm of tunneling to the right side of the wound. R1's primary care provider was notified of the change and a fax was sent requesting wound care. The Communication with Physician Note, dated [DATE], documented R1's Stage 3 pressure wound to his coccyx, which he was admitted with on [DATE], was becoming smaller in size. R1's wound had a huge amount of drainage without odor. Tunneling was noted 2.5 cm at the top of the wound and 0.5 cm noted to the right side of the wound. R1 denied pain since his admission but today his pain was rated 8 out of 10. The New Order Fax, dated [DATE], referred R1 to wound care at the hospital for evaluation and treatment for a Stage 3 decubitus ulcer and an order for oxycodone 5 mg by mouth every four hours as needed for coccyx pain. The Wound Daily Observation Note, dated [DATE] documented R1's dressing was saturated with drainage. The dressing was changed. R1's wound measurements to his coccyx measure 3.2 cm by 7 cm with tunneling to the right side of the wound which measured 0.7 cm. There was no pain with the dressing change. There was an excess amount of drainage, and an ABD pad was applied to accommodate the drainage. The drainage was yellow, pus-like drainage. The wound bed contained slough. R1's primary care physician ordered wound care at the hospital. The Wound Daily Observation Note, dated [DATE], documented R1 had gone to the hospital for wound care. The Wound Culture Result, dated [DATE], documented R1's coccyx wound had MRSA and E. coli. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was intact and to be changed every other day and as needed. The dressing change orders included: Flush with 20 milliliters (ml) of quarter strength Dakin's solution (a topical antiseptic made of diluted sodium hypochlorite traditionally used to clean wounds to prevent infection), Flush with 20 ml normal saline, Aquacel AG rope (a wound dressing) into the wound bed, fluff 4 by 4's (gauze), apply XTRASORB (a super absorbent dressing), and secure with Mefix (skin friendly dressing retention tape). The Wound Daily Observation Note, dated [DATE], documented R1's dressing to his coccyx was intact. No dressing change needed as the dressing was change last night. The Wound Daily Observation Note, dated [DATE] at 08:45 PM, documented R1's dressing was changed to his coccyx. Erythema (redness) and drainage was noted. R1 stated the pain was terrible when the dressing was being changed. The wound had copious amounts of serosanguinous (semi-thick blood-tinged drainage) and purulent (producing or containing pus) drainage. The existing bandage was fully saturated. When flushed, a large amount of serosanguinous fluid was expelled from the wound. The wound bed had a slight amount of slough and tunneling was noted. Primary care physician had already been notified and R1 was being seen at the wound care. The Order Note, dated [DATE], documented doxycycline hyclate (an antibiotic) 100 mg by mouth twice a day for fourteen days for wound. The EMR system identified a possible drug interaction with LiquaCel Oral Liquid. LiquaCel Oral Liquid could impair the gastrointestinal absorption and decrease the antimicrobial effectiveness of doxycycline hyclate (an oral antibiotic) 100 mg. The facility staff failed to notify R1's primary care provider of the drug interaction. The Wound Daily Observation Note, dated [DATE], documented R1's dressing to his coccyx was changed. The skin surrounding the wound was pink. The wound measured 2.0 cm by 0.8 cm with 2.5 cm of tunneling to the right. R1 was given Percocet (a pain pill) at 11:45 AM. The drainage was greenish in color and there was a large amount of drainage. A small amount of odor noted. The wound bed had slough. R1's primary care provider was not notified as R1 would see wound care on Friday at 01:00 PM. The Skin Observation Tool, dated [DATE], documented R1's coccyx wound measured 2.5 cm by 0.5 cm with tunneling on the top side that measured 2.5 cm and tunneling on the right side which measured 0.5 cm. The note documented R1 would sit in his recliner all day and refused to lay in bed during the day. The Physician Note, dated [DATE], documented R1 saw wound cared for a pressure ulcer to his buttock that was infected with Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics) and Escherichia coli (E. coli-bacteria commonly found in the lower intestine that had a potential for causing infections in the urinary tract with inadequate incontinence care) and was on doxycycline. R1 received dressing changes and there was concern about a fistula (abnormal passage from an internal organ to the body surface or between two internal organs) but the Computed Tomography (CT) scan was negative for this. There were findings of osteomyelitis (local or generalized infection of the bone and bone marrow). The wound care practitioner would speak to family about R1's goals. The Wound Daily Observation Note, dated [DATE], documented the dressing to R1's coccyx was saturated and had to be changed. The skin surrounding the wound was pink and R1 denied pain. Tunneling was noted to be deeper on top and both sides of the wound, with heavy yellow drainage noted. R1 primary care provider did not need to be notified as she saw R1 that day. The Wound Daily Observation Note, dated [DATE], documented R1 did not need a dressing change that day because R1 had been to the hospital for wound care. The Wound Daily Observation Note, dated [DATE], documented R1's coccyx dressing had to be changed because it was saturated. The margin around the wound was red and surrounding tissue was pink. R1 stated he was having some pain, but it was tolerable. The drainage was thick, yellow pus with a strong odor. The wound bed contained slough. R1's primary care physician did not need notified as R1 would go to wound care on Friday. The Wound Data Collection, dated [DATE], documented R1's coccyx wound measured 3.2 cm by 0.9 cm by 2.5 cm with 2.5 cm tunneling to the right side. The note documented R1's wound was worsening. The wound bed has 100% slough. The wound had heavy purulent (producing or containing pus) drainage. Preventative measures were air mattress, ROHO (pressure relief cushion that is made of soft, flexible air cells) cushion to the wheelchair, and LiquaCel with meals. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was intact to his coccyx and the dressing was not changed due to R1 would go to wound care that day. The Health Status Note, dated [DATE], documented new orders from wound care for IV antibiotics, weekly labs, and order for a magnetic resonance imaging (MRI-medical imaging used to view soft tissue). Orders would be faxed later that day. The New Order Fax, dated [DATE], documented new orders for R1's coccygeal osteomyelitis. New orders: Daptomycin (antibiotic) 6 mg/kg IV daily to start [DATE], Augmentin (an oral antibiotic) ,d+[DATE] mg one tab twice a day by mouth for six weeks, pharmacy to contact wound care provider on replacing Daptomycin with Dalvance (antibiotic), contact precautions MRSA/E.coli, and MRI of pelvis with and without IV contrast. The Wound Collection Tool, dated [DATE], documented R1's coccyx wound measured 3.0 cm by 1.2 cm by 2.5 cm with tunneling on the right and left of the wound. R1's wound was worsening. The wound bed was 100% slough. The wound had purulent drainage. The skin surrounding the wound was denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound drainage, or friction). Undermining was identified. The wound was suspected of infection. Preventative measures: air mattress, cushion to chair and wheelchair, LiquaCel with meals, stand to reposition every three hours. The Wound Daily Observation Note, dated [DATE], documented the dressing to R1's coccyx was changed because it was completely soiled with bowel movement and drainage. The wound's margin was red, and the surrounding skin was pink. R1 stated the dressing change was very painful. There was a large amount of purulent drainage with strong odor. The wound bed had slough. R1's primary care provider was not notified as she was already aware and R1 was seen at wound care. The Communication with Physician Note, dated [DATE], documented Consultant GG was called to clarify if he wanted the IV antibiotics started that day. The Augmentin (antibiotic) could be started on the following Monday. The Communication with Family Note, dated [DATE], documented R1's responsible party was called to gain permission to transport R1 to the hospital for IV antibiotics. R1's responsible party was notified Augmentin would be started by mouth on Monday and labs would be done weekly per Consultant GG. The Wound Daily Observation Note, dated [DATE], documented R1's dressing to his coccyx was saturated with drainage and bowel movement. The skin surrounding the wound was pink. R1 had pain present while doing the treatment to his coccyx but refused pain medication. The drainage was cloudy, thin, and yellow with no odor. The wound bed contained slough. Consultant GG was called for clarification of faxed order. IV antibiotics were started that day and oral antibiotic could be started the following Monday when the pharmacy was open. The Order Note, dated [DATE], documented Amoxicillin/Pot Clavulanate (Augmentin/antibiotic) ,d+[DATE] mg one tablet by mouth every twelve hours for coccygeal osteomyelitis for sixteen weeks. The Antibiotic Monitoring Note, dated [DATE], documented R1's appetite had decreased. The Antibiotic Monitoring Note, dated [DATE], documented R1 was on Daptomycin (antibiotic) IV 6 mg per kilogram (kg) that had been started that morning. R1 had decreased fluid and food intake. The Wound Daily Observation Note, date [DATE], documented R1's coccyx dressing was saturated with yellow drainage and bowel movement. The skin surrounding the wound was pink. Some pain noted with dressing change but R1 did not require any pain medication. There was a large amount of thick yellow/bloody drainage without odor. R1's primary care provider was not notified due to R1 went to wound care of Fridays and had daily dressing changes at the facility. The Wound Daily Observation Note, dated [DATE], documented R1's dressing was saturated with drainage and bowel movement and was changed per doctor's orders. The skin surrounding the wound was pink. R1 had noted pain with the dressing change and was compliant with lying on his right side while the dressing was changed. The wound bed had slough. There was a large amount of thick yellow drainage without odor. R1's primary care provider did not need notified due to daily dressing changes at the facility and wound care on Fridays. The Antibiotic Monitoring Note, dated [DATE], documented R1's appetite had decreased, and the primary care provider had not been notified. The Communication with Physician Note, dated [DATE], documented Consultant GG was notified to clarify R1 would take doxycycline that morning then it would be discontinued and would start on amoxicillin ,d+[DATE] mg twice a day thru [DATE] and would continue Daptomycin, 6mg/kg IV daily at the hospital, until the new antibiotic arrived; then Daptomycin would be discontinued and R1 would only have one IV antibiotic weekly. The New Fax Order, dated [DATE], documented R1 would receive Dalvance 1500 mg IV on [DATE] and then in eight days R1 would receive the second dose of Dalvance 1500 mg IV for diagnosis of osteomyelitis of the coccyx. Per the Dalvance website (www.dalvance.com) the medication is used to treat acute bacterial skin and skin structure infections (ABSSSI) caused by designated susceptible strains of Gram-positive microorganisms. The Important safety information header noted Clostridioides difficile-associated diarrhea (CDAD) has been reported with nearly all systemic antibacterial agents, including DALVANCE, with severity ranging from mild diarrhea to fatal colitis. Evaluate if diarrhea occurs. The Antibiotic Monitoring Note, dated [DATE], documented R1 had a decreased appetite and R1's primary care provider was not notified. The Wound Daily Observation Note, date [DATE], documented R1's dressing was intact and saturated with yellowish-greenish drainage and some bowel movement. Staff removed the old dressing, provided treatment, and applied a new dressing. The skin surrounding the wound was pinkish. R1 denied pain. There was a heavy amount of yellowish-green tinged drainage without odor. The wound bed was pinkish with a red center. The facility did not have the packing required for the dressing change. R1's primary care physician was not notified as R1 was seen yesterday at wound care. The At Risk Note, dated [DATE], documented R1 was on LiquaCel twice a day. The Certified Dietary Manager (CDM) requested Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine al[TRUNCATED]

The facility identified a census of 43 residents with three residents reviewed for pain. Based on record review and interview, the facility failed to provide Resident (R) 1 with pain relieving measures prior to or after pressure ulcer dressing changes though R1 had documented pain and demonstrated signs of discomfort during dressing change. This deficient practice resulted in untreated pain for R1 and placed him at risk for continued unnecessary pain and altered psychosocial well-being. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Stage 3 pressure ulcer, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), metastatic lung cancer, hypertension (high blood pressure), and hyperlipidemia (condition of elevated blood lipid levels). The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS), which was not completed. The MDS documented R1 did not have an altered level of consciousness, disorganized thinking, or inattention. The MDS documented R1 required substantial staff assistance with toileting, bathing, dressing, bed mobility, and transfer. The MDS documented R1 had not received scheduled pain medication, as needed pain medication, or any non-medication interventions for pain. During the pain interview, R1 stated he had the presence of pain, but the rest of the interview was not completed. The MDS documented R1 was at risk for developing pressure ulcers and had a Stage 3 pressure ulcer that was present on admission. The MDS documented R1 received a pressure reducing device for his bed, was not on a turning/repositioning program, did not have nutrition or hydration interventions to manage skin problems, was receiving pressure ulcer care and applications or nonsurgical dressing other than to his feet. The Quarterly MDS, dated [DATE], documented R1 had a Brief Interview for Mental Status score of five which indicated severely impaired cognition. The MDS documented R1 had impairment on both sides of his lower extremities. The MDS documented R1 was dependent on staff for oral hygiene, toileting hygiene, bathing, lower body dressing, putting on and taking off footwear, and personal hygiene. R1 required substantial staff assistance for rolling left to right, sitting to lying, lying to sitting, transfers, and ambulation. The MDS documented R1 had not received scheduled pain medication, as needed pain medication, or any non-medication interventions for pain. During the pain interview, R1 stated he had occasional pain during the look back period that was moderate in strength. The MDS documented R1 as at risk for developing pressure ulcers and currently had a Stage 4 pressure ulcer that was not present on admission. The MDS documented R1 had a pressure reducing device for his bed, a pressure reducing device for his bed, was not on a turning/repositioning program, had nutrition or hydration interventions to manage skin problems, received pressure ulcer care, and had application of ointments/medication other than to his feet. The Nutrition Care Area Assessment (CAA), dated 06/23/23, documented R1 was admitted with a Stage 3 pressure injury to his coccyx (area at the tailbone) and a deep tissue injury to his right heel. On admission R1 reported stabbing pain to this coccyx. The Pressure Ulcer/Injury CAA, dated 06/23/23, documented R1 had a Stage 3 pressure injury to his coccyx and deep tissue injury to his heel. The CAA documented R1 had bowel incontinence and required extensive assistance with bed mobility. R1 was on a Sizewise (a specialty mattress that provides active pressure redistribution) mattress and was at risk for unidentified pain. R1's Care Plan directed staff to know R1 required extensive assistance of one to two staff for bed mobility and staff were to turn/reposition R1 every two hours in bed (06/19/23). R1 required an air mattress on his bed and cushions in his recliner and wheelchair (09/15/23). R1 required weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (09/15/23). R1 needed to be reminded to turn/reposition every at least every two hours (09/15/23). R1 had acute pain related to pressure injury to the sacrum and R1 would verbalize adequate relief of pain. Staff were to monitor and document side effects of pain medication and report to the nurse any changes in usual activity attendance patterns related to signs or symptoms or complaints of pain or discomfort. (06/19/23). The New Order Fax, dated 09/05/23, ordered for a referral for R1 to wound care at the hospital for evaluation and treatment for Stage 3 pressure ulcer and an order for oxycodone (narcotic opioid pain medication) 5 mg by mouth every four hours as needed for coccyx pain. The Daily Wound Observation Note, dated 09/05/23, documented R1 did not have a dressing in place but the dressing was changed several times due to drainage. The skin surrounding the wound was red. R1 rated his pain an eight on a 0-10 scale (zero being no pain and 10 the worst pain imaginable). There was a huge amount of yellow drainage from the wound. The wound had tunneling present, which measured 2.5 cm at the top of the wound and 0.5 cm of tunneling to the right side of the wound. R1's primary care provider was notified of the change and the facility sent a fax requesting wound care. The Wound Daily Observation Note, dated 09/10/23 at 08:45 PM, documented staff changed R1's dressing to his coccyx and noted erythema (redness) and drainage. R1 stated the pain was terrible when staff changed the dressing. There were copious amounts of serosanguinous (semi-thick blood-tinged drainage) and purulent (producing or containing pus) drainage. The existing bandage was fully saturated. When flushed, a large amount of serosanguinous fluid expelled from the wound. The wound bed had a slight amount of slough and tunneling was noted. The resident's primary care physician was already notified and R1 was being seen at the hospital for wound care. R1's MAR, dated September 2023, documented staff did not administer pain medication to R1 until after the dressing change on 09/14/23. The Wound Daily Observation Note, dated 09/16/23, documented staff changed the dressing to R1's coccyx because it was completely soiled with bowel movement and drainage noted to the area. The wound's margins were red, and the surrounding skin was pink. R1 stated the dressing change was very painful. There was a large amount of purulent drainage noted with strong odor from the wound. The wound bed had slough present. R1's primary care provider was not notified as she was already aware and R1 was seen at the hospital for wound care. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/16/23. The Wound Daily Observation Note, date 09/17/23, documented R1's coccyx dressing was saturated with yellow drainage and bowel movement. The skin surrounding the wound was pink. R1 had some pain noted with the dressing change, but R1 did not require any pain medication. There was a large amount of thick yellow/bloody drainage without odor from the wound. R1's primary care provider was not notified due to R1 went to wound care of Fridays at the hospital and had daily dressing changes at the facility. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/17/23. The Wound Daily Observation Note, dated 09/18/23, documented R1's dressing was saturated with drainage and bowel movement and was changed per doctor's orders. The skin surrounding the wound was pink. R1 had pain with the dressing change and was compliant with lying on his right side while staff changed the dressing. The wound bed had slough present and there was a large amount of thick yellow drainage without odor noted from the wound. R1's primary care provider did not need notified due to daily dressing changes at the facility and wound care at the hospital on Fridays. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/18/23. The Wound Daily Observation Note, dated 09/20/23, documented R1's coccyx dressing was intact but was saturated through the dressing. Staff completed a dressing treatment per doctor's orders. The skin surrounding the wound was a normal pink color. R1 denied pain but jumped a few times while staff completed the treatment. There was a copious amount of light brown, thick, slimy drainage without odor from the wound. The wound bed center was red and had slough present. Tunneling was noted upward and on both sides of the wound. R1's primary care provider was not notified. T R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/20/23. The Wound Daily Observation Note, dated 09/20/23, documented R1's coccyx dressing was changed due to being saturated with bowel and urine. The skin surrounding the wound was pink. R1 verbalized pain during the dressing change but then stated it was ok once staff completed the dressing change. There were copious amounts of yellow and brown tinged discharge with a foul smell from the wound. The wound bed was red with slough and tunneling present. R1's primary care physician was not notified. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/20/23. The Wound Daily Observation Note, dated 09/23/23, documented R1's coccyx dressing was saturated with a large amount of drainage and was changed per doctor's orders. The skin surrounding the wound had undermining present. R1 voiced some pain with the dressing change. There was a large thick amount of slimy brown drainage from the wound. The wound bed had slough present with a bright red center. R1's primary care provider was not notified. Wound care gave new dressing orders on 09/22/23. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/23/23. The Wound Daily Observation Note, dated 09/23/23, documented R1's coccyx dressing was completely saturated and soiled with bowel. The dressing change was completed. The skin around the wound had undermining. R1 had pain with the dressing change. There was thick yellow and brown slimy drainage with a foul odor. The wound bed had slough present with a red center. Staff removed e 45 cm of the existing AG rope (a packing to help absorb moderate to heavy amounts of wound drainage) was and packed 45 cm of new AG rope into the wound. R1's primary care provider was not notified. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/23/23. The Wound Daily Observation Note, dated 09/24/23, documented R1's coccyx dressing was soiled with bowel movement present. Staff changed R1's dressing. Undermining was noted to the wound. R1 had pain with the dressing change. There was thick brown slimy discharge from the wound, which was foul smelling. The wound bed had slough with a bright red center present. R1's primary care provider was not notified as she was already aware. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/24/23. The Wound Daily Observation Note, dated 09/25/23, documented R1's coccyx dressing was intact, old dressing removed, and treatment done with a new dressing in place. The skin surrounding the wound was pink. R1 had pain while the treatment was performed. There was a heavy amount of thick brownish drainage with some odor present. The wound bed had undermining and slough. R1's primary care provider was not notified as she was already aware. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/25/23. The Wound Daily Observation Note, dated 09/26/23, documented R1's coccyx dressing was intact but soiled. The old dressing was removed, and treatment done per order. The skin surrounding the wound was pink. R1 had pain with the treatment. There was a copious amount of thick brown drainage with a foul odor. The would bed had undermining, slough, and was red. During the dressing change 45 cm of AG rope was removed from the wound. No AG rope was inserted into the wound as there was no AG rope available. An AG pad was placed on the wounds entrance. R1's primary care provider was not notified as she was already aware. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/26/23. The Wound Daily Observation Note, dated 09/26/23, documented R1's coccyx dressing was intact. The old dressing was removed, and a new dressing was applied without the AG rope as the facility was out. The skin surrounding the wound was pink. R1 had pain in his coccyx with the dressing change. There was a large amount of dark brown fluid that was very odorous. The wound bed had slough. R1's primary care provider was not notified due to R1 receiving daily dressing changes at the facility and weekly wound care at the hospital. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/26/23. The Wound Daily Observation Note, dated 09/27/23, documented R1's coccyx dressing was intact but saturated with drainage. Staff completed a treatment and applied a new dressing. The skin surrounding the wound was undermining. R1 had intermittent pain during the dressing change. There was a large amount of serosanguineous drainage that was thick and slimy and without odor from the wound. The wound bed had approximately fifty percent granulation tissue. R1's primary care provider was not notified because she was already aware. R1's MAR, dated September 2023, documented R1 was not given any pain medication on 09/27/23. The Wound Daily Observation, dated 10/04/23, documented R1's coccyx dressing was intact but saturated with drainage. Staff completed the treatment per doctor's orders with a new dressing in place. The skin surrounding the wound was pink. R1 denied pain but flinched during the treatment. The wound bed had slough and tunneling present. There was a moderate amount of thick brownish slimy discharge from the wound. R1's wound culture results noted R1 was negative and no longer needed to be in isolation. R1's MAR, dated October 2023, documented R1 was not given pain medication before or after the dressing change on 10/04/23. The Wound Daily Observation, dated 10/05/23, documented R1's coccyx dressing was intact and was changed. The skin surrounding the wound was beefy red. R1 had pain with the dressing change. There was a large amount of thick brown fluid with some odor. The wound bed had slough. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/05/23. The Wound Daily Observation Note, dated 10/07/23, documented R1's dressing was intact and was changed. The skin surrounding the wound was beefy red. R1 had pain with the dressing change. There was a copious amount of thick dark brown fluid with odor from the wound. The wound bed had slough. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/07/23. The Wound Daily Observation Note, dated 10/08/23, documented R1's coccyx dressing was intact but saturated and removed and a new dressing was applied. The skin surrounding the wound had exposed subcutaneous tissue that was beefy red and erythematous with fifty percent granulation tissue present. R1 had pain with the dressing change. The wound bed had slough. R1's primary care provider was not notified because R1 went to weekly wound care at the hospital on Fridays. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/08/23. The Wound Daily Observation Note, dated 10/10/23, documented R1's dressing was intact, saturated, and changed. The skin surrounding the wound had exposed subcutaneous tissue with erythema and fifty percent granulation tissue present. R1 had increased pain with the placement of the Aquacel rope. There was a copious amount of thick brown drainage. The wound bed had slough. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/10/23. The Wound Daily Observation Note, dated 10/12/23, documented R1's coccyx dressing was changed per orders. The skin surrounding the wound was light pink. R1 cussed and moaned when his wound was packed. There was a large amount of brownish liquid drainage. The wound bed was not assessed. R1's primary care provider already aware. R1's MAR, dated October 2023, documented R1 was not given pain medication before or after the dressing change on 10/12/23. The Wound Daily Observation Note, dated 10/13/23, documented R1 had a shower that day and R1's dressing was changed. The ulcer border had undermining and was beefy red. R1 had increased pain with the dressing change to his sacral region. There was an excessive amount of thick, brownish bloody drainage with odor noted from the wound. The wound bed had slough present. R1's primary care provider was not notified because R1 went to wound care that day at the hospital. The Wound Daily Observation Note, dated 10/15/23, documented R1's coccyx dressing was intact but soiled and changed per doctor's orders. The skin surrounding the wound was beefy red. R1 voiced pain with the dressing change. There was a large amount of thick brownish bloody drainage with some odor noted from the wound. The wound bed had slough present. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/13/23. The Wound Daily Observation Note, dated 10/17/23, documented R1's coccyx dressing was intact but soiled and was changed per doctor's orders. The skin surrounding the wound was red. R1 had pain with the dressing change. There was thick drainage with odor present. The wound bed had slough. An AG rope was used with the dressing change. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/17/23. The Wound Daily Observation Note, dated 10/19/23, documented R1's coccyx dressing was changed, and staff was unable to find the AG rope inside R1's wound. R1 was very agitated with the dressing change. R1 moaned a lot during the dressing change and fought with cares and tried hitting at the nurse. There was brownish colored drainage present from the wound. The wound bed was not assessed. R1's primary care provider was already aware. R1's MAR, dated October 2023, documented R1 was not given any pain medication before or after the dressing change on 10/19/23. The Wound Daily Observation Note, dated 10/22/23, documented R1's coccyx dressing was intact but soiled. The dressing was changed per orders. The wound margin showed the ulcers border was undermining and red. R1 had pain with the dressing change and did not tolerate the dressing change well. There was slimy brown malodorous drainage from the wound. The wound bed had slough present. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/22/23. The Wound Daily Observation Note, dated 10/23/23, documented R1's coccyx dressing was intact but saturated from drainage. The treatment was done per orders. The wound margin was undermining. R1 had sharp pain rated an eight while Aquacel (a wound dressing) was being placed inside the tunnel. There was a heavy amount of slimy brownish drainage with odor noted from the wound. The wound bed had slough. R1's primary care provider was not notified as R1 was seen by provider every Friday in wound care. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/23/23. The Wound Daily Observation Note, dated 10/24/23, documented R1's coccyx dressing was soiled and changed. The wound margin was red with undermining. R1 had pain with the dressing change. There was a large amount of thick brown drainage. The wound bed had slough. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/24/23. The Wound Daily Observation Note, dated 10/25/23, documented R1's coccyx dressing was soiled and changed. The wound margin was red and tunneling. R1 complained of pain to the sacral area with the dressing change. There was thick brown drainage present from the wound. The wound bed had slough present. Two AG ropes were used in dressing R1's wound. R1's primary care provider was not notified. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/25/23. The Wound Daily Observation Note, dated 10/26/23, documented R1's coccyx dressing was intact but saturated and leaking drainage from the wound site. Staff completed the wound treatment per doctor's orders. The wound margin had undermining. R1 had pain during the dressing change. There was a large amount of brown drainage with some odor noted from the wound. The wound bed had slough present. R1's primary care provider was not notified as provider would observe the next day. R1's MAR, dated October 2023, documented R1 was not given any pain medication on 10/26/23. The Wound Daily Observation Note, dated 11/14/23, documented R1's coccyx dressing was soiled and removed. Staff completed the treatment per doctor's order. The wound margin was pink and undermining. R1 had pain with the dressing change and did not tolerate the dressing change well. R1 continued to try to roll onto his back. There was a moderate amount of brown slimy drainage from the wound. The wound bed had slough and undermining present. R1's MAR, dated November 2023, documented R1 was not given any pain medication on 11/14/23. On 04/02/24 at 12:30 PM, Licensed Nurse (LN) G stated R1 would refuse to lay down in bed and would sit in his recliner all day. LN G stated R1 always denied pain during dressing changes. LN G stated she could not recall if R1 was on a turning/repositioning program. On 04/02/24 at 02:30 PM, Administrative Nurse D agreed that all interventions to prevent R1's pressure ulcer from worsening were not in place on R1's admission to the facility. Administrative D was unaware R1 was not administered pain medication before or after dressing changes. The facility's Pain Policy, revised October 2022, documented the purposes of this procedure are to help the staff identify pain in the resident, develop interventions that are consistent with the residents' goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and the resident's choices related to pain management. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain, recognizing the presence of pain, identifying characteristics of pain, developing, and implementing approaches to pain management, Identifying, and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The facility failed to provide R1 with pain relieving measures prior to or after pressure ulcer dressing changes though R1 had documented pain and demonstrated signs of discomfort during dressing change. This deficient practice resulted in untreated pain for R1 and placed him at risk for continued unnecessary pain and altered psychosocial well-being.

The facility had a census of 24 residents. The facility identified one main kitchen. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for the 24 residents who resided in the facility and received their food from the facility kitchen, when facility failed to ensure clean and sanitary food prep areas. The facility kitchen staff failed to label and date food in the kitchen refrigerator and freezer. This placed the 24 residents, who resided at the facility and received food from the facility kitchen at risk for receiving foodborne illness. Findings included: - On 09/25/23 at 11:25 AM, observation in the kitchen revealed the following in the two-door silver refrigerator: unlabeled and undated plastic bags of lettuce aproximately three-quarters full, unlabeled and undated five pound (lb) bag of grated cheddar cheese, and unlabeled and undated plastic bags with four hard boiled eggs. The white upright freezer had the following unlabeled and undated food items: a plastic bag with four pork fritter patties, a 22.75 ounce bag of country gravy mix one-quarter full, two (30 oz) bags of chicken breast nuggets, a plastic bag with nine sausage patties, two plastic bags of tator tots one bag of French fries all aproximately three-quarters full. The freezer also contained undated half full plastic bags of fried okra, sweet potato fries, and chicken strips as well as a bag with three breaded fish squares. Inside the freezer door compartment was an unsealed bag of chicken nuggets aproximately one-quarter full On 9/25/23 at 11:36 AM, Certified Dietary Manager (CDM) BB verified the above finding and stated staff should label and date all open food items before placing them in the refrigerator or freezer. CDM BB stated staff were bad about not labeling and dating food items due to the fact the food items were used up very quickly. CDM BB discarded the above food items in a trash can. On 09/26/23 at 10:30 AM, observation revealed in the kitchen the following unlabeled, undated food items in the white upright freezer: a bag of smiley fries, a bag of meat balls one-quarter full, a bag of french fries one half full and an unsealed bag of breaded mushrooms aporximately half full. On 09/26/23 at 10:30 AM observation revealed the flour and sugar bins were unlabeled and undated. On 09/26/23 at 10:30 AM, observation revealed during the preparation of the pureed diets, Dietary Staff (DS) CC applied gloves then touched the oven, counter, and her blouse. DS CC then used the same contaminated gloved right hand to transfer the beef tips and noodles from one container to another, then picked up four rolls and placed them in a blender with same soiled gloves. on 09/26/23 at 03:30 PM. CDM BB verified the above findings and stated staff should label and date food when opened and food items should be in a sealed bag. CDM BB stated staff should not use their gloved hands to transfer food items from one container to another or when picking up rolls, they should use utensils. The facility's Food Preparation and Service Policy, revised November 2022, documented food and nutrition services employees would prepare, distribute and serve food in a manner that complies with safe food handling practices. The facility's Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised November 2022, documented food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The policy instructed staff to conduct hand washing/hand hygiene during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks The policy instructed staff to discard gloves after completing the task for which they are used. The facility failed to prepare, store, and serve food in accordance with professional standards for food service safety. This placed the 24 residents who resided at the facility and received food from the facility kitchen at risk for receiving foodborne illness.

The facility had a census of 24 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2022 Quarter 4 and FY 2023 Quarters 1 and 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (51) dates. Review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 09/25/23 at 10:00AM, observation revealed a registered nurse on duty in the facility. On 09/27/23 at 08:00AM, Administrative Staff A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Reporting Payroll Based Data Journal policy, dated 08/2022, states complete, and accurate direct care staffing information is to be reported electronically and, in the uniform, specified by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 24 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 09/28/23 at 10:00AM, review of the facility's Quality Assurance Performance Improvement (QAPI) meeting attendance sheets lacked signatures of attendees/committee members on the sheets. The sheets had just typed names of who was expected to attend the quarterly meetings. On 09/28/23 at 10:15AM, Administrative Staff A stated the facility does not have members of the QAPI team sign in when they have attended the meeting. The facility's Quality Assurance& Performance Improvement Policy, dated 03/2022, documented it was the facility policy each resident and/or patient received the necessary care to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the resident's comprehensive assessment and plan of care. The QAPI program sets care protocols and implements mechanisms for evaluating compliance with those protocols in accordance with the guidance provided by the Centers of Medicare & Medicaid Services (CMS). the plan was data driven, proactive approach to improving the quality of life, care and services in the centers. The QAPI involved team members at all levels of the organization to identify opportunities for improvement, address gaps in system or processes, developed and implemented an improvement or corrective plan and continuously monitored the effectiveness of interventions. The facility failed to retain evidence the required QAA and QAPI members attended meetings at least quarterly which placed residents at risk of unidentified quality care services.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 22 was treated with dignity, when staff failed to provide a privacy bag for his indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). This placed the resident at risk for an undignified experience. Findings included: - R22's Electronic Medical Record (EMR) documented he had diagnoses of retention of urine (lack of ability to urinate and empty the bladder) and urinary tract infection (UTI-an infection in any part of the urinary system). R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview of Mental Status (BIMS) score of two, which indicated severely impaired cognition. The MDS documented R22 required extensive staff assistance with dressing and toilet use, and limited staff assistance with bed mobility, transfers, and personal hygiene. The MDS documented R22 had an indwelling urinary catheter and was frequently incontinent of bowel. R22's Indwelling Catheter Care Plan, dated 08/30/23, documented R22 had a urinary catheter, and instructed staff to position the catheter collection bag and tubing below the level of R22's bladder and away from entrance room door; check tubing for kinks, and monitor for signs and symptoms of discomfort on urination and frequency. The care plan documented R22 required limited staff assistance with personal hygiene and toileting. On 09/26/23 at 10:00 AM, observation revealed R22 in a resident council meeting, with other residents present, with an uncovered urine drainage bag hooked to the left side of his wheelchair. On 09/26/23 at 11:30 AM, observation revealed R22 self-propelled in a wheelchair to the dining room with an uncovered urine drainage bag hooked on left side of the wheelchair. On 09/26/23 at 01:51 PM, Licensed Nurse (LN) G verified the above observation and stated staff adjusted R22's catheter tubing but the resident pulled on it and took his catheter bag out of the privacy bag and hooked it on the front of his wheelchair. LN G stated the urinary drainage bag should be in the privacy bag. On 09/27/23 at 03:01 PM, Administrative Nurse D stated staff should make sure R22's urinary drainage bag was in a privacy bag. The facility's Dignity Policy, revised February 2021, documented each resident should be cared for in a manner that promotes and enhances his or her sense of well-being , level of satisfaction with life, and feelings of self- worth and self-esteem. Resides would be treated wit dignity and respect at all times. The facility staff failed to ensure R22 was treated with dignity when staff failed to place his urinary catheter bag in a privacy cover. This placed the resident at risk for an undignified experience.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to include Resident (R)9's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - R9's Electronic Medical Record (EMR) documented she had a diagnosis of diabetes mellitus. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition, and required moderate assistance for bed mobility, transfers and locomotion. The MDS further recorded R9 received insulin (a hormone medication to control blood sugar) injections daily. R9's EMR lacked a comprehensive care plan which addressed the use of insulin, signs of symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and direction for the nursing staff to care for the resident with diabetes mellitus. Review of R9's EMR revealed a Physician Order, dated 07/27/23 for an Accucheck (a blood test for glucose levels) four times a day. The Nurses Notes dated 08/23/23 at 04:30PM documented the charge nurse was called to the dining room to assess R9 who was unresponsive, and had an Accucheck reading of 35 milliliters (ml) per deciliter (dL). The note documented the charge nurse administered R9 orange juice with sugar by using a straw and encouraged R9 to swallow. On 09/25/23 at 01:00PM, observation revealed R9 sat in a recliner chair in her room. On 09/26/23 at 12:30PM, Administrative Nurse D verified the facility lacked a care plan for R9's diabetes mellitus and use of insulin. The facility's Care Planning policy, dated 2023, stated each resident is to have a comprehensive care plan regarding individual needs and care provided for each resident. The facility failed to develop a comprehensive care plan for R9, placing her at risk for inadequate care due to uncommunicated care needs.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide care which met professional standards for Resident (R) 9's treatment of hypoglycemia (low blood sugar) when staff adminstered liquids orally to R9 while R9 had decreased consciousness. This placed the resident at risk for further complications including choking. Findings included: - R9's Electronic Medical Record (EMR) recorded a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition, and required moderate assistance for bed mobility, transfers and locomotion. The MDS further recorded R9 received insulin (a hormone medication to control blood sugar) injections daily. R9's EMR lacked a care plan for diabetes mellitus. Review of R9's EMR revealed a Physician Order, dated 07/27/23, for an Accucheck (a blood test for glucose levels) four times a day. The Nurses Notes dated 08/23/23 at 04:30PM documented the charge nurse was called to the dining room to assess R9 who was unresponsive, and had an Accucheck reading of 35 milliliters (ml) per deciliter (dL). The note documented the charge nurse administered R9 orange juice with sugar by using a straw and encouraged R9 to swallow. On 09/25/23 at 01:00PM, observation revealed R9 sat in a recliner chair in her room. On 09/26/23 at 09:20AM, Licensed Nurse (LN) G verified R9's Accuchecks fluctuated. LN G was unsure of the care to provide R9 for hypoglycemia. On 09/26/23 at 12:30PM, Administrative Nurse D verified the nurse should not have given R9 anything orally if R9 was unresponsive. The facility's Professional Standards policy, dated 08/2022, states the licensed nurse will use skills, and abilities and make professional judgments based on the needs of each resident. The facility failed to provide care which met professional standards in the treatment of R9's hypoglycemic episode. This placed the resident at risk for further complications.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide appropriate care for Resident (R) 20's suprapubic catheter (urinary bladder catheter inserted through the abdomen into bladder), placing R20 at risk for infection. Findings included: - R20's Electronic Medical Record (EMR) documented diagnosis of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) urinary retention (lack of ability to urinate and empty the bladder), and suprapubic catheter. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R20 had short and long term memory problems, and moderately impaired cognition. The MDS further documented R20 was independent with bed mobility and transfers and required supervision with ambulation. R20 had a suprapubic catheter. The Urinary Incontinence/Catheter Care Area Assessment Summary (CAA), dated 11/14/22, stated R20 had a suprapubic catheter, and staff were required to provide appropriate care for the catheter. R20's Care Plan, dated 07/14/23, directed the staff to position the suprapubic catheter bag and tubing below the level of the bladder in order for urine to drain into the catheter bag. On 09/25/23 at 01:30PM , observation revealed R20 ambulated with a front wheeled walker down the south hallway. R20's catheter tubing stuck out over the front of his pants and was wrapped around the handles of the walker. On 09/26/23 at 08:10AM, observation revealed R20 sat on a chair in his room. R20's urinary catheter bag laid on the floor. On 09/26/26 at 11:20AM, observation revealed R20 ambulated down the south hallway with a front wheeled walker. R20 held onto the urinary catheter tubing with his right hand and the tubing was wrapped around the handle of the walker. On 09/27/23 at 09:15AM, observation revealed R20 ambulated down the south hallway with his urinary catheter bag dragging on the floor behind him as he walked. On 09/27/23 at 12:50PM, observation revealed R20 ambulated out of the dining room with his urinary catheter tubing wrapped around the handles of his walker. On 09/27/23 at 02:50PM, Administrative Nurse D verified R20's suprapubic catheter tubing should not be wrapped around the walker and the urinary catheter bag should not drag on the floor. The facility's Suprapubic Catheter Care policy, dated 10/2010, states the urinary drainage bag must be positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The resident with a suprapubic catheter is to be checked frequently to make sure the tubing is free of kinks and the urine is flowing freely in the tubing. The facility failed to provide appropriate care for R20's suprapubic catheter tubing and catheter bag, placing the resident at risk for urinary infection.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to ensure staff possessed the skill and knowledge required to conduct a thorough skin assessment in order to identify and treat R22's skin conditions. This placed R22 at risk for ongoing and worsening skin break down. Findings included: - R22's Electronic Medical Record (EMR) documented he had diagnoses of retention of urine (lack of ability to urinate and empty the bladder), urinary tract infection (UTI-an infection in any part of the urinary system) and skin picking disease. R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview of Mental Status (BIMS) score of two, which indicated severely impaired cognition. The MDS documented R22 required extensive staff assistance with dressing and toilet use, and limited staff assistance with bed mobility, transfers, and personal hygiene. The MDS documented R22 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel. R22's Activities of Daily Living (ADLs) Care Plan, revised 08/08/23, documented R22 required extensive staff assistance with bathing and his bath day was Wednesday afternoon, and as needed (PRN). R22's Pressure Ulcer Care Plan, revised 08/08/23, instructed staff to follow facility policies and protocols for the prevention andtreatment of skin breakdown. The plan directed staff to monitor, document, and report any changes in skin status. R22's Bath Schedule documented R22 was scheduled for a bath on Wednesday, 09/27/23 day shift, with skin assessment. R22's Bathing Task, in the EMR documented on 09/27/23 day shift bathing activity did not occur. The Skin Observation Tool, dated 09/27/23 at 02:42 PM, documented R22's right knee still had scabs which had been that way for a long time and no other skin problems. On 09/27/23 at 02:03 PM, observation revealed Certified Nurse Aide (CNA) M provided R22 incontinent cares. R22's scrotum was red and tender to touch. R22 stated the area hurt. CNA M told R22 she would report the skin issue to the charge nurse. On 09/27/23 at 02:52 PM, Licensed Nurse (LN) H stated the CNA had not told her R22 had any skin issues. On 09/27/23 at 02:57 PM, LN H verified she had performed a skin assessment on R22 but did not notice any skin issues regarding R22's scrotum. LN H stated this she did not look at R22's scrotum during the skin assessment because R22 was sitting on toilet when she did the assessment. On 09/27/23 at 03:01 PM, Administrative Nurse D stated she expected staff, to go in and physically assess resident from head to toe during weekly skin assessments and document what they find. Administrative Nurse D stated the assessments were usually performed at bath time. On 09/27/23 at 03:08 PM, LN H stated she usually conducted weekly skin assessments during the resident's bath but R22 had not received a bath that day. The facility did not provide a policy regarding skin assessments. The facility failed to ensure staff possessed the skill and knowledge required to conduct a thorough skin assessment in order to identify and treat R22's skin conditions. This placed R22 at risk for ongoing and worsening skin break down.

The facility had a census of 24 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed follow acceptable standards of infection control when staff failed to provide adequate hand hygiene during personal cares for Resident (R)22 and R7. This placed the residents at increased risk for infection. Findings included: - On 09/27/23 at 08:30 AM, observation revealed Certified Nurse Aide (CNA) M knocked on R7's door and asked the resident if she was ready to get up then explained she was going to provide incontinent care. CNA M washed her hands, applied gloves, unfastened R7's incontinent brief, then provided catheter (tube inserted into the bladder to drain urine) and front perineal (genital) care with a premoistened wipe. Wearing the same soiled gloves, CNA M applied an ace wrap to R7's left foot and lower leg, then placed a gripper sock over the wrap on the same foot. CNA M then touched R7's pillow, and blanket, and assisted CNA N to remove R7's gown. CNA M placed R7's bra, blouse and pants onto the resident wearing the same gloves. CNA M picked up a bottle of deodorant, sprayed under R7's arms, cued R7 to turn to her right side, then removed R7's incontinent brief. CNA M provided perineal care to R7's buttock area, then pulled up a new incontinent brief that CNA N had placed on R7. Continued observation revealed CNA M, with the same soiled gloves, adjusted R7's catheter bag in the resident left leg of pant, readjusted R7's blouse, placed the soiled gloved hands in the residents pant pockets to adjust the lining. CNA M assisted R7 to sit up in bed, touching R7's clothing with the soiled gloves. Further observation revealed CNA M, with the same soiled gloves, touched the curtain to open it, placed the full lift control into her hands, and used it to lift the resident. CNA M adjusted R7's feet on the wheelchair pedals, then removed the full lift jacket from behind R7. CNA M continued to wear the same pair of soiled gloves and readjusted R7's blouse, touched the bars of the wheelchair, propelled R7 to the bathroom, picked up R7's toothpaste and toothbrush, squeezed the toothpaste on the toothbrush, picked up a drinking glass, turned on water and filled the glass. Continued observation revealed CNA M, with the same soiled gloves, returned to R7's bed, and touched the sheets, top cover and pillow when making the bed. On 09/27/23 at 02:03 PM, observation revealed CNA M washed her hands, then applied gloves. CNA M pulled down R22's pants, unfastened the incontinent brief, then provided incontinent care to R22's front perineal (private) area. Wearing the same soiled gloves, the CNA picked up a tube of wash creme, applied some on a premoistened wipe, then assisted R22 to turn on his right side. During this activity, CNA M touched R22's pants, shirt and back with the soiled gloves. Further observation revealed CNA M removed the incontinent brief from underneath the resident to reveal dried stool on the resident's back perineal area. CNA M placed a new incontinent brief underneath the resident, then assisted R22 in turning on his back touching his clothes again, then fastened the brief and removed and discarded the gloves. Further observation revealed CNA M failed to wash her hands after removing the gloves. On 09/27/23 at 08:30 AM, CNA M verified she had not changed gloves during catheter care and said she should have. CNA M stated she usually does change her gloves. On 09/27/23 at 02:03 PM, CNA M verifed she had not changed her gloves after providing perineal care and stated she was unaware she should. On 09/27/23 at 03:01 PM, Administrative Nurse D stated when staff provided incontinent cares, staff should change gloves and wash hands between dirty and clean. The facility's Catheter Care, Urinary Policy, revised August 2022, documented steps in the procedure for routine perineal hygiene was to wash and dry hands. The facility staff failed to failed to follow acceptable standards of infection control when staff failed to change soiled gloves during personal cares and further failed to perform hand hygiene after removal of gloves. This placed the residents at risk for infection.

The facility had a census of 27 residents. The sample included 12 residents. Based on record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 27 residents who resided in the facility at increased risk for receiving an infection and/or negative effects of antibiotic use. Findings included: - On 10/13/22 at 10:11 PM, Administrative Nurse D verified the facility infection prevention program lacked an antibiotic stewardship element and stated she had not implemented one. The facility's Antibiotic Stewardship Policy, revised 12/2016, documented antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. When a nurse called a physician/prescriber to communicate suspected infections and had the following information available: signs and symptoms, when first onset of symptoms were first observed, resident hydration status, current medications list, allergy information, infection type, any orders for [MEDICATION(S)] (medication used to thin blood), last creatinine clearance (a test that helps determine whether the kidneys are functioning normally) if available and time of last antibiotic dose. When antibiotics were prescribed to a resident over the phone the primary care practitioner would assess the resident within 72 hours of the telephone order. The facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 27 residents who resided in the facility at risk for receiving an infection.

The facility had a census of 27. The sample included 12 residents. Based on record review and interview the facility failed to notify Resident (R) 28's physician of an unintended indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) removal and a decline of condition within 24 hours of death. The placed the R28 at risk for unmet care and services. Findings included: -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented R28 had intact cognition, no [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing), or exhibited behaviors. The MDS further documented R28 required extensive assistance of two persons for activities of daily living, and had an indwelling urinary catheter. R28 had no pain treatment and had surgery requiring active skilled nursing facility care. The Urinary Incontinence/Indwelling Catheter Care Area Assessment, dated 09/07/22, documented R28 had moderately impaired cognition, was at risk for falls, had decreased safety awareness, and had an indwelling urinary catheter which placed R28 at risk for trauma and infection due to catheter use. The Care Plan dated 09/07/22, documented R28 had an indwelling catheter due to urinary retention. The care plan further documented to monitor/record/report to medical doctor of urinary track infections, pain, burning, blood tinged urine, urine cloudiness, no output, deepening urine color, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behaviors and eating patterns. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed staff to bladder train as needed per protocol, then discontinue the catheter. The Physician Order, dated 09/16/22, documented R28 was overall approaching a palliative care (care designed to relieve or reduce intensity of uncomfortable symptoms with end of life conditions) approach and staff would do what R28 wanted in terms of eating, sleeping, and work around R28's schedule. The order further instructed staff to discontinue tamsulosin (medication used to treat enlarged prostate) but may restart if R28 had any bladder problems. The 09/16/22 at 05:42 PM Progress Note recorded R28 attempted to transfer himself, was yelling, and pulled out his catheter. The note further documented the catheter was not reinserted and staff would continue to monitor and see about reinserting the next shift. The record review lacked documentation the physician was notified of the catheter removal. The 09/21/22 at 01:45 PM Progress Note documented R28 complained of not feeling well. Staff changed R28's brief and noted 100 cubic centimeter (cc) or less urine output. R28 had not drank. He was assisted to bed and had a Covid-19 (an acute respiratory illness caused by a coronavirus) test with a negative result. The medical record lacked evidence the staff notified the physician of R28's condition. The 09/26/22 Progress Notes documented the follow: Aat 06:37 AM, staff assessed R28's vital signs. He had not opened his eyes; he moaned and spoke incoherently at times. His respirations were 29 breaths per minute; he took both deep and shallow breaths within the minute, and was mouth breathing. At 10:05 AM R28 was talkative and wanting to get up for breakfast; staff tried to get him up, but R28 lost his balance and laid back into bed. The note further documented staff went to get a meal tray and when they returned to the room R28 was snoring. At 01:26 PM, the note documented water was given to R28 with the head of bed elevated and he choked. At 04:06 PM, staff updated the resident's representative on R28's condition. The representative requested [MEDICATION(S)] (a narcotic pain reliever) and [MEDICATION(S)] drops (medication used to decrease respiratory secretions), and requested staff update the representative of any changes. The note documented a fax was sent to the physician. R28's medical record lacked evidence the choking incident was reported to the physician and the medications requested by the resident representative's requests were followed up on. The 09/27/22 at 05:10 AM, Progress Note recorded R28's vital signs had ceased. On 10/13/22 at 10:12 AM, Administrative Nurse D verified the indwelling urinary catheter was not included in R28's baseline care plan, and R28's medical record lacked physician notification of the resident pulling it out on 09/16/22, the choking episode, and the condition change within the 24 hours of death. The facility's Guidelines For Notifying Physician of Clinical Problems, dated 09/2017, documented guidelines are intended to ensure that medical care problems are communicated to the medical staff in a timely, efficient and effective manner, and all significant changes in the resident status are assessed and documented in the medical record. The charge nurse or supervisor would contact the attending physician if a clinical situation appears to require immediate discussion and management. The facility failed to notify R28's physician of an accidental removal of the indwelling catheter and the change of condition experienced 24 hours prior to the resident death, which placed R28 at risk for unmet care needs.

The facility had a census of 27 residents. The sample included 12 residents with two residents reviewed for abuse and four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to report resident to resident abuse to the appropriate State Agency (SA). This placed the facility's residents at risk of ongoing abuse. Findings included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, date 08/10/22, documented R15 had severe cognitive impairment, no signs or symptoms of [CONDITION(S)] (sudden severe confusion, disorientation and restlessness), no [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing). R15 had physical behavioral symptoms directed at others and rejected evaluations or cares which occurred one to three days during the look back period. The MDS further documented R15 required extensive assistance of two persons for activities of daily living. R15 was frequently incontinent of urine and bowel, and received scheduled pain and anxiety medication. The Annual Care Area Assessment (CAA), dated 05/25/22, documented R15 had unspecified dementia, anxiety disorder, chronic pain, [CONDITION(S)] (condition with disordered or absent language function), and severe cognitive impairment. The CAA further documented R15 was at risk for communication deficits and activities of daily living function decline due to her cognitive impairment. The Care Plan dated 08/25/22 documented R15 had impaired cognitive or impaired thought process related to dementia without behaviors. The care plan instructed staff to monitor/document/report any changes in decision, making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The 12/22/21 at 03:00 PM Progress Note documented R15 struck another resident with the back of her hand because the other resident had repeatedly yelled for help. The note further documented R15 was removed from the situation and calmed down and staff kept both residents apart. On 10/12/22 at 02:43 PM, observation revealed R15 sat in a wheelchair in the hallway. Housekeeper U stated R15 followed her because R15 thought they were going downtown. On 10/12/22 at 04:02 PM, Administrative Nurse D stated a report to the SA was not completed for R15's resident to resident incident because the facility's consultant stated the act needed to be malicious in nature to be reportable and R15's actions were determined nonmalicious because of R15's dementia. The facility's Abuse and Neglect Clinical Protocol, dates 03/2018, documented the physician and staff will help to identify factors for abuse within the facility such as residents with unmanaged problematic behavior. The facility management and staff will institute measures to address the needs of resident and minimize the possibility of abuse and neglect. The management and staff, with the physician's support will address situations of suspect or identified abuse and report them in a timely manner to appropriate agencies consistent with applicable laws and regulations. The facility failed to report R15's resident to resident abuse to the SA which placed the residents at risk for ongoing abuse.

The facility had a census of 27 residents. The sample included 12 residents with two residents reviewed for abuse and four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to investigate an unwitnessed fall for cognitively impaired Resident (R) 17. This placed the resident at risk for unidentified and/or ongoing abuse or neglect. Findings Included: - The Electronic Medical Record (EMR) documented R17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required limited assistance of one staff for bed mobility, transfers, and toileting. The MDS further documented R17 had unsteady balance, no functional impairment, and had two falls since prior assessment. The Fall Risk Assessments dated 8/23/22, 6/2/22, 5/21/22, and 02/21/22 documented R17 was a high risk for falls. The Fall Care Plan, dated 09/19/22, directed staff to encourage the resident to use her call light for assistance. The care plan recorded R17 could ambulate independently with her walker and required cues and direction. The care plan lacked further interventions to prevent falls. The Incident Report, dated 05/03/22, documented R17 was found on her knees next to her bed and the resident could not say what happened. The document further stated she was assisted up and put back to bed by two staff; she did not complain of pain. The document lacked an investigation or root cause analysis regarding the fall. Review of the EMR lacked documentation regarding the fall. On 10/11/22 at 10:00 AM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around R17's waist and assisted the resident to stand up. R17's gait was slow, unsteady, and she walked hunched over with her walker to the bathroom. On 10/13/22 10:44 AM, Administrative Nurse D verified an investigation into the fall was not completed because an agency nurse was on duty at the time of the fall. Administrated Nurse D further stated an investigation and root cause analysis should have been completed after the fall. The facility Fall and Fall Risk, Managing policy, dated 03/18/22, documented staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The policy further documented staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falls. If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether those measures were still needed if the problem that the intervention has resolved. The facility failed to investigate an unwitnessed fall for cognitively impaired R17, placing the resident at risk for further injury and unidentified abuse or mistreatment.

The facility had a census of 26 residents. The sample included 3 residents. Based on observation, record review, and interview the facility failed to complete a thorough assessment and reassessment after a change of condition for 1 of 3 sampled residents. Resident #1 returned from the emergency room after he/she swallowed a metal washer and experienced respiratory problems. The facility failed to thoroughly assess/reassess the resident who displayed restlessness, coughing and a decreased oxygen saturation of 87% for approximately 3 hours, and found the resident deceased on [DATE] at 10:05 PM. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's significant change (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had adequate vision, a (BIMS) Brief Interview for Mental Status score of 3, indicating severe cognitive impairment, The MDS further indicated the resident required extensive assistance for bed mobility, transfers, walking in room, supervision for eating and had no swallowing problems. The MDS further indicated the resident had shortness of breath with exertion, sitting and lying flat. The [DATE] Cognitive Loss/Dementia (CAA) Care Area Assessment revealed the resident had dementia (progressive mental disorder characterized by failing memory, confusion) which could contribute to him/her not remembering things. The CAA indicated the resident received continuous oxygen and if he/she was not getting enough oxygen, it would affect his/her cognitive thinking. The [DATE] care plan indicated the resident had impaired cognitive function and thought process related to confusion, and he/she was not oriented to time or place. The care plan directed staff to cue, reorient and supervise the resident, and redirect/reassure as needed. The care plan further revealed the resident had an (ADL) Activities of Daily Living self-care performance deficit related to confusion, dementia, limited mobility and pain, and directed one staff to assist the resident with ADLs. The care plan further indicated the resident received antianxiety medications and directed staff to monitor/document side effects (drowsiness, clumsiness, confusion, disorientation, impaired thinking and judgement, blurred or double vision) and the medication's effectiveness. The care plan further indicated the resident had chronic pain and directed staff to notify the health care provider if interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. The care plan instructed staff to observe/record/report to the nurse any signs or symptoms of non verbal pain (changes in breathing, vocalizations, mood/behavior). The care plan directed staff to monitor/document for side effects of pain medication, observe for new onset of increased agitation, restlessness, confusion, hallucinations (sensations that appear real but are created by your mind), nausea, vomiting, and report to the resident's health care provider. The [DATE] at 2:05 PM, nurse's note revealed the resident had received [MEDICATION NAME] (a medication capable of affecting the mind, emotions, or behavior) for at least one week for dementia with behavioral disturbances, and he/she did not seem to be improving. The note revealed the resident's spouse became upset when the resident was agitated. The note further stated the resident benefited from 1:1 attention and the 2 PM-10 PM shift found it helpful to keep him/her by their side as they work. The note revealed the staff suggested sorting nuts and bolts as an activity, as the resident was a farmer and this may be helpful for him/her. The [DATE] at 2:29 PM, nurse's note revealed an intervention (not clearly specified) was added to the care plan for the resident's anxiety and agitation, and directed staff to provide 1:1 interaction. The [DATE] at 4:06 PM, nurse's note revealed the physician saw the resident today for an acute visit, as the medication [MEDICATION NAME], initiated last week, had not helped much to decrease the resident's symptoms. The resident continued to have confusion, due to his/her advanced dementia and became agitated at times, but was not typically violent. The resident had a PRN (as needed) physician order [REDACTED]. The psychiatric evaluation stated: normal mood/affect, disoriented to place, time and situation - spoke to the physician about doing chores on his/her farm yesterday. Do not feel that [MEDICATION NAME] helped, so will discontinue this. Increase PRN [MEDICATION NAME] for times of agitation and feel that his/her symptoms are natural progression of Alzheimer dementia. Staff working on tasks to perform with resident to help keep him/her occupied - sorting nuts/bolts, reading, etc. which physician felt was a good idea. Orders as follows: Discontinue [MEDICATION NAME], Change [MEDICATION NAME] to: [MEDICATION NAME] 1 (mg) milligram every 6 hours PRN for agitation, Diagnosis: [REDACTED]. The [DATE] at 7:56 AM, nurse's note revealed staff administered [MEDICATION NAME], 1 mg, to the resident for behavior. At 8:39 AM, documentation revealed the resident more calm and the medication was effective. The [DATE] physician's orders [REDACTED]. The [DATE] at 1:38 PM, nurse's note revealed staff administered a [MEDICATION NAME] Solution 0XXX,[DATE].5 mg/3 ml for increased phlegm (thick, sticky, stringy mucus secreted by the mucous membrane of the respiratory tract) and shortness of breath. The [DATE] at 1:41 PM, nurse's note revealed the resident spitting out a large amount of phlegm, exhibited shortness of breath, and O2 (oxygen) on at 2.5 (L) liters per (N/C) nasal cannula (nose piece). The note further indicated staff administered a [MEDICATION NAME] treatment and obtained the resident's vital signs. The [DATE] at 2:17 PM, nurse's note revealed the resident had shortness of breath, expectorating (coughing up) large amounts of phlegm today, with poor food and fluid intake. The change in condition started on [DATE]. The note revealed the resident's blood pressure ,[DATE], pulse 73, respirations 20, temperature 97.8, oxygen saturation 91% with oxygen per N/C (normal range greater than 90%). The note indicated food and drink worsened the resident's symptoms and nebulizer treatment, and oxygen improved the symptoms. The note stated the resident was spitting up a large amount of phlegm today, and had a poor intake of food/drink. The note further stated that staff administered oxygen via N/C to the resident, due to shortness of breath, and administered a [MEDICATION NAME] treatment for [REDACTED]. The [DATE] at 2:50 PM, nurse's note revealed the resident coughing up phlegm, respirations sound very congested in the right lung, oxygen saturations not staying above 90%, with oxygen at 2.5 L. The note revealed staff increased the resident's oxygen to 4.5 L which improved his/her oxygen saturation to 90%. The note revealed the nurse contacted the physician's office at 2:40 PM and was advised to transfer the resident to the (ER) emergency room . The [DATE] at 2:56 PM, nurse's note revealed staff sent the resident to the hospital for a respiratory infection. The medical record lacked evidence of documentation of when the resident returned to the facility from the hospital. The [DATE] at 6:48 PM, nurse's note revealed staff administered a [MEDICATION NAME] Solution 0XXX,[DATE].5 mg/3 ml to the resident, which was ineffective. The medical record lacked documentation of the resident's vital signs including his/her respiratory status. The [DATE] at 6:49 PM nurse's note revealed staff administered [MEDICATION NAME] 1 mg to the resident. The note had no documentation for the reason. The [DATE] at 7:43 PM, nurse's note revealed the [MEDICATION NAME] 1 mg PRN administration was effective. The emergency room report, dated [DATE], revealed the ER staff evaluated the resident 3:30 PM with a chief complaint of cough. The resident presented from the (NH) nursing home with dementia, oxygen on, with a saturation reading of 90% on 4 L per N/C, a loose productive cough with a large amount of clear return, and was receiving breathing treatments with [MEDICATION NAME] PRN only, with no other PRN treatments. The note further indicated the resident had been sorting metal bolts, screws, and washers at the NH. The note further revealed the facility administered an [MEDICATION NAME] breathing treatment, and [MEDICATION NAME] (steroid medication) 0.5 mg with no improvement. The [DATE] (KUB) kidney, ureter, bladder x-ray report revealed there was a centrally lucent (glowing with or giving off light) round metallic (resembling metal) foreign body located at the level the [MEDICAL CONDITION] junction (the place where the esophagus connects to the stomach) just above the diaphragm (the muscle that separates the chest cavity from the abdomen), measuring 3 (cm) centimeters in diameter (larger than a quarter). The [DATE] emergency room discharge directed staff to obtain a follow up KUB Monday morning ([DATE]) or sooner if symptoms worsen. The note further revealed the physician spoke with the surgeon on call, who recommended serial KUB films to see if the washer in the resident's distal esophagus will pass. The note further revealed a repeat KUB was ordered for Monday ([DATE]), as there was a foreign body, in the distal esophagus. The discharge instructions directed staff to encourage intake, for the resident, which may allow the washer to pass through his/her gut, continue current treatment but change [MEDICATION NAME] breathing treatments to (TID) three times a day routinely, elevate the resident's (HOB) head of bed for sleep, return to the hospital on Monday morning ([DATE]) for repeat KUB, to see if the foreign body would pass. The note further revealed a nursing order to have the resident wear oxygen ,[DATE] L per N/C, and adjust to keep O2 saturation greater than 90%. The medical record revealed no further documented nurse's notes until [DATE] at 10:05 PM, (over 3 hours since the documentation revealed the staff administered a breathing treatment that was ineffective per the staff) revealing the resident's VS's were absent, with no spontaneous respirations, skin white in color, warm to touch, pupils fixed and dilated, and unresponsive to voice and touch. The note further revealed staff notified the emergency room physician at 10:15 PM. Review of the medical record lacked documentation of an assessment of the resident following his/her return from the hospital, some time after 2:56 PM, or an assessment after the staff administered a breathing treatment documented as ineffective at 6:48 PM. The documentation lacked a thorough assessment, including breath sounds, from the 2:50 PM nurse's notes of the resident's oxygen saturation levels which declined and staff transferred him/her to ER . The medical record lacked documentation of the resident's return from ER and staff finding him/her unresponsive without vital signs present at 10:05 PM (approximately 7 hours). On [DATE] at 1:39 PM, Licensed Nursing Staff C stated when he/she checked the resident's vital signs on ,[DATE]//16 at approximately 2:15 PM, oxygen was on at 2.5 Liters via nasal cannula, the resident's oxygen saturation was below 90% at that time, so Licensed Nursing Staff C increased the oxygen to 4 Liters to keep his/her oxygen saturation above 90%. Licensed Nursing Staff C further stated the Administrative Staff K told him/her that the resident was coughing up phlegm, so Licensed Nursing Staff C listened to the resident's lungs, and heard crackles (abnormal breath sounds caused by excessive fluid within the airways) in the right lung. Licensed Nursing Staff C reported he/she called Physician B, who responded with orders to send the resident to the (ER) emergency room . Licensed Nursing Staff C stated that he/she called the ER at 5:30 PM to see if the resident was returning to the NH, and was told that the resident had swallowed a foreign object, but would be returning to the facility with orders for repeat x-rays. Licensed Nursing Staff C further stated that Administrative Staff K went to the hospital to pick up the resident at 6:40 PM. Licensed Nursing Staff C further stated the ER had sent an order to administer [MEDICATION NAME] breathing treatments TID and encourage food and fluids to help the object pass. Licensed Nursing Staff C stated the resident didn't want to eat so he/she gave the resident some water but after taking a drink, the resident started coughing, so Licensed Nursing Staff C took the water away from the resident. The resident then became restless and agitated, so Licensed Nursing Staff C tried to talk to the resident to calm him/her, but he/she wouldn't calm down, so Licensed Nursing Staff C administered an [MEDICATION NAME] to the resident around 6:50 PM. Around 8:,[DATE]:00 PM, the resident went to his/her room, where Licensed Nursing Staff C stated he/she directed the direct care staff to elevate the HOB when he/she helped the resident to bed and to turn the resident on his/her side slightly. Licensed Nursing Staff C further stated that when he/she was finished with medication pass, he/she checked on the resident, around 8:45 PM, and then after finishing charting, went back to the resident's room, around 9:40 PM and listened to the resident's breathing audibly, but did not listen to his/her lungs with a stethoscope (a medical instrument for listening to the action of someone's heart or breathing) or complete a thorough assessment. Nurse C stated the resident was a little wheezy (to breathe with a hissing sound and with difficulty) and flinched to touch, but did not appear to be having a hard time breathing. Licensed Nursing Staff C stated the resident's oxygen saturation was 87% on 4 Liters, so Licensed Nursing Staff C increased the oxygen to 4.5 Liters to get his/her saturation to 90%. Licensed Nursing Staff C further stated that was the last time he/she checked on the resident. On [DATE] at 10:44 AM, direct care staff D stated that on [DATE] the resident was fine, and had no coughing. direct care staff D further stated that on [DATE], around 1:30 PM, the resident's spouse turned on the resident's call light because the resident had vomited. direct care staff D further stated he/she had been told the resident had been vomiting earlier that day, and was spitting up a lot of clear mucous. Staff D stated that while he/she was assisting the resident, the resident's spouse pointed at a bolt on the floor. Direct care staff D stated that he/she asked the resident's spouse if it was from his/her walker and the spouse replied that it was not, so Staff D put the bolt in his/her pocket and gave it to the nurse after assisting the resident. Direct care staff D stated the Licensed Nursing Staff C reported he/she would check vital signs on the resident because he/she had vomited, and administer him/her a breathing treatment. Direct care staff D stated that when the breathing treatment was finished, he/she went into the resident's room to put the resident's oxygen back on him/her and remove the breathing treatment. Direct care staff D further stated the resident was lying down in his/her chair, and exhibiting more confusion. The resident then asked for a drink of water, after taking a drink, he/she started coughing up a lot of clear phlegm again. Staff D stated that coughing up the phlegm, was not normal for the resident, that it started on [DATE]. Direct care staff D further stated that he/she informed the nurse of the resident coughing/spitting up the phlegm. On [DATE] at 4:47 PM, Administrative Nurse A stated when the resident came back from the hospital, he/she would have expected staff to do an assessment with a progress note documented in the medical record, and any nursing interventions to be put in writing. He/she further stated staff should have documented the follow up assessments that were done. Administrative Nurse A stated that Licensed Nursing Staff C failed to follow the documentation policy after the resident returned from the hospital, as far as doing an assessment and documenting it. Administrative Nursing staff A further stated that the nurse should have checked the resident every 15 minutes as he/she directed staff to do and document it. Administrative Nurse A verified there was no documentation for approximately 3 hours from when the resident came back from the hospital to when staff found the resident deceased . Administrative Nurse A further stated that when the resident went to the ER the facility was not aware that he/she had swallowed something, staff thought that his/her [MEDICAL CONDITIONS] was just acting up or that he/she had a respiratory infection. On [DATE] at 7:05 AM, Licensed Nursing Staff E stated that on [DATE] the resident was fine, had no coughing, and was not in any respiratory distress. The resident wore oxygen continuously at night at 2 Liters via N/C, slept flat in his/her bed. Licensed Nursing Staff E stated that on [DATE], he/she came to work at 9:40 PM, and saw the evening shift nurse running down the hall into resident #1's room and then come back out. Licensed Nursing Staff E further stated that at 9:45 PM, he/she received report from Licensed Nursing Staff C, that the resident had gone to the ER, and had apparently swallowed a washer, which the physician felt would pass on its own. Licensed Nursing Staff C reported the hospital was going to do more tests on Monday ([DATE]) if the washer had not passed on its own, and instructed Licensed Nursing Staff E to do 15 minute checks, check VS, do assessments, and document his/her findings in the medical record. Licensed Nursing Staff E further stated that he/she instructed his/her direct care staff that nursing staff were going to check the resident frequently, and to let Licensed Nursing Staff E know if they saw anything abnormal. Licensed Nursing Staff E further reported that when he/she walked into the resident's room, around 10:05 PM, the resident had passed away, his/her skin was pale white, still warm, and the resident had no VS. Licensed Nursing Staff E further stated that when he/she entered the resident's room, the resident was wearing oxygen at 4.5 Liters via N/C, he/she was lying on his/her back, and the HOB was not elevated. Licensed Nursing Staff E further stated that when he/she notified the primary physician, the physician wanted to know what the resident's VS had been, how he/she ate, and what the assessments had been like since the resident's return from the ER. Licensed Nursing Staff E further stated he/she was unable to provide the physician the requested information, because there was no documentation of these assessments or vital signs. Licensed Nursing Staff E further stated the primary physician asked if the resident had been sent back to the ER, and he/she informed the physician that the last documentation charted on the resident was the transfer to the hospital, with the last VS's documented at 2:30 PM. The facility's September, 2012, Documentation Policy stated documentation of all nursing care and observations, assessments and treatments, and effects will be written by an authorized professional using the Point Click Care System and resident services system of forms. The frequency of documentation was determined depending on the condition of the resident. Staff would clearly document all of the following according to the respective policies and procedures: 1. Physical health observations 2. Assessments 3. Reassessments (such as change in resident status or condition) 4 physician's orders [REDACTED]. 5. Transfers and discharges The facility failed to thoroughly assess and reassess cognitively impaired resident #1, who returned to the facility from the ER, with a report of swallowing a foreign object. The clinical record lacked evidence of documentation of nurse's assessment following the resident's return from the ER for approximately 3 hours, even when the resident displayed coughing, restlessness and decreased oxygen saturation of 87% (signs of respiratory distress), and staff found the resident had passed away on [DATE] at 10:05 PM. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE], when they completed the following: Developed a policy and procedure for nursing assessment/reassessment of residents with a change of condition and/or ER visit. In-serviced and educated all staff by administrative staff/designee of the facility's [DATE] Documentation Policy, to ensure all residents were assessed and reassessed in a timely manner, as physician ordered. The deficient practice remained at a scope and severity of G.

The facility had a census of 29 residents. The sample included 3 residents reviewed for bowel management. Based on observation, record review and interview, the facility failed to provide the necessary care and services for bowel management for 1 of the 3 sampled residents who did not have a bowel movement for 7 days on 2 separate occasions. (#1) The resident developed a fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) and died . This placed the resident in Immediate Jeopardy. Findings included: - Resident #1's medical record revealed a Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had severe cognitive impairment, inattention and disorganized thinking that fluctuated, rejected cares and wandered. The MDS further indicated the resident required minimal assistance of 1 staff with transfers, walking in the room or corridor, toilet use, was unsteady and only able to stabilize with staff assistance. The MDS indicated the resident used a walker and wheelchair, was occasionally incontinent of bladder and always continent of bowel. The Cognitive Loss/Dementia (CAA) Care Area Assessment, dated [DATE], indicated the resident had memory loss and wandering behavior. The (ADL) Activity of Daily Living CAA indicated the resident needed extensive to limited assistance with (ADLs) activities of daily living. The [DATE] care plan directed the staff to ask the resident if he/she needed the bathroom every 2 hours while awake. The care plan did not direct the staff on bowel management for the resident. Review of the medical record revealed the resident received a [MEDICATION NAME], 12 (mcg) micrograms/hr, every 72 hours, for pain which could cause constipation. The [DATE] physician's orders [REDACTED]. Milk of Magnesia, 400 mg/5 (ml) milliliters, give 30 ml orally, PRN (initiated [DATE]) [MEDICATION NAME] powder, give 17 grams orally, every 24 hours, PRN (initiated [DATE]) [MEDICATION NAME] capsule 100 mg, give 1 orally, PRN (initiated [DATE]) [MEDICATION NAME] suppository, 10 mg, insert rectally, PRN (initiated [DATE]) Senna Plus tablet, 8.6 - 50 (mg) milligrams, 1 tablet, orally, (PRN) as needed (initiated [DATE]) Review of the bowel movement record revealed the resident did not have a (BM) bowel movement from ,[DATE] - ,[DATE] (6 days), ,[DATE] - ,[DATE] (4 days), ,[DATE] - ,[DATE] (7 days), and ,[DATE] - ,[DATE] (7 days). The [DATE] (MAR) Medication Administration Record [REDACTED]ineffective. The medical record revealed no documentation of further interventions or physician notification after the staff documented the PRN medication was ineffective. The [DATE] at 11:39 AM nurse's note revealed the resident stated he/she was too sick to eat lunch and was going to throw up. The medical record revealed no documentation of any physical assessment or physician notification of the resident who had not had a BM for 5 days. The [DATE] at 9:28 PM food and fluid intake report revealed the resident consumed no fluids and ,[DATE]% of supper. The [DATE] at 8:10 AM nurse's note stated the resident ate 1 bite of breakfast and complained of not feeling good. The [DATE] at 11:40 AM nurse's note stated the resident ambulated to the dining room and as soon as he/she sat in the chair, he/she complained that he/she was going to throw up, vomited, and staff assisted him/her back to his/her room. The medical record revealed no documentation the staff assessed the resident for the 24 hours, from [DATE] at 11:39 AM to [DATE] at 11:40 AM, although he/she complained of not feeling well, had not eaten well and had vomited. The medical record revealed no documentation of a thorough assessment including lung sounds, vital signs or bowel sounds or physician notification although the medical record revealed no documentation the resident had a BM in the last 6 days. The [DATE] at 5:35 PM food and fluid intake report revealed the resident consumed no fluids or food for supper. The [DATE] at 6:45 PM nurse's note revealed an aide reported the resident had a chocolate shake and a cookie, then vomited and refused to eat anymore. The [DATE] at 6:48 PM fax to the on-call provider stated the resident vomited a slimy, dark liquid, was not eating good, and he/she directed the staff to send the resident to the emergency room . The [DATE] at 7:15 PM nurse's note revealed a family member expressed concern the resident had upper gastric pain yesterday, had previously experienced a [MEDICAL CONDITION] and requested the resident be sent to the emergency room by ambulance if he/she got worse in the night. The resident refused to go to the emergency room at this time. The medical record revealed no documentation the staff physically assessed the resident. The [DATE] at 1:30 AM nurse's note revealed the resident's bed alarm sounded, and the staff found the resident had a small mucous brown bowel movement and vomited approximately 100 (cc) cubic centimeters of a brown colored watery liquid. The nurse's note further stated the staff assisted the resident back to bed and determined his/her bowel sounds were hypoactive (any abnormally less than normal activity in the body or its organs) and he/she had not voided. The [DATE] at 5:20 AM nurses note stated the resident had not voided this shift, had refused any water offered, and when asked how he/she felt, he/she stated not too good. The clinical record lacked documentation of any physical assessment of the resident. The medical record revealed documentation the staff knew the resident had hypoactive bowel sounds and had not voided the day of [DATE]. The medical record revealed no further documentation of a physical assessment of the resident since 1:30 AM (3 hours 50 minutes). The [DATE] at 8:00 AM nurse's note revealed the resident complained of stomach discomfort and spit up phlegm (thick mucus secreted in the respiratory passages and discharged through the mouth). The [DATE] at 9:30 AM nurse's note stated the aide gave the resident a protein shake and the resident vomited. Review of the medical record revealed no documentation of any physical assessment of the resident since 1:30 AM (8 hours) when the staff first noted the resident had hypoactive bowel sounds and had not voided. The [DATE] at 10:18 AM nurse's note revealed the resident had not responded to a family member at the bedside and kept his/her eyes closed. The notes indicated the resident had hypoactive bowel sounds and had not voided in 24 hours. At [DATE] at 10:45 AM, the facility contacted the provider regarding the resident's condition and were directed to transfer him/her to the emergency room . On [DATE] at 11:00 AM the staff transferred the resident to the hospital. The [DATE] at 1:00 PM emergency room progress note stated the resident had decreased bowel sounds and increased abdominal distention. The [DATE] radiology report indicated the resident either had an early ileus (obstruction of the intestines, caused by immobility of the bowel) or an early partial small bowel obstruction. The [DATE] physician's note stated the resident was less responsive, vomited bilious (dark green to yellowish brown fluid produced by the liver) liquid, and an x-ray showed a dilated loop of small bowel. The [DATE] at 1:22 AM nurse's notes revealed the hospital called the facility and reported the resident passed away. The [DATE] discharge summary by the primary physician indicated the resident's final [DIAGNOSES REDACTED]. On [DATE] at 1:18 PM, Nurse Aide A stated the resident had constipation, the staff would hear the resident straining to have a BM and the resident did not drink very much. On [DATE] at 1:56 PM, Nurse Aide B stated on ,[DATE] and ,[DATE] the resident wouldn't eat or drink, said his/her stomach hurt, was not incontinent and staff did not take him/her to the bathroom on those days. On [DATE] at 2:34 PM, Nurse D stated the resident had constipation. Nurse D stated the computer system alerted the staff if a resident had not had a BM for 2 or 3 days but did not add any more days after the 3rd day of no BM so it could have been the 4th, 5th, etc. day and it would still read 3rd day no BM. Nurse D stated on ,[DATE] the resident stated he/she was not feeling well. Nurse D stated on ,[DATE] he/she received report from the night nurse that the resident had not voided and had hypoactive bowel sounds but he/she did not complete a physical assessment of the resident. On [DATE] at 3:14 PM, Nurse G stated on ,[DATE] he/she did not complete a physical assessment on the resident after he/she vomited because Nurse G thought the resident might be coming down with the flu. Nurse G stated the computer system would alert the staff if a resident had not had a bowel movement for 3 days but he/she did not know how to find out exactly when the last bowel movement occurred. Nurse G stated the computer system would read 3rd day no BM even if the resident had not had a BM for more than 3 days. On [DATE] at 8:20 AM, Administrative Nurse F stated the computer system alerted the staff if a resident had not had a BM for 2 or 3 days, staff should administer (PRN) as needed medications and if still no BM, contact the physician. Administrative Nurse F stated all staff should have been looking daily at the computer system to see when the last BM occurred, monitoring the resident's hydration status and assessing bowel sounds and abdomen distention. Administrative Nurse F verified the nurse should have contacted the physician on [DATE] at 1:30 AM when the resident vomited the brown colored watery liquid and on [DATE] at 10:18 AM when the resident had not urinated for 24 hours and had hypoactive bowel sounds. Administrative Nurse F stated the facility did not have a policy or procedure regarding bowel management and documentation indicated the resident had no bowel movement for 7 days on two separate times in July. On [DATE] at 9:13 AM, Administrative Nurse F stated the facility did not have a policy for providing care for a resident regarding bowel movements and constipation. On [DATE] at 9:53 AM, Nurse Aide C stated previously the resident was able to tell the staff when he/she needed to have a BM, but the last few days before he/she went to the hospital, the staff would take the resident to the bathroom every few hours and the resident would not void. Nurse Aide C stated the resident complained of stomach pain the last week in the facility and did vomit after the staff tried to give him/her a shake. On [DATE] at 10:53 AM, Physician H stated he/she was not notified of the resident not having a bowel movement for 7 days, the examination of the resident suggested a small bowel obstruction and the facility should have notified him/her of the resident being lethargic (feeling a lack of energy), complaining of stomach pain and not wanting to eat. Physician H stated he/she disagreed with the radiology report, dated [DATE], which stated no evidence of bowel obstruction due to his/her clinical findings and verified the resident did have an area in the small bowel that was a little more filled with air. The facility's Recognition of Change policy, dated ,[DATE], stated if a resident eats or drinks less than usual, is less talkative, is sleepier, more confused or more agitated, needs more help with ADLs, has increased falls, complaints of not feeling well, fever, pain, or has a roommate or family member who expresses concern the staff should suspect illness. The staff should observe the resident - gather data including but not limited to vital signs, pain, respiratory status, abdomen, skin, respiratory rate, oral food, fluid intake, bowel record, urine input, skin for redness, discharge, swelling, listen to lung sounds, bowel movements, palpate abdomen for tenderness, check for fecal impaction, warmth of skin. The staff should have the information ready when they call the physician to obtain orders. The facility failed to thoroughly assess and seek physician involvement for Resident #1 who had a history of [REDACTED]. This failure placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy, on [DATE], when it provided an in-service to nursing staff employed at the facility about the use of the BM protocol, change of condition, stop and watch documentation, and shift report audit regarding bowel management effective [DATE]. Ongoing review of the computer report would be performed daily at shift report by the (DNS) Director of Nursing Service, and the charge nurses and nurse aides would discuss any questions or concerns about their data entry whenever such questions would occur. This deficient practice remained at the scope and severity of a G.

The facility had a census of 29 residents. The sample included 6 residents of which 3 were reviewed for elopement risk. Based on observation, record review and interview, the facility failed to provide adequate supervision for 1 of the 3 sampled residents, who eloped from the facility. Resident #1, who was cognitively impaired and independently mobile, exited the facility without staff knowledge, while seat belted in a wheelchair. A passerby observed the resident in the wheelchair in a ditch in front of the nursing home. This failure placed the Resident #1 in immediate jeopardy for potential harm to occur. Findings included: - Resident #1's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 7/14/15, indicated the resident had severe cognitive impairment, inattention, disorganized thinking that fluctuated, rejected cares, and wandered almost daily. The MDS indicated the resident required supervision of 1 staff with bed mobility, locomotion off the unit, eating, minimal assistance of 1 staff with transfers, and walking in the room or corridor. The MDS indicated the resident had unsteady balance, only able to stabilize with staff assistance, used a walker, and a wheelchair with a trunk restraint. The Cognitive Loss/Dementia (CAA) Care Area Assessment, dated 4/21/15, indicated the resident had memory loss and wandering behavior. The (ADL) Activity of Daily Living CAA indicated the resident had daily behavioral problems because of confusion to place, unable to understand he/she was a resident of the facility, and propelled his/her wheelchair throughout the facility. The Physical Restraint CAA indicated the staff placed a soft waist restraint on the resident when he/she was out of bed. The 7/14/15 care plan directed the staff to place the resident in a regular chair in the dining room with a restraint, place a wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on the resident's wheelchair and the resident used a wheelchair for locomotion. The medical record revealed the resident had attempted to open exit doors several times in May and July 2015. The 7/24/15 at 5:20 PM nurse's progress note stated a passerby came into the facility and alerted staff a resident was outside, in the north parking lot by a telephone pole, on the west side of the street in the ditch. The wheels on the wheelchair were stuck in the grass. Three alarms were going off in the west part of the facility but could not be heard by staff who were in the dining room with the rest of the residents for supper. The note indicated the resident had a temperature of 99.9 Fahrenheit upon his/her return to the facility. The temperature outside was 96.8 degrees with a heat index of 97.1 degrees. On 8/12/15 at 1:18 PM, Nurse Aide A stated on 7/24/15 at supper time a citizen came into the dining room and told the (CMA) Certified Medication Aide there was a man outside. Nurse Aide A stated the resident was in his/her wheelchair for supper and in the past he/she would leave the dining room during meals and come back in a few minutes. Nurse Aide A stated in the past he/she had observed the resident push on the exit doors. Nurse Aide A verified the staff could not hear the front door alarms from the dining room where all staff are located during meals. On 8/12/15 at 1:56 PM, Nurse Aide B stated on 7/24/15 at supper time, he/she was in the dining room assisting a resident to eat supper. A citizen came into the dining room and talked with the CMA on duty and he/she immediately told Nurse Aide B to go to the front door. Nurse Aide B stated after he/she got out of the dining room, he /she could hear the front door alarms sounding. Nurse Aide B looked outside and saw the resident, seated in his/her wheelchair, tipped downward, with a seatbelt in place. The front wheels of the wheelchair were in a drop between the edge of the facility driveway and the edge of the sidewalk, the back wheels were on the sidewalk and the resident's feet were on the asphalt of the driveway leading up to the nursing home, approximately 150 feet from a 45 miles per hour highway. Nurse Aide B stated the resident had made the doors alarm sound by pushing on them several times in the past and daily he/she observed the resident watching the front door, waiting for someone to open it and then attempted to get out the door. Nurse Aide B stated the resident had a wanderguard on his/her wheelchair which would set off an alarm if he/she was too close to an open door. On 8/12/15 at 2:34 PM, Nurse D stated the resident would become more restless in the afternoon and evening. Nurse D stated he/she had observed the resident grab the door handles and set off the door alarms. On 8/12/15 at 7:45 PM, Nurse E stated on the evening of 7/24/15, all staff were in the dining room. Nurse E stated he/she assisted 2 residents with supper while Resident #1 wheeled himself/herself around the dining room. Nurse E stated a citizen came into the building and told us a resident was outside and the staff did not hear the front door alarms because they are on the other side of the building. Nurse E stated the resident had a low grade temperature upon returning to the building because it was hot outside. Nurse E verified he/she had observed the resident attempt to leave the building numerous times. On 8/12/15 at 8:20 AM, Administrative Nurse F stated Resident #1 had a wanderguard on his/her wheelchair that alarmed if he/she was too close to the front door. Administrative Nurse F verified all the staff were in the dining room for supper on the evening of 7/24/15 and could not hear the activated front door alarms. Administrative Nurse F verified there are 7 cognitively impaired, independently mobile residents in the facility. On 8/13/15 at 9:53 AM, Nurse Aide C stated the resident wandered a lot more in the afternoon and evening, and had a seatbelt around him/her when in the wheelchair. Nurse Aide C stated all staff go to the dining room during all meals. The facility's Elopement procedure, dated 9/13, stated the facility would identify environmental hazards and individual resident risks, including the need for supervision; evaluate/analyze hazards and risks; implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care and current standards of practice and monitor/modify interventions as needed. The facility failed to ensure adequate supervision for cognitively impaired Resident #1 who exited the facility, while seat belted in his/her wheelchair and wandered approximately 150 feet before the wheelchair became stuck in a shallow drainage ditch. This location was approximately 150 feet from the highway with a 45 mph speed limit. This failure placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy, on 8/14/15, when it provided an in-service to all staff employed at the facility about the policy and new procedures for elopement and door alarms, assigned 1 staff member to remain near the front entrance to prevent possible elopements, placed a wireless video/audio monitoring system to enable remote monitoring of the west door in the dining room, weekly door alarm checks, and scheduled a digital upgrade alarm system including signals from all 9 doors with enunciators in the nursing station and dining room to be installed the week of August 24, 2015. This deficient practice remained at the scope and severity of a D.

The facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of potential accidents/hazards when water temperatures in an unlocked bathroom, used by residents, located adjacent to the dining room measured 153.3 degrees F (Fahrenheit) on 8/26/13 at 11:30 a.m. and 152.2 degrees F on 8/26/13 at 11:50 a.m. This deficient practice placed residents that used the dining room bathroom in immediate jeopardy of burns. Findings included: - During initial tour on 8/26/13 at 11:30 a.m., the water temperature in the rest room adjacent to the dining room presented at 153.3 degrees F (Fahrenheit). After alerting Maintenance staff D at 11:50 a.m. the same sink measured 152.2 degrees F per maintenance staff D's thermometer. During an interview on 8/26/13 at 11:50 a.m. Maintenance staff D stated that the temperature of that sink normally measured at 145 digress F (Fahrenheit). Staff D stated he/she checked the dining room bathroom water temperature monthly. Staff D lacked knowledge of what the safe temperature should be. Maintenance staff D locked the rest room door and placed a " Do Not Use " sign on the door. During an observation on 8/27/13 at 9:00 a.m. the door to the bathroom remained locked. During an observation on 8/29/13 at 8:05 a.m., the bathroom by the dining room, now unlocked, had a water temperature of 106.8 degrees F with the "Do Not Use" sign removed. Review of the maintenance water temperature check logs between July 2012 and August 2013 revealed that the maintenance staff checked the bathroom sink temperature monthly. The log included water temperatures above 120 degrees F for the bathroom sink by the dining room as follows: *July 2012- 145 degrees F *August 2012- 145 degrees F *September 2012- 157 degrees F *November 2012- 157 degrees F *December 2012- 148 degrees F *January 2013- 136 degrees F *February 2013- 140 degrees F *March 2013- 134 degrees F *April 2013- 150 degrees F *June 2013- 152 degrees F *July 2013- 159 degrees F *August 2013- 157 degrees F The maintenance temperature logs lacked evidence that facility staff addressed excessive water temperatures when they obtained readings above 120 degrees F. According to the January 2005 Sunflower Connection, 'Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water." During an interview on 8/26/13 at 2:30 p.m. resident # 11 revealed that he/she used the rest room near the dining room and was aware that staff assisted residents in the bathroom by the dining room at meal time. During an interview on 8/26/13 at 2:35 p.m. resident #14 stated he/she used the rest room " all the time " and the water temperature was " pretty warm" at times. During an interview on 8/26/13 at 2:40 p.m. resident # 6 revealed that he/she did not use the rest room by the dining room but stated that it can be used by residents. Review of the undated facility Policy #608 Water temperature/hardness record revealed that " checks should be completed and recorded at minimum weekly or more often if needed." The facility failed to ensure the residents environment remained free of accident hazards when water temperatures in the rest room adjacent to the dining room measured 153.3 degrees F (Fahrenheit) on 8/28/13 at 11:30 a.m. The facility abated the immediate jeopardy related to hot water temperatures in excess of 140 degrees Fahrenheit on 8/26/13 at 4:00 p.m. when they implemented the following corrective measures: * The door of the bathroom in question is now locked. * An "Out of Service" sign is posted on the door. * The water heater temperature setting has been turned down. Temperature this morning was 123 degrees F. * The hot water temperature will be checked at the tap tomorrow morning and the water heater temperature control adjusted that tap water temperature is in a compliant range. Tap water temperature will be monitored daily x 1 week, then weekly per policy. *Maintenance supervisor has been educated to proper range for tap water temperature. He has been provided with the Kansas Statutes and regulations page which specifies compliant hot water temperatures range of 98 -120 degrees in resident and clinical areas. * Staff education: a sign off notice has been posted for staff describing procedure for reporting suspected too hot water temperatures. The notice is posted at the time clock for signatures. After removal of the immediate jeopardy, the deficient practice of facility failure to ensure the resident environment remained free of accident/hazards remained at a scope/severity of "E".

The facility had a census of 31 residents with 3 sampled for review. Based on observation, interview, and record review, the facility failed to provide 1 of 3 sampled residents with necessary care and services (ongoing nursing assessments of a resident with a significant change in his/her medical condition, including neurological assessments after an unwitnessed fall and failure to notify the physician of the changes in the resident's medical condition) to maintain the resident's highest practicable physical well-being. Resident #1's physical condition deteriorated over a time period of approximately 2 days in which staff failed to complete neurological assessments and notify the physician of changes in the resident's level of consciousness. Facility failure to complete ongoing nursing assessments after a significant change in condition and failure to notify the physician of the changes delayed prompt medical intervention, thereby placing resident #1 in immediate jeopardy. The facility also failed to provide 2 of 3 sampled residents with necessary care and services (failed to complete neurological assessments following an unwitnessed fall for a resident with cognitive impairment and failed to complete neurological assessments for a resident with suspected head injuries) to maintain the resident's highest practicable physical well-being. (#2 and #3) Findings included: - Resident #1's 3/29/12 physician order [REDACTED]. Resident #1's 2/5/13 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 9 which indicated moderate cognitive impairment. The resident required limited assistance of 1 staff for bed mobility, transfers, and ambulation. The assessment also revealed the resident's balance during transitions and waking was not steady, but he/she could stabilize without staff assistance. The resident had functional limitations in range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The resident sustained [REDACTED]. Resident #1's 2/5/13 CAA (care area assessment) summary related to cognitive loss revealed the resident had a [DIAGNOSES REDACTED]. The summary also indicated the resident had severe [MEDICATION NAME] degeneration (progressive deterioration of the retina) and hearing impairment. The CAA summary for falls stated the resident had a history of [REDACTED]. He/she used a walker and required assistance of 1 person with a gait belt for ambulation. Resident #1's 2/5/13 nursing care plan identified the problem of alteration in self care related to hip pinning and dementia with the need for supervision because the resident did not understand restrictions. The care plan indicated the resident required assistance of 1 staff for ADLs (activities of daily living), 1 person assist with gait belt for transfers, and 1 person assist with gait belt and walker for ambulation. The care plan stated the resident could bear weight as tolerated. The care plan indicated the resident had a high risk for falls and had a bed alarm as the resident was unable to remember to use the call light. Resident #1's 1/29/13 Fall Data Collection Tool revealed a score of 18 (greater than 12 considered high risk for falls) and a score of 28 on 3/31/13 placing the resident at "high risk" for falls since admission to the facility. According to nurses' notes on 3/31/13 resident #1's bed alarm sounded at 12:10 a.m. and staff found the resident standing by his/her bed. The resident thought his/her spouse was there. At 1:30 a.m. the alarm sounded again and the resident stood by the bed and asked what time his/her family would be there to take him/her home. At 3:00 a.m. the alarm sounded again and the resident wanted to go home. The nurse's note stated the CNA (certified nurse assistant) told him/her it was 3:00 a.m. and he/she needed to sleep. At 4:10 a.m. the alarm again sounded and staff found the resident on the floor laying at the end of the bed on his/her left side. The note stated the resident was alert, confused, and complained of pain in the left shoulder. After notification of the physician on call and the resident's family, staff called for an ambulance to transfer the resident to the hospital for treatment. The 3/31/13 emergency room record revealed the resident had a dislocated left shoulder with a displaced left humeral head fracture. The resident received IV (intravenous) sedation of MS ([MEDICATION NAME] sulfate, narcotic) 4 mg (milligrams) and [MEDICATION NAME] (anti-anxiety medication) 0.25 mg during the closed reduction of the fracture and dislocation. Discharge instructions included "shoulder immobilizer for 2 weeks then re-X-ray, may start PT (physical therapy) range of motion in 2 weeks, but otherwise stay in immobilizer for 6 weeks, follow up with (doctor) on Tuesday. According to nurses' notes on 3/31/13 at 11:30 a.m., the facility driver went to pick up the resident at the hospital, but the resident remained sleeping after the procedure. Nurses' notes on 3/31/13 at 3:40 p.m. revealed the resident returned to the facility and the resident was in bed with the alarm on and "eyes closed, unresponsive, but right hand moves and responsive to touch". At 8:20 p.m. licensed nurse C administered [MEDICATION NAME] (medication to reverse the effects of [MEDICATION NAME]) 0.4 mg injection as ordered if resident still not awake. The note further stated licensed nurse C asked the resident if he/she was hungry and he/she said "no". Nurses' notes on 3/31/13 at 10:25 p.m. revealed the resident attempted to removed the shoulder immobilizer and remained drowsy. On 4/1/13 at 12:20 a.m., nurses noted indicated licensed nurse D administered a second dose of [MEDICATION NAME] (as ordered if the resident was still drowsy). The note further stated the resident had the immobilizer partially undone and staff secured the immobilizer in place. The resident also was incontinent of urine and staff provided peri-care and placed a clean incontinence brief. At 2:15 a.m., 3:30 a.m., and at 5:00 a.m. the resident attempted to removed the shoulder immobilizer. A nurses' note on 4/1/13 at 7:00 a.m. revealed resident #1 remained asleep and "hard to waken". A note at 9:00 a.m. stated, "unable to give meds, would not wake up to swallow". At 12:00 p.m. the resident was able to drink a shake and some soft foods. At 1:30 p.m. staff documented the resident as "restless, but denied pain". Nurses' notes on 4/1/13 at 3:00 p.m. revealed the resident wakened for vital signs, tried to talk with his/her eye closed and denied pain. At 5:00 p.m. 2 staff assisted the resident to a wheelchair and took him/her to the dining room. According to the notes at 6:00 p.m. the resident's spouse could not get the resident to eat. The resident then ate 25% of the his/her biscuits/gravy and drank his/her fluids with staff assistance. The resident took his/her medications at 8:00 p.m. and had some applesauce and pudding at 8:30 p.m. Nurses' notes on 4/1/13 at 10:30 p.m. stated staff called the resident's name several times and he/she briefly opened his/her eyes and the notes described the resident as lethargic and drowsy. At 11:00 p.m. staff held the resident medications due to he/she "is not awake enough to swallow". The record lacked evidence of physician notification. Nurses' notes on 4/2/13 at 1:00 a.m. stated, "still lethargic and drowsy". At 2:00 a.m. nurses' notes stated the resident was asleep. At 5:00 a.m. staff documented they tried to awaken the resident for scheduled medications. The resident responded "yes" once when name called, but was unable to suck water with a straw. Staff attempted to spoon feed water but he/she did not swallow and kept his/her eyes closed. Staff held the medications due to "not awake enough". The record lacked evidence of physician notification. Nurses notes on 4/2/13 at 6:20 a.m. stated, "resident sleeping soundly in bed. Difficult to arouse for assessment. Lethargic. Sleeps through vital signs and assessment....resident (did not) wake to sternum rub." At 7:30 a.m. staff described the resident as "very weak and limp". A nurses' note 9:00 a.m. stated, "resident continues to be limp, lethargic, and difficult to arouse". The record lacked evidence of physician notification. A nurses' note on 4/2/13 at 10:20 a.m. revealed PT (physical therapy) working with the resident as he/she sat at the side of the bed. The PTA (physical therapy assistant) assisted the resident with a supplemental drink and had to hold the resident's head up for him/her to be able to drink. At 11:30 a.m. staff attempted to feed the resident ice cream, but he/she could not swallow. At 12:10 p.m. the nurses' note indicated the attending physician saw the resident and the note stated, "Transfer to hospital per unresponsiveness". At 12:25 p.m. the facility transferred the resident to the hospital per ambulance. Review of the clinical record revealed staff obtained vital signs every shift after returning to the facility on [DATE] following the closed reduction of the shoulder and administration of IV sedation of [MEDICATION NAME] and [MEDICATION NAME]. Facility staff did not obtain neurological checks after the resident had an unwitnessed fall with injury on 3/31/13. Resident #1 had moderately impaired cognition, a [DIAGNOSES REDACTED]. Review of resident #1's nurses notes on 3/31/13, 4/1/13, and 4/2/13 revealed repeated documentation of lethargy, difficulty to arouse, inability to take medications/swallow, and periods of unresponsiveness without notification of the resident's physician or physician on call for emergencies. Resident #1's 4/3/13 discharge summary note from the hospital revealed a [DIAGNOSES REDACTED]. The summary stated the resident was in an unresponsive state on admission. The summary identified the cause of death as "subdural hematoma". The U.S. National Institutes of Health website http://nim.nih.gov gives the following definition: * Subdural hematoma: a collection of blood on the surface of the brain...may occur after a very minor head injury, especially in the elderly...may go unnoticed for days to weeks. Symptoms include headache, lethargy or confusion, loss of consciousness and nausea and vomiting. Nurses' notes on 4/4/13 (un-timed) revealed the resident passed away at the hospital on [DATE] at 4:35 p.m. During an interview on 4/24/13 at 3:36 p.m. licensed nurse C stated he/she worked on the evening the resident returned from the hospital after the closed reduction on 3/31/13. He/she stated physician C saw the resident in the facility on that evening and ordered the [MEDICATION NAME] to be given due to the resident still being "sleepy" following the closed reduction and sedation. An interview on 5/1/13 at 3:45 p.m. with administrative nurse B revealed the resident was "too sleepy" to return to the facility per facility vehicle and returned by ambulance. He/she further stated the resident had some periods of wakefulness on 4/1/13, but was unaware staff had held medications due to his/her inability to swallow or waken. Administrative nurse B confirmed staff failed to notify the physician or physician on call of the resident's change of condition. He/she further confirmed staff did not complete neurological assessments following resident #1's unwitnessed fall on 3/31/13 when he/she sustained the dislocated shoulder and fracture. Administrative nurse B stated staff knew the resident's physician would be making rounds on 4/2/13 and made the decision to wait until the doctor came to the facility for rounds. During an interview on 5/6/13 at 12:15 p.m., physician F confirmed resident #1 had dementia, memory impairment and gait instability prior to the fall on 3/31/13. Physician F further confirmed staff failed to notify him/her or the physician on call when the resident had changes in consciousness following the fall and closed reduction of the shoulder dislocation/fracture on 3/31/13. He/she made rounds on 4/2/13 and transferred the resident to the hospital due to unresponsiveness. Physician F reported the facility had a physician available at all times for emergencies. He/she stated facility staff should have notified a physician when the resident had changes in consciousness and further stated it was an emergency situation and should not wait until the physician made rounds. The facility's 2005 revised Notification of Change in Resident Status policy stated the center will immediately...consult with the resident's physician...(of) significant change in the resident's physical, mental, or psychosocial status. The facility's 2011 Neurological Evaluation policy stated a purpose "to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. The policy listed using the neurological evaluation "following an un-witnessed fall (when a head injury may be suspected)". The procedure stated neurological checks should be completed initially and every 30 minutes (4 times), then every shift for 3 days or as appropriate or more frequently as directed by the physician....Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. The facility failed to provide resident #1 with the necessary care and services (ongoing nursing assessments including neurological evaluation of a resident with a significant change in his/her medical condition) to maintain the resident's highest practicable physical well being. Resident #1's physical condition deteriorated over a period of 2 days in which staff failed to complete adequate assessments and failed to ensure the physician knew of the change in the resident's medical condition and level of consciousness. Facility failure to complete ongoing nursing assessment after a significant change in condition and failure to notify the physician of the changes delayed prompt medical intervention, thereby placing resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 5/7/13 at 11:00 a.m. when they developed and implemented the following measures: Protocol for post fall assessments Revision of the facility's unwitnessed fall policy to include neurological assessments Protocol for immediate physician notification on significant change in condition All nursing staff were inserviced on the notification of change in resident's condition policy, SBAR (physician communication and progress note for new symptoms, signs and other changes in condition), notification of condition change and observation, and the policy for unwitnessed falls. The inservices were completed on 5/7/13 at 11:00 a.m. The deficient practice remains at a scope/severity of a "G". - Resident #3's 3/29/13 physician order [REDACTED]. Resident #3's 2/8/13 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 8 which indicated moderate cognitive impairment. The resident required extensive assist of 2 persons for bed mobility, transfers, and toilet use. The assessment also indicated the resident had functional limitations in range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The resident had a fracture related to a fall within 6 months prior to admission and no falls since admission to the facility. Resident #3's 2/8/13 CAA (care area assessment) summary for cognitive loss stated the resident had a [DIAGNOSES REDACTED]. The summary indicated the resident had confusion. The ADL (activities of daily living) CAA summary stated the resident required assistance with all ADLs and PT worked with him/her for strengthening , transfers, and ambulation. The fall CAA summary identified the resident as a fall risk. Resident #3's 2/26/13 nursing care plan directed staff the resident required 1 person assist with all ADLs. A 3/21/13 revision to the care plan stated "no weight bearing" on the right side due to pelvic fracture. The care plan related to safety awareness further directed staff to use an alarm on the chair and bed and stated the resident was unable to remember to use the call light. The Falls Data Collection tool dated 2/1/13 (on admission) revealed a score of 18 (scores greater than 12 indicated high risk for falls), after a fall on 2/19/13 revealed a score of 20, and after the fall on 3/18/13, the resident scored 23. According to the facility's fall investigation, resident #3 sustained an unwitnessed fall on 2/19/13 when he/she did not use the call light and got up independently. Immediate interventions included reorienting the resident to the call light and staff education to anticipate the resident's needs. The report also stated, "If this happens again should consider chair alarm and/or bed alarm." Nurses' notes on 3/18/13 at 10:10 a.m. stated staff found the resident on the floor and he/she did not use the walker or use the call light. The resident informed staff he/she wanted to throw something away. At 5:00 p.m. the nurses' note stated the resident ambulated to the dining room without any discomfort. Nurses' notes on 3/19/13 at 8:30 a.m. revealed the resident ambulated to the dining with a walker and staff noted the resident "limping" on the left leg and the resident stated he/she had pain in the right leg. Review of resident #3's clinical record lacked evidence of neurological assessments following unwitnessed falls on 2/19/13 and 3/18/13. Resident #3 had dementia, confusion, and moderate cognitive impairment. Physician's progress notes dated 3/19/13 stated the resident fell and now had right thigh pain and ordered an X-ray of the right hip and right femur. Resident #3's 3/20/13 X-ray revealed an acute appearing right pubic rami (pelvic) fracture. During an observation on 4/24/13 at 9:41 a.m. direct care staff G wheeled resident #3 to his/her room and assisted the resident from the wheelchair to the toilet with a gait belt. After toileting, the direct care staff G transferred the resident back to the wheelchair in the same manner. During an interview on 4/24/13 at 2:23 p.m. licensed nurse H stated if a resident has a witnessed fall with a head injury, they did neuro checked initially and every 30 minutes (4 times), then maybe every 4 hours, and then every shift. If a resident has an unwitnessed fall, they ask the resident if they hit their head and if the resident can't tell them if they hit their head, then they look around to see if there is anything they could have hit their head on when they fell . On 5/1/13 at 3:45 p.m. administrative nurse B confirmed staff did not complete neurological assessments following resident #3's unwitnessed fall on 2/19/13 and on 3/18/13 when he/she sustained a pelvic fracture. During an interview on 5/6/13 at 12:15 p.m. physician F confirmed resident #3 had confusion, poor judgement, poor memory, and gait instability. He/she further stated neurological assessments for unwitnessed falls should be completed for residents with cognitive impairment. The facility's 2011 Neurological Evaluation policy stated a purpose "to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. The policy listed using the neurological evaluation "following an un-witnessed fall (when a head injury may be suspected)". The procedure stated neurological checks should be completed initially and every 30 minutes (4 times), then every shift for 3 days or as appropriate or more frequently as directed by the physician....Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. The facility failed to complete ongoing nursing assessments including neurological evaluation after unwitnessed falls for resident #3 who had cognitive impairment and confusion. - Resident #2's 9/3/12 significant change MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 15 which indicated intact cognition. The resident required limited assist of 1 person for transfers, ambulation, and toilet use. The resident had no functional limitations in range of motion and used a walker and wheelchair for mobility. The resident had a fall in the past 6 months, but no falls since admission. Resident #2's 4/9/13 quarterly MDS revealed the resident had a BIMS score of 11 which indicated moderate cognitive impairment and now required extensive assist of 1 person for ambulation and toilet use and extensive assistance of 2 persons for transfers. The resident had functional limitations in range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The assessment also stated the resident had 2 or more non-injury falls since the prior assessment. Resident #2's 8/3/12 CAA (care area assessment) summary for [MEDICAL CONDITION] revealed the resident had a recent hospital admission for pneumonia and dehydration with fever and had increased confusion at that time. Since returning to the facility the resident's memory improved as the acute illness resolved. The fall CAA stated the resident had poor safety awareness and a strong desire to be independent. The summary further stated the resident loses his/her balance easily and his/her falls did not result in serious injury. Resident #2's 4/16/13 nursing care plan directed staff the resident required extensive assistance the ADLs (activities of daily living) and assistance of 1 person for transfers. Interventions related to safety awareness directed staff to remind the resident to call for assistance and to close the privacy curtain. The resident had a bed alarm to notify staff he/she was standing up. The care plan further instructed staff to remind the resident to ring the call light for assistance and not to open the curtain as the resident would try to close it by him/herself. Nurses' notes on 4/3/13 at 7:10 p.m. stated staff found resident #2 on the floor on his/her left side. The resident stated he/she fell while trying to pull the curtain back and hit his/her head. Staff initiated neurological assessments. Review of neuro checks on 4/3/13 revealed neuro assessments done at 7:30 p.m., 10:35 p.m., on 4/4/13 at 8:00 a.m., 2:30 p.m., and at 11:00 p.m. The record lacked evidence of completed neuro checks as directed in the facility's policy. Nurses' notes on 4/5/13 at 3:30 a.m. stated resident #2's bed alarm sounded and staff found the resident on the floor with his/her head by the oxygen concentrator. Staff initiated neurological assessments. Review of neuro checks on 4/5/13 revealed neuro assessments done at 3:30 a.m., 9:45 a.m., 2:30 p.m. 10:35 p.m., on 4/6/13 at 7:00 a.m., 3:00 p.m., 10:30 p.m. and on 4/7/13 at 10:00 a.m. and at 3:00 p.m. The record lacked evidence of completed neuro checks as directed in the facility's policy. During an observation on 5/1/13 at 9:29 a.m., licensed nurse I assisted resident #2 to the toilet in the therapy room with a walker and gait belt. After toileting, licensed nurse I assisted the resident to the wheelchair in the same manner. During an interview on 4/24/13 at 2:23 p.m. licensed nurse H stated if a resident had a witnessed fall with a head injury, they did neuro checks initially and every 30 minutes (4 times), then maybe every 4 hours, and then every shift. During an interview on 5/1/13 at 3:45 p.m. administrative nurse B confirmed licensed staff should complete the neurological assessments as directed in the facility policy. The facility's 2011 Neurological Evaluation policy stated a purpose "to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined. The policy listed using the neurological evaluation "following a witnessed fall (when a resident has hit his/her head)". The procedure stated neurological checks should be completed initially and every 30 minutes (4 times), then every shift for 3 days or as appropriate or more frequently as directed by the physician....Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. The facility failed to complete ongoing nursing assessment including neurological evaluation after falls when resident #2 hit his/her head during falls on 4/3/13 and 4/5/13.

The facility had a census of 31 residents with 3 sampled for review. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 sampled residents received adequate supervision (appropriate and effective fall prevention strategies) to prevent accidents. (#3 and #2) Resident #3 fell on [DATE], the facility failed to implement effective interventions and the resident fell again on 3/18/13 and sustained a pelvic fracture. Findings included: - Resident #3's 3/29/13 physician order [REDACTED]. Resident #3's 2/8/13 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 8 which indicated moderate cognitive impairment. The resident required extensive assist of 2 persons for bed mobility, transfers, and toilet use. The assessment also indicated the resident had functional limitations in range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The resident had a fracture related to a fall within 6 months prior to admission and no falls since admission to the facility. Resident #3's 2/8/13 CAA (care area assessment) summary for cognitive loss stated the resident had a [DIAGNOSES REDACTED]. The summary indicated the resident had confusion. The ADL (activities of daily living) CAA summary stated the resident required assistance with all ADLs and PT (physical therapy) worked with him/her for strengthening , transfers, and ambulation. The fall CAA summary identified the resident as a fall risk. Resident #3's 2/26/13 nursing care plan directed staff that the resident required 1 person assist with all ADLs. A 3/21/13 revision to the care plan stated "no weight bearing" on the right side due to pelvic fracture. The 3/21/13 revised care plan related to safety awareness further directed staff to use an alarm on the chair and bed and stated the resident was unable to remember to use the call light. The Falls Data Collection tool dated 2/1/13 (on admission) revealed a score of 18 (scores greater than 12 indicated high risk for falls), after a fall on 2/19/13 revealed a score of 20, and after the fall on 3/18/13, the resident scored 23. A nurses' note on 2/19/13 at 1:50 p.m. stated staff found the resident on the floor without injury. According to the nurses' note staff oriented the resident to use the call light. According to the facility's fall investigation, resident #3 sustained an unwitnessed fall on 2/19/13 when he/she did not use the call light and got up independently. Immediate interventions included reorienting the resident to the call light and staff education to anticipate the resident's needs. The report also stated, "If this happens again should consider chair alarm and/or bed alarm." Nurses' notes on 3/18/13 at 10:10 a.m. stated staff found the resident on the floor and he/she did not use the walker or use the call light. The resident informed staff he/she wanted to throw something away. At 5:00 p.m. the nurses' note stated the resident ambulated to the dining room without any discomfort. Nurses' notes on 3/19/13 at 8:30 a.m. revealed the resident ambulated to the dining with a walker and staff noted the resident "limping" on the left leg and the resident stated he/she had pain in the right leg. Review of resident #3's clinical record lacked evidence of neurological assessments following unwitnessed falls on 2/19/13 and 3/18/13. Resident #3 had dementia, confusion, and moderate cognitive impairment. Physician's progress notes dated 3/19/13 stated the resident fell and now had right thigh pain and ordered an X-ray of the right hip and right femur. Resident #3's 3/20/13 X-ray revealed an acute appearing right pubic rami (pelvic) fracture. During an observation on 4/24/13 at 9:41 a.m. direct care staff G wheeled resident #3 to his/her room and assisted the resident from the wheelchair to the toilet with a gait belt. After toileting, the direct care staff G transferred the resident back to the wheelchair in the same manner. During an interview on 4/24/13 at 2:23 p.m. direct care staff G stated resident #3 got up to throw a yogurt carton away and fell and broke his/her pelvic bone. He/she further stated they (staff) check on him/her frequently. An interview on 4/24/13 at 2:23 p.m. with licensed nurse H revealed resident #3 does not remember to use his/her call light and confirmed that after the fall on 3/18/13 the facility initiated a bed and chair alarm. On 5/1/13 at 3:45 p.m. administrative nurse B confirmed the resident had confusion and dementia. He/she further stated reminding the resident to use the call light was not an effective intervention to prevent falls. Administrative nurse B stated the facility initiated the chair/bed alarm after resident #3 fell on [DATE] and sustained a pelvic fracture. During an interview on 5/6/13 at 12:15 p.m. physician F confirmed resident #3 had confusion, poor judgement, poor memory, and gait instability. He/she further stated that reminding resident #3 to use his/her call would not be an appropriate intervention for fall prevention. The facility's revised April 2011 Fallen or Injured Resident policy directs staff to complete an incident report, update the care plan with any changes or new interventions, and to monitor the resident's condition and the effectiveness of the interventions put in place to prevent further falls. The facility failed to implement effective fall prevention strategies after resident #3 fell on [DATE]. Resident #3 fell again on 3/18/13 and sustained a pelvic fracture. - Resident #2's 9/3/12 significant change MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 15 which indicated intact cognition. The resident required limited assist of 1 person for transfers, ambulation, and toilet use. The resident had no functional limitations in range of motion and used a walker and wheelchair for mobility. The resident had a fall in the past 6 months, but no falls since admission. Resident #2's 4/9/13 quarterly MDS revealed the resident had a BIMS score of 11 which indicated moderate cognitive impairment and now required extensive assist of 1 person for ambulation and toilet use and extensive assistance of 2 persons for transfers. The resident had functional limitations in range of motion on one side of the lower extremities and used a walker and wheelchair for mobility. The assessment also stated the resident had 2 or more non-injury falls since the prior assessment. Resident #2's 8/3/12 CAA (care area assessment) summary for delirium revealed the resident had a recent hospital admission for pneumonia and dehydration with fever and had increased confusion at that time. Since returning to the facility the resident's memory improved as the acute illness resolved. The fall CAA stated the resident had poor safety awareness and a strong desire to be independent. The summary further stated the resident loses his/her balance easily and his/her falls did not result in serious injury. Resident #2's 4/16/13 nursing care plan directed staff that the resident required extensive assistance the ADLs (activities of daily living) and assistance of 1 person for transfers. Interventions related to safety awareness directed staff to remind the resident to call for assistance and to close the privacy curtain. The resident had a bed alarm to notify staff he/she was standing up. The care plan further instructed staff to remind the resident to ring the call light for assistance and not to open the curtain as the resident would try to close it by him/herself. Resident #2's 1/22/13 nursing care plan had interventions to remind the resident to use the call light, keep bed in low position, and bed alarm in place. Review of nurses' notes revealed the resident had non injury falls on 3/18/13, 4/1/13, 4/3/13, and 4/5/13. Review of the facility's fall investigations revealed the following fall prevention strategies: * 3/18/13 Remind to call for help, bed in lowest position (on 1/22/13 care plan) * 4/1/13 Instructed to use call light and bed in lowest position (on 1/22/13 care plan) * 4/3/13 Educated and reminded to use the call light, continue bed alarm, bed in lowest position (on 1/22/13 care plan) During an observation on 5/1/13 at 9:29 a.m., licensed nurse I assisted resident #2 to the toilet in the therapy room with a walker and gait belt. After toileting, licensed nurse I assisted the resident to the wheelchair in the same manner. During an interview on 4/24/13 at 9:21 a.m., direct care staff J stated resident #2 fell "a lot" because he/she gets up on his/her own. During an interview on 4/24/13 at 3:36 p.m. licensed nurse C stated resident #2 had a bed alarm to alert staff when he/she gets up and stated the MDS coordinator updated the care plans after falls. During an interview on 5/1/13 at 3:45 p.m. administrative nurse B confirmed the interventions placed for resident #2 following the falls on 3/18/13, 4/1/13, and 4/3/13 were previously in place on the 1/22/13 nursing care plan. The facility's revised April 2011 Fallen or Injured Resident policy directs staff to complete an incident report, update the care plan with any changes or new interventions, and to monitor the resident's condition and the effectiveness of the interventions put in place to prevent further falls. The facility failed to implement effective fall prevention strategies after resident #2 fell on [DATE], 4/1/13, and 4/3/13.2/19/13.

The facility had a census of 31 residents, with 4 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 1 of 4 sampled residents with the necessary care and services (timely physician notification of severe leg pain, development/implementation of effective pain management measures) to attain/maintain the resident's highest practicable physical well-being. Resident #1 experienced severe leg pain late in the evening on 1/4/13, on 1/5/13 and again on 1/6/13 which caused the resident to frequently cry out in pain. Staff failed to notify the physician of that change and failed to implement pain management measures to control the pain. An xray done on 1/7/13 revealed a fracture of resident #1's leg. Findings included: - Resident #1's clinical record included a 10/30/12 Quarterly MDS (Minimum Data Set) that identified the resident with moderately impaired cognitive abilities, independence with bed mobility, the need for minimal staff assistance with transfers, an inability to ambulate, functional limitations in range of motion of both legs, occasional pain treated with non-medication approaches and rated a "4" by the resident on a "1-10" numeric pain scale in which 1 described minimal pain and 10 described the worst pain imaginable. A 1/22/13 Significant Change MDS identified resident #1 with an inability to complete the interview used to determine cognitive status, the needs for extensive assistance of two staff for bed mobility, total dependence on staff for transfers, and daily pain which required use of prn (as needed) and scheduled pain medications. CAAs (Care Area Assessments) completed on 1/24/13 included a CAA for ADLs (activities of daily living). According to that CAA, resident #1 now required "extensive care because of fracture .... now total care and non-weight bearing on L (left) leg .... ". Resident #1's 1/9/13 Care Plan directed staff to transfer the resident with a maxi-lift and assistance of two staff, and noted "no weight bearing on L (left) leg.". Resident #1's physician orders [REDACTED]. o Whiskey 30 cc (cubic centimeters) every night as needed - resident request may also have up to 3 drinks twice a week o Aspirin 5 mg. (milligrams) orally every 4 hours as needed for headache o Tylenol 325 mg. one or two tabs every 6 hours as needed for pain Interdisciplinary Progress Notes included frequent entries between the hours of 10:30 a.m. and 1:35 p.m. on Friday 1/4/13 related to resident #1's complaints of left knee pain. According to those notes, staff notified the physician of the knee pain, obtained orders for medication which the resident spit out, and staff notified the physician again of the resident's refusal to take the medication. The Interdisciplinary Progress Notes also included: o 1/4/13 at 1:35 p.m.: " .... Provider orders to provide comfort until xray can be taken after the weekend." o 1/4/13 at 11:00 p.m. described staff assistance with a transfer to a bedside commode and the resident, "yelling loudly, c/o (complains of) pain lt (left) knee" upon transfer from the bed to the commode and again upon transfer from the commode to the bed. o 1/4/13 at 4:30 a.m.: " .... up to BR (bathroom) at 1:30 with same yelling ...." o 1/6/13 at 1:20 a.m.: ".... L (left) knee painful, cries out in pain with any movement ...." o 1/6/13 at 3:20 a.m.: "Rang call light for assistance. L knee painful, cries out ...." o 1/6/13 at 10:40 p.m.: "Resident continues to cry out in pain with movement of L leg." o 1/7/13 at 5:15 a.m.: "Continuing pain when L leg moved...." o 1/7/13 at 10:00 a.m.: "To (hospital) for xray .... " Review of Interdisciplinary Progress notes revealed no evidence staff notified resident #1's physician of the resident's continued leg pain which caused the resident to repeatedly "cry out" over the weekend of 1/5/13 and 1/6/13. On 1/4/13, resident #1's physician ordered Tylenol 1000 mg followed by 15 cc of whiskey as a one time dose to treat the resident's complaints of leg pain. According to Interdisciplinary Progress Notes and the MAR (medication administration record), resident #1 spit out the dose of Tylenol 1000 mg. when staff attempted to administer it. According to January 2013 MARs, staff administered 15 cc of whiskey to resident #1 six different times on 1/4/13, 1/5/13 and 1/6/13. According to nursing documentation on the back of the MAR, resident #1 achieved "some pain relief" after some doses of whiskey and "no relief" after others. One of the entries on 1/5/13 at 11:00 a.m. described the resident's pain as an "8" on a scale of 1-10 which indicated severe pain. Staff also administered one dose of Tylenol 650 mg on 1/6/13 at 4:00 a.m. for complaint of knee pain. Staff failed to document the effectiveness of that dose of Tylenol. The MARs showed no evidence of administration of additional doses of medications to treat resident #1's pain during the weekend beginning on Friday 1/4/13 in the evening, 1/5/13, and 1/6/13. A physician progress notes [REDACTED].". During an observation on 1/29/13 at 1:00 p.m., resident #1 required assistance of two staff for a mechanical lift transfer from the wheelchair to the bed. The resident wore a leg brace/immobilizer on the left leg. The resident had severe hearing limitations and lacked the ability to understand and then respond to questions asked. During an interview on 1/29/13 at 11:45 a.m., Administrative Nurse A reported the physician directed staff to wait until Monday to get the xray of resident #1's knee because the knee pain didn't warrant use of an ambulance for the transfer to the local hospital. Nurse A also reported staff kept resident #1's physician advised of the resident's severe pain throughout the weekend. Upon review of the clinical record, Nurse A confirmed the record did not include evidence of physician notification of the significant change in resident #1's condition over the weekend of 1/5/13 and 1/6/13. During an interview on 1/29/13 at 1:45 p.m., Direct Care Staff B reported resident #1, "wasn't the same person" on the weekend of 1/5/13 and 1/6/13. According to Staff B, prior to that weekend resident #1 complained frequently of leg discomfort that staff eased by applying lotions to the legs and/or feet. On the weekend of 1/5/13 and 1/6/13, Staff B reported resident #1, "literally screamed" in pain whenever staff moved him/her. During a telephone interview on 1/31/13 at 1:40 p.m., Physician F reported staff failed to contact him/her or the PA (physician's assistant) on the weekend of 1/5/13 and 1/6/13 when resident #1 experienced significant changes in his/her condition. According to Physician F, if staff had notified him/her the resident would have either been sent to the hospital immediately for an xray or the physician or PA would have gone to the facility to assess the resident. According to the facility's February 2005 "Notification of Change in Resident Status" policy, "The center will IMMEDIATELY inform the resident, if appropriate (except in a medical emergency or when resident is incompetent) and consult with the resident's physician and, if known, notify the resident's family or legal representatives in the following cases .... Significant change in the resident's physical, mental or psychosocial status....". The facility failed to provide resident #1 with the necessary care and services (timely physician notification of severe leg pain, development/implementation of effective pain management measures) to attain/maintain the resident's highest practicable physical well-being. Resident #1 experienced severe leg pain late in the evening on 1/4/13, on 1/5/13 and again on 1/6/13 which caused the resident to frequently cry out in pain. Staff failed to notify the physician of that change and failed to implement adequate pain management measures to control the pain. On 1/7/13 an xray revealed a fracture of resident #1's leg.

The facility reported a census of 27 residents and 9 residents sampled for review. Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents sampled for nutrition maintained acceptable parameters of nutritional status. Resident #30 experienced a severe weight loss of 15.43% over 19 day period and a 12.91% weight loss over a 33 day period. The facility failed to address the weight loss or to follow physician's orders [REDACTED]. Findings included: - Resident #30's 4/30/12 physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. The physician discontinued the [MEDICATION NAME] and [MEDICATION NAME] on 4/10/12 and no other diuretics or antipsychotic medications had been ordered. Resident #30's 4/10/12 Admission MDS (Minimum Data Set) Assessment reported moderately impaired cognition. The MDS reported the need for setup assistance only for eating and no swallowing, mouth, or weight loss issues. Resident #30's 4/11/12 Nutritional CAA (Care Area Assessment) Summary reported the resident had a height of 67 inches and a weight of 175 pounds, with a BMI (body mass index) of 27 (overweight). The Nutritional CAA reported the resident had [DIAGNOSES REDACTED]. The Nutritional CAA reported the resident had a history of [REDACTED]. The Nutritional CAA reported the resident stated he/she felt "pleased at (his/her) present weight and had no wish to be on a reduced diet." The Nutritional CAA failed to mention the diet order for high protein with Ensure/Boost twice a day. Resident #30's 4/10/12 care plan included a goal to maintain his/her weight within 5% for the next 90 days, an admission weight of 175 pounds, and instructed staff to provide high protein snacks and Ensure twice a day and to obtain his/her weight on a weekly basis. Resident #30's 4/5/12 "Initial Interdisciplinary Data Collection Tool," completed by Dietary Staff C, reported the resident did not experience weight changes or appetite changes recently and had no difficulties using utensils or eating independently. Resident #30's 4/9/12 "Nutritional Assessment," completed by Consultant Staff J, reported the resident's ideal body weight ranged between 134 and 162 pounds. The report indicated the resident had "[MEDICAL CONDITION]" (a skin infection) related to a blood clot in his/her right leg, chronic airway obstructive disease, and a history [MEDICAL CONDITION]. The report indicated the resident's laboratory values remained within acceptable limits and had no risk for dehydration. The report indicated the resident needed 1876 kcal (calories) a day and 80 grams of protein per kilogram per day. The report indicated the resident received [MEDICATION NAME]. The reported lacked mention of the physician order [REDACTED]. Resident #30's 4/10/12 "Mini-Nutritional Assessment Short Form," completed by Dietary Staff C, reported the resident had a score of "11," indicating a risk for [MEDICAL CONDITION]. Review of the electronic record revealed the resident sat in a wheelchair to obtain his/her weight and the resident weighed 175 pounds on 4/4/12 and 4/9/12, no weight recorded on 4/16/12, and weighed 148 pounds on 4/23/12 (a weight loss of 15.43% in 19 days). The electronic weight record revealed on 4/30/12, the resident stood on a scale and weighed 152 pounds (an increase of 4 pounds in 7 days and a 12.91% weight loss in 26 days). On 5/7/12, the resident stood on a scale and weighed 157 pounds (an increase of 5 pounds and a 10.29% weight loss in 33 days). The electronic weight recorded lacked the resident's weight on 5/14/12. Review of the clinical record revealed staff failed to notify the physician of the weight loss during April and May 2012. Review of the physician's progress notes from 4/10/12 to 5/15/12 lacked mention that the resident experienced weight loss. Resident #30's 4/5/12 "Daily Skilled Note" recorded by nursing staff that the resident experienced "a change in appetite and fluid intake" and the presence of normal bowel sounds during the day shift. The evening and night shift documented the resident had no appetite or fluid intake changes and normal bowel sounds on 4/5/12. Documentation between 4/6/12 and 5/15/12 revealed the resident had normal bowel sounds and no appetite or fluid intake changes. Review of resident #30's "Dining Record" revealed between 4/4/12 and 5/15/12, the resident's usual intake for breakfast as 100%, lunch between 75% to 100%, and the evening meal between 75% to 100%. The clinical record lacked documented of a nutritional supplement offered or taken from 4/4/12 to 5/15/12. Resident #30's laboratory record revealed a complete metabolic panel blood test on 4/13/12 with an [MEDICATION NAME] level of 3.8 (normal for a range of 3.7 to 5.1) and a total protein level of 6.3 (slightly lower than a normal range of 6.4 to 8.3). Observations on 5/15/12 at 5:20 p.m. revealed resident #30 received a half of a sliced beef and cheese sandwich on white bread, approximately 25 corn chips, a small bowl of sliced bananas, kiwi, and strawberries, 8 ounces of hot chocolate, and 8 ounces of water for the evening meal. At 5:33 p.m., the resident ate 100% of the evening meal without difficulty. At 5:43 p.m., staff assisted the resident to his room and failed to ask to resident if he/she would like more food. Further observations revealed staff failed to offer Ensure to resident #30 during or after the evening meal. Observations on 5/16/12 at 7:16 a.m. revealed resident #30 received a bowl of cold oats cereal, two slices of an English muffin with butter, 4 ounces of milk, 8 ounces of hot chocolate, and 4 ounces of water. The resident poured the 4 ounces of milk into his/her bowl and placed grape jelly on the English muffin sliced without difficulty. At 7:35 a.m., the resident ate 100% of his/her breakfast without difficulty. At 7:45 a.m., staff assisted the resident to his/her room and failed to ask the resident if he/she would like more food. Observations on 5/16/12 at 10:01 a.m. revealed Direct Care Staff F offered resident #30 a snack-sized container of vanilla pudding. Further observations revealed staff F did not offer the resident Ensure or Boost. At 10:13 a.m., resident #30 ate 100% of the pudding without difficulty. Observations on 5/16/12 at 2:29 p.m. revealed Direct Care Staff L offered resident #30 a banana. Further observations revealed staff L failed to offer the resident Ensure or Boost. At 2:32 p.m., the resident ate 100% of the banana without difficulty. During an interview on 5/19/12 at 1:59 p.m., Direct Care Staff F stated resident #30 did not have a physician's orders [REDACTED]. Staff F stated staff obtained residents' weights on Monday mornings before breakfast on a routine basis. Staff F stated staff subtracted the wheelchair weight prior to entering the weight into the computer and the log listed resident #30's wheelchair weight as 49.4 pounds. Staff F stated direct care staff entered the weights into the computer which will alert staff if a weight changed more than 4 pounds since the last entry, and if alerted, staff reported weight changes to the nurse immediately. Staff F stated an awareness that resident #30 had lost weight, he/she recalled the resident suffered from a urinary tract infection shortly after admission which affected his/her appetite, and assumed the nursing staff knew of the weight loss. During an interview on 5/16/12 at 3:41 p.m., Administrative Nursing Staff A reported a lack of awareness that resident #30's weight decreased. Staff A stated he/she first thought that staff failed to subtract the resident's wheelchair weight prior to the computer entry and stated an average wheelchair weighed approximately 20 pounds. Staff A reported he/she weighed the wheelchair again on 5/16/12 and confirmed the wheelchair weighed 49.4 pounds. During an interview on 5/17/12 at 8:29 a.m., Dietary Staff C reported an awareness of the physician's diet order for high protein with "Ensure/Boost" twice a day and set up the times to receive a can of Ensure as 3:00 p.m. and 8:00 p.m. Staff C reported an awareness that staff failed to provide Ensure at 3:00 p.m. and 8:00 p.m. between 4/4/12 and 5/2/12 and between 5/6/12 and 5/16/12. Dietary Staff C reported residents can choose food items from the menu, if the resident has an order for [REDACTED]. Staff C reported he/she and the director of nursing met on 5/7/12 for a monthly meeting related to weight issues, he/she and director of nursing failed to note resident's weight loss during April 2012, and failed to alert the registered dietitian consultant of the resident's weight loss prior to or during the consultant's monthly visit on 5/9/12. During an interview on 5/17/12 at 10:35 a.m., Consultant Staff J reported a lack of awareness that resident #30 experienced a severe weight loss during April 2012 and did not recall Dietary Staff C had notified him/her prior to or during his/her visit on 5/9/12. During an interview on 5/17/12 at 2:05 p.m., Physician K reported a lack of awareness that resident #30's decreased weight in April 2012, and after reviewing his/her notes confirmed staff failed to notify the physician or an on-call provider on his/her team. Physician K reported the resident possibly experienced swelling due to the blood clot in his/her leg on admission which resolved by his/her next visit on 4/10/12, currently had a possibility of [MEDICAL CONDITION], and both could have contributed to the weight loss. Physician K stated staff should provide more calories during meals and snacks. The facility failed to ensure that resident #30 maintained acceptable parameters of nutritional status. Resident #30 experienced a severe weight loss of 15.43% over 19 day period and a 12.91% weight loss over a 33 day period. The facility failed to address the weight loss or to follow physician's orders [REDACTED].