Every finding on record at Edenbrook of Green Bay

Based on interview and record review, the facility did not ensure the right to make healthcare decisions was provided for 1 resident (R) (R1) of 1 sampled resident.R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record contained multiple documents signed by a family member who was not their POAHC. The facility did not have authorization to allow someone other than R1's POAHC to make medical decisions on their behalf.Findings include:R1 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment, dated 6/30/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. R1's medical record contained an activated POAHC document that designated POAHC-C as R1's primary decision maker. R1's medical record contained the following documents that were signed by Family Member (FM)-D without authorization or declination to act from POAHC-C: ~ Consent and authorization to treat dated 3/2/26~ Consent for bupropion dated 3/7/26~ Consent for trazodone dated 3/7/26~ Consent for fluoxetine dated 3/7/26~ Consent for Lamictal dated 3/7/26~ Do Not Resuscitate (DNR) paperwork dated 3/2/26 On 7/14/26 at 10:46 AM, Surveyor interviewed Social Services (SS)-E who stated FM-D informed the facility that they were the primary POAHC for R1. FM-D verified R1's POAHC document listed POAHC-C as their POAHC. SS-E stated when the facility does not receive a response from a POAHC, their policy is to send a letter and/or email and contact Adult Protective Services if needed. On 7/14/26 at 11:20 AM, Surveyor interviewed R1 who stated their primary POAHC for medical decisions is POAHC-C. On 7/14/26 at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated it was identified during R1's 6/30/26 hospitalization that the facility did not have the right contact information for R1's primary POAHC.

Based on interview and record review, the facility did not ensure 1 resident (R) (R2) of 11 sampled residents received care and treatment in accordance with their plan of care.The physician was not notified when R2's blood pressure (BP) was outside the ordered parameters. The provider indicated they would have instructed staff to recheck R2's BP, notify their cardiologist, and monitor their symptoms which were not completed.Findings include:The American Heart Association defines a low blood pressure as under 90/60 millimeters of mercury (mm/Hg).The facility's Change of Condition policy, revised 11/13/24, indicates: The physician and power of attorney/responsible party will be notified when there has been a change that is sudden in onset, that is a marked difference in usual signs/symptoms, and/or the signs/symptoms are unrelieved by measures already in place .Specific information that requires prompt notification includes, but is not limited to: a. Significant change or instability of vital signs .r. Instructions to notify the physician of changes in the resident's condition .3. The nurse will complete an assessment and document the findings in the resident's record, including but not limited to vitals signs, pain, respiratory status, and cardiac status as applicable Notification of the medical professional and resident representative will be documented in the medical record .9. The care plan will be updated as necessary.R2 was admitted to the facility on [DATE] and had diagnoses including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, presence of automatic cardiac defibrillator, chronic obstructive pulmonary disease, and chronic combined systolic and diastolic heart failure.On 7/13/26, Surveyor reviewed R2's medical record. Physician orders indicated staff should check R2's BP daily. R2 was under the care of a cardiologist. R2's medical record did not contain a cardiac-specific care plan.On 7/13/26 at 1:15 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-H who stated R2 had swelling of the arms, legs, and feet. R2's edema was significant enough that the physician prescribed 120 milligrams (mg) of Lasix daily for a period of time and was monitoring kidney function. ADON-H stated the facility planned to transfer R2 to an assisted living facility; however, R2's heart failure had declined and they were not comfortable with the transfer. R2 then had a stroke and was transferred to the hospital on 7/2/26. R2 did not return to the facility.R2's medical record indicated they had a BP of 78/55 mm/Hg on 3/4/26. The medical record did not contain a repeat BP or indicate the physician was notified.On 7/14/26 at 12:53 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the physician should be contacted for a critical blood pressure level. DON-B indicated a critical level would be if a resident was getting down in the 90s over 50s/60s. Upon reviewing R2's medical record, DON-B stated R2's blood pressure parameters were 80-170 for systolic and 50-100 for diastolic. DON-B confirmed R2 had a BP of 78/55 mm/Hg on 3/4/26 and stated Unit Coordinator (UC)-F entered the BP in the medical record.On 7/14/26 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R2's medical record did not indicate the physician was notified, a repeat BP was obtained, or contain monitoring instructions for R2.On 7/14/26 at 3:51 PM, Surveyor interviewed UC-F who recalled the day in question because there were 2 residents who had low BP at the same time. UC-F thought Nurse Practitioner (NP)-G was notified and told UC-F to monitor for symptoms, including lethargy, nausea, light-headedness, and palpitations and to call cardiology for any symptoms. UC-F stated they thought they passed on the instructions to the next shift nurse. UC-F confirmed they did not document the call or instructions to monitor for symptoms in R2's medical record. (It was confirmed the facility's 24-hour nursing report did not contain documentation either.)On 7/14/26, Surveyor reviewed R2's care plan which did not include instructions on what to do if their BP was outside the ordered parameters.On 7/14/26 at 4:33 PM, Surveyor interviewed NP-G who stated R2 had a pacemaker, had low BPs intermittently, and was being closely monitored around the time of the low BP on 3/4/26. NP-G stated if the facility notified them of a low BP, NP-G would have told them to complete a follow-up BP and monitor R2 for symptoms. NP-G stated there was a lot going on with R2's medication and they blew up like a balloon at one point (related to fluid). NP-G stated they would have instructed staff to include the cardiologist and would have made sure a repeat BP was taken in case the wrong cuff size was used.On 7/15/26 at 8:00 AM, Surveyor interviewed DON-B who confirmed R2's medical record did not indicate a repeat BP was obtained or indicate the cardiologist was notified of the low BP. DON-B also confirmed there was no documentation to alert the following shifts of R2's low BP, monitoring instructions, or the need to contact the cardiologist.

Based on staff interview and record review, the facility did not ensure assessments and daily skilled/alert charting was completed for 2 residents (R) (R7 and R12) of 13 sampled residents.R7's medical record did not contain assessments on 5/14/26 and 5/19/26 to ensure R7 was monitored and evaluated post-fall.R12 was admitted to the facility without initial nursing assessments to determine R12's required level of assistance.Findings include:The facility's Fall Prevention, Post Fall, and Communication policy, dated 1/21/26, indicates: Purpose: To promote resident safety by identifying fall risk, implementing individualized fall-prevention interventions, ensuring timely post-fall evaluation, and reviewing outcomes to prevent recurrence .Post fall response: .2. Monitoring and re-evaluation: Document on resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status. Staff will have increased awareness that the resident has recently fallen and report any changes in function, increased pain, and changes in cognition to the nurse for further evaluation. Monitor for signs of head injury, including but not limited to reduced level of consciousness, lethargy, significant weakness in one or more of the extremities, and rapid deterioration in neurological function .1. Between 5/19/26 and 5/20/26, Surveyor reviewed R7's medical record. R7 had diagnoses including schizoaffective disorder, bipolar type, Takotsubo syndrome (a condition in which the heart muscle weakens suddenly, often mimicking a heart attack but without a blockage in the coronary arteries), epilepsy, and diabetes type II. R7's care plan, initiated 4/30/26, indicated R7 was at moderate risk for falls related to impaired balance, amputation, and psychotropic medication use.R7's medical record indicated R7 fell on 4/28/26, 5/12/26 (3 times), 5/13/26, and 5/19/26 but did not contain post-fall assessments on 5/14/26 and 5/19/26.(See interview under example 2.)2. Between 5/19/26 and 5/20/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including diabetes type II, chronic kidney disease (CKD), sepsis, hypertension, and major depressive disorder. A progress note, dated 5/6/26 at 11:38 AM, indicated R12 arrived at the facility in a wheelchair via flexible transport. R12 was alert and oriented and transferred with the assistance of one staff into bed. Surveyor noted there was no other admission documentation in the progress note, including diagnoses, nursing assessments (including a skin assessment), vital signs, antibiotic medication prescribed for infection, other high-risk medications, or that R12 required assistance with activities of daily living (ADLs).Daily skilled charting, dated 5/7/26 at 10:17 PM (approximately 34-1/2 hours later), indicated R12 had osteomyelitis of the left lower extremity, diabetes type II, sepsis, gout, fatty liver, anemia, major depressive disorder, acquired absence of left toe, hypertension, and gastroesophageal reflux disease (GERD). R12 remained in bed all shift and refused to get up for meals. R12 ate all meals in bed and complained of left lower extremity pain. Oxycodone was administered and effective. R12 was alert and able to make needs known. The note indicated R12 had a periwound that measured 6.57 centimeters (cm) (length) x 1.52 cm (width) x 0.6 cm (depth) with a wound dressing (the wound location was not indicated) and a wound vac on a left lower ankle wound that measured 9.89 cm (length) x 2.33 cm (width) x 1.6 cm (depth).On 5/19/26 at 2:45 PM, Surveyor interviewed Registered Nurse (RN)-G who indicated alert charting is completed for falls. RN-G indicated monitoring is completed for antibiotics, new skin conditions, and for COVID-19 and other infections. RN-G did not know the last time RN-G completed a change of condition or admisssion assessment. RN-G indicated RN-G does not complete alert charting but completes the assessment and documents it in a daily skilled progress note. On 5/20/26 at 1:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-F. ADON-F was not aware nurses were not completing alert/daily skilled charting, assessments (including post-fall assessments), and admission documentation. ADON-F verified nurses should complete alert/daily skilled charting on a daily basis and post-fall assessments once per shift. DON-B verified R7's medical record did not contain post-fall assessments on 5/14/26 and 5/19/26 per facility policy and indicated R12's admission documentation should have included more information to ensure R12 was assessed so staff could meet R12's needs. DON-B indicated nursing staff were focused on R12's suicidal ideation and not R12's medical needs. DON-B indicated R12's admission documentation was not in accordance with the facility's practice.

Based on staff interview and record review, the facility did not provide timely laboratory services for 1 resident (R) (R2) of 3 sampled residents. Nurse Practitioner (NP)-E ordered a potassium lab to be drawn for R2 by 3:00 PM on 3/25/26 due to a critical potassium blood level. The lab was not drawn until 3/26/26 at approximately 9:00 AM. Findings include: The facility's Physician Orders policy, revised 11/13/24, indicates physician orders will be transcribed and implemented in accordance with professional standards. On 5/19/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including paraplegia, pneumonia, diabetes, cirrhosis of the liver, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 4/13/26, stated R2's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact cognition. R2 discharged from the facility on 5/6/26. Surveyor reviewed R2's Treatment Administration Record (TAR) and lab reports. Lab results, dated 3/25/26 at 6:44 AM, indicated R2's potassium level was 2.7 millimoles/liter (mmo/L) (the normal range is 3.5-5.1 mmo/L). R2's TAR contained an order for a potassium level draw re-check for hypokalemia (low potassium) on 3/25/26 at 3:00 PM. The order was not initialed as completed. On 5/20/26 at 8:40 AM, Surveyor interviewed NP-E who stated R2 had a critically low potassium level on 3/25/26 and NP-E instructed staff to give oral potassium and re-check R2's potassium level at 3:00 PM on 3/25/26. NP-E noted the order was not completed and faxed the facility on 3/26/26 stating R2 had a critically low potassium on 3/25/26 and an order was given to re-check R2's potassium level by 3:00 PM on 3/25/26. NP-E stated the re-check was not done which was unacceptable. NP-E also stated it is imperative the facility ensures orders are followed when a resident has a critical lab value so it does not result in hospitalization. NP-E ordered a STAT (immediate) potassium level and to update NP-E with the results. NP-E stated there have been concerns with labs not being completed timely in the past. NP-E stated symptoms of low potassium can include irregular heart rate/palpitations and fatigue. On 5/20/26 at 9:19 AM, Surveyor interviewed Registered Nurse (RN)-C who stated RN-C received the verbal order from NP-E to give R2 oral potassium and draw a potassium lab at 3:00 PM on 3/25/26. RN-C stated RN-C gave R2 the oral potassium and transcribed the lab order in R2's TAR. RN-C also updated Licensed Practical Nurse (LPN)-D who was the PM supervisor on 3/25/26. RN-C stated RN-C worked on 3/26/26 and noted the lab had not been drawn on 3/25/26 as ordered. On 5/20/26 at 9:55 AM, Surveyor interviewed LPN-D who indicated R2's potassium lab had to be drawn by 3:00 or 4:00 PM on 3/25/26 but stated the order RN-C entered did not specify a time. LPN-D stated by the time LPN-D completed medication pass on 3/25/26, it was after 6:00 PM so the lab was not drawn. On 5/20/26 at 1:40 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the lab was drawn on 3/26/26 (not 3/25/26 as ordered). DON-B stated several nursing staff are able to draw labs throughout the day and if they are unable to get the lab, they request an order to send the resident to the hospital to draw the lab if needed. DON-B was not sure why R2's potassium lab was not drawn on 3/25/26 per the physician's order.

Based on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 3 residents (R) (R7, R11, and R12) of 4 sampled residents.R7 was prescribed oral vancomycin (an antibiotic medication) for clostridioides difficile (C. diff) infection. R7's medical record did not indicate staff monitored R7 for adverse reactions to the high-risk medication.R11 was prescribed IV cephalexin (an antibiotic medication) for cellulitis. R11's medical record did not indicate staff monitored R11 for adverse reactions to the high-risk medication.R12 was prescribed IV ceftriaxone sodium (an antibiotic medication) for osteomyelitis and sepsis. R12's medical record did not indicate staff monitored R12 for adverse reactions to the high-risk medication.Findings include:The facility's Policy and Procedure Alert Charting, revised 11/13/24, indicates: Purpose: To provide guidance for documentation in the medical record for situations that meet the criteria of a change in condition, and incident/accident, or as otherwise clinically indicated .follow-up documentation is required for residents on antibiotic/anti-infective therapy for the duration of therapy .On 5/20/26 at 8:20 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated alert charting is required each shift to ensure monitoring for adverse reactions when a resident is prescribed antibiotics.1. Between 5/19/26 and 5/20/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of C. diff with prescribed antibiotic therapy. R7's medical record did not contain documentaton on 5/17/26 to indicate staff monitored R7 for adverse reactions to the antibiotic.2. Between 5/19/26 and 5/20/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] following hospitalization for sepsis secondary to urinary tract infection (UTI) and bilateral lower extremity cellulitis with an order for a 10-day course of IV cephalexin. R11's medical record did not contain documentation on 5/11/26 to indicate staff monitored R11 for adverse reactions to the antibiotic. 3. Between 5/19/26 and 5/20/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] with an order for IV ceftriaxone for osteomyelitis and sepsis. R12's medical record did not contain documentation from 5/10/26 through 5/12/26 to indicate staff monitored R12 for adverse reactions to the antibiotic.On 5/19/26 at 2:45 PM, Surveyor interviewed Registered Nurse (RN)-G who indicated staff monitor and complete alert charting for residents on antibiotics. RN-G indicated RN-G does not complete alert charting but completes an assessment and documents it in a daily skilled nursing progress note. On 5/20/26 at 1:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-F. ADON-F indicated ADON-F was not aware nurses were not completing alert charting. ADON-F verified nurses should complete alert charting once per shift and monitor for adverse reactions when a resident is prescribed a course of antibiotics. DON-B verified R7, R11, and R12's medical records did not contain monitoring documentation for adverse reactions to antibiotic medication on the dates listed above. DON-B confirmed R7, R11 and R12 were admitted to the facility on antibiotic therapy and monitoring is required throughout the duration of antibiotic therapy.On 5/20/26 at 2:45 PM, and 3:45 PM, Surveyor requested the facility's policy on high-risk medication monitoring from DON-B. A policy was not provided.

Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This practice had the potential to affect all 70 residents residing in the facility. Findings include:On 8/26/25, Surveyor requested to review Dietary Manager (DM)-R's certification. On 8/26/25 at approximately 1:00 PM, Surveyor received paperwork from Nursing Home Administrator (NHA)-A that included a screenshot of test results for DM-R. The paperwork for DM-R indicated DM-R did not pass the dietary manager certification test and was not certified. Surveyor interviewed NHA-A who indicated DM-R did not pass the test and was not able to take the test again for 90 days. NHA-A was unsure when DM-R failed the test. On 8/26/25 at 2:18 PM, Surveyor interviewed NHA-A who indicated NHA-A had not filed a waiver with the State Agency (SA) for the dietary manager position. NHA-A was aware DM-R needed to complete the dietary manager certification because it was discussed with the facility during the facility's last recertification survey.On 8/26/25 at 2:33 PM, Surveyor interviewed DM-R who indicated DM-R failed the test on 7/21/25 and was going to re-take the test when eligible. DM-R indicated DM-R did not have a food service manager certification and/or food service management or hospitality associate's degree. On 8/26/25 at 2:34 PM, Surveyor interviewed RD-Q who was aware DM-R did not have the required certification and did not pass the dietary manager certification test. RD-Q indicated RD-Q did not work full time at the facility but was actively working with DM-R to study for the next test.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R2, R3, and R59) of 11 sampled residents.R2 was on isolation precautions for Clostridium Difficile (C. diff). During observations of care, staff did not don the appropriate personal protective equipment (PPE) and complete hand hygiene prior to entering and exiting R2's room and did not dispose of soiled linens in accordance with the facility's policy. In addition, R2's Kardex (an abbreviated care plan used by nursing staff) did not indicate R2 was on isolation precautions and R2's medical record did not contain Clostridium Difficile as a diagnosis.Staff did not don the appropriate PPE while completing a dressing change and nephrostomy tube care for R3.R59 had a wound. Enhanced barrier precautions (EBP) were not initiated in a timely manner. In addition, staff did not adhere to EBP during high- contact cares for R59.Findings include:The facility's policy titled Policy & Procedure Enhanced Barrier Precautions, dated 3/26/24, indicates: Enhanced barrier precautions (EBP) require gown and glove use for residents with a novel or targeted multidrug-resistant organism (MDRO) or any resident with a wound or indwelling medical device during specific high-contact resident care activities. High-contact resident care activities include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device; central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.The facility's policy titled Policy & Procedure Isolation Precautions, revised 5/8/24, indicates: Purpose: To establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others .2. Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required PPE .Contact precautions: 1. Implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment .3. Prior to entering an isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves and gown prior to entering room; b. While providing direct resident care, wear gloves and wash hands after coming in contact with infectious material; c. Remove gloves and perform hand hygiene before leaving room. (Do not use alcohol-based hand gels for isolation due to suspected or confirmed Clostridium Difficile and Norovirus); d. Adequately clean/disinfect items with an approved solution prior to removing the item from the room and before use on another resident.The facility's policy titled Policy & Procedure Clostridium Difficile, revised 5/8/24, indicates: Purpose: To provide guidelines for the care of persons with Clostridium difficile (C. diff) verified by culture or by evidence of positive cytotoxin, essay, and to prevent transmission of C. diff to others .Residents with diarrhea-associated C. diff will be placed on contact precautions .5. All physically contaminated articles must be considered potentially infectious. C. diff is spore forming, and if not well contained, all surfaces in a resident's room must be considered potentially contaminated. 6. Steps toward prevention and early intervention include: .c. Hand washing of staff and residents; d. Wearing gloves and gowns (if necessary) when handling feces or fecal contaminated articles .7. All equipment in the resident's room must be considered potentially contaminated by C. diff spores .9. Observe proper hand hygiene procedures by washing hands with conventional antiseptic-containing soap and water. Alcohol-based hand sanitizers are not effective on C. diff.1.From 8/25/25 to 8/27/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, neuromuscular dysfunction of bladder, neurogenic bowel, and extended-spectrum beta lactamase resistance (ESBL). R2's Minimum Data Set (MDS) assessment, dated 7/20/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC). R2's care plan indicated: Isolation Precautions: Contact precautions initiated on 7/30/25. R2's Kardex indicated R2 was on EBP.PCR tests, dated 2/19/25 and 7/29/25, indicated R2 was positive for Clostridium difficile glutamate dehydrogenase (gdh) enzyme and toxin. R2 had a physician order, dated 7/30/25, for Vancomycin HCl oral capsule 125 milligrams (mg) Give 1 capsule by mouth every 6 hours for Clostridium difficile for 14 days; Give 1 capsule by mouth two times a day for Clostridium difficile for 7 days; Give 1 capsule by mouth one time a day for Clostridium difficile for 7 days (end date 8/29/25). A diagnosis of enterocolitis due to Clostridium difficile, recurrent was added to R2's diagnosis list on 8/27/25 with an active date of 7/29/25.A note, dated 8/11/25 and written by Nurse Practitioner (NP)-K, indicated R2 was diagnosed with enterocolitis due to Clostridium difficile, recurrent and to continue a prolonged course of Vancomycin due to recurrence. On 8/25/25 at 9:53 AM, Surveyor observed an EBP sign on R2's door. Surveyor did not observe a contact precautions sign posted on R2's door or near R2's room. On 8/26/25 at 9:36 AM, Surveyor observed contact precautions and EBP signs on R2's door. On 8/26/25 at 9:52 AM, Surveyor observed Certified Nursing Assistant (CNA)-J change R2's bed linens without wearing a gown or gloves. CNA-J held the bed linens and R2's gown against CNA-J's body, exited the room (without completing hand hygiene), and placed the soiled linens in a cart in the hallway. CNA-J then sat down at a computer and used the keyboard.On 8/26/25 at 9:55 AM, Surveyor observed Housekeeper (HSK)-H sweep and clean R2's bathroom while wearing gloves but no gown. HSK-H then exited the room, removed gloves at a housekeeping cart in the hallway, and used hand sanitizer to cleanse HSK-H's hands. On 8/26/25 at 9:57 AM, Surveyor interviewed HSK-H who indicated housekeeping staff do not use gowns because they do not have direct contact with residents. HSK-H indicated if a resident is on droplet precautions, HSK-H dons a gown. HSK-H indicated hand sanitizer was appropriate for hand hygiene because HSK-H wore gloves in R2's room.On 8/26/25 at 9:59 AM, Surveyor interviewed CNA-J who indicated R2 was on contact precautions due to C. diff. CNA-J indicated CNA-J should have worn a gown and gloves in R2's room, should have double-bagged R2's linens, and should have placed the linens in a separate C. diff linen bin. CNA-J confirmed CNA-J should have completed hand hygiene prior to exiting R2's room but stated CNA-J was rushing to get done on time.On 8/26/25 at 10:26 AM, Surveyor interviewed Registered Nurse (RN)-F who indicated R2 was on contact precautions for C. diff, however, R2's roommate was not on precautions. RN-F indicated staff should wear contact PPE when working with R2 but do not need to wear contact PPE when working with R2's roommate. RN-F indicated R2's linens are bagged and put in a special bin due to R2's contact precautions. On 8/26/25 at 11:56 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who indicated if a resident's room has a contact precautions sign on the door, staff should don a gown and gloves prior to entering and wash their hands prior to exiting. ADON-C indicated soiled linens from a C. diff positive resident's room should be bagged and placed in a separate laundry bin.On 8/26/25 at 2:23 PM, Surveyor interviewed CNA-I who indicated CNA-I refers to a resident's Kardex to determine cares and precautions that need to be followed. CNA-I indicated R2's Kardex indicated R2 was on EBP and not contact precautions.On 8/27/25 at 8:37 AM, Surveyor interviewed CNA-I who indicated soiled linens from R2's room should be placed in a red bag and put in a red bin in the soiled utility room. Surveyor and CNA-I then observed Sharps containers and intravenous (IV) tubing in a red bin in the soiled utility room and CNA-I indicated CNA-I was unsure which bin to use for soiled linens from a C. diff positive resident's room. On 8/27/25 at 9:02 AM, Surveyor interviewed Infection Preventionist (IP)-D who indicated R2's C. diff PCR test in July 2025 was positive. IP-D verified R2's first C. diff positive toxin was on 2/19/25. IP-D indicated R2 was on contact precautions, currently had a positive C. diff toxin, and was being treated for C. dif. IP-D indicated all staff, including housekeeping staff, need to wear a gown and gloves upon entering R2's room and need to remove the gown and gloves and wash hands prior to exiting R2's room.On 8/27/25 at 9:58 AM, Surveyor interviewed ADON-C who indicated R2's soiled linens should be placed in a yellow bag and then double-bagged with a clear bag. ADON-C indicated the double-bagged should be put in the dirty linen bin in the soiled utility room with other residents' soiled linen.On 8/27/25 at 1:02 PM, Surveyor interviewed MDS Nurse (MDSN)-E via phone. MDSN-E indicated MDSN-E just finished entering C. diff in R2's diagnoses list. MDSN-E indicated R2's diagnosis of C. diff was inadvertently missed in February 2025 when R2 was diagnosed.On 8/27/25 at 12:29 PM, Surveyor interviewed NP-K who indicated R2 had a recurrence of C. diff 3 times since February 2025 when R2 was initially diagnosed. NP-K indicated R2 was currently being treated for C. diff and R2's last positive PCR toxin was in July 2025. NP-K indicated R2 restarted Vancomycin in July 2025 and continues treatment. NP-K indicated all staff and visitors who enter R2's room should adhere to contact precautions. 2. From 8/25/25 to 8/27/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, stage 4, urinary tract infection (UTI), klebsiella pneumoniae, ESBL resistance, and acute cystitis with hematuria. R3's MDS assessment, dated 8/3/25, had a BIMS score of 14 out of 15 which indicated R3 had intact cognition. R3's did not have an activated POAHC.R3 had a Foley catheter and right nephrostomy tubes. A care plan, dated 8/27/24, indicated R3 had actual alteration in elimination due to functional bowel incontinence, use of a Foley catheter, and right nephrostomy tube placement. The care plan also indicated R3 had the potential for infection due to nephrostomy tube placement, a personal history of methicillin-resistant Staphylococcus aureus (MRSA) and ESBL. The care plan indicated EBP was initiated on 8/4/25. R3's Kardex also indicated R3 was on EBP.On 8/25/25 at 9:53 AM, Surveyor observed an EBP sign on R3's door. On 8/27/25 at 9:38 AM, Surveyor observed Licensed Practical Nurse (LPN)-G change R3's right nephrostomy dressing and observed CNA-I assist LPN-G with turning R3. LPN-G and CNA-I wore gloves but no gowns. LPN-G and CNA-I completed hand hygiene after cares and prior to exiting R3's room.On 8/27/25 at 9:49 AM, Surveyor interviewed LPN-G and CNA-I. LPN-G indicated LPN-G and CNA-I should have donned gowns prior to cares and the dressing change because R3 was on EBP. CNA-I agreed.3. From 8/25/25 to 8/27/25, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, severe dementia with psychotic disturbance, schizoaffective disorder, panic disorder, and anxiety. R59's MDS assessment, dated 8/25/25, had a BIMS score of 3 out of 15 which indicated R59 had severely impaired cognition.R59's medical record indicated R59 had open wounds which were assessed weekly.On 8/25/25 at 10:15 AM, Surveyor noted there was not an EBP sign on or near R59's door or a PPE cart near R59's room.On 8/25/25 at 10:16 AM, Surveyor observed ADON-C approach R59's room and post an EBP sign on the door. Surveyor interviewed ADON-C who verified ADON-C posted an EBP sign for R59, but wasn't sure what the sign was for. ADON-C thought the sign was for ESBL (which refers to enzymes produced by bacteria such as E. coli) which ADON-C stated R59 had at one time but was no longer being treated for. ADON-C confirmed R59 should have been on EBP before ADON-C posted the sign. ADON-C did not know why the sign was down and indicated ADON-C had to check with a management staff who was not there at that time.On 8/25/25 at 11:01 AM, Surveyor interviewed LPN-G who indicated R59 should have been on EBP for ESBL but was unsure if R59 had wounds or why R59 was taken off of EBP.On 8/25/25 at 1:01 PM, Surveyor observed CNA-S enter R59's room. Surveyor observed an EBP sign on R59's door and noted CNA-S did not don gloves or a gown prior to entry. At 1:02 PM, Surveyor observed CNA-T enter R59's room without donning gloves or a gown and close R59's door.On 8/25/25 at 1:06 PM, CNA-S and CNA-T opened R59's door and exited R59's room. Surveyor interviewed CNA-S who indicated CNA-S and CNA-T used a Hoyer lift to transfer R59 to bed. When asked if CNA-S and CNA-T wore and PPE, CNA-S and CNA-T indicated they did not wear PPE and were not aware that R59 was on EBP. CNA-S and CNA-T confirmed they should have donned PPE prior to providing care for R59. On 8/27/25 at 11:11 AM, Surveyor interviewed IP-D who indicated an EBP sign should have been posted on R59's door prior to 8/25/25. ADON-D indicated R59 developed an open wound and EBP should have been initiated right away. IP-D indicated all nurses can initiate EBP. IP-D indicated without an EBP sign and PPE cart, it is likely that R59 received high-contact cares without the required PPE for infection prevention. IP-D indicated staff should be aware of and use the appropriate PPE for EBP.On 8/27/25 at 12:20 PM, Surveyor interviewed ADON-C (who was also the facility's wound nurse) who indicated R59's wound had reopened and was bleeding the day prior.

Based on observation, staff interview, and record review, the facility did not maintain dignity during meal time for 3 residents (R) (R22, R29, and R59) of 4 sampled residents.R22, R29, and R59 required assistance with eating. On 8/26/25, staff moved between R22, R29, and R59 (who were at different tables) while providing assistance with breakfast and stood while feeding them.Findings include:From 8/25/25 to 8/27/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, cancer, end stage renal disease, diabetes, and hemiplegia/hemiparesis. R22's Minimum Data Set (MDS) assessment, dated 6/23/25, indicated R22 was rarely or never understood.From 8/25/25 to 8/27/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including muscular dystrophy, calorie deficit at risk for malnutrition, and Friedreich's ataxia. R29's MDS assessment, dated 8/11/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R29 had severely impaired cognition.From 8/25/25 to 8/27/25, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had diagnoses including severe dementia with psychotic disturbance, schizoaffective disorder, panic disorder, and anxiety. R59's MDS assessment, dated 8/25/25, had a BIMS score of 3 out of 15 which indicated R59 had severely impaired cognition.On 8/26/25 at 8:08 AM, Surveyor observed 14 residents in the second-floor main dining room during breakfast and witnessed the following:~ At 8:10 AM, Surveyor observed Certified Nursing Assistant (CNA)-J walk up to and feed R59 one spoonful of food while standing. CNA-J assisted R59 for one to two minutes then walked away to assist R29 at another table. CNA-J applied a clothing protector to R29 then fed R29 a bite of food while standing. CNA-J then walked to R22 at another table and fed R22 one bite of food while standing. CNA-J then walked back to R29 and continued to feed R29 bites of food while standing. ~ At 8:16 AM, Surveyor observed CNA-J retrieve a char and sit down to feed R29. ~ At 8:26 AM, Surveyor observed CNA-J stand up and continue to feed R29 until R29 was finished eating.~ At 8:31 AM, Surveyor observed CNA-J walk to R22, feed R22 a couple bites of food while standing, and then walk away.~ At 8:34 AM, Surveyor observed CNA-J walk back to R22 and continue to feed R22 until R22 was finished.On 8/26/25 at 8:34 AM, Surveyor interviewed CNA-P who identified the residents and staff observed in the dining room and indicated Surveyor's observation was a typical occurrence during dining room service.On 8/26/25 at 2:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should sit down while feeding residents. On 8/26/25 at 2:24 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should not stand while feeding residents. DON-B indicated staff should be aware of and follow the facility's expectations for serving food and assisting residents.On 8/26/25 at approximately 3:30 PM, Surveyor interviewed Registered Dietitian (RD)-Q who indicated staff should sit down while feeding residents for safety and dignity.Surveyor requested policies from NHA-A and DON-B regarding the resident dining experience and/or feeding of residents by staff. No applicable policies were provided.

Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 3 residents (R) (R65, R52, and R9) of 3 sampled residents.Staff did not update the provider with a weight gain of 3 pounds or more in one day or 5 pounds or more in one week as ordered for R65, R52, and R9. Findings include: The facility's Heart Failure policy, dated 3/19/24, indicates: .2. In addition, the nurse will assess and document/report the following: .b. Daily weights or as ordered by the provider .i. Call for weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week or as directed by the provider .d. Provider will be updated with changes in condition . 1. From 8/25/25 to 8/27/25, Surveyor reviewed R65's medical record. R65's most recent admission to the facility was on 7/15/25. R65 had diagnoses including chronic systolic congestive heart failure (CHF), acquired absence of left leg below knee, and diabetes mellitus type 2. R65's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R65 had intact cognition. R65's plan of care indicated R65 had altered cardiovascular status related to heart failure (initiated on 4/8/25) and contained interventions to monitor/document/report as needed (PRN) .changes in weight. R65's physician orders, dated 7/15/25, indicated the following: ~CHF monitoring: Monitor respiratory status, edema, fatigue, and change in mental status every shift and document findings in electronic health record (EHR). Update provider with any signs/symptoms of worsening CHF. ~Daily weights upon admission for residents with heart failure unless directed otherwise by provider. Call for weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week unless otherwise directed by the provider. Surveyor reviewed R65's weights for 6/1/25 to 8/25/25 and noted the following: ~ On 6/5/25, R65 weighed 273.2 pounds.~ On 6/6/25, R65 refused to be weighed.~ On 6/7/25, R65 weighed 279.6 pounds (which was a gain of 6.4 pounds). ~ On 6/9/25, R65 weighed 279.6 pounds.~ On 6/10/25, R65's weight was not recorded~ On 6/11/25, R65 weighed 284.0 pounds. ~ On 6/12/25, R65 weighed 286.2 pounds (which was a gain of 6.6 pounds). ~ On 6/14/25, R65 weighed 280.2 pounds.~ On 6/15/25, R65 weighed 284.4 pounds (which was a gain of 4.2 pounds). ~ On 6/20/25, R65 weighed 270.4 pounds.~ On 6/25/25, R65 weighed 278.7 pounds (which was a gain of 8.3 pounds). ~ On 7/21/25, R65 weighed 263.9 pounds.~ On 7/22/25, R65 weighed 269.0 pounds (which was a gain of 5.1 pounds). ~ On 7/27/25, R65 weighed 267.0 pounds.~ On 7/28/25, R65 weighed 261.6 pounds (which was a loss of 5.4 pounds). ~ On 7/31/25, R65 weighed 263.4 pounds.~ On 8/1/25, R65 weighed 268.2 pounds (which was a gain of 4.6 pounds). ~ On 8/8/25, R65 weighed 263.4 pounds.~ On 8/9/25, R65 weighed 270.8 pounds (which was a gain of 7.4 pounds). ~ On 8/16/25, R65 weighed 234.6 pounds.~ On 8/17/25, R65 weighed 267.6 pounds (which was a gain of 33 pounds). ~ On 8/18/25, R65 weighed 263.2 pounds.~ On 8/19/25, R65 weighed 268.8 pounds (which was a gain of 5.6 pounds). ~ On 8/21/25, R65 weighed 259.6 pounds.~ On 8/22/25, R65 weighed 269.4 pounds (which was a gain of 9.8 pounds). Surveyor noted R65's medical record did not indicate the provider was updated when R65 gained 3 or more pounds in 24 hours or 5 or more pounds in one week. 2. From 8/25/25 to 8/27/25, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had diagnoses including CHF and diabetes. R52's MDS assessment, dated 8/7/25, had a BIMS score of 15 out of 15 which indicated R52 had intact cognition. R52's plan of care indicated R52 had potential for altered nutritional status related to recent surgery and contained interventions to weigh R52 per facility policy or as ordered and notify the provider per order or with significant changes. R52's physician orders, dated 7/25/25, indicated the following: ~ CHF monitoring: Monitor respiratory status, edema, fatigue, and change in mental status every shift and document findings in EHR. Update provider with any signs/symptoms of worsening CHF. ~ Daily weights for residents with heart failure. Call for weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week unless otherwise directed by the provider. Surveyor reviewed R52's weights for 7/24/25 to 8/25/25 and noted the following: ~ On 7/30/25, R52 weighed 286.0 pounds. ~ On 7/31/25, R52 weighed 290.2 pounds (which was a gain of 4.2 pounds). ~ On 8/1/25, R52 weighed 286.0 pounds.~ On 8/2/25, R52 weighed 293.3 pounds (which was a gain of 7.3 pounds). ~ On 8/24/25, R52 weighed 288.3 pounds.~ On 8/25/25, R52 weighed 292.9 pounds (which was a gain of 4.6 pounds). Surveyor noted R52's medical record did not indicate the provider was notified when R52 gained 3 or more pounds in 24 hours or 5 or more pounds in one week. On 8/26/25 at 3:52 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-N and CNA-O who indicated the nurse provides a list of residents with daily weights. After obtaining a resident's weight, CNA-N and CNA-O indicated they update the nurse and the nurse updates the doctor. CNA-N and CNA-O indicated if a resident's weight is off by an abnormal amount, they re-weigh the resident. On 8/26/25 at 4:00 PM, Surveyor interviewed Registered Nurse (RN)-L who indicated the facility has a daily weight list and the provider should be updated if a resident gains 3 or more pounds in 24 hours. On 8/26/25 at 4:24 PM, Surveyor and RN-M reviewed R65 and R52's weights. RN-M confirmed R65 and R52 had weight changes that met the physician's order of 3 or more pounds within 24 hours and 5 or more pounds within one week. RN-M confirmed the weight changes should have been communicated to the provider. RN-M reviewed progress notes for R65 and R52 and confirmed R65 and R52's medical records did not indicate the provider was notified of the weight changes. RN-M indicated the facility did not have a formal daily weight list and indicated the nurse writes a daily list per residents' daily weight orders. On 8/27/25 at 8:31 AM, Surveyor interviewed Infection Preventionist (IP)-D regarding R65 and R52's weight gains. IP-D confirmed R65 and R52's medical records did not indicate the provider was updated regarding R65 and R52's weight gains and confirmed the provider should have been updated per R65 and R52's orders. IP-D indicated the facility recognized daily weights were an issue in February 2025 and had a plan of correction with audits until June 2025. IP-D indicated the facility recognized the same issue again on 8/25/25 and started another plan of correction with education. Nursing Home Administrator (NHA)-A indicated the plan of correction was started at approximately 12:00 PM on 8/25/25 (which was after the survey team had entered). IP-D also indicated R65's 33 pound weight gain should have triggered a re-weigh and a progress note should have been entered. IP-D indicated if the re-weight did not change, the provider should have been updated. 3. From 8/25/25 to 8/27/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including CHF, hypertension, chronic kidney disease, and diabetes. R9's MDS assessment, dated 7/25/25, had a BIMS score of 10 out of 15 which indicated R9 had moderate cognitive impairment. R9's care plan, revised 7/25/25, indicated R9 had congestive heart failure and contained interventions to monitor and report signs of congestive heart failure such as edema, crackles/wheezes, weakness, and weight gain unrelated to intake. R9's physician's orders, dated 4/18/25, indicated: ~ Weights on Monday, Wednesday, and Friday related to heart failure as directed by provider. Call for weight gain of 3 pounds or greater in 24 hours or 5 pounds in one week. ~ Update provider with any signs/symptoms of worsening CHF. A weight change progress note, dated 7/11/25, indicated R9 weighed 177 pounds and had a 13 pound (7.9%) weight gain in 3 months and a 17 pound (10.6%) weight gain in 6 months. The note stated R9's weight showed an upward trend with a history of CHF. An update to the provider was requested. R9's medical record did not indicate the provider was notified of R9's significant weight gain. R9's medical record contained the following weights: ~ On 8/6/25, R9 weighed 171 pounds. ~ On 8/15/25, R9 weighed 180.3 pounds (which was a 9.3 pound gain). Suveyor noted R9's medical record did not indicate the provider was notified when R9 gained over 5 pounds in one week. On 8/27/25 at 11:09 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the provider should be notified of a significant weight gain within 24 to 48 hours of identification or as otherwise ordered. DON-B could not verify that R9's provider was updated within 24 to 48 hours of identifying R9's significant weight gain.

Based on staff and resident interview and record review, the facility did not ensure pain medication was provided timely for 1 resident (R) (R4) of 3 sampled residents.R4 received Hospice services and had an order for as needed (PRN) morphine for pain. On either 7/8/25 or 7/20/25, R4 requested PRN pain medication. R4 did not receive the medication timely. Findings include:The facility's Pain Management and Assessment policy, revised 4/25/25, indicates: The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living. On 8/18/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including lung cancer, brain cancer, encounter for palliative care, chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder. R4's Minimum Data Set (MDS) assessment, dated 6/20/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition. R4 received Hospice services. R4 had the following orders: ~ 0.5 milliliters (ml) of morphine sulfate (concentrate) oral solution 20 mg/milliliter (ml) by mouth every hour as needed for pain or shortness of breath. ~ 0.25 ml of morphine sulfate oral solution 20 mg/ml every hour as needed for pain or shortness of breath.On 8/18/25 at 10:45 AM, Surveyor interviewed R4 who indicated sometimes R4 did not get pain medication timely. R4 indicated it took staff 2 hours to provide R4's as needed (PRN) morphine approximately 1 month ago. R4 indicated R4 told staff that R4 was upset that it had taken so long to receive the medication. R4 could not recall the date or the nurse who administered the medication. In a subsequent interview at 3:55 PM, R4 indicated R4's stomach was bothering R4 and R4's ass was on fire the day R4 had to wait 2 hours to receive morphine. R4 indicated R4 was not a drug user and only asked for morphine when it was needed. A progress note, dated 7/20/25, indicated R4 had constipation issues. R4 received Miralax at 12:06 PM which was documented as ineffective at 3:57 PM. The facility contacted R4's Hospice provider who prescribed a one time dose of Senna which was effective.On 8/18/25 at 1:00 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated approximately 1 month ago it took the nurse a long time to administer R4's pain medication. LPN-D indicated 2 nurses worked the floor and usually split R4's wing. LPN-D indicated the Certified Nursing Assistants (CNAs) used walkie talkies to notify the nurses that R4 had requested pain medication. LPN-D indicated R4 was not LPN-D's resident and LPN-D thought the other nurse administered the medication. LPN-D indicated a CNA approached LPN-D a while later and indicated R4 was still waiting for medication. LPN-D assessed R4 who indicated R4 had been waiting 2 hours for pain medication. LPN-D notified the other nurse who provided R4's pain medication.On 8/18/25 at 2:00 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who was not aware that R4 did not receive pain medication timely. ADON-C indicated the nurse should have reported the information to ADON-C.On 8/18/25 at 2:42 PM, Nursing Home Administrator (NHA)-A and ADON-C indicated to Surveyor that a grievance was started for the concern that R4 had not received PRN pain medication timely. ADON-C indicated ADON-C spoke with LPN-D and they narrowed the date down to either 7/8/25 or 7/20/25. On 7/8/25, R4 received Tylenol. On 7/20/25, R4 received PRN morphine at 8:30 AM which was documented as effective. ADON-C later provided Surveyor with the phone number of the nurse who worked with LPN-D and administered pain medication to R4 on both dates. Surveyor left a message with the nurse but did not receive a return call. ADON-C indicated staff should have filled out a grievance form and indicated ADON-C would provide staff education. In a subsequent interview at 4:01 PM, ADON-C indicated when PRN pain medication is requested, the nurse should finish what they are doing and provide the medication to the resident.

Based on observation, staff interview, and record review, the facility did not ensure medication was dated when opened and stored appropriately for 2 residents (R) (R9 and R10) of 3 residents observed during medication administration. In addition, staff left a medication cart unlocked and unattended and R11's Medication Administration Record (MAR) exposed during medication administration. This practice had the potential to affect more than 4 of the 74 residents residing in the facility. On 6/6/25, Surveyor observed Licensed Practical Nurse (LPN)-D prepare and administer timolol maleate ophthalmic solution 0.5 % eye drops to R9. The eye drops did not contain an open date. On 6/6/25, Surveyor observed LPN-D prepare and administer 5 units of Basaglar KwikPen (insulin) 100 units/milliliter (ml) to R10. The insulin pen did not contain an open date. On 6/6/25, Surveyor noted a medication cart was left unlocked and unattended when LPN-D entered R11's room to administer medication. LPN-D also did not ensure a computer on top of the medication cart that displayed R11's Medication Administration Record (MAR) was closed prior to entering the room. The medication cart was not within LPN-D's view during medication administration. Findings include: The facility's Medication Storage Policy, revised 2/12/24, indicates: Purpose: To ensure medications and biologicals are stored in a safe, secure storage and safe handling. Procedure: .3. No discontinued, outdated, or deteriorated medications should be available for use in the facility .4. Expired medications are to be removed from area medication carts prior to or at the time of expiration .7. Compartments containing medications should be locked when not in use. Trays or carts used to transport such items should not be left unattended. (Note: Compartments include but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) .Multi-dose vials: 1. Vials must be dated upon opening and discarded within 30 days unless otherwise specified by the manufacturer . The facility's Administering Medications Policy & Procedure, revised 1/22/24, indicates: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: .17. Privacy and confidentiality of Medication Administration Records (MARs) will be maintained throughout the medication pass. 18. Medications will remain secured in a locked cabinet/cart unless in direct view of the individual administering the medication. 1. On 6/6/25 at 7:27 AM, Surveyor observed LPN-D prepare and administer timolol maleate ophthalmic solution 0.5 % 1 drop to R9's right eye. Surveyor noted the eye drops did not contain an open date. (The eye drops were opened and dispensed on 3/27/25.) On 6/6/25 at 7:50 AM, Surveyor interviewed LPN-D who verified R9's eye drops did not contain an open date. 2. On 6/6/25 at 7:55 AM, Surveyor observed LPN-D prepare and administer 5 units of Basaglar KwikPen 100 units/ml insulin to R10. Surveyor noted the KwikPen did not contain an open date. (The insulin pen was dispensed on 5/31/25 and had a manufacturer's expiration date of 1/5/26.) On 6/6/25 at 1:15 PM, Surveyor interviewed LPN-D who verified R10's Basaglar KwikPen did not contain an open date. 3. On 6/6/25 at 8:21 AM, Surveyor observed LPN-D leave the medication cart unlocked after LPN-D prepared R11's medication and entered R11's room. Surveyor also noted a computer screen that displayed R11's MAR was left open on top of the cart. The medication cart was left unattended in the hallway while LPN-D administered medication to R11. During medication administration, the medication cart was not visible to LPN-D and was located to the left of R11's doorway out of LPN-D's sight. On 6/6/25 at 8:25 AM, Surveyor interviewed LPN-D who verified LPN-D left the medication cart unlocked and unattended during medication administration for R11. LPN-D indicated LPN-D should have ensured the medication cart was securely locked. On 6/6/25 at 2:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated LPN-D should have locked the unattended medication cart during medication administration. DON-B also indicated eye drops and insulin should be dated when opened and computers and medication carts should be locked when the nurse is not present.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmacy services to ensure the accurate and safe administration of medication for 1 resident (R) (R10) of 3 residents observed during medication administration. R10 had an order for insulin aspart injection solution 100 units/milliliter (ml) inject 5 units subcutaneously before meals for hyperglycemia related to type 2 diabetes. On 6/6/25, Licensed Practical Nurse (LPN)-D incorrectly administered 5 units of Basaglar KwikPen (long-acting insulin) 100 units/ml to R10. Findings include: The facility's Administering Medications Policy & Procedure, revised 1/22/24, indicates: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: .4. Medications shall be administered per provider's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards . On 6/6/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes and morbid obesity. R10's Minimum Data Set (MDS) assessment, dated 5/8/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R10 had intact cognition. On 6/6/25 at 7:55 AM, Surveyor observed LPN-D prepare and administer medication for R10, including 5 units of Basaglar KwikPen 100 units/ml insulin. On 6/6/25 at 1:10 PM, Surveyor reviewed R10's Medication Administration Record (MAR) which contained a physician order for insulin aspart injection solution 100 units/ml inject 5 units subcutaneously before meals for hyperglycemia related to type 2 diabetes (dated 3/14/25). R10's MAR indicated the medication was administered by LPN-D on 6/6/25. On 6/6/25 at 1:15 PM, Surveyor interviewed LPN-D regarding the Basaglar KwikPen 5 units administered to R10 and asked LPN-D to show Surveyor R10's insulin pens. LPN-D could not find R10's insulin aspart in the insulin storage box in the medication cart and could only find a Basaglar KwikPen and an insulin lispro pen. LPN-D indicated R10 should have received insulin aspart per R10's MAR. LPN-D verified R10's MAR incorrectly indicated insulin aspart was administered on 6/6/25. LPN-D indicated LPN-D would document the medication error, monitor R10, and update the physician due to the incorrect administration of insulin. LPN-D indicated no side effects had been reported from R10 thus far. On 6/6/25 at 2:01 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated LPN-D did not realize the wrong insulin was administered to R10 and probably did not perform the 5 rights of medication administration. DON-B indicated LPN-D would receive education about correct medication administration. DON-B instructed LPN-D to update the physician regarding the medication error and monitor R10 for adverse reactions.

Based on observation, staff interview, and record review, the facility did not ensure staff followed proper infection control practices for 4 residents (R) (R9, R10, R11, and 14) of 4 sampled residents. On 6/6/25, Licensed Practical Nurse (LPN)-D did not complete hand hygiene before preparing or after administering medication to R9, R10, and R11. On 6/6/25, Certified Nursing Assistant (CNA)-E placed wash cloths in an unsanitized sink and ran water over them. CNA-E then wrung out the wash cloths, hung them over the side of the sink, and used them to complete pericare for R14. Findings include: The facility's Hand Hygiene policy, revised 5/8/24, indicates: Purpose: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Procedure: .2. The use of gloves does not replace hand hygiene. 3. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE) .Washing Hands with Soap and Water: 1. Staff will perform hand hygiene by washing hands for at least twenty seconds with antimicrobial or non-antimicrobial soap and water under the following conditions: .b. Before applying gloves and after removing gloves or other PPE; .d. After handling items potentially contaminated with blood, body fluids, or secretions; e. Before moving from a contaminated body site to a clean body site during resident care; example; after providing pericare, before applying moisture barrier or other treatments; f. After providing direct resident care .Using Alcohol-Based Hand Gel: 1. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: a. When hands are not visibly soiled .c. Before preparing or handling medications; d. Before applying gloves and after removing gloves or other PPE .f. Before moving from a contaminated boy site to a clean body site during resident care . The facility's Activities of Daily Living policy, revised 2/25/25, indicates: Procedure: .2. The facility will provide care and services for the following activities of daily living: .bathing and hygiene - assistance with bathing or showering and maintaining personal hygiene; toileting - assistance with using the the bathroom and maintaining cleanliness. 1. On 6/6/25 at 7:27 AM, Surveyor observed LPN-D prepare medication for R9 without completing hand hygiene prior to donning gloves. LPN-D also did not complete hand hygiene after LPN-D administered the medication and removed gloves. 2. On 6/6/25 at 7:55 AM, Surveyor observed LPN-D prepare medication for R10 without completing hand hygiene prior to donning gloves. LPN-D also did not complete hand hygiene after LPN-D administered the medication and removed gloves. 3. On 6/6/25 at 8:15 AM, Surveyor observed LPN-D prepare medication for R11 without completing hand hygiene prior to donning gloves. LPN-D also did not complete hand hygiene after LPN-D administered medication and removed gloves. On 6/6/25 at 8:25 AM, Surveyor interviewed LPN-D who verified LPN-D did not complete hand hygiene between residents during medication preparation and administration. On 6/6/25 at 8:57 AM, Surveyor interviewed Infection Preventionist (IP)-C who indicated LPN-D should have completed hand hygiene between residents during medication preparation and administration either by washing hands or sanitizing hands with alcohol-based sanitizer.4. On 6/6/25 at 3:49 AM, Surveyor observed CNA-E transfer R14 to the toilet with a gait belt. On 6/6/25 at 3:55 AM, Surveyor observed CNA-E put clean wash cloths in R14's sink and wet them with warm water. CNA-E let the water run over the wash cloths and then wrung them out and laid them over the side of the sink. Surveyor observed basins in a rack next to the sink. CNA-E indicated the sink was not sanitized before CNA-E wet the wash cloths. CNA-E indicated CNA-E uses a basin if cares are completed in bed but does not use a basin if cares are completed in the bathroom. On 6/6/25 at 4:32 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should use a basin or wipes for cares in accordance with the facility's policy. On 6/6/25 at 5:52 AM, Surveyor reviewed the facility's Activities of Daily Living policy referenced above that Nursing Home Administrator (NHA)-A provided to Surveyor and indicated included the facility's pericare procedure. Surveyor noted the policy does not specify that staff should use a basin or wipes during pericare. Surveyor clarified with NHA-A and DON-B (who confirmed with the corporate office) that the Activities of Daily Living policy was the facility's only pericare policy.

Based on staff and resident interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 2 residents (R) (R9 and R10) of 8 sampled residents. R9's care plan contained an intervention for the assistance of two staff and a full-body (Hoyer) lift for transfers. The intervention was not consistently followed. R10's care plan contained an intervention for the assistance of two staff and a sit-to-stand (EZ Stand) lift for transfers. The intervention was not consistently followed. Findings include: The facility's Sit-to-Stand Mechanical Lift Policy, revised 8/22/23, indicates: To assist residents with transfers who are able to bear weight with some assistance. Employees will use the sit-to-stand mechanical lift per policy to ensure safety for the resident and the employee .1. Sit-to-stand mechanical lift will be used with two caregivers . The facility's Total Mechanical Transfer Policy, revised 8/22/23, indicates: To safely transfer residents who have been assessed .Also to ensure a safe work environment for the employees .2. The total mechanical lift must have two staff members present . 1. On 2/26/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including quadriplegia (paralysis of all four limbs), diabetes, and hypotension (low blood pressure). R9's most recent Minimum Data Set (MDS) assessment, dated 11/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was not cognitively impaired. R9's plan of care indicated R9 had limited physical mobility and contained an intervention to transfer R9 with the assistance of two staff and a full-body (Hoyer) lift. On 2/26/25 at 10:30 AM, Surveyor interviewed R9, who indicated two of R9's showers were late in the last month because there were not enough staff to assist with a Hoyer transfer. R9 indicated staff attempted to transfer R9 with one staff present but R9 did not feel safe and refused. R9 indicated there have been issues finding a second staff to assist with R9's transfers in the last month. 2. On 2/26/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including high blood pressure and chronic venous insufficiency (a condition in which blood pools in the veins and leads to increased pressure and strain on the vein walls). R10's most recent MDS assessment, dated 1/12/25, had a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. R10's plan of care indicated R10 had limited physical mobility and contained an intervention to transfer R10 with the assistance of two staff and an EZ stand lift. On 2/26/25 at 10:20 AM, Surveyor interviewed R10 who indicated only one staff assisted R10 with EZ stand transfers. On 2/26/25 at 9:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who confirmed LPN-C observed staff transfer residents with mechanical lifts without a second staff present. LPN-C indicated mechanical lift transfers with the assistance of one staff are an ongoing issue. LPN-C verified EZ Stand and Hoyer lift transfers require the assistance of two staff unless therapy indicates otherwise for EZ Stand lifts. On 2/26/25 at 11:58 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who indicated CNA-E has transferred residents with a mechanical lift without a second staff present because there was not another staff available to help and CNA-E did not want to fall behind with cares. On 2/26/25 at 1:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow residents' care plans for transfers. DON-B confirmed R9 and R10 require the assistance of two staff for mechanical lift transfers.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R5) of 10 sampled residents received assistance with a request in a timely manner. On 2/26/25, R5's call light was activated at 6:46 AM. Certified Nursing Assistant (CNA)-G turned R5's call light off at 7:12 AM after R5 requested a cup of coffee. R5 was not provided coffee until R5's breakfast tray was delivered at 8:10 AM. Findings include: On 2/26/25, Surveyor reviewed R5's medical record. R5 had diagnoses including spinal stenosis, type 2 diabetes mellitus, choric obstructive pulmonary disease (COPD), anxiety, and chronic pain syndrome. R5's most recent Minimum Data Set (MDS) assessment, dated 12/6/24, had a Brief Interview for Mental Status (BIMS) score of 13 out 15 which indicated R5 had intact cognition. The MDS assessment also indicated R5 required set up assistance for eating. R5's plan of care indicated R5 had an activity of daily living (ADL) deficit related to weakness and impaired mobility. On 2/26/25 at 6:46 AM, Surveyor noted R5's call light was activated. From 6:46 AM to 7:08 AM, Surveyor noted there were no staff in the hallway on which R5 resided. On 2/26/25 at 7:09 AM, Surveyor interviewed R5 who indicated R5 had been waiting awhile and nobody had stopped to see what R5 wanted which was a cup of coffee. R5 indicated it is common to wait a long time in the morning for staff to answer R5's call light. R5 indicated R5 has waited as long as 2 hours. On 2/26/25 at 7:12 AM, Surveyor observed CNA-G enter R5's room, turn the call light off, leave the room, and enter another resident's room. On 2/26/25 at 7:25 AM, Surveyor interviewed R5 who confirmed CNA-G turned R5's call light off after R5 asked for coffee. R5 indicated CNA-G stated CNA-G would get coffee for R5, however, R5 had not received coffee. R5 indicated R5 wanted coffee every day between 6:00 AM and 7:00 AM. On 2/26/25 at 8:06 AM, Surveyor observed dietary staff bring a cart with three meal trays to the unit. Surveyor noted the cart contained R5's breakfast tray which included a cup of coffee. On 2/26/25 at 8:10 AM, Surveyor observed CNA-G deliver R5's breakfast tray. On 2/26/25 at 8:12 AM, Surveyor interviewed CNA-G who confirmed CNA-G turned R5's call light off approximately one hour earlier after R5 requested a cup of coffee. CNA-G confirmed CNA-G did not get coffee for R5 prior to the provision of R5's breakfast tray. CNA-G indicated CNAs cannot provide coffee to residents per instructions from dietary staff approximately one week ago. CNA-G confirmed CNA-G did not explain to R5 that CNA-G could not bring R5 coffee. On 2/26/25 at 8:15 AM, Surveyor interviewed CNA-H who indicated dietary staff indicated approximately one week ago that too much coffee was wasted and a carafe of coffee would no longer be provided. CNA-H indicated if a resident wants coffee, staff have to use the radio to request coffee from the kitchen. On 2/26/25 at 9:05 AM, Surveyor interviewed Dietary Manager (DM)-I who indicated dietary staff used to send a carafe of coffee to R5's unit on the beverage cart but no longer do so. DM-I indicated coffee is sent on meal trays as of last week. DM-I indicated nursing and kitchen staff have radios and CNAs can let kitchen staff know if a resident requests coffee before their tray arrives on the unit. DM-I indicated kitchen staff will bring coffee to the unit ahead of the resident's tray. DM-I indicated R5 can be set up to receive coffee sooner each day. On 2/26/25 at 1:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident's call light should stay on until the resident's need is met.

Based on staff and resident interview and record review, the facility did not provide the necessary care and treatment to maintain the highest practicable well being for 2 residents (R) (R7 and R10) of 10 sampled residents. Staff did not consistently complete daily weights as ordered for R7 and R10. Findings include: The facility's Heart Failure policy, dated 3/19/24, indicates: .The nurse will assess and document/report the following: a. Daily vital signs or as ordered by the provider; b. Daily weights or as ordered by the provider .i. Call for weight gain 3 pounds or greater in 24 hours or 5 pounds in one week or as directed by the provider .5. The physician will help identify individuals at risk for having cardiac decompensation, for example, because of arrhythmia .chronic obstructive pulmonary disease . 1. On 2/26/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF) and diabetes. R7's most recent Minimum Data Set (MDS) assessment, dated 2/12/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R7 had intact cognition. An MDS assessment, dated 11/12/24, indicated R7 was dependent on staff for transfers (helper does all the effort, resident does none). R7's plan of care indicated R7 was at risk of lower extremity imbalanced fluid volume due to CHF and venous insufficiency and contained interventions to monitor R7's weight per policy and notify the provider of any significant changes. R7 had an order for daily weights and vital signs for CHF monitoring and to ensure R7's weight was obtained prior to breakfast (dated 8/7/24 and revised 2/20/25 to indicate if vital signs are out of range, recheck manually and chart per the Nurse Practitioner (NP)). Surveyor reviewed R7's weights for 11/10/24 to 2/25/25 and noted 44 of R7's daily weights were missing. On 2/26/25 at 11:38 AM, Surveyor interviewed R7 who indicated R7's weights were often missed because there were not enough staff to complete a 2 assist transfer which was needed to obtain R7's weight. R7 indicated R7 should be weighed before breakfast which was not consistently done. 2. On 2/26/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including high blood pressure and chronic venous insufficiency (a condition in which blood pools in the veins and leads to increased pressure and strain on the vein walls). R10's most recent MDS assessment, dated 1/12/25, had a BIMS score of 15 out of 15 which indicated R10 had intact cognition. R10's plan of care contained interventions to monitor R10's weight per policy and notify the provider of any significant changes. R10's plan of care also indicated R10 had limited physical mobility and contained an intervention to transfer R10 with the assistance of two staff and an EZ Stand (sit-to-stand) lift. R10 had an order for daily weights and to notify the provider of a greater than three pound increase in 24 hours or five pounds in 1 week (revised 7/15/23). Surveyor reviewed R10's weights for 10/9/24 to 2/26/25 and noted 64 of R10's daily weights were missing. On 2/26/25 at 1:37 PM, Surveyor interviewed R10 who indicated R10 was not weighed daily on a consistent basis because there were not enough staff to complete a transfer with the assistance of two staff and a sit-to-stand lift. On 2/26/25 at 6:46 AM, Surveyor interviewed Registered Nurse (RN)-D who confirmed daily weights were not consistently obtained because there were not enough staff in the morning. RN-D indicated daily weights were missed for residents with CHF and edema because staff were too busy to obtain weights prior to breakfast. On 2/26/25 at 9:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated staff did not consistently obtain daily weights prior to breakfast. LPN-C indicated there were not enough staff to complete daily weights for residents who required two staff for mechanical lift transfers. On 2/26/25 at 12:09 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who indicated daily weights were hard to consistently complete prior to breakfast because there were not enough staff for residents who required the assistance of two staff for transfers. On 2/26/25 at 12:17 PM, Surveyor interviewed Nurse Practitioner (NP)-K who indicated weights are missed and staff need prompting to obtain residents' weights per physician orders. NP-K indicated NP-K had to enter specific orders for specific dates in order for staff to obtain weights. NP-K indicated staff should obtain daily weights for residents with a diagnosis of CHF and any resident with a change in weight. NP-K indicated NP-K would like to be updated as soon as staff recognize a weight gain or weight loss. NP-K indicated NP-K should not be the first person to notice weight changes and call the facility to monitor. On 2/26/25 at 1:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated daily weights should be obtained prior to breakfast or per the physician's order. DON-B indicated if a daily weight is missed, the provider should be updated the same day. DON-B verified R7 and R10's daily weights were not consistently obtained and indicated nurses should ensure CNAs consistently obtain daily weights.

Based on observation, staff interview, and record review, the facility's nursing staff postings did not contain accurate data and were not retained for 18 months. This practice had the potential to affect all 68 residents in the facility. The facility did not update the daily nursing staff postings when there were schedule changes. The nursing staff postings contained numbers for staff in a full shift row despite the fact staff only worked a partial shift. In addition, the facility did not retain the postings for 18 months. Findings include: The facility's Staff Posting policy, revised 10/19/23, indicates: The facility shall post daily the actual hours and total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care on each shift in the facility. On 2/26/25 at 4:51 AM, Surveyor observed a nursing staff posting on the first floor which contained 7 rows and 6 columns. The rows indicated shift times and the columns indicated staffing positions. Surveyor noted the 10:00 PM to 6:00 AM row for 2/25/26 indicated there were 3 Certified Nursing Assistants (CNAs) for a total number of 22.5 hours. On 2/26/25 at 6:06 AM, Surveyor noted the 2/26/25 daily nursing staff posting was posted. The 6:00 AM to 2:00 PM row (which is a 7.5 hour shift) indicated 9 CNAs worked for a total number of 64 hours, however, Surveyor noted 9 CNAs at 7.5 hours was equal to 67.5 hours. Surveyor reviewed the 2/26/25 nursing department schedule which indicated 9 CNAs worked the AM shift, one of which only worked 10:00 AM to 2:00 PM. On 2/26/25, Surveyor requested nursing staff postings for multiple dates from November 2024 to February 2025. Surveyor noted the facility's management team printed the postings instead of providing the original postings. In addition, the postings did not contain edits which typically occur for staffing changes. Surveyor compared the nursing staff postings to the staff schedules and noted for split or partial shifts worked, the postings contained the number of staff who worked the partial shift under the row for the full shift. For example, the 10:00 PM to 6:00 AM row on the posting would indicate 4 CNAs worked even if one of the 4 CNAs only worked from 10:00 PM to 2:00 AM and another worked from 2:00 AM to 6:00 AM. Surveyor noted the postings did not contain rows that indicated partial shifts were worked. On 2/26/25 at 11:25 AM, Surveyor reviewed the 12/26/24 posting with Nursing Home Administrator (NHA)-A. The posting indicated 6 CNAs worked from 6:00 AM to 2:00 PM, however, the nursing schedule indicated 1 of the 6 CNAs worked from 6:00 AM to 10:00 AM, 1 of the CNAs worked from 10:00 AM to 2:00 PM, and 1 of the CNAs worked from 8:00 AM to 2:00 PM. There were 4 nurses listed under the AM shift row as having worked from 6:00 AM to 2:30 PM, however, the nursing schedule indicated 1 of the nurses worked from 6:00 AM to 10:00 AM. Five CNAs were listed under the 10:00 PM to 6:00 AM row, however, the nursing schedule indicated 1 of the CNAs worked from 10:00 PM to 2:00 AM and another CNA worked from 2:00 AM to 6:00 AM. The posting also indicated 3 nurses worked, however, 1 of the nurses worked from 10:00 PM to 2:00 AM and another nurse worked from 2:00 AM to 6:30 AM. Surveyor interviewed NHA-A who indicated data for the postings is pulled from a computer program. NHA-A confirmed what was provided to Surveyor was pulled from the program. NHA-A confirmed the facility does not retain the original nursing staff postings. NHA-A indicated Staffing Coordinator (SC)-F prints the posting each day but does not keep the posting when the day ends. NHA-A confirmed a number of staff listed as having worked in 7.5 or 8 hour shift rows may have only worked a partial shift during that timeframe, such as a 2:00 AM to 6:00 AM staff listed in the 10:00 PM to 6:00 AM shift. On 2/26/25 at 12:06 PM, Surveyor interviewed SC-F who indicated posting information pulls from the facility's program. SC-F indicated SC-F enters the census and notes any bed holds in the program. SC-F confirmed the nursing staff postings are not edited when there are call-ins or changes in the schedule throughout the day.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 4 residents (R) (R49, R3, R22, and R27) of 5 sampled residents. The facility did not clean continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines per manufacturer's instructions and the facility's policy. Findings include: The facility's CPAP/BiPAP Use policy, with a revision date of 6/15/23, indicates: To provide guidelines for the use of CPAP/BiPAP therapy for the treatment of the following conditions: Obstructive sleep apnea .history of respiratory failure .Procedure: .6. Filter on CPAP/BiPAP will be replaced based on manufacturer's recommendations. The Air Fit ResMed Mask User Guide indicates: When to replace CPAP supplies .To get the most out of your sleep apnea therapy, using your CPAP machine is only half the battle. The other half is making sure you inspect and replace your supplies as often as needed to maximize seal, comfort, and health benefits .CPAP machine filters need to be changed out for the same reasons that your car and vacuum filters do; build-up over time makes them less effective and may contribute to nasal symptoms such as sneezing, runny nose, and watery eyes .Based on general wear and tear, we suggest you use the following as a guideline to replace your CPAP parts: Every month: mask cushion and/or nasal pillow, CPAP machine filter . Harvard Health Publishing of Harvard Medical school, dated 10/8/2019, indicates: A CPAP machine is one of the best treatments for people with obstructive sleep apnea, a condition that causes you to stop breathing periodically during sleep. The pauses in sleep occur when muscles in the throat relax so much that they block the airway. CPAP keeps your airway open. The CPAP system consists of a small bedside pump that pushes a forceful stream of air through a tube and into a mask you wear while you sleep. Bacteria and mold can accumulate in different parts of the device .Given that the mask, tubing, and other components are breathed into and deliver air throughout the night, their cleanliness can be a serious health concern. Daily cleaning removes dangerous microbes, mold, dust, and debris .CPAP machines are humid and often warm, making them the perfect home for mold, bacteria, viruses, and other harmful microbes. Cleaning your CPAP components regularly washes these microbes away and prevents them from reaching dangerous levels, but neglecting your CPAP machine's hygiene can lead to both acute and chronic respiratory conditions. 1. On 7/15/24, Surveyor reviewed R3's medical record. R3 had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, moderate persistent asthma, acute on chronic diastolic (congestive) heart failure, and obstructive sleep apnea. R3's Minimum Data Set (MDS) assessment, dated 7/3/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. R3 had an order for CPAP to be worn daily when sleeping. R3 also had an order to wash the mask, nose pillow, tubing, and water tray weekly and empty the leftover distilled water and add new water every evening shift. Surveyor noted there were no orders to check and change the CPAP filter. On 7/15/24 at 9:46 AM, Surveyor interviewed R3 who stated R3 used a CPAP machine every evening and when R3 napped during the day. R3 stated R3 occasionally cleaned the mask and received assistance from staff to clean other parts of the machine. R3 was not sure if staff checked the CPAP's filter and whether the filter was dirty or clean. R3 used a ResMed AirSense 10 CPAP machine with an oxygen concentrator attached. Surveyor noted the filter was dark in color and contained what appeared to be dirt and dust. R3 stated R3 called 911 recently. R3 stated R3 had dropped the CPAP mask and was having a harder time breathing but was fine and breathing ok when 911 arrived. R3 stated R3 wears the CPAP religiously when sleeping and experiences shortness of breath without it. On 7/16/24 at 9:03 AM, Surveyor again interviewed R3 who stated nursing staff filled the CPAP machine with water but did not check or change the parts. Surveyor noted the filter was still dark in color and contained what appeared to be dirt and dust. The filter did not appear to be changed since Surveyor's observation on 7/15/24. 2. On 7/16/24, Surveyor reviewed R49's medical record. R49 had diagnoses including obstructive sleep apnea and asthma. R49's MDS assessment, dated 4/28/24, had a BIMS score of 6 out of 15 which indicated R49 had severe cognitive impairment. R49 had an activated health care decision maker. A hospital discharge summary, dated 1/19/23, indicated R49 should start using a BiPAP machine because R49 was observed during a sleep study with apneas that lasted 2 minutes. R49 had an order for the BiPAP to be worn daily. R49 also had an order to wash the mask, nose pillow, tubing, and water tray weekly and empty the leftover distilled water and add new water every evening shift. R49 did not have an order to check and change the BiPAP filter. On 7/16/24 at 8:44 AM, Surveyor interviewed R49 who stated R49 wore a ResMed BiPAP machine every night and staff assisted with cleaning the BiPAP machine; however, R49 did not think staff checked or changed the filter. Surveyor noted the BiPAP filter was dark in color and contained what appeared to be dust, dirt, and hair. R49 stated the filter looked very dirty. R49 was concerned the filter had not been checked prior to Surveyor checking the filter. 3. On 7/16/24, Surveyor reviewed R22's medical record. R22 had diagnoses including chronic respiratory failure with hypoxia, obstructive sleep apnea-on BiPAP, COPD, oxygen dependence, wears cardiac monitor, and quadriplegia. R22's MDS assessment, dated 6/21/24, had a BIMS score of 15 out of 15 which indicated R22 had intact cognition. R22 had an order for BiPAP to be worn daily when sleeping. R22 also had an order to wash the mask, nose pillow, tubing, and water tray weekly and empty the leftover distilled water and add new water every evening shift. R22 did not have an order to check and change the BiPAP filter. On 7/16/24 at 8:52 AM, Surveyor interviewed R22 who stated R22 used a BiPAP machine last night. R22 stated there are times when R22 sleeps without the BiPAP, but R22 has been better at wearing the BiPAP recently. Surveyor noted R22 had a ResMed BiPAP machine with a filter that was dark in color and contained what appeared to dust, hair, and other particles. R22 stated R22 could not clean or apply the BiPAP machine independently and received assistance from staff to maintain and apply the BiPAP. 4. On 7/16/24, Surveyor reviewed R27's medical record. R27 had diagnoses including atrial fibrillation, acute on chronic diastolic (congestive) heart failure, and obstructive sleep apnea. R27's MDS assessment, dated 6/26/24, had a BIMS score of 15 out of 15. R27 had an order for CPAP to be worn daily when sleeping. R27 also had an order to wash the mask, nose pillow, tubing, and water tray weekly and empty the leftover distilled water and add new water every evening shift. R27 did not have an order to check and change the CPAP filter. On 7/16/24 at 8:57 AM, Surveyor interviewed R27 who stated R27 used a CPAP machine every night. R27 stated R27 did not remember the last time the machine and its parts were cleaned and said, All I do is wear it. Surveyor noted R27 had a ResMed AirSense 10 CPAP machine that did not contain a filter. On 7/16/24 at 1:46 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B did not know the manufacturers' recommendation for changing CPAP and BiPAP filters but would obtain the information. When Surveyor asked when R49, R3, R22, and R27's CPAP and BiPAP filters were checked and changed, DON-B confirmed R49, R3, R22 and R27's care plans did not contain information on how and when to change the filters. DON-B and Surveyor observed R49, R3, R22, and R27's CPAP and BiPAP machines. DON-B confirmed the unsanitary filters and the missing filter for R27. DON-B stated the facility did not have supplies to change the filters but would obtain the filters and add an order to R49, R3, R22 and R27's plans of care.

Based on observation, staff interview, and record review, the facility did not ensure menu serving sizes were followed for therapeutic and mechanically altered diets for 5 residents (R) (R69, R12, R62, R11, and R2) of 19 sampled residents. Staff served smaller portions than the extended menu indicated for R69 who had an order for double protein and R12, R62, R11, and R2 who were prescribed mechanically altered diets. Findings include: The facility's Diet and Diet Orders policy, with a revision date of 12/11/23, indicates: All diets will be prescribed by the attending physician. The dietitian will review diets for accuracy and therapeutic goals and recommend changes to the physician as deemed appropriate .When necessary, the attending physician will order therapeutic or mechanically altered diets to address certain diseases and/or facilitate oral intake .The purpose of this policy is to provide consistency and accuracy in all diets provided to our residents and patients .Procedure: .5. Specific requests such as high protein .will be assessed by the dietitian and adjusted on the resident tray card and listed in the care plan .9. The facility will use a tray identification system to ensure diet accuracy in the service of meals. 10.When diet orders are changed, the care plan and tray card will be updated to reflect the change in order .Dietictian will monitor compliance with policy by ensuring accuracy of diets and communicating changes or recommendations. Ensures that care plan is updated with diet changes. Food Service Director/Dietary Manager will ensure that food provided is consistent with diet order and that tray card accurately reflects resident/patient diet order and food preferences. On 7/16/24, the facility's extended menu indicated the lunch meal serving size double portion of protein was 2 portions of 3 ounces of pork loin. The mechanically altered (minced and moist) serving size was a #8 scoop (gray handle food scoop) which equaled 4 ounces. 1. On 7/16/24, Surveyor reviewed R69's medical record. R69 was dependent on hemodialysis and was admitted to the facility with diagnoses including chronic renal failure related to end stage disease. R69 physician orders indicated the Registered Dietitian could make diet changes and orders as necessary. A Registered Dietician assessment, dated 6/23/24, included a diet change order for double protein with 85 to 106 grams of protein per day due to dialysis. Surveyor noted the diet change was not listed on R69's care plan. 2. On 7/16/24, Surveyor reviewed R12's medical record. R12 had diagnoses including dysphagia, oropharyngeal phase, and Barrett's esophagus without dysplasia. R12's diet order indicated Level 6 soft & bite-sized with Level 5 minced and moist meat and Level 7 regular bread and bread products. 3. On 7/16/24, Surveyor reviewed R62's medical record. R62 had diagnoses including malignant neoplasm of tonsil and adult failure to thrive. R62's diet order indicated Level 6 soft & bite-sized with Level 5 minced and moist meat and Level 7 regular bread and bread products. 4. On 7/16/24, Surveyor reviewed R11's medical record. R11 had diagnoses including dysphagia, oropharyngeal phase. R11's diet order indicated Level 6 soft & bite-sized with Level 5 minced and moist meat and Level 7 regular bread and bread products. 5. On 7/16/24, Surveyor reviewed R2's medical record. R2 had diagnoses including encounter for palliative care and cerebral palsy. R2's diet order indicated Level 6 soft & bite-sized with Level 5 minced and moist meat and Level 7 regular bread and bread products. During a continuous kitchen observation that began at 11:00 AM on 7/16/24, Surveyor observed [NAME] (CK)-D serve lunch at the tray line. Surveyor noted the steam table contained food scoops placed in containers of pork loin roast, potatoes, green beans, carrots, rice, and alternative menu items. Dietary Manager (DM)-C stated the food scoop size chart was on the wall. Surveyor noted the container of mechanically altered (minced and moist) pork loin contained a green food scoop. The poster on the wall indicated the green food scoop was a #12 scoop with a serving size of 2-2/3 ounces. Surveyor noted the extended menu and meal tray tickets for R12, R62, R11, and R2 indicated for minced and moist meat, a 4 ounce #8 scoop should be used for the serving size. Surveyor observed CK-D use a #12 green scoop for R12, R62, R11, and R2's portions of pork loin. Surveyor noted R69's meal ticket indicated a regular portion size for protein and noted R69 was served one 3 ounce pork loin. On 7/16/24 at 1:40 PM, Surveyor interviewed DM-C who stated when the Registered Dietician completes an assessment and makes a recommendation for a diet change, it is DM-C's responsibility to update the resident's meal ticket card, preferences, and care plan. DM-C confirmed R69 had an order for double protein which was not on R69's meal ticket or care plan and verified dietary staff have not been serving R69 double protein. Regarding moist and minced diets for R12, R62, R11 and R2, DM-C confirmed moist and minced protein was served with a #12 scoop with a serving size of 2-2 2/3 ounces; however, the meal ticket and extended menu for moist and minced protein indicated the portions should be served with a #8 gray scoop with a serving size of 4 ounces. DM-C verified the facility had a #8 scoop and confirmed R12, R62, R11 and R2 were not served the correct portion size.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R54) of 19 sampled residents had a self-administration of medication assessment or a physician's order to self administer medication. On 715/24, Surveyor observed medication left at R54's bedside. R54 did not have a self-administration of medication assessment or a physician's order to self-administer medication. Findings include: The facility's Medication Self Administration policy and procedure, revised on 2/12/24, indicates: 1. The resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medication .3. Or with supervision/cueing or after set up, shall have a physician order to do so .5. Medications to be self-administered shall be secured in a locked area in the resident's room or stored in the medication cart for provision to the resident to self-administer. 1. On 7/15/24, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE], had an indwelling catheter, and had diagnoses including hydronephrosis, urinary tract infection (UTI), sepsis, and type 2 diabetes. R54's Minimum Data Set (MDS) assessment, dated 5/14/24, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R54 had intact cognition. R54 had an activated power of attorney for healthcare (POAHC). On 7/15/24 at 11:37 AM, Surveyor observed R54's bedside table which contained a basin with a bottle of 12% ammonium lactate lotion and a pharmacy label that identified R54 and the physician's order for application. Surveyor interviewed R54 who stated R54 self-administered the medication and kept the medication on R54's bedside table. Surveyor noted R54's medical record did not contain a physician's order or a self-administration of medication assessment for the 12% ammonium lactate lotion. On 7/16/24 at 9:03 AM, Surveyor observed R54's bedside table which contained a basin of personal care items including the 12% ammonium lactate lotion that had been moved from the previous day. R54 stated R54 applied the lotion to R54's body without staff assistance. On 7/16/24 at 4:10 PM, Surveyor and Director of Nursing (DON)-B observed R54's room. DON-B indicated R54 did not have a self-administration of medication assessment or a physician's order to self-administer medication or keep medication at bedside. DON-B verified medication should not be stored on a resident's bedside table. DON-B stated medication should be stored in a treatment or medication cart unless there is an order to store at bedside. On 7/16/24 at 4:11 PM, DON-B asked a Registered Nurse (RN) to remove the medication from R54's room and indicated the medication should be locked up and not stored at bedside.

Based on staff interview and record review, the facility did not ensure the provision of care and treatment in accordance with professional standards of practice for 2 Residents (R) (R7 and R6) of 8 sampled residents. The facility did not follow their policy or clarify a physician's order related to blood sugar parameters for R7. As a result, R7 was sent to the emergency room (ER) for treatment of hypoglycemia (low blood sugar) on 11/26/23. The facility did not ensure physician orders were followed for R6's PICC (peripherally inserted central catheter) line. Findings include: The facility's Care of the Diabetic Resident policy, dated 8/22/23, indicates: Purpose: To assist the resident to establish a balance between diet, exercise, and insulin; prevent recurrence of hyperglycemia/hypoglycemia; recognize, assist, and document the treatment of complications commonly associated with diabetes; .a. Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: .v. pale cool moist skin; .vii. dilated pupils; .ix. blurred or impaired vision; .xvi. stupor, unconsciousness; .b. Upon presentation of symptoms, the licensed nurse should check the blood glucose level via an accucheck; i. If an accucheck reveals a blood glucose level below 70 mg/dL (milligrams per deciliter) or level identified per individual physician orders, hypoglycemia should be suspected. 1. Should evidence of severe or life-threatening signs/symptoms exist, contact the physician immediately or call 911. ii. If any of the above signs or symptoms, or other abnormal conditions are identified, report the diabetic resident's condition to the physician immediately. c. Follow the resident's individual hypoglycemic protocol, if ordered by a physician. If no individual protocol is ordered, update the physician based on clinical assessment and current blood sugar. d. Hypoglycemic Treatment Protocol: .iv. Repeat the accucheck and report findings to the physician. v. Repeat the protocol only once if the blood glucose level remains less than 70 mg/dL and report findings to the physician. 1. On 2/26/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. R7's Minimum Data Set (MDS) assessment, dated 10/20/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R7 had moderate cognitive impairment. R7's Power of Attorney for Health Care (POAHC) document was activated on 9/25/23 and indicated R7's POAHC was responsible for R7's health care decisions. A care plan (initiated 11/3/23) indicated R7 had altered endocrine status related to IDDM (insulin dependent diabetes mellitus) and hypothyroid (sic). Interventions included: Monitor/document/report PRN (as needed) any signs/symptoms of hypoglycemia, including sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait; and Obtain, monitor, record: Fasting Serum Blood Sugars as ordered. Report results outside of parameters. R7 had the following physician orders: ~Insulin lispro subcutaneous solution pen-injector 200 units/ml (milliliter). Inject as per sliding scale: if 0-150=0 units; 151-200=2 units; 201-300=4 units; 301-350=6 units; 351-400=8 units; 401-450=10 units call Medical Doctor (MD), subcutaneously before meals and at bedtime for diabetes. ~Insulin glargine 100 units/ml pen-injector. Inject 10 units under the skin nightly. Dose adjustment per discretion of provider. Max daily dose 50 units. R7's blood sugars were as follows: ~11/20/23 at 9:18 AM: 47 mg/dL (normal range 80-120 mg/dL) ~11/21/23 at 6:22 AM: 57 mg/dL ~11/22/23 at 7:22 AM: 70 mg/dL ~11/25/23 at 6:45 AM: 44 mg/dL ~11/25/23 at 5:35 PM: 58 mg/dL ~11/25/23 at 5:38 PM: 70 mg/dL ~11/25/23 at 5:45 PM: 56 mg/dL ~11/26/23 at 12:08 PM: 40 mg/dL R7's medical record did not indicate R7 was symptomatic for hypoglycemia on 11/20/23, 11/21/23, and 11/23/23. A progress note written by Registered Nurse (RN)-F, dated 11/25/23 at 11:10 AM, indicated: Blood sugar at 6:30 AM=44 mg/dL. Orange juice and 2 glucose (sugar) tabs given. (R7) ate breakfast. Blood sugar at 9:00 AM=89 mg/dL. (R7) receives 10 units of insulin glargine on the PM shift. (MD-E) made aware. No new orders received. A medication administration note, dated 11/25/23 at 5:46 PM, indicated: Inject 1 mg glucagon intramuscularly as needed for hypoglycemia. Blood sugars range from 48-70 mg/dL. (R7) pale, non-responsive to verbally (sic) .Eyes glazed and unable to focus or follow commands. Unable to answer questions. A progress note, dated 11/26/23 at 9:36 AM, indicated: Blood sugar at 6:40 AM=40 mg/dL. (R7) is non-responsive. Half of glucose gel and IM glucose given .Blood sugar at 6:55 AM=53 mg/dL. Writer spoke with (Nurse Practitioner (NP)-F). (R7) sent to ER at 6:45 AM .At 7:42 AM, (ER Physician) called and spoke with writer related to (R7's) recent low blood sugars in the morning. (ER Physician) was made aware this had been going on for about a week and MD and NP were made aware. (ER Physician) took phone number for MD and NP and was going to speak with them about the low blood sugars and med orders A hospital provider note, dated 11/16/23, indicated: (R7) has been hypoglycemic at the facility yet they have continued to give (R7) insulin .(R7) should not be receiving nighttime insulin as (R7) has been having hypoglycemic episodes in the morning .recommended they hold (R7's) evening insulin and follow-up with (R7's) primary physician . A hospital discharge summary, dated 11/26/23, indicated: Per staff at (R7's) facility, (R7) has been hypoglycemic in the morning for at least the last 5 days. Blood glucose in the 40s yesterday. Have been giving oral glucose and blood sugars improved. Yesterday, (R7) received glucagon. Today, (R7) was unresponsive with blood sugars in the 40s. Gave glucagon again. EMS (Emergency Medical Services) were called. Staff reported (NP) was contacted, but no changes were made to (R7's) insulin. I did discuss with NP on-call who stated (NP) is 'just covering the weekend' and doesn't know of (R7) or about the hypoglycemic issues . A note written by NP-C, dated 11/27/23 at 2:10 PM, indicated: (R7) is being seen for follow up of hypoglycemia. Over the weekend was sent to ER for hypoglycemia with (altered mental status). Had not been made aware of low (blood sugar) reads prior to this . On 2/27/24 at 9:45 AM, Surveyor interviewed NP-C who stated NP-C did not receive any calls from 11/16/23-11/26/23 regarding R7's low blood sugars. NP-C indicated NP-C last saw R7 on 11/16/23 for respiratory illness and no low blood sugar concerns were noted. NP-C indicated NP-C expected staff to report blood sugars below 70 mg/dL. NP-C stated if NP-C was made aware of R7's low blood sugars, NP-C would have decreased R7's long-acting insulin. NP-C reviewed R7's medical record in NP's system and indicated there were no calls received regarding low blood sugars until 11/26/23. NP-C stated, (MD-E) also would have addressed the blood sugar if had been aware of low blood sugars. Nursing should always call with a low blood sugar. On 2/27/23 at 10:11 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expected nursing staff to report a blood sugar less than 70 mg/dL to the physician and recheck the blood sugar. DON-B indicated DON-B had a conversation with RN-D after the incident with R7 on 11/25/23, but did not document the conversation. DON-B confirmed DON-B did not perform resident audits to identify if there were concerns regarding physician notification of other residents with low blood sugars. DON-B stated the facility did not change their practice following the incident and confirmed education was not provided to nursing staff. On 2/27/24 at 10:30 PM, Surveyor interviewed RN-D who indicated RN-D did not recall any low blood sugars for R7 and did not receive education from DON-B regarding low blood sugars. This example was cited at level G (Actual Harm/Isolated). 2. The facility's Central Vascular Access Device (CVAD) Dressing Change policy, dated 6/1/21, indicates: .2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Guidance: 1. Perform sterile dressing changes using Standard ANTT (aseptic non-touch technique) .1.1 Upon admission; 1.2 At least weekly; 1.3 If the integrity of the dressing has been compromised (wet, loose, or soiled) . On 2/26/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection) of the symphysis pubis (section of bone in pelvis) and had a PICC line in place to receive antibiotics (used to treat infection) for six weeks. R6's MDS assessment, dated 10/20/23, contained a BIMS score of 13 out of 15 which indicated R6 had minimal cognitive impairment. R6's medical record indicated R6 was responsible for R6's healthcare decisions. R6's admission orders, dated 11/22/23, indicated PICC line dressing changes should be completed every seven days. R6's PICC line dressing change assessment, completed 2/27/24, indicated R6's last documented dressing change was completed on 12/4/23 (which indicated dressing changes were not completed for 32 days). R6's PICC line was replaced by Infectious Disease with an order to have R6 return to the clinic weekly for dressing changes until the PICC line could be discontinued. R6's medical record indicated R6's PICC line was not changed after 12/4/23. Nursing staff were concerned with R6's PICC line placement. Staff made numerous calls to obtain an X-ray to confirm placement. R6's medical record indicated NP-C discontinued R6's PICC line dressing changes via a verbal order on 12/4/23. On 2/27/24 at 9:45 AM, Surveyor interviewed NP-C who indicated NP-C was familiar with R6 and received thousands of calls with concerns regarding PICC line migration (movement from correct place in vein). NP-C denied providing a verbal order to discontinue R6's dressing changes. NP-C indicated NP-C diverted all questions and concerns regarding PICC line management to Infectious Disease physicians. On 2/27/24 at 1:15 PM, Surveyor interviewed DON-B who indicated if a nurse writes a verbal order the nurse should have the physician sign the order. DON-B verified R6's medical record did not contain a verbal order to discontinue R6's PICC line dressing changes.

Based on interview and record review, the facility did not immediately consult with the physician for 1 (resident #1) of 9 sampled residents when the resident had a significant change in condition. Resident #1 had a significant change in condition on 3/23/16 when the resident stopped eating. The resident developed a fever during the early morning hours on 3/24/16 and continued with fevers and refusing meals through 3/25/16. The facility did not consult with resident #1's physician until approximately 3:26 p.m., on 3/25/16. The resident's condition required hospitalization which commenced that evening and continued through 4/5/16, for the treatment of [REDACTED]. Findings include: According to the facility's Change in Resident Condition policy and procedure dated 11/30/14, facility nurses are to recognize and appropriately intervene in the event of a change in resident condition. The policy also directs staff to notify the resident's physician as soon as possible. The resident is to be assessed to include any relevant information related to the change in condition. Resident #1's face sheet, contained in the resident's medical record, documented the resident was admitted to the facility on [DATE] and then re-admitted on [DATE]. Resident #1 had multiple [DIAGNOSES REDACTED]. Resident #1's MARs (Medication Administration Record) included documentation that resident #1 received [MEDICATION NAME] (a diuretic) 0.5 mg (milligrams) twice daily, beginning on 2/29/16. Resident #1's admission Nutrition Evaluation documented resident #1 was assessed to require 2760 ml (milliliters) of fluid daily. The assessment indicated resident #1 was at risk for altered nutritional status due to multiple factors including needing cueing to eat. Resident #1's medical record did not include documentation that a hydration assessment had been completed. Despite resident #1's risk factors for dehydration, the facility did not develop a care plan addressing resident #1's risk for dehydration. Resident #1's meal intake report included documentation that resident #1 typically ate between 25% and 100% of meals and occasionally refused evening snacks. However, on 3/22/16, the resident ate less than 25% of all three meals and accepted the evening snack. On 3/23/16, resident #1 ate less than 25% of breakfast and refused lunch, dinner and the evening snack. On 3/24/16, the resident refused breakfast, lunch, ate less than 25% of dinner and refused the evening snack. On 3/25/16, the resident refused all three meals. This change in condition was not recognized by the facility, and resident #1's medical record did not include documentation in the nursing progress notes that addressed this change in the resident's intake. In addition, the medical record did not include documentation that the resident's physician was notified of this change and no additional monitoring, hydration assessments, or fluid intakes were completed. The nursing progress notes documented the following regarding resident #1: ~ 3/24/16 at 8:45 a.m., had temp (temperature, i.e., fever) on noc (night) shift. Resident #1's medical record did not include night shift documentation and did not include documentation of the actual temperature of the fever. This note indicated the resident received Tylenol and did not have a fever at the time of the note, the resident drank 240 ml of water and that the resident did not want to get up for breakfast. ~ 3/24/16 at 11:30 a.m., temperature began to increase again and was 99.2 degrees Fahrenheit (F). The resident was noted to be responsive and was becoming more alert than earlier that morning. Tylenol was given. ~ 3/24/16 at 1:00 p.m., the resident's temperature was rechecked and found to be 98.6 F. ~ 3/24/16 from 1:00 p.m. until 3/25/16 at 10:00 a.m., the resident's medical record do not include documentation on the status of this resident. ~ 3/25/16 at 10:00 a.m., documentation included that the resident had been running temperatures for the last two nights. The resident's current temperature was noted to be 101.3 F and the resident was noted to have increased weakness. No hydration assessment was noted. A fax was sent to the resident's physician at this time and although the update included decreased appetite, the fax did not include the resident's fluid intake or hydration status as noted. Resident #1 continued to decline with decreased responsiveness, fevers, and heart rate of 40. ~ 3/25/16 at 9:40 p.m., resident #1 was sent out to the hospital ED (Emergency Department) via ambulance. Resident #1's hospital discharge summary dated 4/5/16, documented resident #1 was hospitalized from [DATE] through 4/5/16, for treatment of [REDACTED]. On 4/26/16 at 2:40 p.m., surveyor # interviewed Physician-D regarding resident #1. Physician-D verified by reviewing resident #1's medical record that the resident had stopped eating and developed a fever beginning on 3/22/16. The physician verified based on the information provided by the facility via a fax on 3/25/16, the initial order for a urinalysis was appropriate. The physician indicated he would not speak as to whether or not the facility should have or shouldn't have updated him sooner or whether the facility should have been monitoring the resident for infection or hydration. On 4/26/16 at 3:30 p.m., surveyor # interviewed RN (Registered Nurse)-B regarding resident #1. RN-B verified the CNAs document the percentage of each meal each resident eats, but not how much the residents drink. RN-B verified nurses should know if residents are not eating or drinking because they should be watching meals. RN-B also verified a resident's meal intake may not be reviewed by nurses unless they trigger for weight loss. RN-B stated when a resident experiences a change in condition, such as fevers and refusing meals, the physician should be notified and the resident should be monitored. Fluid intakes are not monitored unless a physician orders [REDACTED]. On 4/26/16 at 4:00 p.m., surveyor # interviewed DON (Director Of Nursing)-C regarding resident #1. DON-C verified when resident #1 refused two consecutive meals, staff should have began documenting and monitoring the resident for a change of condition and hydration. DON-C stated resident #1's physician should have been consulted regarding the resident's change of condition at least 12 hours sooner, when the morning fax was sent on 3/25/16. The resident was on a diuretic and should have been monitored for dehydration risk. Failure to promptly consult with the physician allowed the resident's underlying condition to go untreated and, thus, to worsen.

Based on staff interviews and record review, the facility did not ensure 1 (resident #1) of 9 sampled residents received sufficient fluid intake to maintain proper hydration. Resident #1 was admitted to the facility with multiple dehydration risk factors. The facility did not develop a hydration or risk for dehydration care plan and did not have a system in place to monitor the resident for hydration. When the resident had a change of condition, further increasing the resident's risk for dehydration, the facility did not identify this risk, did not implement measures to prevent dehydration, and did not complete resident hydration assessments. The resident ultimately required hospitalized relating to multiple [DIAGNOSES REDACTED]. Findings include: Resident #1's face sheet located in the resident's medical record, indicated the resident was admitted to the facility on [DATE] and then re-admitted on [DATE]. Resident #1 had multiple [DIAGNOSES REDACTED]. Resident #1's MARs (Medication Administration Record) included documentation that resident #1 received [MEDICATION NAME] (a diuretic) 0.5 mg (milligrams) twice daily, beginning on 2/29/16. Resident #1's admission Nutrition Evaluation documented resident #1 was assessed to need 2,760 ml (milliliters) of fluid daily. The assessment indicated resident #1 was at risk for altered nutritional status due to multiple factors that included needing cueing to eat. No hydration assessment had been completed for the resident at that time. Although resident #1 had multiple risk factors for dehydration, the facility did not develop a care plan addressing the resident's risk for dehydration. Resident #1's ADL (Activity of Daily Living) scores documented every shift for March 2016, indicated resident #1's assistance for eating ranged from independent at times to set-up only, to dependent on staff. Resident #1's meal intake report for March 2016, documented resident #1 typically ate between 25% and 100% of meals and would occasionally refuse evening snacks. However, on 3/22/16, resident #1 ate less than 25% of all three meals and accepted the evening snack. On 3/23/16, the resident ate less than 25% of breakfast and refused lunch, dinner, and the evening snack. On 3/24/16, resident #1 refused breakfast, lunch, ate less than 25% of dinner, and refused the evening snack. On 3/25/16 the resident refused all three meals. This change in condition was not recognized by the facility, no nursing progress notes addressed this change in intake, the physician was not notified of this change, and no additional monitoring or hydration assessments were completed. The nursing progress notes documented the following regarding resident #1: ~ 3/24/16 at 8:45 a.m., had temp (temperature, i.e., fever) on noc (night) shift. Resident #1's medical record did not include night shift documentation and did not include documentation of the actual temperature of the fever. This note indicated the resident did not have a fever at the time of the note, the resident drank 240 ml of water and that the resident did not want to get up for breakfast. ~ 3/24/16 at 11:30 a.m., temperature began to increase again and was 99.2 degrees Fahrenheit (F). The resident was noted to be responsive and more alert than earlier that morning. Tylenol was given. ~ 3/24/16 at 1:00 p.m., the resident's temperature was rechecked and found to be 98.6 F. ~ 3/24/16 from 1:00 p.m. until 3/25/16 at 10:00 a.m., the resident's medical record do not include documentation on the status of this resident. ~ 3/25/16 at 10:00 a.m., documentation included that the resident had been running temperatures for the last two nights. The resident's current temperature was noted to be 101.3 F and the resident was noted to have increased weakness. No hydration assessment was noted. A fax was sent to the resident's physician at this time and although the update included decreased appetite, the fax did not include the resident's fluid intake or hydration status as noted. Resident #1 continued to decline with decreased responsiveness, fevers, and a heart rate of 40 beats per minute. The resident was sent out to the hospital ED (Emergency Department) via ambulance at 9:40 p.m. on 3/25/16. Resident #1's hospital discharge summary dated 4/5/16, documented resident #1 was hospitalized from [DATE] through 4/5/16 for treatment of [REDACTED]. On 4/26/16 at 3:15 p.m., surveyor # interviewed LPN (Licensed Practical Nurse)-A regarding resident #1. LPN-A verified the CNAs (Certified Nursing Assistants) document how much residents eat for each meal. LPN-A indicated the documentation does not include how much fluid a resident drinks. LPN-A indicated the nurses review the meal documentation if a resident is being monitored for weight loss, but may not look at the documentation otherwise. On 4/26/16 at 3:30 p.m., surveyor # interviewed RN (Registered Nurse)-B regarding resident #1. RN-B verified the CNAs document the percentage of each meal each resident eats. RN-B verified nurses should know if residents are not eating or drinking because they should be watching meals. RN-B indicated a resident's meal intake may not be reviewed by nurses unless the resident triggers for weight loss. RN-B stated that when a resident experiences a change in condition, such as fevers and refusing meals, the physician should be notified and the resident should be monitored. RN-B indicated resident's fluid intakes are not monitored unless a physician orders [REDACTED]. On 4/26/16 at 4:00 p.m., surveyor # interviewed DON (Director Of Nursing)-C regarding resident 31. DON-C verified that when resident #1 refused two consecutive meals, staff should have began documenting and monitoring the resident for a change of condition and hydration. DON-C reviewed that resident #1 was on a diuretic and staff should have been monitored for dehydration risk. DON-C stated that any resident taking a diuretic should have a care plan for hydration. DON-C also verified the facility had not completed hydration assessments for resident #1 but should have done so.

Based on observation, interview and record review, the facility did not ensure 1 (resident #1) of 8 sampled residents received medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #1 expressed signs of not wanting to live by refusing to eat. Although the facility was aware that the resident refused to eat, the appropriate medically-related social services were not provided to assure the resident's health and safety were maintained. Findings include: Resident #1's face sheet, contained within the medical record and dated 11/19/14, indicated the resident was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Additionally, the face sheet indicated the resident had a guardian in place. Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE], documented the resident had short and long-term memory problems and was severely impaired with cognitive skills for daily decision making. The MDS assessment also documented the resident's mood score was 8, which indicated the resident had mild depression. The behavior section of the MDS assessment documented resident #1 rejected cares daily. Additionally, the MDS assessment indicated the resident required supervision, oversight, encouragement, and cueing while eating, and did not have any signs/symptoms of a possible swallowing disorder. Resident #1's current plan of care related to "resistance to eating/history of refusing meals and weights" dated 11/22/14, indicated staff were to explain the importance of diet prescribed/eating and need for adequate nutrition. Resident #1's current plan of care related to "resistance to eating, refusing snacks/meals and drinking limited fluids" dated 12/11/14, indicated staff were to continue to provide education daily at each meal as needed to the resident. Resident #1's current plan of care related to "psychosocial well-being" dated 11/22/14, indicated the resident was to receive a mental health consultation/medication review as needed. Resident #1's CAA (Care Area Assessment) related to "psychosocial well-being" was triggered and dated 11/20/14, documenting the resident had a [DIAGNOSES REDACTED]. Resident #1's CAA related to "behavioral symptoms" was triggered and dated 11/20/14, documenting the resident had cognitive status problems to include delirium and that the resident displayed behavior symptoms that might impact self or others, and is an immediate threat to self and others (immediate intervention required). The analysis of findings indicated the resident had a history of [REDACTED]. The hospital discharge summary dated 11/13/14, indicated resident #1 was admitted to the hospital after ingesting part or all of an aluminum can and part or all of a writing pen. The resident refused to eat at times and as a result, the resident was placed on temporary parenteral nutrition which was discontinued with adequate caloric intake. A guardian was appointed during this hospital stay for resident #1. Due to the resident's complex psychiatric component, safe discharge was lengthy and complicated and required an intricate multidisciplinary approach. The resident was discharged to the facility with discharge instructions that included the facility was to ensure close follow-up with psychiatry/psychology/counselor. Resident #1's nursing home physician completed an admission history and physical examination [REDACTED]. Past medical history assessment included dementia; psychosis; self harm behaviors; combative behaviors; depression; suicide attempts; alcohol abuse; learning disability. Added [DIAGNOSES REDACTED]. The resident has a flat affect and does not respond verbally. The social service progress notes written by SW (Social Worker)-C on 11/18/14, documented that resident #1 does not leave room and does not want to get out of bed. In addition, SW-C documented that resident #1 has been refusing meals, however is drinking fluids. The social service progress notes written by SWD (Social Worker Designee)-D on 12/3/14, documented resident #1 was participating in ST (speech therapy) today and wrote down "(resident)'s dying and (resident)'s loving it." The SW notes documented resident #1 has a long history of not wanting to eat and hasn't really ate anything since admission to the facility. The social service progress notes written by SWD-D on 12/8/14, documented resident #1 continues to lose weight and refuses meals. SWD-D spoke with GW (Guardian's wife)-F. GW-F indicated the resident was independent (resident's) entire life until now, it is a big change for the resident and (resident) does not like the change. Hospice was discussed with GW-F and a Hospice was chosen. Resident #1's physician completed a follow up nursing home visit. Documentation dated 12/9/14, indicated resident #1 continues to refuse meals. The guardian is aware of weight loss, does not want a feeding tube placed and is requesting a Hospice referral for the resident. The physician wrote the order for Hospice and discontinued one of resident #1's anti-depressant medications that was ordered. The social service progress notes written by SWD-D on 12/9/14, documented SWD-D spoke with APS (Adult Protective Services)-E regarding the physician orders [REDACTED]. Additionally, SWD-D's documentation indicated the resident "has never had psych treatment, but has had psych issues in past." The social service progress notes written by SWD-D on 12/11/14, documented a message was left with APS-E to "see what is going on with resident. Wanting to know if a referral can be made for inpatient psych stay due to resident not wanting to eat and states in writing (resident) wants to die. Resident has had a 7.8 percent weight loss (since admission). Will wait to see what APS says." The dietary progress notes dated 12/12/14, documented resident #1's weight on admission was 190 pounds. The resident's current weight on 12/10/14 was 170.2 pounds, which equates to a 10 percent loss of weight over 30 days. The resident frequently refuses meals and does not follow swallow guidelines established and refuses to follow recommended diet of pureed foods. Per fax to MD (Medical Doctor) resident states "(resident) will die first before (resident) eats." Will continue to monitor weights and intake trends. On 12/15/14 at 11:27 a.m., surveyor # completed a telephone interview with GW-F regarding resident #1. GW-F indicated Hospice is on hold after speaking to APS-E. GW-F also indicated resident #1 is "fearful, paranoid and in (resident's) mind would rather go than have all of (resident's) independence gone. Feels it is okay not to eat. Hearing is almost gone, hates it, can't handle living in a quiet world. Time to move on to be with mom and brother." On 12/15/14 at 11:50 a.m., surveyor # completed a telephone interview with APS-E regarding resident #1. APS-E stated "this is mental health, not Hospice." APS-E indicated she had a meeting with resident #1's physician to discuss the resident because "time is not on our side." According to APS-E, resident #1's physician indicated the resident has "weeks to months to live if follows the path" of refusing to eat food. "Can't allow (resident) to die if it is mental health" related. "It seems like we are watching (resident) commit suicide. Psych staff will be assessing (resident)." On 12/15/14 at 12:20 p.m., surveyor # interviewed SWD-D regarding resident #1. SWD-D stated the resident "does not have a plan to commit suicide. Says (resident) wants to die, but no plan to kill self." When surveyor # asked SWD-D if not eating could be considered a "plan," SWD-D stated "(resident) says (resident) wants to die." SWD-D verified a psych evaluation had not been requested by the facility until APS was involved and requested a psych veal for the resident. On 12/15/14 at 12:35 p.m., surveyor # interviewed NHA (Nursing Home Administrator)-G regarding resident #1. NHA-G stated resident #1 "has no plan in place, not eating, is (resident's) and family choice." On 12/15/14 at 3:00 p.m., surveyor # interviewed DON (Director of Nursing)-H regarding resident #1. DON-H stated resident #1 was a "harm to (resident)self last week and asked SWD-D to call for a psych veal." APS was involved by then and SWD-D "has stayed in contact with them to get a psych veal" for resident #1. On 12/15/14 at 3:25 p.m., surveyor # interviewed SLP (Speech Language Pathologist)-B regarding resident #1. SLP-B stated "worried about (resident #1's) mental health because of the things said." Resident #1 stated in writing when communicating to SLP-B on 12/4/14, "I dying and loving it" and "day 15 and counting, no eating. How long can I go?" SLP-B indicated these statements were reported to SWD-D and nursing staff immediately. On 12/15/14 at 4:04 p.m., surveyor # interviewed DON-H regarding resident #1. DON-H stated "was under the assumption psych services were involved" with the resident. DON-H had asked SWD-D what psych said and SWD-D answered there was not a psych veal completed. DON-H stated she was "livid" when she found out there had not been a psych veal scheduled or completed as the resident met criteria for a psych veal. On 12/16/14 at 9:55 a.m., surveyor # completed a telephone interview with NHA-G regarding resident #1. NHA-G stated currently resident #1 "is 1:1 with staff and emergency psych veal is getting scheduled." On 12/16/14 at 10:10 a.m., surveyor # completed a telephone interview with SW-C regarding resident #1. SW-C stated involvement with resident #1 "has been much more involved in the past 24 hours" than before. SW-C stated SWD-D daily provided updates of what was occurring with resident #1 and trusted SWD-D. SW-C indicated she did not ask SWD-D if a psych veal was scheduled for resident #1 and stated "obviously, I needed to ask more questions." SW-C indicated resident #1 would be assessed by psych today at 4:00 p.m.

Based on observation, staff interviews and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 (resident #8) of 1 sampled residents with pressure ulcers in a total sample of 18 residents. Resident #8 obtained a femur fracture on 6/21/14 when the resident's right foot was bumped while being wheeled into the facility. PCP (Primary Care Physician)-A ordered an immobilizer to resident #8's right leg, as a result of the fracture. The facility did not implement appropriate preventative treatment after OMD (Orthopedic Medical Doctor)-C ordered resident #8 to continue to wear the immobilizer with removal for hygiene only. The facility did not assess resident #8's change of condition skin breakdown risk and initiate a care plan for this increase in skin breakdown risk until 7/2/14. On 7/5/14, resident #8 had a 2 cm (centimeter) by 3 cm open area the facility classified as a "skin tear" located on the right posterior leg above the ankle, located under the immobilizer which the facility identified as caused by the immobilizer. The same day, the facility obtained treatment orders for the open area that included non-adhesive pads and a kerlix wrap, potentially creating greater pressure to the wound site. The facility did not reevaluate resident #8's skin breakdown risk or make any changes to resident #8's care plan for this increase in skin breakdown risk. On 7/16/14, resident #8's record included "Consultant Report" from WCC/RN (Wound Care Certified/Registered Nurse)-D for the open area; at that time, the facility reclassified the wound as an unstageable pressure area measuring 11.7 cm by 7.1 cm. The immobilizer was discontinued, the skin breakdown care plan changed to include interventions including a dietary consult, therapy referral, bilateral prevlon boots, an alternating air mattress, and the wound treatment orders were changed. On 8/13/14, resident #8 received a second consult from WCC/RN-D who documented the wound included tendon exposure. At this time, the facility continued to identify resident #8's stage IV pressure ulcer as unstageable. The facility did not have an RN assess resident #8's wound weekly; RN assessments were 7/8/14, 7/16/14, 8/7/14, 8/13/14 and 8/21/14, as documented. Failure to assess, re-evaluate, review and revise resident #8's care plan interventions for potential and actual skin breakdown in relation to a medical device (the immobilizer) created an immediate jeopardy situation, which began with resident #8's initial skin breakdown on 7/5/14 and was removed on 8/21/14. The facility was formally notified of the Immediate Jeopardy on 8/21/14. The deficient practice continues at a scope/severity level of G (actual harm/isolated) until the facility is able to develop, implement, evaluate, monitor and train all staff on policies and procedures to address the use of immobilizers with special attention to skin breakdown. Findings include: NPUAP (National Pressure Ulcer Advisory Panel) www.npuap.org Pressure Ulcer Prevention documents "Risk Assessment: 10. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition." "Skin Assessment: 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. 6. Observe the skin for pressure damage caused by medical devices." NPUAP: MDRPU (Medical Device Related Pressure Ulcers): The Hidden Epidemic Across the Lifespan documents MDRPU occur because of: ? "rigidity & inelasticity of devices ? difficulties in adjusting/securing to the body ? may be difficult to safely remove/lift ? prolonged pressure in the same place ? altered microclimate with increased moisture and heat ? tight securement ? poor positioning or fixation of device ? inappropriate size, selection ? obscured skin from visualization ? lack of awareness of [MEDICAL CONDITION] impact" "2010 research indicates patients with a medical device were 2.4 times more likely to develop a pressure ulcer." "Practice: thorough skin assessment under devices Q (every) shift if not medically contraindicated; avoid replacing devices on injured skin as feasible; Ensure proper sizing (resize with [MEDICAL CONDITION])." NPUAP: Pressure Ulcer Treatment Quick Reference Guide classification system: "Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stage (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Category/Stage IV: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/;or supporting structions (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable." Facility policy and procedure titled "Assessment and Documentation of Wounds, revision dated 1/1/11, documents: Skin assessment for all admissions and residents identified at risk or with acute pressure area. To identify potential risk factors in the development of pressure ulcers and/or appropriateness of currently prescribed interventions/appliances and documentation of wound statistics of active pressure ulcers." "Size: Measurements should be taken from wound edge to wound edge." On 8/20/14, surveyor # reviewed resident #8's medical record and it indicated that the resident was admitted to the facility in 2012 and has a legal guardian. Resident #8's [DIAGNOSES REDACTED]. Resident #8's Braden Scale, dated 4/22/14, used for predicting pressure ulcer risk score was 15, indicating that the resident was at risk for the development of pressure ulcers. Nurse's notes on 6/24/14 at 10:00 p.m., documented the resident's foot was bumped during wheel chair transport. Nurse's notes on 6/25/14 at 10:20 a.m., documented the resident complained of pain in the right knee, refused breakfast and an X-ray was ordered. Nurse's notes on 6/25/14 at 3:30 p.m., documented the resident's PCP ordered an orthopedic consultation and right knee immobilizer until the orthopedic consult for the resident's fractured right femur. Resident #8's care plan, with onset date of 6/25/14, included a right femur fracture problem with the following approaches: ~ Right knee immobilizer until ortho sees ~ Right knee immobilizer to be worn at all times, for 3 to 4 weeks. Remove for hygiene only (hand written and dated 6/27/14) OMD-C's consultation report, dated 6/27/14, documented resident #8's [DIAGNOSES REDACTED]. The treatment included immobilizer for 3-4 weeks until fully healed, no weight bearing and "May remove for hygiene only." Resident #8's Braden Scale score, dated 7/2/14 was 14, indicating that the resident now was at moderate risk for the development of pressure ulcers. Resident #8's care plan, with onset date of 7/2/14, included a moderate risk for skin breakdown problem. Braden score 13 - 14, with the following approaches: ~ Assist with repositioning ~ Pressure reducing device on bed/chair ~ Encourage good nutritional intake ~ Daily observation of skin with routine care ~ Full evaluation weekly by nurse Nurse's notes on 7/5/14 at 10:00 a.m., documented "at about 0600 (6:00 a.m.) CNA reported finding skin tear to area above heel on RLE (right lower extremity). Resident had been wearing leg immobilizer. Serosang (serous-sanguineous) drainage noted on immobilizer." Documentation and assessment completed by an LPN. The medical record included a fax that was sent to PCP-A on 7/5/14 informing that a skin tear noted 2 by 3 cm above right heel under immobilizer. The staff asked PCP-A for treatment orders to cleanse with normal saline, apply TAO (triple antibiotic ointment) F/B (followed by) NA (non-adhesive) pad and wrap with kerlix. To change everyday and PRN until healed. PCP-A agreed with requests and signed the fax on 7/8/14. The facility obtained treatment orders for the open area that included non-adhesive pads and a kerlix wrap, potentially creating greater pressure to the wound site. The facility did not reevaluate resident #8's skin breakdown risk or make any changes to resident #8's care plan for skin breakdown risk at this time. Nurse's notes on 7/5/14 at 8:10 p.m., documented "During assessment right ankle appears swollen/[MEDICAL CONDITION] +2, red and warm to touch." Documentation and assessment completed by an LPN. The non-pressure skin condition record included the following documentation regarding an upper right heel skin tear: ~ 7/5/14, 2 cm (centimeter) by 3 cm, documented as assessed by an LPN ~ 7/8/14, 3 cm by 3 cm, documented as assessed by a RN ~ 7/15/14, 4 cm by 3.5 cm, documented as assessed by an LPN Nurse's notes on 7/6/14 at 3:00 a.m., documented "Right lower extremity appears to be swollen and warm to touch". Documentation and assessment completed by an LPN. Nurse's notes on 7/6/14 at 7:00 p.m., documented "....Continues with imobilizer (immobilizer) on RLE at all times. Resident with noted increased confusion." Documentation and assessment completed by an LPN. Nurse's notes on 7/7/14 at 10:00 a.m., documented "...ordered leg sleeve for res (resident) to wear under immobilizer to protect skin." Documentation and assessment completed by a RN. On 7/8/14, PCP-A saw resident #8 and documented "Chief Complaint: Right distal femur fracture." "The patient did have her knee in an immobilizer and she was examined in this right knee immobilizer" Extremities: "She has 1 plus [MEDICAL CONDITION] (swelling) to the left lower extremity, she has 3 plus [MEDICAL CONDITION] to the right lower extremity. She has [MEDICAL CONDITION] to the ankle which is right greater than left." PCP-A's documentation did not address the resident's open area that had been under the immobilizer. Nurse's notes on 7/15/14 at 11:00 a.m., documented "wound to RLE (posterior) increased in size. Slough present to some of wound bed." Nurse's notes on 7/16/14 at 11:30 a.m., documented "Wound has gotten larger 11.1 cm by 7.1 cm. Wound bed 70% necrotic tissue present. Small amount serous-sang drainage....right leg brace removed (causing pressure wound)....EZ air loss pressure alternating mattress put in place." An additional problem added to care plan dated 7/16/14 included Pressure wound, Right lateral/posterior LE 11.7 by 7.1 eschar visible caused by pressure from brace (immobilizer), approaches included: ~ Brace (immobilizer) RLE on hold. Observe everyday and measure wound weekly The pressure ulcer record included the following documentation regarding the right lateral/posterior lower extremity pressure ulcer: ~ 7/16/14, 11.7 cm by 7.1 cm, wound bed- pink, yellow, black with eschar, documented as unstageable by RN-E ~ 7/22/14, 12 cm by 7 cm, documented as unstageable by an LPN ~ 7/29/14, 13 cm by 7.5 cm, documented as unstageable by an LPN ~ 7/31/14, 13.3 cm by 7.4 cm, documented as unstageable by an LPN ~ 8/7/14, 17.2 cm by 8.6 cm, wound bed pink, yellow with eschar and slough, drainage with odor, documented as unstageable by a RN ~ 8/13/14, 11.4 cm by 8.4 cm, wound bed- granulation and slough, documented as unstageable by a RN ~ 8/21/14, 10.5 cm by 7.1 cm, documented as unstageable by On 7/16/14, resident #8's Consultant Report completed by WCC/RN-D, included comments: "11.1 x(by) 7.1 x necrotic tissue. 70% necrotic tissue present. Area caused from RLE immobilizer (which should be on @ (at) all times)." This report documented change in treatment orders and interventions to include foam mattress on bed, prevlon boots bilaterally and immobilizer use on hold. A referral was made to have the dietician see resident #8 that day. The Dietitian's consult, dated 7/16/14 included laboratory draw recommendations and a recommended order for Prostat AWC (liquid protein) 30 ml (milliliter) BID (twice a day). The medical record included a fax that was sent to PCP-A on 7/16/14 asking for an order to place right leg immobilizer on hold, R/T (relating to) rubbing and pressure causing wound under brace. Staff informed PCP-A that the resident's current pain medication was no longer effective for pain control. The Dietitian's consult, dated 8/4/14 included laboratory draw recommendations and recommendations for Juven (therapeutic nutritional mixture) 1 packet per day, Vitamin C 500 mg daily, Zinc 220 mg daily and a Multivitamin daily. On 8/13/14, resident #8's Consultant Report completed by WCC/RN-D, included comments: "11.4 x 8.4 x 0.3. Tendon exposed in LE. lt (light) in color. Minimal slough noted on tendon. Scant serosanguinous (sic) drainage note." New treatment orders were recommended. On 8/20/14 at 10:50 a.m., surveyor # observed resident #8's pressure ulcer dressing change treatment provided by LPN (Licensed Practical Nurse)-F, with assistance from CNA-G. LPN-F indicated that resident #8 was pre-medicated prior to the treatment. Measurements were not taken of the wound during this treatment. The tendon was visible with yellow slough present. On 8/20/14 at 12:20 p.m., surveyor # interviewed RN-E regarding the resident #8's open area and the difference in measurements from 7/15/14 to 7/16/14, which were documented as a change increasing more than double the size. RN-E stated, "The wound literally grew overnight! I saw (the wound) but didn't take the measurements on 7/15/14." On 8/20/14 at 1:30 p.m., surveyor # interviewed DON-B regarding resident #8's pressure ulcer. DON-B verified the facility utilizes the NPUAP as its standard of practice. DON-B stated resident #8's immobilizer was ordered by an orthopedic specialist (OMD-C) because of the resident's femur fracture. DON-B confirmed the facility did not contact OMD-C to pursue any alternate device treatment options when resident #8's open area was discovered on 7/5/14. DON-B said, "We didn't think it was pressure." DON-B stated the open area doubled in size overnight (from 7/15/14 to 7/16/14). DON-B indicated the facility does not have a Wound Care nurse on staff and WCC/RN-D consults in the facility monthly and as needed. Surveyor # asked DON-B about the facility staging of resident #8's pressure ulcer as "unstageable", pointing out the WCC/RN-D's consultation note, dated 8/13/14, documenting: "Tendon exposed in LE, lt. yellow in color. Minimal slough noted on tendon." DON-B stated it is WCC/RN-D's practice not to write a pressure ulcer's stage on WCC/RN-D's consultation notes. DON-B stated, "I'm not denying tendon showing is stage IV, but we still called it unstageable because of the slough." DON-B stated WCC/RN-D was out-of state on vacation during survey. Surveyor # inquired about contact information for the facility dietician. DON-B stated an interim and the regional dietician were consulted regarding resident #8 and the facility's new dietician was starting tomorrow (8/21/14). DON-B provided surveyor # with contact information for the corporation's regional dietician. DON-B stated the facility got hospice "on board" to help with nutrition and pain management for resident #8. DON-B stated PCP-A was on medical leave with an anticipated return date of 10/1/14. On 8/20/14 at 4:45 p.m., surveyor # interviewed DON-B regarding resident #8. DON-B indicated that staff did not complete a Braden scale assessment for the resident with the initiation of the right leg immobilizer or at the appearance of the 7/5/14 open area. DON-B stated, "We had just completed the Braden days prior to the skin tear." On 8/21/14 at 7:55 a.m., surveyor # observed LPN-F perform a wound treatment to resident #8's pressure ulcer. Prior to the observation, DON-B informed surveyor # 2 that LPN-F would be completing the weekly wound assessment. Surveyor # asked to have a facility RN present and DON-B directed RN-E to assist LPN-F with the procedure. Both staff performed hand hygiene and applied disposable gloves. Resident #8 was supine in bed and did not have the protective boots on. LPN-F indicated the protective boots were off because staff were anticipating that the LPN was going to be doing the dressing change. The protective boots were in the resident's room and appeared tall enough to completely cover the resident's pressure ulcer. LPN-F removed the soiled dressing from the resident's right lower extremity. The dressing was soiled with a bloody drainage and no foul odor was noted. RN-E was asked to describe the wound and indicated the peri-wound was pink, the wound bed was beefy red and surrounded a visible white and yellow tendon. RN-E indicated there was a small amount of slough to the base of the wound and a small area of necrotic tissue on the visible tendon. RN-E stated the wound be classified as unstageable because there was slough present. RN-E verified even though the tendon was "clearly visible" the wound was still unstageable because she was taught any amount of slough present would make the ulcer unstageable. LPN-F performed hand hygiene and cleansed the ulcer with normal saline and gauze. LPN-F performed hand hygiene and applied clean gloves. LPN-F began measuring the wound starting where full thickness tissue loss was present and RN-E corrected LPN-F to begin the measurements where the skin breakdown began. The pressure ulcer was located above the resident's right external malleolus and measured 10.5 cm in length and 7.1 cm wide. LPN-F performed hand hygiene, applied clean gloves, applied skin prep to the peri-wound, and hydrogel soaked gauze the wound bed. LPN-F covered the wound with two derma foam dressings and secured them in place with kerlix. The Immediate jeopardy was removed on 8/21/14 when the facility completed the following: 1. All residents utilizing braces, immobilizers, and splints were assessed. 2. Wounds to be assessed and measured weekly by a RN 3. Education of licensed nursing staff was initiated on 8/21/14. Any licensed nurse not educated on 8/21/14 removed from staff schedule until education is completed. Education included: ~ Potential for development of impaired skin integrity with use of brace, immobilizer, and splint devices ~ Identification of changes in skin integrity including bruising, skin tears, friction, abrasion, and pressure ulcers ~ Appropriate staging definitions per NPUAP guidelines. Staging of wounds is done by RN ~ Proper treatment protocols to minimize additional pressure to wound areas ~ RN wound consultant is available as needed 4. Resident's utilizing braces, immobilizers, or splints will have skin integrity checked daily by licensed nurse 5. Audits of residents utilizing braces, immobilizers, or splints five times weekly times 4 weeks, then three times weekly times 4 weeks, then two times weekly times 4 weeks. Audit results will be documented on a Quality Assurance tool. Results will be reviewed weekly and brought through QAPI (quality assurance performance improvement) committee members monthly times 3 months for review and further recommendations.

Based on record review and staff interview, the facility did not ensure that a resident who enters the facility without pressure sores does not develop pressure sores and receives necessary treatment and services to promote healing for 1 (resident #1) of 10 sampled residents. Resident #1 was admitted to the facility and assessed to have been at risk for developing pressure sores. Resident #1's skin was intact on admission to the facility. On 6/30/12, resident #1 developed [MEDICAL CONDITION] of the penis and scrotum. The physician was notified and orders received to elevate the scrotum until swelling resolved. Staff utilized a rolled/folded towel to have been placed under the scrotum for elevation. On 7/3/12, resident #1 developed a dark purple area under and just to the right of the scrotum. Staff sent a fax to the physician at 9:30 p.m. and initiated Dermamed cream (a barrier cream) to the purple area. The physician had not responded to the fax. The facility continued to utilize a rolled/folded towel under resident #1's scrotum for elevation. The facility did not assess the causal factor for the new development of the purple area nor did the facility change resident #1's plan of care to treat resident #1's concern in skin integrity to promote healing. FM-B (family member) made arrangements for resident #1 to have been transferred to the VA (Veteran's Administration) Hospital in Milwaukee on 7/10/12. Resident #1 was admitted to the VA Hospital and diagnosed with [REDACTED]. Findings include: The European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, Pressure Ulcer Prevention, Quick Treatment Guide, 2009 indicated a suspected deep tissue injury is defined as a purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be surrounded by tissue that is painful, firm, boggy, mushy, warmer or cooler as compared to adjust tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Treatment to the Deep Tissue Injury should include to, "Position the individual off of the area(s) of suspected deep tissue injury with intact skin. If pressure over the area cannot be relieved by repositioning, evaluate the individual and provide a support surface properly matched to his/her needs, considering pressure redistribution, shear reduction and microclimate control. Keep the individual off of the area as much as possible". The facility policy and procedure for "Skin Care and Wound Management", revised 8/10, directed staff to "review and select the appropriate protocol for the identified skin impairment: * Stage 1 * Stage 2 * Stage 3 and 4 * Suspected deep tissue injury * Slough * Eschar * [MEDICAL CONDITION] ulcer * Arterial insufficiency and diabetic neuropathic ulcer * Wound with increased surface overgrowth * Skin tear The facility policy and procedure for "Treatment Protocol: Suspected Deep Tissue Injury", revised 9/11, indicated a suspected deep tissue injury is defined as a purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be surrounded by tissue that is painful, firm, boggy, mushy, warmer or cooler as compared to adjust tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Procedure: * Obtain a physician's orders [REDACTED]. * Evaluate resident for pain prior to, during, and post dressing change. * Cleanse wound with normal saline or wound cleanser. * Apply skin prep to periwound skin and allow to dry. * Implement treatment protocol as ordered. * Document wound measurements and characteristics....no less than weekly. More frequent documentation may be indicated based on changes in condition of wound. * Verify prevention interventions are in place. * Review effectiveness of treatment plan every 2 weeks and revise as needed. On 7/23/12, surveyor # reviewed resident #1's medical record. According to the facesheet, dated 7/19/12, resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed an MDS (minimum data set) with an assessment reference date of 5/14/12, indicating resident #1 had moderate cognitive impairment, required extensive staff assist with bed mobility, and was dependent on staff for transfers. The MDS indicated resident #1 was at risk for pressure sore development and had no current pressure sores. The CAA's (Care Area Assessment), without date when completed, indicated resident #1 had a history of [REDACTED]. Resident #1 was on a SB3000 air mattress and had his own electric w/c (wheelchair) with a pressure relieving cushion. The CAA's indicated an admission Braden scale is 15/23 for mild risk of developing a pressure ulcer. A Braden scale would be done weekly for 4 weeks, then monthly for 2 months and then quarterly. Skin sweep completed upon admission and then weekly by the licensed nurse. The CAA's didn't indicate if the facility would continue to care plan development. The facility did develop a plan of care for "Is at risk for pressure ulcers, dated 5/16/12, which indicated the following interventions for prevention of pressure sores: * Reposition every three hours at night when in bed * Specialty Mattress SB3000 on bed. Roho cushion in w/c * Develop turning/repositioning plan with input from resident * Teach risk factors for development of pressure ulcers * Maintain head of bed at angle less than 30 degrees * Needs two person to assist with repositioning to avoid skin friction/shearing * Refer to dietician to evaluate resident nutritional status * Labs as ordered * Encourage good nutritional intake * Encourage resident/family on consequences of noncompliance with therapeutic regime * Needs daily observation of skin with routine care * Needs full evaluation weekly by licensed nurse "Notes For Interdisciplinary Team Meeting", with meeting date of 5/24/12, indicated resident #1's skin was intact and required frequent repositioning. The note indicated resident #1 weighed #226. The nurses' notes, dated 6/30/12 at 0900 (9:00 a.m.) indicated resident #1 was incontinent of urine-soaked bed. No urine was noted in the Foley bag. Upon observation, penis and scrotum was very red, swollen and warm to the touch. Foley removed, new Foley inserted...... The nurses' notes dated, 6/30/12 at 1000 (10:00 a.m.) indicated an on call physician was updated and orders received... A telephone order, dated 6/30/12 indicated the on call physician ordered to administer [MEDICATION NAME] 500 mg (milligrams) twice daily for 7 days and to elevate the scrotum/penis. Resident #1 was diagnosed with [REDACTED]. The TAR (Treatment Administration Record) initiated on 6/30/12, had directions to place a towel under the scrotum as patient allows until [MEDICAL CONDITION] resolves. The TAR indicated resident #1 refused towel placement on the day shift of 6/30/12, and there was no documentation for the PM shift for 6/30/12. The July 2012, TAR continued directions to elevate resident #1's penis and scrotum with a towel as resident allows until swelling, related to [MEDICAL CONDITION], resolves. The TAR indicated the towel had been placed on all shift from 7/1/12 through the night shift of 7/9/12. The nurses' notes indicated the following: * 7/1/12 at 1250 (12:50 p.m.)- towel under scrotum for elevation when in bed. States its uncomfortable in the chair. * 7/2/12 at 1400 (2:00 p.m.)- penis and scrotum continues with redness and swelling. Scrotum elevated. * 7/3/12 at 0001 (12:01 a.m.) placed towel under scrotum to area -elevated. The nurses' notes, dated 7/3/12 at 2130 (9:30 p.m.) indicated resident has an area on right lower buttock that is dark purple that measures 7.4 cm (centimeters) by 4.4. cm, within the darkened area there is an open area measuring 3.2 cm by 4.4 cm by 0.1 cm. The skin is rolled back. Meaty red flesh is observed. Repositioned off bottom. Dermamed applied, MD (medical doctor) faxed.... The medical record contained a fax to the physician that was dated 7/4/12, which indicated resident #1 has a dark purple area on the right lower gluteal area measuring 7.4 cm X 4.8 cm. Within the darkened area there is an open area with rolled edges, meaty red flesh observed measuring 3.2 X 4.4 X 0.1. Dermamed applied four times daily and as needed. Please advise. The fax was signed and dated by the physician on 7/17/12 and had written, pt (patient) d/c'd (discharged ) 7/10/12. The nurses' notes on 7/5/12, and 7/6/12 had not contained any assessment of the purple area that had developed behind and to the right of resident #1's scrotum. The nurses' notes indicated the following: * 7/6/12 at 1330 (1:30 p.m.)- resident #1 was alert and oriented times three. Resident denies pain. Resident refused to reposition himself in bed and w/c. Resident was educated on status of ulcer and the importance of offloading. He still refused...... * 7/6/12 at 1410 (2:10 p.m.)- "Bellin wound and ostomy called to set up an appointment for deep tissue injury on buttock. Message left". * 7/7/12 at 1015 (10:15 a.m.)- writer spoke to wife concerning deep tissue injury to buttocks. (No assessment of injury documented in the medical record). * 7/7/12 at 1300 (1:00 p.m.)- wife at bedside and saw tissue injury. Made aware we are awaiting a return call from the wound clinic. Made aware of present treatment to site with repositioning every 2 hours..... Repositioned at this time....Offloading to site maintained. * 7/8/12 at 1310 (1:10 p.m.)- aggressive offloading and repositioning continues. Dermamed to deep tissue injury...continues on bedrest. (No assessment of injury documented in the medical record). * 7/9/12 at 1400 (2:00 p.m.)- aggressive offloading and repositioning every 2 hours per staff continues on bedrest secondary to deep tissue injury. Wife informed of wound clinic appointment for today at 10:15 a.m.. Wife refused appointment and patient to be transferred to the Milwaukee VA spinal cord injury center on 7/10/12. * late entries for 7/2/12, 7/4/12 and 7/5/12- educated on need and importance of elevation of scrotum due to [MEDICAL CONDITION] to site. Needs encouragement, especially when up in w/c. The Skin grid, dated 7/9/12, indicated resident #1's wound had increased to 8.0 cm X 5.1 cm without any depth. Documentation indicated there was a small amount of serous draining and the wound edges were rolled with and the periwound was red. Written documentation indicated "shearing top layer of skin rolled back". * 7/10/12 at 1310 (1:10 p.m.)- left facility at 11:00 a.m. for VA appointment in Milwaukee. On 7/23/12 at 12:00 p.m. and 7/24/12 at 12:20 p.m., surveyor # interviewed Day RN-A (Registered Nurse) regarding care provided to resident #1. RN-A stated resident #1 was alert and oriented and very meticulous of cares. RN-A indicated resident #1 directed cares and if wasn't positioned correctly in his w/c, he would instruct staff until he was positioned the way he wished to be. RN-A stated resident #1 would transfer into the w/c after breakfast and would remain in the w/c until after supper. RN-A indicated resident #1 had a motorized w/c which he was able to change positions of his seating, forwards and backwards, independently. RN-A stated staff also repositioned resident #1 every 2 hours. RN-A indicated nurses elevated resident #1's scrotum with a rolled towel when diagnosed with [REDACTED].#1 did accept placement of the rolled towel. Surveyor # questioned how the development of the purple area just to the right of the scrotum and under the right buttock had occurred. RN-A stated she believed the pressure from the towel had caused the injury. RN-A indicated resident #1 could not feel pain in the area due to his [MEDICAL CONDITION]. RN-A verified she had assessed resident #1's [MEDICAL CONDITION] on the day shift of 7/3/12, and there was no evidence of any deep tissue injury. RN-A indicated she had updated FM-B (family member) on 7/7/12 and she came to the facility and observed the injury. RN-A stated after FM-B observed the area, she became very upset. RN-A verified the rolled towel was utilized under the scrotum for elevation, even after the belief was the rolled towel had caused the injury. RN-A stated the last few days prior to discharge, resident #1 was placed on bedrest, but the rolled towel was continued to have been placed under the scrotum, as it caused less pressure than when he was seated in the w/c. (RN-A worked day shift with resident #1 on 7/2/12, 7/3/12, 7/4/12, 7/5/12, 7/7/12, 7/8/12 and 7/9/12) On 7/23/12 at 12:50 p.m., surveyor # interviewed Day CNA-C (Certified Nursing Assistant) regarding care provided to resident #1. CNA-C verified she frequently cared for resident #1. CNA-C stated nurses placed a small rolled towel under his scrotum for elevation. CNA-C indicated staff repositioned resident #1 every 2 hours, and indicated resident #1 also repositioned the seating on his w/c independently. On 7/23/12 at 1:35 p.m., surveyor # interviewed ADON-D (Assistant Director of Nursing)-D regarding care provided to resident #1. ADON-D stated on 6/30/12, resident #1 developed swelling and redness of the scrotal area and the physician was updated. ADON-D indicated he was not sure if the physician ordered or if the nurses just elevated the scrotum. ADON-D stated resident #1's scrotum was elevated in the w/c by resident #1 having his seating laying back. ADON-D indicated he was unaware of any rolled towel utilized to elevate the scrotal area. ADON-D indicated resident #1 was repositioned by staff every 2 hours and occasionally he would have refused repositioning, but was not very often. ADON-D stated the purple, open area was caused by the [MEDICAL CONDITION], and had fragile skin due to past history of an ulcer in the same area. ADON-D stated when resident #1 was diagnosed with [REDACTED]. ADON-D indicated Dermamed was a barrier cream which the staff utilized. On 7/23/12 at 2:55 p.m., surveyor # interviewed PM shift RN-E regarding cares provided to resident #1. RN-E stated resident #1 was alert and oriented and slightly forgetful, but was able to make needs known. RN-E indicated resident #1 developed scrotal swelling and redness and looked painful, but resident #1 was unable to feel pain due to his [MEDICAL CONDITION]. RN-E verified after the development of scrotal swelling she had elevated resident #1's scrotum with a folded hand towel which she encased in a pillow case, and she placed under resident #1's scrotum. RN-E stated she had only elevated the scrotum with the towel when he was in bed and wasn't used on the PM shift when up in the w/c. RN-E indicated resident #1 was up in his w/c when second shift staff arrived, and remained in his w/c until approximately between 8:00 p.m. - 9:00 p.m., when he went into the bed. RN-E stated she hadn't worked with resident #1 after he had developed an open area to the right and under the scrotum. RN-E indicated resident #1 was repositioned every 2 hours by staff, and on occasion would refuse repositioning when in the w/c, but always allowed repositioning when in bed. RN-E stated she was unaware of how the open area had developed. On 7/23/12 at 3:08 p.m., surveyor # interviewed PM shift CNA-F regarding care provided to resident #1. CNA-F stated resident #1 was alert and oriented and able to make his needs known. CNA-F stated resident #1 was up in his w/c until between 9:00 p.m. - 10:00 p.m. and wouldn't allow staff to reposition when in his w/c, but would allow staff assistance when in bed. CNA-F indicated resident #1 utilized a mechanical w/c, in which he was capable to independently offload pressure by mechanically moving his w/c seat forward and backwards. CNA-F indicated on the PM shift, resident #1 did not utilize a towel under his scrotum, but a folded towel was placed under the scrotum to elevate, when he was in bed and was utilized until his discharge. CNA-F stated she first had observed the dark area just to the right and under resident #1's scrotum on 7/3/12, which was new, and immediately updated the nurse. On 7/23/12 at 3:25 p.m., surveyor # interviewed PM shift CNA-G regarding cares provided to resident #1. CNA-G stated resident #1 was up in the w/c on second shift until approximately 8:30 p.m. - 9:00 p.m.. CNA-G stated staff did not reposition resident #1 when he was in the w/c due to he could independently change position mechanically, moving the seating either forward or backwards. CNA-G stated resident #1 would request assistance as he needed. CNA-G stated nurses indicated to elevate resident #1's scrotum when in bed and a folded hand towel was placed under the scrotum. CNA-G stated resident #1 utilized the folded hand towel when in bed until discharge. On 7/23/12 at 4:00 p.m., surveyor # conducted a telephone interview with night shift RN-H regarding care provided to resident #1. RN-H indicated the first time he worked with resident #1, was after the development of the deep tissue injury and was on 7/6/12. RN-H stated when he observed the deep tissue injury it looked "brutal". RN-H stated the deep tissue injury was deep purple in color, didn't appear to be open, but there was serous drainage. RN-H indicated he, "knew it was more than facility staff was capable of treating". RN-H stated he updated ADON-D regarding the injury and was told to schedule an appointment with the local wound clinic. RN-H stated he had placed a rolled cloth under the scrotal area to keep elevated, but didn't have the cloth touch the area of the deep tissue injury, but he wasn't aware how other staff placed the rolled cloth. RN-H stated he did not know what caused the deep tissue injury. RN-H indicated at times resident #1 had refused repositioning. On 7/23/12 at 5:40 p.m. and on 7/24/12 at 12:45 p.m., surveyor # conducted a telephone interview with night shift RN-I regarding care provided to resident #1. RN-I stated resident #1 developed [MEDICAL CONDITION] of the scrotum and a folded hand towel was placed under the scrotum for elevation. RN-I indicated the PM shift staff placed the hand towel under the scrotum when he went to bed as the towel was already in place when the night shift staff came to work. RN-I indicated the placement of folded towel had the potential to have been coming in contact with the area where the deep tissue injury had developed. RN-I stated she was unsure when the placement of the towel was discontinued. RN-I stated resident #1 was usually positioned side to side on the night shift and the towel was continued to have been placed under the scrotum towards the leg area to ensure the the towel stayed in place. RN-I stated her feeling of how the deep tissue injury developed was because resident #1 didn't wear underwear or incontinent products, it has been warm weather, resident #1 had [MEDICAL CONDITION] and had decreased resistance. RN-I stated all factors caused the purplish area below the scrotum. RN-I indicated resident #1 did not refuse repositioning when in bed. On 7/23/12 at 6:05 p.m., surveyor # conducted a telephone interview with day shift CNA-J regarding care provided to resident #1. CNA-J stated night shift would wash and dress resident #1 and he would remain in bed until after breakfast. CNA-J indicated day shift staff would assist resident #1 into his w/c approximately at 9:00 p.m.. CNA-J stated she wasn't aware of a rolled/folded cloth placed under resident #1's scrotum while in the w/c, as CNA staff never placed. CNA-J indicated resident #1 wasn't assisted with repositioning while in the w/c, as resident #1 had an advanced motorized w/c which he changed his position, forward/backwards, when he desired. CNA-J stated resident #1 remained in the w/c for the remainder of the day shift. On 7/23/12 at 6:18 p.m., surveyor # conducted a telephone interview with PM shift LPN-K (Licensed Practical Nurse) regarding care provided to resident #1. LPN-K stated the only time she had worked with resident #1 was on 7/3/12, when the CNA updated her on a new skin concern which she was requested to look at. LPN-K indicated she observed a deep purple area with a flap of skin in the center which was open, but was not draining any fluid at the time of the observation. LPN-K indicated she called ADON-D (who was acting as the DON in her absence) regarding the observation. LPN-K indicated ADON-D directed her to fax the physician and apply Dermamed (a barrier cream). LPN-K indicated resident #1 had a rolled/folded towel that was placed under his scrotum by the CNA's when he was placed in bed. LPN-K indicated the purplish area was caused from pressure, but was unaware of what caused the pressure. On 7/24/12 at 7:56 a.m., surveyor # conducted a telephone interview with night shift CNA-L regarding cares provided to resident #1. CNA-L stated she couldn't recall if a folded/rolled cloth was placed under the scrotum when he was in bed. CNA-L indicated resident #1 was repositioned by staff every 2 hours. On 7/24/12 at 8:14 a.m., surveyor # conducted a telephone interview with PM shift CNA-M regarding cares provided to resident #1. CNA-M indicated resident #1 stayed in the w/c on the PM shift until transferred into bed at approximately 8:00 p.m.- 8:30 p.m.. CNA-M stated CNA staff never placed a towel under resident #1's scrotum for elevation, but it was possible nurses had. CNA-M indicated resident #1 was not repositioned while in his w/c, and was unsure as to why. CNA-M did indicate resident #1 was repositioned every 2 hours when in bed. On 7/24/12 at 9:00 a.m., surveyor # conducted a telephone interview with night shift RN-N regarding cares provided to resident #1. RN-N indicated resident #1 was already in bed when night shift arrived to work at 10:00 p.m.. RN-N stated resident #1's scrotum was elevated with the placement of a rolled towel which was placed underneath the scrotum. RN-N stated the rolled towel would be in contact with the area of skin tissue behind and right of the scrotum. RN-N indicated she could not recall the condition of the skin tissue behind the scrotum prior to 7/8/12, but indicated on 7/8/12, the tissue was "really bad". RN-N stated she reviewed resident #1's medical record and noted staff were placing a cream on the affected area. RN-N indicated the skin integrity to the right and behind the scrotum was worse than observed on 7/3/12 and 7/4/12. RN-N stated she hadn't any idea how the area had developed. RN-N indicated she hadn't updated a physician because she had heard in report that someone was already proceeding with a treatment. RN-N stated resident #1 was repositioned when in bed every 2 hours, but he was unable to feel pain below the waist because he was a paraplegic. RN-N verified a rolled towel was always placed under the scrotum when in bed. On 7/24/12 at 9:20 a.m., surveyor # interviewed day shift CNA-O regarding cares provided to resident #1. CNA-O stated resident #1 was up in his w/c most of the day. CNA-O indicated she assumed there had been a rolled/folded cloth that was placed under resident #1's scrotum for elevation, but she had actually never observed. CNA-O indicated a few days prior to discharge, resident #1 remained in bed all the time due to his "bottom" was deteriorating. CNA-O stated when resident #1 was in bed a rolled/folded cloth of some kind was placed between his legs and under his scrotum to elevate the scrotum. CNA-O indicated resident #1 could not feel pain due to [MEDICAL CONDITION]. On 7/24/12 at 9:45 a.m., surveyor # conducted a telephone interview with day shift CNA-P regarding cares provided to resident #1. CNA-P stated day shift staff transferred resident #1 into his w/c between 8:00 a.m. and 9:00 a.m.. CNA-P indicated she had observed a folded/rolled washcloth when up in the w/c. CNA-P stated resident #1 didn't require staff repositioning during the day as resident #1 was able to independently change his position in his w/c by moving the seat forward or backwards. On 7/24/12 at 10:45 a.m., surveyor # re-interviewed ADON-D (who was acting DON when resident #1's suspected deep tissue injury had developed). ADON-D stated the purple area between resident #1's legs, just to the right and below the scrotum, was not a new area and developed when the [MEDICAL CONDITION] was diagnosed . ADON-D verified he had assessed the area and observed a dark purple area, but was unable to indicate the size as he hadn't taken a measurement. ADON-D stated it had appeared the top layer of skin was damaged, it was red and not draining. ADON-D indicated "it needed to be taken care of" and he told the RN to schedule an appointment with the wound care clinic. ADON-D stated he couldn't recall if he had told the RN to call a physician, but was aware a fax was sent to the physician and was aware the physician had not responded as of 7/6/12. Surveyor # questioned if the deep purple area was possibly a deep tissue injury and ADON-D responded he was unable to diagnose as he was not a physician. ADON-A stated the purplish area never deteriorated, but hadn't improved. On 7/24/12 at 12:55 p.m., surveyor # conducted a telephone interview with night shift CNA-Q regarding care provided to resident #1. CNA-Q stated resident #1 was repositioned by staff every 1 1/2 hours. CNA-Q verified the nurses placed a folded hand towel that he believed was placed under the butt cheek. CNA-Q stated the folded hand towel was always placed on the night shift. On 7/24/12 at 1:05 p.m., surveyor # conducted a telephone interview with MD(Medical Doctor)-R regarding the fax which was sent to the physician's office on 7/3/12 at 9:30 p.m.. MD-R verified he had received the fax on 7/5/12 and hadn't responded. MD-R stated he hadn't responded to the fax because the facility had an excellent wound care team and knew it would be taken care of. MD-R stated resident #1 was a quadriplegic, was immobile and was going to get decubitus. MD-R indicated the facility "are more experienced of taking care of wounds than I do. They made recommendations and I agree". On 7/24/12 at 1:15 p.m., surveyor # interviewed DON (Director of Nursing)-S regarding facility wound care team and her awareness of resident #1's condition. DON-S stated she returned to work on 7/5/12. DON-S stated the facility had a wound care team which consisted of the DON, 2 RN managers, 2 Social Workers, 2 MDS coordinators and the Activity Director (the team discusses other topics as well as wounds). DON-S indicated the facility contracted with a Certified Wound Nurse who came to the facility monthly and more often if needed. DON-S indicated the wound care team met every Thursday at 10:00 a.m.. DON-S verified the wound care meeting which was held on 7/5/12 had not included a discussion regarding resident #1's wound, as they were not made aware of the wound prior to the meeting. DON-S verified the Certified Wound Nurse Consultant was not updated on resident #1's wound. DON-S indicated some time later that day she had became aware of resident #1's wound. DON-S stated she asked ADON-D regarding resident #1's wound, and she was told the wound was an open purple area which was caused from a failed flap surgery, which was done sometime prior to admission to the facility. DON-S stated she specifically asked ADON-D if the wound was from pressure and she was told no, so she hadn't proceeded with any investigation regarding the wound. DON-S she had never observed the wound so she hadn't any idea of what the causal factor for the wound development was. DON-S verified the facility had not assessed the root cause of the injury nor had changed the plan of care. DON-S stated she was not aware a rolled/folded towel was used to elevate the scrotum until surveyor # updated DON-S regarding the documentation and staff interviews. On 7/25/12, surveyor # reviewed a fax which was sent from the VA Hospital regarding resident #1. According to the "Admitting Note", dated 7/10/12, resident #1 had a large right ischial wound with an adherent necrotic cover, upon palpation seems to have a soft tissue defect, reported to have copious serosanguinous drainage, no foul smell, no purulent drainage. The plastic surgeon's consult note, dated 7/11/12, indicated resident #1 presents with a new ulcer right ischial area......appears to be pressure area which measures about 9 X 6 overlying right ischial area adjacent to the scrotum. About half of it has reasonably capillary fill. About a third is dark and may progress to full thickness necrosis. We should have a better idea over the next week if he will need surgery... The plastic surgeon's consult note, dated 7/18/12 indicated the ischial wound has progressed to full thickness necrosis and will be debrided as there is foul smelling fat necrosis. The operative report, dated 7/23/12, indicated a culture was completed on the ischial bone.