Every finding on record at Emporia Rehabilitation and Healthcare Center

Based on observation, resident interviews, staff interviews, and facility documentation reviews the facility staff failed to ensure water was available to maintain resident hydration for four residents, Resident#3 (R3), Resident #4 (R4), Resident #43 (R43), and Resident #49 (R49)out of a survey sample of 28 residents. The findings included:The facility staff failed to provide ice water to the residents to have for hydration. On 6/1/26 at 1:00 pm, a tour of the unit one nursing unit was conducted. During the observation, there were several rooms observed without water available to the residents. On 6/1/26 at 2:50 pm, an observation was made of no fluids available in room for hydration for R43 or her roommate. On 6/1/26 at 2:52 pm, an interview was conducted with R43. She said, very seldom do we get water passed to us I ask and sometimes it comes sometimes not. On 6/01/2026 at 3:28 pm, an interview was conducted with R4. R4 said, have to ask and sometimes might take a minute. On 6/01/2026 at 3:47 pm, a second observation was conducted. During this observation R3, R4, and R49 was observed having no available water provided. On 6/02/2026 at 9:51 am, another observation was made of no fluids in the rooms of R3, R4, R43 and R49. During the observation R43 said, teeth are rotten and mouth is dry. On 6/2/26 at 3:30 pm, an observation was made of the staff passing water out to the residents on unit one. R3, R4, R43, and R49 was receiving water for hydration at this time. On 6/02/2026 at 4:43 pm, an interview was conducted with a certified nursing assistant, CNA2. During the interview, she stated hydration should be provided to the residents on each shift. CNA2 stated all residents should have a cup of ice water in their rooms. CNA2 also stated that these rooms were not her assigned rooms. On 6/2/26, a facility documentation was reviewed. The facility documentation titled, Resident Hydration and Prevention of Dehydration, read in part, .This facility will strive to provide adequate hydration and to prevent and treat dehydration. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. On 6/2/26, an end of day meeting was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services and they were made aware of the above concerns. No additional information was provided prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to develop a comprehensive care plan regarding post-traumatic stress disorder for one of twenty-eight residents in the survey sample (Resident #11). The findings include:Resident #11 had no care plan developed regarding post-traumatic stress disorder. Resident #11 (R11) was admitted to the facility with diagnoses that included asthma, collapsed vertebra, cervical fracture, dysphagia, polyneuropathy, anxiety, neurogenic bladder, chronic post-traumatic stress disorder (PTSD), major depressive disorder and delusional disorder. The minimum data set (MDS) dated [DATE] assessed R11 with severely impaired cognitive skills. R11's clinical record documented the resident was admitted to the facility with a history of chronic PTSD related to physical trauma from a ground level fall at home that resulted in spinal fractures that caused limited range of motion and pain. R11's clinical record documented ongoing assessment by the nurse practitioner (NP), psychiatric NP and licensed clinical social worker. Psychiatric providers documented interventions for R11 that included psychoactive medications and non-drug interventions that included participation in talk therapy, encouragement to assist with activities of daily living and participation in social activities. R11's plan of care (revised 2/16/26) documented the resident had a history of chronic PTSD but included no problems or goals regarding PTSD and no interventions to minimize potential for re-traumatization. The goals/interventions documented by the psychiatric providers were not mentioned in the care plan. On 6/2/26 at 3:51 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about R11's PTSD diagnosis. LPN #2 stated R11 was admitted from another nursing facility with diagnosis of chronic PTSD. LPN #2 stated she thought the PTSD was related to serious injuries from a traumatic fall in the resident's home. LPN #2 stated when asked about past trauma, R11 did not want to talk about her past or injuries. LPN #2 stated the resident had behaviors of yelling out and waking thinking she was in another place. LPN #2 stated at first, R11 did not want to open the window blinds and did not talk or interact with staff much. LPN #2 stated the resident was followed by nurse practitioner (NP), psychiatric NP and licensed clinical social worker and had improved since arriving in the facility. LPN #2 stated R11 now had less behaviors, was more talkative and interactive with staff and agreed to open the blinds. LPN #2 stated behaviors were listed on the care plan, but she was not sure about a PTSD care plan. On 6/2/26 at 3:53 p.m., the NP that routinely cared for R11 was interviewed. The NP stated R11 had anxiety and history of PTSD related to severe physical injuries from a fall at home in addition to past military service. The NP stated the resident was monitored/treated by psychiatry. The NP stated R11 every now and then would wake from sleeping, panic and think she was somewhere else. The NP stated at first the resident wanted the room dark with blinds closed and was not talkative or revealing about her past. The NP stated now the resident was more interactive with staff, has a friend she routinely talks with and allows the blinds open. On 6/3/26 at 10:06 a.m., MDS coordinator (LPN #3) responsible for care plan development was interviewed about R11. LPN #3 stated the PTSD was listed as part of the behavior care plan. LPN #3 stated, We need to link the behaviors to the PTSD. LPN #3 reviewed the care plan and presented no individualized plan regarding the resident's PTSD. The facility's policy titled Care Plan, Comprehensive Person-Centered (revised Dec. 2016) documented, .A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .include measurable objectives and timeframes .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .incorporate identified problem areas .reflect treatment goals, timetables and objectives in measurable outcomes .identify the professional services that are responsible for each element of care .aid in preventing or reducing decline in the resident's functional status and/or functional levels .enhance the optimal functioning of the resident by focusing on a rehabilitative program .Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan . This finding was reviewed with the administrator and director of nursing during a meeting on 6/2/26 at 4:20 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, clinical record review and facility documentation review, the facility failed to ensure oxygen was administered as ordered by the physician for one resident, resident #14 (R14) out of a sample survey of 28 residents. The findings include: The facility staff failed to administer oxygen per the physician's order. On 6/2/26 at 10:00 am, an observation was conducted. During the observation, R14 was wearing oxygen via nasal cannula (nc) and his oxygen concentrator was set on one liter per minute to be administered. On 6/2/26 at 10:10 am, a staff interview was conducted with a licensed practical nurse (LPN5). LPN5 came into R14's room to check his oxygen level with a pulse oximeter. (a small non-invasive device to measure how much oxygen is in your blood). LPN5 stated R14's oxygen level was fluctuating between 92% and 93%. LPN5 reviewed the physician's order and stated that R14 has an order for oxygen for 2-4L(liters) to be administered as needed. LPN5 adjusted R14's oxygen concentrator to two liters per minute to be administered per physician's orders. LPN5 stated that if R14's oxygen saturations were lower, he would need a higher liter of oxygen to be administered. LPN5 stated that the physician's orders should be followed. On 6/2/26 at 10:35 am, a clinical record review of the physician's orders was conducted. There was an order for R14 that read oxygen gas 2-4L[liters] prn [as needed] shortness of breath/comfort via nc [nasal cannula]as needed. R14's care plan was reviewed and read in part .Oxygen 2-4 LPM [liters per minute] via nc [nasal cannula] as needed for shortness of breath, hypoxia. On 6/3/26 at 10:00 am, a facility documentation review was conducted. The facility documentation titled, Oxygen Administration Policy, read in part .1. verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. On 6/3/26, a meeting was held with the Administrator, Director of Nursing and the Regional Director of Clinical Services, and they were made aware of the above concerns. No additional information was provided prior to exit conference.

Based on observation, staff interviews, clinical record reviews, and facility documentation reviews the facility staff failed to provide pharmaceutical services to meet the needs of one resident, Resident #78 (R78) one out of 44 opportunities. The findings included:R78 was not administered his medications per physician's orders. On 6/02/2026 at 8:05 AM, a medication administration observation was conducted. A licensed practical nurse, LPN5 was administering medications to R78 and stated that she was unable to give Eliquis 2.5 mg because it was not available. On 6/2/26 at 8:15 AM, an interview was conducted with LPN5. LPN5 stated she was going to order the Eliquis 2.5 mg medication for R78, but when she looked at R78's medication profile she stated, it was ordered yesterday. LPN5 marked the medication unavailable because she was waiting for the medication to be delivered by the pharmacy. On 6/2/26 at 9:00 AM, a clinical record review was conducted. R78's medication administration record was reviewed, and LPN5 marked Eliquis 2.5 mg that was to be given every morning unavailable. LPN5 wrote a progress note in R78's clinical record that read in part, 6/2/2026 08:08:31 Note Text: Eliquis Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for afib,[atrial fibrillation] CVA [cerebral vascular accident] On order On 6/2/26, a facility documentation review was conducted. The facility document titled, Administering Medications, and read in part, .Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). On 6/2/26, an end of day meeting was conducted with the Administrator, the Director of Nursing, and the Regional Director of Clinical Services. They were informed of the above concerns. No additional information was provided prior to exit conference.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for urinary catheter care for one of 28 in the survey sample, resident #97. The Findings Include:The facility did not provide a catheter flush as ordered for Resident #97 (R97). R97 diagnoses include paraplegia, diabetes, and neuromuscular dysfunction of bladder requiring suprapubic catheter. The most recent MDS (minimum data set) was a quarterly assessment 3/25/26 and indicated R97 was cognitively intact. On 6/1/2026 at 1:20 p.m. R97 requested to be interviewed by the surveyor. During the interview R97 reported that on 5/26/26 R97 did not receive a catheter flush from the evening nurse. R97 said because of this R97 called the police, the police came over and after interviewing R97 was told by the police that it was documented that he had refused the catheter flush. R97 verbalized he had not refused care or catheter flush and had asked the assigned certified nursing assistant (CNA) to ask the nurse to do the flush. Review of R97's active orders indicated, flush suprapubic catheter every shift with 30 cc's of Normal Saline. The Treatment Administration Record (TAR) was then reviewed and noted R97 had refused the flush. It was also noted in the TAR for the month of May that R97 had not refused catheter flushes any other time in the month. Review of R97's care plan indicates that R97 is resistive to care (last revised on 4/26/22) and provides an intervention when being resistant to leave and return five to ten minutes later. Review of R97's progress notes dated 5/26/26 and 5/27/26 indicated a linked EMAR (Electronic Medication Administration Record) note referencing R97 refusing care and medication. The EMAR notes are automatically populated into the progress notes when documenting in the medication administration record. There were no other nursing progress notes regarding the incident of refusals. On 6/2/26 at 9:00 a.m. license practical nurse (LPN #6, currently assigned to R97) was interviewed. LPN #6 said that R97 doesn't typically refuse medications or treatments and has probably done it once on her. LPN #6 said that R97 has a good memory and can tell you what is going on with care being performed.On 6/2/26 at 3:45 p.m. LPN #8 (evening supervisor where R97 resides) was interviewed. LPN #8 verbalized unawareness of the incident at the time that it was happening and it was not reported to her by the assigned nurse (identified as LPN #7) and found out about the incident about a day later. LPN #8 verbalized after finding out about the incident, she also found out the assigned certified nursing assistant (CNA #3) had been asked by R97 to get the nurse to do catheter care but CNA #3 was unable to find the nurse and had asked another staff member to send the nurse to R97's room when she comes back from break. LPN #8 verbalized R97 can be resistive to care and refuses treatments and medications at times, when this happens it should be reported so that another staff member could possibly provide the care needed.On 6/2/26 at 5:15 p.m. CNA #3 was interviewed via telephone. CNA #3 said that R97 can be picky and sometimes will only allow certain people to take care of him. CNA #3 said that on 5/26/26 R97 had complained about not getting his medications and catheter flushed and wanted to get it done, so (CNA #3) went to find the nurse (LPN #7) who was also working on the back hall and could not find the nurse, so had asked another staff member to tell LPN #7 that R97 was wanting his medications and catheter flush. CNA #3 was unaware if LPN #7 had or had not gone to R97's room and verbalized R97 did not indicate not wanting LPN #7 to be assigned to him.On 6/2/26 at 5:25 p.m. LPN #7 was interviewed via telephone. LPN #7 verbalized being assigned to R97 on 5/26/26 from 7:00 p.m. to 11:00 p.m. and going to R97's room between 9:00 p.m. and 10:00 p.m. LPN #7 said that when entering R97's room to do catheter care and give a medication, R97 refused care and had gotten angry calling LPN #7 a white [expletive] because R97 thought I didn't know how to do a flush the catheter. LPN #8 said that she did not hear from other staff that R97 was requesting treatments or medications prior to entering R97's room to do the treatment and give medications. When asked about documenting the incident, LPN #7 said refusing care was documented, but did not report this to anyone and wasn't sure what the protocol was. LPN #7 then verbalized that the incident should have been documented. On 6/3/26 9:00 a.m. R97 was interviewed again and said that there was no confrontation between himself and the nurse assigned, had not seen the nurse come to the room, and did not tell anyone he did not want treatments or medications.On 6/3/26 at 9:35 a.m. the assistant director of nursing (ADON) was interviewed. The ADON verbalized had followed up on the incident but had not talked with CNA #3, the nurse supervisor or R97, but had spoken to LPN #7 who verbalized R97 had refused care from LPN #7. The ADON verbalized typically when a resident refuses care from a staff member or does not get along with a staff member then it should be reported so that care can still be provided by another staff member. On 6/3/26 at 9:50 a.m. the director of nursing (DON), administrator, and nurse consultant was presented with the above finding. The administrator verbalized when a resident refuses or does not get along with a staff member, that it is the facilities protocol and expectation to reassign staff to the resident or have another staff member try and perform a treatment or give a medication.No other information was presented prior to exiting the facility on 6/3/26.

Based on resident interview, clinical record review, staff interview ,and facility documentation review the facility staff failed to ensure assistance was provided for showers for one resident, Resident#4 (R4) out of a survey of 28 residents. The findings included:The facility staff failed to assist R4 with his showers weekly. On 6/01/2026 at 2:06 PM, an interview with R4 was conducted. R4 said. I don't get showers like I am told I am suppose to get. R4 then said, I rarely get showers like I should. On 6/2/26, a clinical record review was conducted. The care plan was reviewed and the care plan read in part, .,BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Provide a tub bath/ shower at least 2 days week. Report any refusal of care. Shave as needed. Requires (limited assistance) of (1) staff for all bathing needs. The care plan was revised on 3/6/2026. R4's physician's orders were reviewed. R4 had an order that read, CNA to give shower on Tuesday Thursday and Saturday (Dialysis days) every night shift every Monday Wednesday Friday every night shift every Mon, Wed, Fri . This order was a verbal and active order dated 02/24/2026. R4's shower sheets were reviewed for the month of April, May, and June. Reviewing of the shower sheets showed that R4 had received approximately four showers that was documented on the shower sheets. There were no refusals documented on the shower sheets. R4 was scheduled for a shower on Monday 6/1/26 and there was no documentation of refusal or that he received his shower. R4's activities of daily living documentation was reviewed. R4's scheduled shower days was marked not applicable for most of the documentation. On 6/03/2026 at 8:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that R4's shower order was worded wrong and R4's showers were supposed to be done on the evening before dialysis days which was Monday, Wednesday, and Friday evenings. The DON stated that R4 would refuse his showers sometimes. On 6/3/26, a review of facility documentation was conducted. The facility document titled, Care Plans Person-Centered Comprehensive, read in part, A comprehensive person centered care plan that include measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. The facility document titled, Activities of Daily Living (ADLs), Supporting, read in part, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. On 6/3/26, a meeting was held with the Administrator, Director of Nursing, and the Regional of Clinical Services and they were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for one of 28 residents in the survey sample, Resident #97. The Findings Include:The facility did not give medications as ordered for Resident #97 (R97). R97 diagnoses include paraplegia, diabetes, and neuromuscular dysfunction of bladder requiring suprapubic catheter. The most recent MDS (minimum data set) was a quarterly assessment 3/25/26 and indicated R97 was cognitively intact. On 6/1/2026 at 1:20 p.m. R97 requested to be interviewed by the surveyor. During the interview R97 reported that on 5/26/26 R97 did not receive medications from the evening nurse. R97 said because of this R97 called the police, the police came over and after interviewing R97 was told by the police that it was documented that he had refused medications. R97 verbalized he had not refused any medications and had asked the assigned certified nursing assistant (CNA) to ask the nurse to get the medications. Review of R97's active orders indicated R97 was ordered Atorvastatin Calcium 40 milligrams to be given at 9:00 p.m. each evening for hyperlipidemia, and Docusate Sodium 100 milligrams given at 9:00 p.m. each evening for constipation. The Medication Administration Record (MAR) was then reviewed and noted R97 had refused the medications. It was also noted in the MAR for the month of May that R97 had not refused any of these medications any other time in the month. Review of R97's care plan indicates that R97 is resistive to care (last revised on 4/26/22) and provides an intervention when being resistant to leave and return five to ten minutes later. Review of R97's progress notes dated 5/26/26 and 5/27/26 indicated a linked EMAR (Electronic Medication Administration Record) note referencing R97 refusing care and medication. The EMAR notes are automatically populated into the progress notes when documenting in the medication administration record. There were no other nursing progress notes regarding the incident of refusals. On 6/2/26 at 9:00 a.m. license practical nurse (LPN #6, currently assigned to R97) was interviewed. LPN #6 said that R97 doesn't typically refuse medications or treatments and has probably done it once on her. LPN #6 said that R97 has a good memory and can tell you what is going on with care being performed.On 6/2/26 at 3:45 p.m. LPN #8 (evening supervisor where R97 resides) was interviewed. LPN #8 verbalized unawareness of the incident at the time that it was happening and it was not reported to her by the assigned nurse (identified as LPN #7) and found out about the incident about a day later. LPN #8 verbalized after finding out about the incident, she also found out the assigned certified nursing assistant (CNA #3) had been asked by R97 to get the nurse to do catheter care and give medications but CNA #3 was unable to find the nurse and had asked another staff member to send the nurse to R97's room when she comes back from break. LPN #8 verbalized R97 can be resistive to care and refuses treatments and medications at times, when this happens it should be reported so that another staff member could possibly provide the care needed.On 6/2/26 at 5:15 p.m. CNA #3 was interviewed via telephone. CNA #3 said that R97 can be picky and sometimes will only allow certain people to take care of him. CNA #3 said that on 5/26/26 R97 had complained about not getting his medications and catheter flushed and wanted to get it done, so (CNA #3) went to find the nurse (LPN #7) who was also working on the back hall but could not find the nurse, so had asked another staff member to tell LPN #7 that R97 was wanting his medications and catheter flush. CNA #3 was unaware if LPN #7 had or had not gone to R97's room and verbalized R97 did not indicate not wanting LPN #7 to be assigned to him.On 6/2/26 at 5:25 p.m. LPN #7 was interviewed via telephone. LPN #7 verbalized being assigned to R97 on 5/26/26 from 7:00 p.m. to 11:00 p.m. and going to R97's room between 9:00 p.m. and 10:00 p.m. LPN #7 said that when entering R97's room to do catheter care and give a medication, R97 refused care and had gotten angry calling LPN #7 a white [expletive] because R97 thought I didn't know how to do a flush the catheter. LPN #8 said that she did not hear from other staff that R97 was requesting treatments or medications prior to entering R97's room to do the treatment and give medications. When asked about documenting the incident, LPN #7 said refusing care was documented, but did not report this to anyone and wasn't sure what the protocol was. LPN #7 then verbalized that the incident should have been documented. On 6/3/26 9:00 a.m. R97 was interviewed again and said that there was no confrontation between himself and the nurse assigned, had not seen the nurse come to the room, and did not tell anyone he did not want treatments or medications.On 6/3/26 at 9:35 a.m. the assistant director of nursing (ADON) was interviewed. The ADON verbalized had followed up on the incident but had not talked with CNA #3, the nurse supervisor or R97, but had spoken to LPN #7 who verbalized R97 had refused care from LPN #7. The ADON verbalized typically when a resident refuses care from a staff member or does not get along with a staff member then it should be reported so that care can still be provided by another staff member. On 6/3/26 at 9:50 a.m. the director of nursing (DON), administrator, and nurse consultant was presented with the above finding. The administrator verbalized when a resident refuses or does not get along with a staff member, that it is the facilities protocol and expectation to reassign staff to the resident or have another staff member try and perform a treatment or give a medication.No other information was presented prior to exiting the facility on 6/3/26.

Based on observation, facility document review, clinical record review, and staff interviews, the facility failed to revise the comprehensive care plan to ensure accurate person-centered interventions were present for 3 of 28 residents in the sample, Residents #8, #9 and #43.The findings include: For Resident #8 (R8), the facility failed to update the Comprehensive Care Plan to include updated and changed interventions that had been implemented relating to nutrition. Pertinent diagnoses for R8 include dementia, schizoaffective disorder, and dysphagia. On the most recent Minimum Data Set (MDS) assessment, a quarterly assessment with an assessment reference date (ARD) of 5/5/2026, R8 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On this same MDS assessment, R8 was noted to be dependent on staff for eating. R8 was also documented to have unintended weight loss and a mechanically altered diet. A care plan for nutrition was developed for R8 on 9/16/2020, with most recent revision on 5/5/2026. The focus statement for this care plan states the R8 has a nutrition problem related to severe dementia. Not eating at this time, but small bites. The interventions for this care plan are: Assist resident during meal as needed (initiated on 6/28/22) Lab work as ordered, report results to physician and follow up as indicated (initiated on 9/16/202 and last revised 10/11/2021) Monitor/document/report and signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals (initiated on 9/16/2020 and last revised on 6/28/2022) Provide diet as ordered (initiated on 9/16/2020 and last revised on 10/11/2021) Registered Dietician to evaluate and make diet change recommendations as needed (initiated on 9/16/2020 and last revised on 10/11/2021) Serve diet as ordered. Document percentage of each meal consumed (initiated on 9/16/2020 and last revised on 10/11/2021) Serve nutritional supplement as ordered (initiated on 9/27/2022) Weight monthly and as needed (initiated on 9/16/2020 and last revised on 10/11/2021) On 3/20/2026, a progress note in the clinical record states that the provider held discussions with R8's family regarding the recommendation to place a Percutaneous Endoscopic Gastrostomy (PEG) tube for feedings on 3/19/2026. Family declined the placement of PEG tube. A physician's order for Remeron (an anti-depressant medication that has an off-label use as an appetite stimulant) was placed on 4/22/2026. The order states to give one tablet by mouth every night at bedtime for decreased appetite. An interview was conducted with MDS coordinator on 6/3/2026 at 8:24 AM. MDS coordinator stated that care plans are reviewed quarterly, annually, and with any significant change(s). When asked how significant changes are communicated, MDS coordinator stated changes are identified in morning meetings. Per MDS coordinator, the last update to this care plan was made by dietary on 5/6/2026 and only included the revision of the focus statement. MDS coordinator noted that the addition of the appetite stimulant was not on the care plan but stated that there was a care plan in place for anti-depressant usage. When asked if it would be appropriate to include the anti-depressant medication on the nutrition care plan as it was being used for appetite stimulation and not as an anti-depressant, the MDS coordinator stated that this intervention should have been added to the care plan. In addition, the MDS coordinator stated that an intervention should have been added to the care plan to show that family declined placement of a PEG tube. A facility policy stated Care Plans: Comprehensive Person-Centered that was most recently revised in December of 2016 demonstrated that care plans are revised as information about the resident and their conditions changed, and that the facility must review and update the care plan when there has been a significant change in the resident's condition. The above information was presented to facility leadership at 2:00 PM on 6/3/2026. No further information was provided prior to exit. 2. The facility failed to update a care plan for Resident #9 (R9) after a fall. On 6/1/26, a clinical record review was conducted. During the review R9's care plan was reviewed. The care plan had no revision completed after R3 had a fall on 5/27/26. There was no documentation on the care plan about the fall and no new intervention implemented. During the review, R9's progress notes were reviewed. R9's progress note dated 5/27/26 about the fall read, pt yelled out for help. Upon entering room, pt was observed lying on right side on floor. Pt immediately assessed and noted with skin tear to right forearm, small laceration not requiring steri-strips, and mild swelling noted to affected area. Hospice nurse [name redacted] was notified and gave order to obtain one set of vital signs for comparison upon hospice arrival. Hospice also informed facility that a nurse would be coming out to assess pt. On 6/03/2026 at 8:51 am, an interview was conducted with the Minimum Data Set Coordinator (MDS), a licensed practical nurse, LPN3. She stated that she updated all the residents care plans. LPN3 stated that care plans were updated every three months, annually and when needed. LPN3 gave examples for updates would be wounds, falls, change in condition, and weight loss. She stated that she obtained the information about a residents fall from the progress notes, risk management, and morning meeting. LPN3 stated she would update the care plan when the fall happened and interventions was included with that update. 3. The facility failed to update a care plan for Resident #43 (R43) after a fall. On 6/2/26, a clinical record review was conducted. During the review R43's care plan was reviewed. The care plan had no revision completed after R43 had a fall on 4/14/26. There was no documentation on the care plan about the fall and no new intervention implemented. During the review, R43's progress notes were reviewed. R43's progress note dated 4/14/26 about the fall read, During the review, R43's progress notes were reviewed. R43's progress note dated 4/14/26 about the fall read, Resident was pushing chair in the hallway, and suddenly fell on the floor leaning on her right side. Floor nurse was also in the hallway and witnessed the incident. Resident stated I'm fine, I'm in no pain. Assisted back to chair. No complaints of pain or injuries noted. Wrote concern on Provider's book. On 6/03/2026 at 8:51 am, an interview was conducted with the Minimum Data Set Coordinator (MDS), a licensed practical nurse, LPN3. She stated that she updated all the residents care plans. LPN3 stated that care plans were updated every three months, annually and when needed. LPN3 gave examples for updates would be wounds, falls, change in condition, and weight loss. She stated that she obtained the information about a residents fall from the progress notes, risk management, and morning meeting. LPN3 stated she would update the care plan when the fall happened and interventions was included with that update. On 6/3/26, a facility documentation review was conducted. The facility document titled, Care Plans, Comprehensive Person-Centered, read in part, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 14. The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. On 6/3/26, a meeting was held with the Administrator, Director of Nursing, and Regional of Clinical Services and they were informed of the above concerns. No additional information was provided prior to the end of the survey.

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for one resident, Resident#4 (R4) out of a survey sample of 28 residents. The findings included:R4 had no comprehensive person centered care plan for nutrition. On 6/03/2026 at 8:51 AM, a licensed practical nurse, LPN3 was interviewed. LPN3 was the Minimum Data Set (MDS) Coordinator. LPN3 stated that she updated all the residents care plans. LPN3 stated that care plans was reviewed every three months and annually, but was changed when needed. LPN3 stated, all residents should have a focus for nutrition on the care plan and I put a risk for nutrition on everyone when I do their admission care plan. LPN3 reviewed R4's care plan and she said, I don't know how I missed his but I do have weight loss on there I will fix that now and put a focus for his nutrition. On 6/3/26, a clinical record review was conducted. R4's care plan was reviewed. The care plan had no focus area for R4's nutrition. There was no nutrition care plan developed for R4. His diet order, likes/dislikes, and any dietary concerns were not addressed on his care plan. R4's physician orders were reviewed. R4 had an order that read in part, . Renal diet Regular texture, Regular consistency, that was ordered on 3/5/26. On 6/3/26, a review of facility documentation was conducted. The facility policy titled, Care Plan, Comprehensive Person-Centered, read in part, .The comprehensive, person-centered care plan will .include measurable objectives and timeframes .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .incorporate identified problem areas .reflect treatment goals, timetables and objectives in measurable outcomes .identify the professional services that are responsible for each element of care. On 6/3/26, a meeting was held with the Administrator, the Director of Nursing, and the Regional Director of Clinical Services. They were informed of the above concerns prior to the exit conference. No additional information was provided prior to the end of the survey.

Based on staff interview, clinical record review, and facility record review, the facility failed to have evidence that alleged violations were investigated thoroughly for 1 of 28 residents in the sample, Resident #117 (R117).The findings include:For R117 the facility failed to thoroughly investigate all allegations regarding alleged abuse.Diagnoses for R117 include schizophrenia and osteoarthritis. On the most recent applicable Minimum Data Set (MDS) assessment, a quarterly assessment with an Assessment Reference Date (ARD) of 12/5/2024, R117 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment.A progress note in the clinical record dated 4/29/2024 stated that R117 made facility staff aware of allegations of abuse. R117 stated that a Certified Nursing Assistant (CNA) #4 hit him in the head and threw him into a wheelchair. R117 stated that a second CNA, CNA #5, was present during this alleged incident and did not intervene. Review of the incident synopsis revealed that both CNA #4 and CNA #5 were both listed as alleged perpetrators in the incident. Review of the incident summary demonstrated that CNA #4 was suspended from work during the investigation. The incident summary failed to include a statement from the CNA #5. Review of the personnel file for CNA #5 revealed that CNA #5 was not suspended from work during the investigation. The incident summary stated that allegations were unsubstantiated as The CNA would not have been able to transfer the resident from the bed to the chair without assistance. This result failed to include the presence of CNA #5 during the alleged incident.During an interview with the Administrator that took place on 6/3/2026 at 9:25 AM, the Administrator stated that CNA #4 was terminated following their return to work after the suspension for an unrelated issue. The Administrator reviewed the personnel file of CNA #5 and was unable to demonstrate evidence that showed that CNA #5 was suspended during the investigation. In addition, the Administrator was unable to provide any evidence showing that CNA #5 had been interviewed regarding the alleged incident.Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed that upon notification of alleged abuse, the Director of Nursing Services, Administrator, or designee will Obtain statements from direct care staff and Suspend the accused Team Member pending completion of the investigation.The above information was presented to facility leadership on 6/3/2026 at 2:00 PM. No additional information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a written notice prior to a room change for one of twenty-eight residents in the survey sample (Resident #31). The findings include:No written notice was provided to Resident #31 or the resident's responsible party prior to a room change. The clinical record documented no reason for the room move. Resident #31 (R31) was admitted with diagnoses that included aphasia, peripheral vascular disease, seizure, cerebral infarction, dementia, mood disorder, hypertension, dysphagia, major depressive disorder and intellectual disability. The minimum data set (MDS) dated [DATE] listed staff were unable to assess R31's cognitive status. R31's clinical record documented a nursing note dated 1/7/26 at 1:19 p.m. stating the resident moved rooms. This note documented a voice message was left for the responsible party and that an alternate contact person was notified of the change. A nursing note dated 1/7/26 at 1:59 p.m. documented R31's responsible party was called and informed of the resident's room change. R31's clinical record documented no written notice of the room change and no explanation of why the resident was moved to another room. There was no documentation the resident's responsible party was notified prior to the room change and the verbal notification listed occurred on the same day the resident moved. On 6/2/26 at 2:07 p.m., the social services director was interviewed about notification regarding R31's room change on 1/7/26. The social services director stated she thought R31's room change was initiated by the facility to make beds available for male residents. The social services director stated that verbal notifications were usually made regarding room changes and that written notice about the room change was not provided. On 6/2/26 at 3:48 p.m., the licensed practical nurse unit manager (LPN #2) caring for R31 was interviewed. LPN #2 reviewed R31's clinical record and stated she did not find documentation of why R31 moved rooms. LPN #2 stated that the resident and/or responsible party were typically called and agreement with the room change was obtained verbally. LPN #2 stated she was not aware of a written notice about the change. LPN #2 stated she thought some room changes were made during that time to make more beds available. The facility's policy titled Room Change/Roommate Assignment (revised May 2017) documented, .Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives (sponsors)) will be given advance notice of such change .Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate . The facility's resident admission agreement documented on page 9 regarding room changes, .The Resident and the Representative will be notified in writing prior to a room transfer or roommate change and will have an opportunity to provide input on roommate selection and location . This finding was reviewed with the administrator and director of nursing during a meeting on 6/2/26 at 4:20 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interviews, and facility documentation review the facility staff failed to ensure that the accommodation of residents needs were met for two residents, Resident #3 (R3) and Resident #43 out of a survey sample of 28 residents. The findings included:The facility staff failed to ensure resident's call bells were within reach to be able to call for assistance if needed. On 6/1/26 at 1:00 pm, a tour of the unit one nursing unit was conducted. During the tour several resident's were observed to have their call bell out of reach and not able to use the call bell. R3's call bell was observed to be on the floor under his bed and not in reach for the resident to use. R43's call bell was observed to be lying behind the head board of the bed on the floor. On 6/2/26 at 10:00 am, a tour of the unit was conducted. R3's call bell remained lying on the floor under his bed. R43's call bell remained behind the head board on the floor not within reach if the resident needed assistance. On 6/02/2026 at 4:43 pm, an interview was conducted with a certified nursing assistant, CNA2. CNA2 observed the call bells on the floor in R3's and R 43's room. During the interview, she stated that call bells should be within the reach of the resident and should not be placed on the floor or under the beds. She stated call bells needed to be in reach so if residents need to call for assistance. CNA2 also stated that these rooms were not her assigned rooms. On 6/2/26, an end of day meeting was conducted with the Administrator, Director of Nursing, and the Regional Director of Clinical Services and they were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on observation, staff interview, and facility documentation review the facility staff failed to ensure a topical medication was properly labeled for one resident, Resident #91 (R91) in the medication cart, one out of five medication carts. The findings included:The facility staff failed to label R91's anti-itch cream that was stored in the medication cart. On 6/02/2026 at 8:33 AM, a medication administration observation was being conducted. During the observation a licensed practical nurse, LPN5 administered a topical anti itch cream that was on R91's medication administration record. LPN5 put a small amount of the cream into a medication cup and applied it to R91's legs. It was observed that the anti-inch cream had no label with a resident name, directions, or any identifying label information. On 6/2/26 at 8:35 AM, an interview was conducted with LPN5. She stated, I don't know how much to give. I just put a good amount in the cup to apply to R91's [name redacted] areas. I don't know who it is for but moving forward I will make sure the residents name is on there and will talk with the doctor about the amount to apply. LPN5 removed the anti-itch cream from the medication cart and stated, I will order another one to make sure that it's labeled. On 6/2/26, a facility documentation review was conducted. The facility policy titled, Storage of Medications, read in part, .3. The nursing staff is responsible for maintaining a clean, safe, and sanitary medication storage and preparation areas. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 6/2/26, an end of day meeting was conducted with the Administrator, the Director of Nursing, and the Regional Director of Clinical Services. They were informed of the above concerns. No additional information was provided prior to exit conference.

Based on resident interview, and staff interview, the facility staff failed to provide dietary needs for one of 28 residents, Resident #6 (R6). The Findings Include:The facility did not provide R6 with breakfast while being sent out to dialysis. R6 diagnoses included diabetes, peripheral vascular disease, and kidney failure requiring dialysis. The most recent MDS (minimum data set) was a quarterly dated 4/10/26 and indicated R6 was moderately cognitively impaired. On 6/1/26 at 4:49 p.m. during an interview, R6 verbalized that he was not provided breakfast at times when going to dialysis. R6 verbalized sometimes the staff will send R6 with an egg sandwich, but a lot of times no food is given. R6 mentioned his dialysis days were on Tuesday, Thursday, and Saturday.On 6/2/26 at 9:30 a.m. the dialysis center was contacted via telephone. An interview was conducted with administrative assistant (other staff, OS #2). OS # 2 confirmed R6 was currently at dialysis and had not been sent with breakfast. OS#2 verbalized that a lot of times R6 is not sent with breakfast and sometimes the staff (at dialysis) will give R6 snacks.On 6/2/26 at 9:50 a.m. license practical nurse (LPN #6, assigned to R6) was interviewed. LPN #6 said that R6 is already transported to dialysis before the day shift starts and was unaware if R6 gets breakfast or not because of already being at dialysis before the shift starts. LPN #6 said that typically the kitchen will bring a bagged breakfast down and put it in the refrigerator or the staff will go to kitchen and get it and will send food with the residents. At this time the unit refrigerator was checked for a breakfast meal with LPN #6 and did not evidence a bagged breakfast for R6.On 6/2/26 at 10:40 a.m. the dietary manager (DM) was interviewed regarding the above finding. The DM verbalized that the dietary staff takes breakfast over to R6 (as the dialysis center is across the road from the facility). The DM was then informed of the interview with the dialysis center (that no breakfast was sent). The DM verbalized being unaware that R6 was not getting breakfast while at dialysis and verbalized that one of the kitchen staff called off this morning and would investigate what happened. On 6/2/26 at 10:50 a.m. the DM verbalized a bagged breakfast should have been put into the unit's refrigerator by the second shift the day before dialysis but was not and sometimes staff will provide a hot sandwich and take it to R6 but not always.On 6/2/26 at 4:22 p.m. the above finding was presented to the administrator, director of nursing, and regional nurse. No other information was presented prior to exiting the facility on 6/3/26.

Based on resident interviews, staff interviews, observations and facility documentation reviews, facility staff failed to provide routinely available snacks to residents on one of three units. The findings include: The staff failed to provide snacks for residents at bedtime.On 6/2/26 at 2:00 pm, a resident council meeting was conducted with approximately 15 people in attendance. During the meeting, several residents expressed that they do not receive snacks throughout the day and especially at night. Several residents stated that they go to bed hungry at night.On 6/2/26 at approximately 3:13 pm, an interview was conducted with the Dietary Manager. The Dietary Manager stated, I take snacks to the nourishment rooms at 10 am, 3 pm and 8pm. The Dietary Manager stated that she takes graham crackers, fig newtons, saltine crackers and nabs. The Dietary Manager stated that snacks come out with the hydration cart daily. Snacks are taken to the nourishment room on the unit and residents get snacks every day.On 6/2/26 at 3:25 pm, an interview was conducted with certified nursing assistant, (CNA1). CNA1 stated that she did not know anything about hydration carts and snacks being passed on the hydration cart. CNA1 stated me personally, I ask if they want a snack and if the resident does, I will go to the nourishment room and get them one.On 6/2/26 at 3:30 pm, an interview was conducted with CNA2. CNA2 stated that she was not aware of snacks coming to unit on a hydration cart. She stated that snacks are kept in the nourishment room.On 6/2/26 at 3:35 pm, An observation of the nourishment room was conducted. During the observation, there were no snacks noted in the refrigerator, in the cabinets, and only a zip lock bag with graham crackers on the top of refrigerator.On 6/3/26 approximately 9:30 am, an interview was conducted with the Director of Nursing (DON). DON stated, to be honest, snacks are not available a lot of the times, but hopefully after this, that will improve.On 6/3/26 at 9:45 am, a review of facility documentation was conducted. The facility policy titled, Snacks (Between Meal and Bedtime), Serving read in part .purpose of the procedure is to provide the resident with adequate nutrition. The facility policy titled Resident Hydration and Prevention of Dehydration, read in part .Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.On 6/3/26, a meeting prior to exit conference was conducted with Administrator, Director of Nursing, and Regional Director of Clinical Services. They were informed of the above concerns.No additional information was provided prior to exit conference.

Based on observation, staff interview and clinical record review, the facility staff failed to provide a therapeutic weighted spoon for one of twenty-eight residents in the survey sample (Resident #20). The findings include:Resident #20 was not provided with a weighted spoon for use during meals as ordered by the physician. Resident #20 (R20) was admitted to the facility with diagnoses that included traumatic brain injury, cardiomyopathy, hypertension, hyperlipidemia, metabolic encephalopathy and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R20 with severely impaired cognitive skills. On 6/2/26 at 8:30 a.m., R20 was observed in bed with the breakfast tray on the overbed table. Standard utensils were observed on the tray with no weighted spoon observed. R20 had not eaten any of the eggs or grits. R20 stated he did not want any more food. R20's meal ticket listed food items served but did not include instructions for a weighted spoon. R20's clinical record documented a physician's order dated 3/25/26 for a weighted spoon with each meal. R20's plan of care (revised 3/25/26) documented the resident was at risk of weight loss due to diagnoses. The registered dietitian (RD) documented that the resident's weights were stable but there had been a history of significant weight loss in the last six months. On 6/2/26 at 1:49 p.m., the dietary manager was interviewed about R20 not having a weighted spoon with breakfast. The dietary manager stated the kitchen sent the weight spoon on each meal tray. The dietary manager stated, If we don't get it back [spoon], we can't send it back. The dietary manager stated there was only one weighted spoon available in the facility and that the therapy department was responsible for re-ordering weighted spoons. The dietary manager repeated that if the weighted spoon was not returned to the kitchen that kitchen staff would be unable to put the spoon on the next tray and that there nothing she could do about the spoon if it was not returned. 6/2/26 at 3:29 p.m., the rehab director (other staff #1) was interviewed about R20's need for a weighted spoon. The rehab director stated R20 had hand tremors and that the weighted spoon helped the resident feed himself without spillage. The rehab director stated there were always extra therapeutic spoons in the therapy department. The rehab director displayed a supply of weighted spoons. The rehab director stated that the dietary manager had requested a replacement spoon for R20, but that was approximately two months ago. The rehab manager stated she had not heard anything recently about a misplaced spoon for R20 and assumed that he had the spoon as required. The rehab manager stated R20 currently was the only resident using a weighted spoon and again stated that R20 was assessed by speech therapy to need the spoon so he could feed himself without spillage. On 6/2/26 at 3:37 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about R20's weighted spoon. LPN #2 stated R20 had hand tremors, and the weighted spoon helped the resident manage food items when eating. LPN #2 stated that the weighted spoon was routinely returned to the kitchen. LPN #2 stated she was not aware the spoon was not provided as ordered. On 6/3/26 at 9:42 a.m., the RD caring for R20 was interviewed. The RD stated R20 was able to feed himself and that the weighted spoon was needed to minimize food spillage due to the resident's hand tremors. The RD stated she was not aware that the weighted spoon was not being provided. This finding was reviewed with the administrator and director of nursing during a meeting on 6/2/26 at 4:20 p.m. with no further information provided prior to the end of the survey.

Based on resident interview, staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 28 residents in a survey sample, Resident #97. The findings include:The Treatment Administration Record (TAR) and Medication Administration Record (MAR) inaccurately documented all treatments and medications were refused by Resident #97 (R97). R97 diagnoses include paraplegia, diabetes, and neuromuscular dysfunction of bladder requiring suprapubic catheter. The most recent MDS (minimum data set) was a quarterly assessment 3/25/26 and indicated R97 was cognitively intact. On 6/1/2026 at 1:20 p.m. R97 requested to be interviewed by the surveyor. During the interview R97 reported that on 5/26/26 R97 did not receive medications or catheter flush from the evening nurse. R97 said because of this R97 called the police, the police came over and after interviewing R97 was told by the police that it was documented that he had refused medications. R97 verbalized he had not refused any medications and had asked the assigned certified nursing assistant (CNA) to ask the nurse to get the medications. Review of R97's active orders indicated R97 was ordered Atorvastatin Calcium 40 milligrams to be given at 9:00 p.m. each evening for hyperlipidemia, Docusate Sodium 100 milligrams given at 9:00 p.m. each evening for constipation, and to flush suprapubic catheter every shift with 30 cc's of Normal Saline. The Medication Administration Record (MAR) and the Treatment Administration Record were reviewed and documented R97 had refused the medications and catheter flush. It was also noted in the MAR and TAR for the month of May that R97 had not refused any of these medications or treatments any other time in the month. Further review of R97's TAR also documented on 5/26/26 refusals of catheter privacy bag in place, air mattress function, placement of catheter strap, monitor liquid intake, and to ensure enhanced barrier precautions. All are observational check off's that don't necessarily require a task to be performed. Review of R97's care plan indicates that R97 is resistive to care (last revised on 4/26/22) and provides an intervention when being resistant to leave and return five to ten minutes later. Review of R97's progress notes dated 5/26/26 and 5/27/26 indicated a linked EMAR (Electronic Medication Administration Record) note referencing R97 refusing care and medication. The EMAR notes are automatically populated into the progress notes when documenting in the MAR or TAR. There were no other nursing progress notes regarding the incident of refusals. On 6/2/26 at 3:45 p.m. LPN #8 (evening supervisor where R97 resides) was interviewed. LPN #8 verbalized unawareness of the incident at the time that it was happening and it was not reported to her by the assigned nurse (identified as LPN #7) and found out about the incident about a day later. LPN #8 verbalized after finding out about the incident, she also found out the assigned certified nursing assistant (CNA #3) had been asked by R97 to get the nurse to do catheter care and give medications but CNA #3 was unable to find the nurse and had asked another staff member to send the nurse to R97's room when she comes back from break. LPN #8 verbalized R97 can be resistive to care and refuses treatments and medications at times, when this happens it should be reported so that another staff member could possibly provide the care needed.On 6/2/26 at 5:15 p.m. CNA #3 was interviewed via telephone. CNA #3 said that R97 can be picky and sometimes will only allow certain people to take care of him. CNA #3 said that on 5/26/26 R97 had complained about not getting his medications and catheter flushed and wanted to get it done, so (CNA #3) went to find the nurse (LPN #7) who was also working on the back hall but could not find LPN #7, so had asked another staff member to tell LPN #7 that R97 was wanting his medications and catheter flush. CNA #3 was unaware if LPN #7 had or had not gone to R97's room and verbalized R97 did not indicate not wanting LPN #7 to be assigned to him.On 6/2/26 at 5:25 p.m. LPN #7 was interviewed via telephone. LPN #7 verbalized being assigned to R97 on 5/26/26 from 7:00 p.m. to 11:00 p.m. and going to R97's room between 9:00 p.m. and 10:00 p.m. LPN #7 said that when entering R97's room to do catheter care and give a medication, R97 refused care and had gotten angry calling LPN #7 a white [expletive] because R97 thought I didn't know how to do a flush the catheter. LPN #8 said that she did not hear from other staff that R97 was requesting treatments or medications prior to entering R97's room to do the treatment and give medications. When asked about documenting the incident, LPN #7 said refusing care was documented, but did not report this to anyone and wasn't sure what the protocol was. LPN #7 then verbalized that the incident should have been documented. LPN #7 verbalized regarding documenting refusals of air mattress functioning, catheter privacy bag in place and other checks offs mentioned above, that it was done in error. On 6/3/26 9:00 a.m. R97 was interviewed again and said that there was no confrontation between himself and the nurse assigned, had not seen the nurse come to the room, and did not tell anyone he did not want treatments or medications.On 6/3/26 at 9:35 a.m. the assistant director of nursing (ADON) was interviewed. The ADON verbalized typically when a resident refuses care from a staff member or does not get along with a staff member then it should be reported so that care can still be provided by another staff member. On 6/3/26 at 9:50 a.m. the director of nursing (DON), administrator, and nurse consultant was presented with the above finding. The administrator verbalized when a resident refuses or does not get along with a staff member, that it is the facilities protocol and expectation to reassign staff to the resident or have another staff member try and perform a treatment or give a medication so it can be documented as being performed. The administrator reviewed R97's TAR and agreed that the monitoring tasks should not have been documented as being refused. No other information was presented prior to exiting the facility on 6/3/26.

Based on interviews and clinical record review, the facility staff failed to notify the Nurse Practitioner and resident's Responsible Party immediately of a significant change condition for 1 resident (Resident #1) in a survey sample of 6 residents. The findings included: The facility staff failed to notify the Nurse Practitioner and the Responsible Party of decrease in urinary output and fluid intake for Resident #1.Resident #1 was admitted to the facility on [DATE] after a hospitalization from 7/16/25 to 8/6/25 for nausea and vomiting coffee-ground emesis. He presented with a persistent ileus (a temporary condition where one's intestine cannot push food and waste out of the body) with abdominal pain and distention. He was treated conservatively after small bowel obstruction was ruled out. The hospital discharge summary revealed his overall prognosis was guarded. Resident #1's diagnoses included but not limited to Ogilvie's Syndrome (a rare condition that causes a severe dilation of the large intestine without any physical obstruction. This leads to symptoms similar to bowel obstruction, despite the absence of an actual blockage), history of complete intestinal obstruction, unspecified as to cause, unspecified dementia with psychotic disturbance, gastro-esophageal reflux disease, history of kidney stones, abnormal urinalysis, history of bladder cancer with placement of an ileostomy, femur fracture surgically repaired, acute and chronic kidney disease and hypertension. Resident #1's admission assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/2025 coded the resident as having a Brief Interview of Mental Status (BIMS) score of 02 out of a possible 15 indicating resident had severe cognitive impairment and was not able make decisions independently. Section GG of the MDS coded the resident as requiring maximum assistance or being totally dependent for turning/repositioning, lying to sitting, sitting to stand, chair/bed to chair transfer, toileting, bathing and dressing. He required assistance with feeding. Resident #1 had a urostomy (surgically created opening in the abdomen to divert urine from the kidneys to an external bag due to his diagnosis of bladder cancer). Resident #1 was incontinent of bowel.On 10/21/25, a review of the clinical record revealed:On 8/22/25, Resident #1 was transferred to hospital for nausea, vomiting, abdominal pain due to concerns that he may be obstructed again. He was treated with intravenous fluids (fluids administered via his veins), pain medications and antibiotics to finish on 8/30/25. A CT scan (computerized tomography which is a medical imaging that uses x-rays to create detailed images of the body's internal organs) was completed at the hospital which revealed mild thickening indicating possible colitis, no obstruction. On 9/13/25, per the nurse's notes an order was given from the Nurse Practitioner {name redacted} to obtain a urine sample due to cloudy urine with sedimentation. The nurse's note revealed the nurse attempted to contact Resident #1's Responsible Party, his daughter {name redacted.Results of the 9/13/25 Urinalysis Culture and sensitivity revealed: greater than 100, 000 CFU/ML mixed flora - No predominant microorganisms present On 9/15/25, the progress notes of the Nurse Practitioner {name redacted} revealed urine sample results no microorganisms, urostomy draining yellow urine with sediment noted, bowel sounds in all four (4) quadrants, well nourished, in no acute distress, encourage oral (by mouth) fluids.There was no evidence in the clinical record that the Responsible Party, his daughter, was ever reached via phone regarding the urinalysis and culture and sensitivity results.On 10/7/25 at 12:23 PM, the Nurse Practitioner {name redacted} documented in her progress notes acute visit for increased confusion and amber, malodorous urine, Patient seen lying in bed in no acute distress, no complaints of pain, very confused at this time. Plan: Encourage hydration, urinalysis with culture and sensitivity ordered and pending.10/7/25 Urinalysis culture and sensitivity results: greater than 100, 000 CFU/ML mixed flora - No predominant microorganisms are present.On 10/8/25, a progress note written by the Social Services Director {name redacted) revealed that Resident #1 had been accepted to transfer to another facility closer to family. Transport scheduled for 10/09/2025 @ 11AM. Resident's daughter, {name redacted} was notified.There was no evidence in the clinical record that Resident #1's Responsible Party was notified of change in resident's condition which prompted a visit from the Nurse Practitioner on 10/7/25 where resident presented with confusion, amber, malodorous urine via ileostomy, urine sample ordered for urinalysis and culture and sensitivity and order to encourage hydration.On 10/9/25, LPN-E caring for Resident #1 notified the Nurse Practitioner and the resident's Responsible Party, his daughter of an emergent change in condition requiring transfer to the emergency room. At 9:36 AM, the Resident's responsible party, his daughter, was notified of residents change in condition and informed that this nurse wasn't comfortable transferring resident to another facility in his present condition. She was informed of new order for intravenous (IV-fluids via the veins) hydration. She was asked if resident could be sent to the local emergency room and she stated she did not want resident to be sent to the hospital, and she wanted him to be sent to receiving facility. She was pleasant and cooperative and thanked this nurse for giving her information and status. Another call was later made to Resident #1's Responsible Party with the order to transfer to the local emergency room due to rapid decline. According to the clinical record, the facility staff were recording Resident #1's meal intake (fluid intake was not measured) Documentation revealed appetite was varied. The facility's electronic medical record software provides alerts to trigger in the nurses' progress notes when residents consume 50% or less x 2 meals or more on in a 24-hour period. For Resident #1, the following alerts triggered for 50% or less x 2 meals in a 24-hour period indicating poor meal intake. (no evidence in the clinical record that the medical provider was notified of poor meal intake including poor fluid - alerts' triggered on 9/14/25, 9/16/25, 9/25/25, 9/29/25, 10/6/25 and 10/8/25.Per the clinical record, Resident #1 was assessed by the facility's Registered Dietician {name redacted} on 9/3/25 noting 25-50% meals; varying appetite, nutritional requirements include 1500-1600 fluids per day; and 9/10/25, 9/17/25 and 10/8/25 noting resident consuming 50-75% meal intake. On 10/22/25, an interview was conducted with the facility's Registered Dietician, Employee-F, who stated she recommended health shakes to add dietary calories and protein for residents who may have difficulty consuming enough nutrients through solid food intake. When asked how she knew if Resident #1 consumed his health shakes, she stated that the Dietary Manager would let her know if they (the shake) came back on the tray untouched. She stated she had recommended one (1) every day on lunch tray for Resident #1. When asked if the carton did not return on the tray did that indicate if Resident #1 consumed the shake or that it was left at the bedside? She responded Well, then I really don't know if he actually consumed the shake or not. She stated that Resident #1 usually consumed about 50-75% meal intake. When shown documentation of meal intake by the certified nursing assistants from 9/21/25 to 10/9/25 she responded, Oh, that is definitely not 50-75% I must have overlooked that When asked if the facility held At Risk meetings to discuss vulnerable residents she stated, Yes. When asked if they had discussed Resident #1's poor oral (by mouth) intake she stated, I do not recall if we talked about him. When asked if she had knowledge of the amount of fluid intake Resident #1 consumed daily, she stated they did not measure his fluid intake daily.There was no evidence in the clinical record that the Registered Dietician notified the Nurse Practitioner or the Responsible Party of Resident #1's poor meal intake. According to the clinical record review, nurses were monitoring urostomy sites and completing urostomy care every shift. The urostomy was noted to be positional and leaking at times and was documented on 9/1/25, 9/2/25 (Resident #1 pulling at bag), 9/5/25, 9/6/25 wafer and bag changed, 9/17/25 wafer and bag changed, placed to the right side to allow better flow, 9/30/25 new urinary bag.Review of the clinical record (Treatment Administration Record - TAR) for October 2025, the urostomy output showed a decline in output (no evidence that the medical provider was notified of low output)10/3/25 Day shift-100cc, Evening shift-100cc, Night shift-50cc; 10/4/25 Day shift-100cc, Evening shift-100cc, Night shift; 10/5/25 Day shift-25cc, Evening shift-100cc, Night shift-10/6/25 Day shift-100cc, Evening shift-100cc, Night shift-100cc; 10/7/25 Day shift-100cc, Evening shift-150cc, Night shift-100cc; 10/8/25 Day shift-150cc, Evening shift-100cc, Night Shift-100cc.On 10/22/25 at 11:40 AM, an interview was conducted with LPN -B who reported she had worked with Resident #1 a few times and that she administered his medications by crushing them and putting them in applesauce and he would consume about 2 or 3 ounces of water and most of the time would drink his Health Shake about 4 ounces but he was not a big eater or drinker. When asked if she reported his poor meal and fluid intake to the Nurse Practitioner or Physician she stated No, everyone knew he didn't eat or drink much, that was his baseline.On 10/22/25 at 11:50 AM an interview was held with Nurse Practitioner Employee-D who stated that Resident #1 had flagged a bit for poor meal intake. We tried to ensure someone helped feed him, he was able to pick up his cups most of the time but did need much encouragement to eat and drink. I saw him the day before we sent him out to the emergency room in the hallway, he was holding his cup and drinking water I think that was what the fluids was in the cup. When asked if she was aware of Resident #1's intake and output she replied, I was not notified of Mr. {Name redacted} (Resident #1's) low urostomy output, I am aware that it leaked and noted it was disconnected a couple times, he would pick at it or turn over and it would become disconnected. The Nurse Practitioner was shown the urostomy outputs recorded on Treatment Administration Record for October 2025 and the nurses' notes indicating alerts for 50% or less for 2 or more meals she stated if I had known fluid intake was poor, I would have ordered fluids sooner. They can do hypodermoclysis (administering fluids directly into the subcutaneous tissue (under the skin) here as well as intravenous fluids for hydration. We had checked his urine around September 15th and again around October 7th, but nothing was growing per the lab results, like I said, I saw him the day before we sent him out and he was up in his wheelchair in the hallway his usual self.On 10/22/25 at 2:30 PM, an interview was conducted with LPN- E. She stated she had been working at the facility for about thirteen (13) months. She stated she had taken care of Resident #1 several times by administering his medications, completing skin assessments, caring for his urostomy and ensuring the CNA's bathed him, fed him and got him up in the chair. When asked how he took his medications, LPN- E stated, he only took a few pills, and we crushed them and put them in applesauce because that he how he liked to take them. When asked if she gave him fluids with his medications, she responded Yes, he would drink some water sometimes, more at other times and then sometimes none at all, I tried to encourage him to drink 8 ounces, but he wouldn't do that much. She stated that when he was admitted that the hospital nurse who called in the report stated that he was not drinking or eating much, that he had a very poor intake. When questioned on if they had considered monitoring his fluid intake, she responded, No, I had asked the Director of Nursing (name redacted) and the Nurse Practitioner (name redacted), not the Nurse Practitioner we have now but the one before her if they wanted us to do an intake and they said it was not necessary as this was his baseline and he was only taking in about 50% or less with his meals When questioned if she had reported the poor intake to the Nurse Practitioner she responded, No, if it was an new concern, then yes, I would have notified her but this was not new for Mr. (Resident #1 name redacted) as he came in here in such poor condition. When asked about Resident #1's change in change on 10/9/25 LPN-E stated I noticed a decline when I rounded that morning and notified the Nurse Practitioner to assess. We gave him breathing treatment, started him on oxygen and then gave him Rocephin (antibiotic) intramuscularly. I didn't feel comfortable giving him anything by mouth as he was not responding at his baseline and I told the Nurse Practitioner that. She gave us an order to start an IV (intravenous fluids via his veins) and then I called his daughter to report his decline. We could not get an intravenous line in after several nurses tried and so the Nurse Practitioner gave the order to send him to the emergency room. We called the daughter back and told her he was declining and had to go to the emergency room. She said she would meet him there. It all happened pretty quick. On 10/22/25 at 2:47 PM, an interview was conducted with the Director of Nursing who stated they were not doing fluid intake on Resident #1 as they had discussed it with the Nurse Practitioner, and she did not feel it was necessary. She stated she was not aware the urostomy was leaking and that his oral intake was getting poorer. When asked if an order for measuring oral intake was required or if it was a nursing intervention she responded, we should have been doing monitoring his intake since he wasn't eating or drinking much. When asked what her expectation of nurses was in notifying the medical provider and family if a resident is not eating and drinking enough, she replied, It is our responsibility as a nurse to notify the nurse practitioner or the doctor and the responsible party of any change in condition even for poor intake. Further interview regarding morning of Resident #1's transfer to the emergency room and she reported, It started around 9:30 am or sooner where the nurses did not feel comfortable sending him to the other nursing home where he was supposed to be transferred to that day to be closer to family due to sudden decline in condition, we made a few calls to his daughter (his Responsible Party because she thought we were sending him to the emergency room just because we could not get an intravenous line in, which we couldn't get a line started and several nurses had tried and couldn't but it was because he was rapidly declining. It was me; the Nurse Practitioner and I think the nurse all together making the last call. I don't know if he still would have passed but additional fluids sooner may have helped.On 10/22/25 at 3:58 PM, the Director of Nursing presented a Complaint/Grievance Report that she had received from Resident #1's Responsible Party, his daughter on 9/29/25 {name redacted. Per the report: the daughter voiced concern that the resident was becoming dehydrated, and when she visited her father, she observed a cup on his table with a lid but no straw and he was unable to drink from it. She requested supplemental shakes two (2) times a day and to be checked for a UTI (urinary tract infection). The Director of Nursing and Unit Manager investigated the daughter's concern and per their investigation the Nurse Practitioner Employee-D stated the resident was not dehydrated per lab tests and a urine test with culture and sensitivity was obtained with results showing no UTI (urinary tract infection). The Nurse Practitioner also started the resident back on supplements that was discontinued at the hospital. According to the Grievance report, the Unit Manager shared with the daughter that the resident had been taking his straw out of the cup himself. The report stated that the resident would be started back on supplement shake twice daily and had instructed the Certified Nursing assistants to check his beverage cups when going into his room to ensure he had a straw. Per the Grievance Report they discussed their investigative findings on 9/29/25 with the daughter and she expressed her satisfaction.There was no evidence in the clinical record that the facility staff continued to monitor Resident #1 for signs and symptoms of dehydration due to more frequent episodes of low urine output and poor oral intake both solid and fluid intake considering the concern voiced by the Responsible Party, his daughter and there was no evidence of supplement shakes started twice a day.On 10/22/25 at approximately 4:45 PM the Administrator and Director of Nursing provided a copy of a Complaint/Grievance initiated 10/15/25 from Resident #1's Responsible Party, his daughter stating patient passed away at the hospital. Daughter stated he had a UTI (urinary tract infection) and was septic. Doctor at the hospital told the family He hadn't had anything to eat or drink in 4 days She had not been informed about the urinalysis or antibiotic. The facility Administrator provided a copy of the Facility Reported Incident that she had completed and submitted dated 10/22/25.On 10/22/25 a review of Resident #1's meal intakes for the 4 days prior to discharge to the emergency room was completed (fluid intake was not recorded): 10/5/25 0-25% meal intake for breakfast and lunch meals, 51-75% evening meal; 10/6/25 76-100% for breakfast and lunch meals, 0-25% for evening meal; 10/7/25 0-25% for breakfast, lunch and evening; 10/8/25 76-100% for breakfast and lunch meal, 0-25% for evening mealThere was no evidence in the clinical record that the Nurse Practitioner or the Responsible Party, his daughter had been notified of the poor meal and fluid intake and low urine output.On 10/22/25 during the end of day meeting, the Administrator, Director of Nursing and the Regional Director Clinical Services were made aware of the concerns, no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents are free from significant medication error for 1 resident (#2) in a survey sample of 6 residents.For Resident #2 the facility staff failed to follow the physician orders for parameters on administering the drug Midodrine (an alpha-Adrenergic Agonist used to raise blood pressure).Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Interstitial pulmonary disease, generalized anxiety disorder, major depressive disorder, unspecified dementia, dysphagia, Barretts esophagus, and generalized weakness. Resident #2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/9/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 8 out of possible 15 indicating moderate cognitive impairment.On 10/21/25 a review of the clinical record revealed that Resident #2 had orders that included the medication Midodrine for hypotension (low blood pressure). A review of the MAR (Medication Administration Record) for September and October 2025 revealed the following orders: Midodrine HCL Tablet 5 mg. Give 5 mgt by mouth three times per day for low bp HOLD FOR SYSTOLIC GREATER THAN 130. Order date 10/7/25The MAR revealed the following regarding the administration of Midodrine:10/10/25 - bp was 139/73 medication marked as administered at 2 pm.10/12/25 - bp was 132/76 medication marked as administered at 9 pm.10/19/25 - bp was 145/71 medication marked as administered at 9 pm. On 10/20/25 the order was changed to read: Midodrine HCL Tablet 5 mg. Give 5 mgt by mouth three times per day for low bp HOLD FOR SYSTOLIC GREATER THAN 120. Order date 10/7/25A review of the MAR revealed the following:10/20/25 - bp was 131/75 and medication marked as administered at 9 pm. On 10/22/25 an interview was conducted with LPN # who stated that the importance of paying attention to the parameters on a medication is that in this case you can either cause a blood pressure to be too high if you give it when you should hold it, but also cause someone to bottom out if you hold it when you should have given it, either way it could cause negative outcomes for the resident. On 10/22/25 at approximately 3:30 p.m the DON was asked about the expectation of the nurses following physician orders, and she stated nurses are expected to follow physician orders exactly as they are prescribed. On 10/22/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interviews and clinical record review, the facility staff failed to ensure appropriate resident care and services were provided in accordance with accepted professional standards of care for 1 resident (Resident #1) in a survey sample of 6 residents. The findings included: For Resident #1, the facility staff failed to assess for signs and symptoms of dehydration.Resident #1 was admitted to the facility on [DATE] after a hospitalization from 7/16/25 to 8/6/25 for nausea and vomiting, coffee-ground enemies. He presented with a persistent ileus (a temporary condition where one's intestine cannot push food and waste out of the body) with abdominal pain and distention. He was treated conservatively after small bowel obstruction was ruled out. The hospital discharge summary revealed his overall prognosis was guarded. Resident #1's diagnoses included but not limited to Ogilvie's Syndrome (a rare condition that causes a severe dilation of the large intestine without any physical obstruction. This leads to symptoms similar to bowel obstruction, despite the absence of an actual blockage), history of complete intestinal obstruction, unspecified as to cause, unspecified dementia with psychotic disturbance, gastro-esophageal reflux disease, history of kidney stones, abnormal urinalysis, history of bladder cancer with placement of an ileostomy, femur fracture surgically repaired, acute and chronic kidney disease and hypertension. Resident #1's admission assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/2025 coded the resident as having a Brief Interview of Mental Status (BIMS) score of 02 out of a possible 15 indicating resident had severe cognitive impairment and was not able make decisions independently. Section GG of the MDS coded the resident as requiring maximum assistance or being totally dependent for turning/repositioning, lying to sitting, sitting to stand, chair/bed to chair transfer, toileting, bathing and dressing. He required assistance with feeding. Resident #1 had a urostomy (surgically created opening in the abdomen to divert urine from the kidneys to an external bag due to his diagnosis of bladder cancer). Resident #1 was incontinent of bowel. On 10/21/25, a review of the clinical record revealed: On 8/22/25, Resident #1 was transferred to the hospital for nausea, vomiting, abdominal pain due to concerns that he may be obstructed again. He was treated with intravenous fluids (fluids administered via his veins), pain medications and antibiotics and discharged back to the facility on 8/26/25 with order to complete antibiotic course on 8/30/25. A CT scan (computerized tomography which is a medical imaging that uses x-rays to create detailed images of the body's internal organs) was completed at the hospital which revealed mild thickening indicating possible colitis, no obstruction. On 9/13/25, per nurse's notes an order was given from the Nurse Practitioner {name redacted} to obtain a urine sample due to cloudy urine with sedimentation. The nurse's note revealed the nurse attempted to contact Resident #1's Responsible Party, his daughter {name redacted).9/13/25 Urinalysis and C & S results: The results of the culture and sensitivity revealed: greater than 100, 000 CFU/ML mixed flora - No predominant microorganisms present. On 9/15/25, the Nurse Practitioner {name redacted} progress notes revealed urine sample results no microorganisms, urostomy draining yellow urine with sediment noted, bowel sounds in all four (4) quadrants, well nourished, in no acute distress, encourage oral (by mouth) fluids.On 10/3/25, the Nurse Practitioner {name redacted} progress notes revealed resident (Resident #1) observed lying in bed, in no acute distress, no complaints of pain, no new nursing concerns; ileostomy in place draining yellow urine with sediment noted, bladder non-distended, bowel sounds present in all four (4) quadrants On 10/7/25, the Nurse Practitioner {name redacted} documented in her progress notes acute visit for increased confusion and amber, malodorous urine via ileostomy, patient seen lying in bed in no acute distress, no complaints of pain, very confused at this time. Plan: Encourage hydration, urinalysis with culture and sensitivity ordered and pending.On10/8/25 results of the Urinalysis culture and sensitivity lab test revealed: Greater than 100, 000 CFU/ML mixed flora - No predominant microorganisms present.On 10/9/25, Nurse LPN-E caring for Resident #1 documented in a nurse progress note: during morning rounds at the start of the shift, Resident #1 was noted to be pale for baseline color, noted increased respirations. When spoken to, he was responsive to voice and spoke to this nurse. The Nurse Practitioner was in the building at this time and was asked to come to room to assess resident. She ordered a one-time Albuterol 0.083% nebulizer treatment (a rescue medication used to treat or prevent bronchospasm, a condition where the muscles around the airways tighten, causing breathing difficulty) after she assessed lung sounds. Resident #1 was administered the nebulizer treatment with no issues. Per the residents' medication administration record he was to receive Rocephin (an antibiotic) intramuscularly (IM) and an oral antibiotic for reported urinary tract infection. The Rocephin IM was administered in left thigh per order with no issues. Vital signs: blood pressure 115/85, pulse 58 beats per minute, respirations 22, temporal temperature 97.6 degrees Fahrenheit, and 84% oxygen level on room air. Oxygen was applied at 2L via nasal cannula and pulse ox increased to 90%. The Unit Manager, Director of Nursing and Social Services Director were made aware of residents' change in condition. The Nurse Practitioner (NP) was notified that this writer was not comfortable giving medications orally (by mouth) at this time due to safety. The NP assessed the resident again and gave a verbal order for a one (1) time order for one (1) liter of normal saline to run at 100ml/hour intravenously (via the veins). Several attempts were made by multiple staff members to get intravenous access with no success. Resident reassessed by the Nurse Practitioner at which time she gave the verbal order to transfer resident to local emergency room for evaluation and treatment. At 9:36 AM, the Resident's responsible party, his daughter was notified of residents change in condition and informed that this nurse wasn't comfortable transferring resident to another facility in his present condition. She was informed of the new order for intravenous (IV-fluids via the veins) hydration. She was asked if resident could be sent to the local emergency room and she stated she did not want resident to be sent to the hospital; she wanted him to be sent to receiving facility. She was pleasant and cooperative and thanked this nurse for giving her information and status.On 10/9/25, the Nurse Practitioner documented in her progress notes at 11:43 AM: Acute visit for decline in condition: Patient (Resident #1) is being seen today for a decline in mental status. He is less responsive today per nursing. When assessing him, he did not respond to questions. He is currently being treated for a urinary tract infection, awaiting culture results, ordered Rocephin IM (antibiotic intramuscularly) and Augmentin PO (antibiotic by mouth), will adjust antibiotics per culture once results in, intravenous (IV) fluids (fluids via his veins) ordered for hydration, unable to obtain intravenous access, order given to send out to the emergency room due to decline in health and inability to obtain intravenous access. Spoke with patient's responsible party, daughter {name redacted} and informed her of the decision to send her dad out for evaluation and treatment, she states she will go see him at the hospital.On 10/9/25, Resident #1 was transferred to the hospital at 1:06 PM via emergency transport.According to the hospital notes, Resident #1 was received in the hospital at 1:33 PM, the emergency room doctor's documentation revealed Resident #1 was received in acute distress, ill-appearing, toxic-appearing, mucous membranes dry, rhonchi present in his lungs, ureterostomy right quadrant with grossly purulent urine, cachectic, debilitated gentleman, lethargic with minimal response to voice, appears severely dehydrated, septic. Note also revealed that approximately 3:30 PM Resident #1's responsible party, his daughter {name redacted} and son-in-law arrived and the emergency room doctor {name redacted} spoke with them at the bedside concerning the patient's poor condition and advised them that he was gravely ill and could pass away enroute to the receiving hospital. Per his note he documented that Resident #1's daughter and other family members reported that Resident #1 had been in decline over the last week, noting cloudy urine in his ureterostomy bag and poor oral (by mouth) intake.According to the clinical record, the facility staff were recording Resident #1's meal intake (fluid intake was not measured) Documentation revealed appetite was varied. The facility's electronic medical record software provides alerts to trigger in the nurses' progress notes when residents consume 50% or less x 2 meals or more in a 24-hour period. For Resident #1, the following alerts triggered for 50% or less x 2 meals in a 24-hour period indicating poor meal intake. (no evidence in the clinical record that the medical provider was notified of poor meal intake including poor fluid intake) 9/14/25 appetite varies 9/16/25 oral intake varies 9/25/25 appetite varies 9/29/25 oral intake varies 10/6/25 oral intake varies 10/8/25 appetite varies Per the clinical record, Resident #1 was assessed by the facility's registered dietician and noted that on 9/3/25 Resident #1 consumes 25-50% meals; nutritional requirements include 1500-1600 fluids per day; noted varying intakes, 9/10/25 Consumes 50-75% meal intake , 9/17/25 Resident #1 consumes 50-75% meal intake, 10/8/25 Resident consumes 50-75% meal intakeOn 10/22/25, an interview was conducted with the facility's Registered Dietician, Employee-F, who stated she recommended health shakes to add dietary calories and protein for residents who may have difficulty consuming enough nutrients through solid food intake. When asked how she knew if Resident #1 consumed his health shakes, she stated that the Dietary Manager would let her know if they (the shake) came back on the tray untouched. She stated she had recommended one (1) every day on lunch tray for Resident #1. When asked if the carton did not return on the tray did that indicate if Resident #1 consumed the shake or that it was left at the bedside? She responded Well, then I really don't know if he actually consumed the shake or not. She stated that Resident #1 usually consumed about 50-75% meal intake. When shown documentation of meal intake by the certified nursing assistants from 9/21/25 to 10/9/25 she responded, Oh, that is definitely not 50-75% I must have overlooked that When asked if the facility held At Risk meetings to discuss vulnerable residents she stated, Yes. When asked if they had discussed Resident #1's poor oral (by mouth) intake she stated, I do not recall if we talked about him. When asked if she had knowledge of the amount of fluid intake Resident #1 consumed daily, she stated they did not measure his fluid intake daily.According to the clinical record review, nurses were monitoring urostomy sites and completing urostomy care every shift. The urostomy was noted to be positional and leaking at times and was documented on 9/1/25, 9/2/25 (Resident #1 pulling at bag), 9/5/25, 9/6/25 wafer and bag changed, 9/17/25 wafer and bag changed, placed to the right side to allow better flow, 9/30/25 new urinary bag.Review of the clinical record (Treatment Administration Record - TAR) for October 2025, the urostomy output showed a decline in output (no evidence that the medical provider was notified of low output) 10/3/25 Day shift-100cc, Evening shift-100cc, Night shift-50cc; 10/4/25 Day shift-100cc, Evening shift-100cc, Night shift-500cc; 10/5/25 Day shift-25cc, Evening shift-100cc, Night shift-100cc; 10/6/25 Day shift-100cc, Evening shift-100cc, Night shift-100cc; 10/7/25 Day shift-100cc, Evening shift-150cc, Night shift-100cc; 10/8/25 Day shift-150cc, Evening shift-100cc, Night Shift-100ccOn 10/22/25 at 11:00 AM, an interview was conducted with Certified Nursing Assistant (CNA-B) who stated she had worked at the facility since June 2025 and had worked with Resident #1. She stated she bathed him, fed him, emptied his bag on side of his stomach of urine and got him up in the chair. He would use his legs to scoot himself around in his wheelchair in the hallway. She stated, I emptied his urine whenever it had urine in it and reported the amount to the nurse and if I saw anything unusual, you know, like blood or pus I would tell the nurse. She stated he was usually cooperative until at the end he wasn't doing anything much and wouldn't eat or drink, I reported it to the nurse {name redacted} and the Nurse Practitioner {name redacted} and they would go and check him out. When asked if she was familiar with Health Shakes she replied Yes, they were on his tray, I think it was his lunch tray, but he didn't drink much of those. When asked if she recorded how much fluid Resident #1 drank during her shift she responded, No, we just put in how much they eat off their trays, not how much they drink.On 10/22/25 at 11:20 AM, an interview was conducted with Certified Nursing Assistant (CNA-C) regarding her care to Resident #1. She stated she had been working in the facility for about a year and had taken care of Mr. {name redacted} Resident #1 but had never emptied his urine bag, she said He never had a lot in his, I cleaned around the opening in his side when I bathed him. He required a lot of assistance with feeding. She said he could pick up his milk carton when he wanted to but only drank sips at a time or sometimes nothing at all. When asked if she reported this to anyone, she replied, He came in like that and everyone knew he didn't eat or drink much, it wasn't anything new When asked if she recorded his fluid intake she replied, No, we only chart what they eat, not what they drink.On 10/22/25 at 11:30 AM, an interview was conducted with Certified Nursing Assistant (CNA D). According to CNA D she has been employed at the facility since January 2025 and worked with Resident #1. She stated he was dependent on the staff for his activities of daily living. She said she cleaned around the opening of his stomach and emptied his urine bag, but very seldom did he have much output in the bag and that it leaked a lot and at times would come apart and he would be wet, and she would report that to the charge nurse. She stated he required a lot of assistance with feeding, but he would hold his own juice cup and milk carton, but he did not drink or eat much. On 10/22/25 at 11:40 AM, an interview was conducted with LPN -B who reported she had worked with Resident #1 a few times and that she administered his medications by crushing them and putting them in applesauce and he would consume about 2 or 3 ounces of water after taking his pills and most of the time would drink his Health Shake about 4 ounces but he was not a big eater or drinker. When asked if she reported his poor meal and fluid intake to the Nurse Practitioner or Physician she stated No, everyone knew he didn't eat or drink much, that was his baseline.On 10/22/25 at 11:50 AM an interview was held with Nurse Practitioner Employee-D who stated that Resident #1 would flag occasionally for poor meal intake. We tried to ensure someone helped feed him, he was able to pick up his cups most of the time but did need much encouragement to eat and drink. I saw him the day before we sent him out to the emergency room in the hallway, he was holding his cup and drinking water, I think that was the fluids in the cup. When asked if she was aware of Resident #1's fluid intake was and output low, she replied, I was not notified of Mr. {Name redacted} (Resident #1's) low urostomy output, I am aware that it leaked and noted it was disconnected a couple times, he would pick at it or turn over and it would become disconnected. The Nurse Practitioner was shown the urostomy outputs recorded on Treatment Administration Record for October 2025 and the nurses' notes indicating alerts for 50% or less for 2 or more meals she stated if I had known fluid intake was poor, I would have ordered fluids sooner. They can do hypodermoclysis (administering fluids directly into the subcutaneous tissue (under the skin) here as well as intravenous fluids for hydration. We had checked his urine around September 15th and again around October 7th, but nothing was growing per the lab results, like I said, I saw him the day before we sent him out and he was up in his wheelchair in the hallway his usual self.On 10/22/25 at 2:30 AM, an interview was conducted with LPN- E. She stated she had been working at the facility for about thirteen (13) months. She stated she had taken care of Resident #1 several times by administering his medications, completing skin assessments, caring for his urostomy and ensuring the CNA's bathed him, fed him and got him up in the chair. When asked how he took his medications, LPN- E stated, he only took a few pills, and we crushed them and put them in applesauce because that he how he liked to take them. When asked if she gave him fluids with his medications, she responded Yes, he would drink some water sometimes, more at other times and then sometimes none at all, I tried to encourage him to drink about 8 ounces or so, but he wouldn't do that much. She stated that when he was admitted to the facility that the hospital nurse who called in the report stated that he was not drinking or eating much, that he had a very poor intake. When questioned on if they had considered monitoring his fluid intake, she responded, No, I had asked the Director of Nursing (name redacted) and the Nurse Practitioner (name redacted), not the Nurse Practitioner we have now but the one before her if they wanted us to do an intake and they said it was not necessary as this was his baseline and he was only taking in about 50% or less with his meals When questioned if she had reported the poor intake to the Nurse Practitioner she responded, No, if it was an new concern, then yes, I would have notified her but this was not new for Mr. (Resident #1 name redacted) as he came in here in such poor condition.On 10/22/25 at 2:47 PM, an interview was conducted with the Director of Nursing who stated they were not doing fluid intake on Resident #1 as they had discussed it with Nurse Practitioner, and she did not feel it was necessary. She stated she was not aware the urostomy was leaking and that his oral intake was getting poorer. When asked if an order for measuring oral intake was required or if it was a nursing intervention she responded, we should have been monitoring his intake since he wasn't eating or drinking much. When asked what her expectation of nurses were in notifying the medical provider and family if a resident is not eating and drinking enough, she replied, It is our responsibility as nurses to notify the nurse practitioner or the doctor and the responsible party of any change in condition even for poor intake. Further interview regarding the morning of Resident #1's transfer to the emergency room, she reported, his condition changed at the beginning of day shift or so and the nurses did not feel comfortable sending him to the other nursing home where he was supposed to be transferred to that day due to his sudden decline. We made a few calls to his daughter (his Responsible Party) because she thought we were sending him to the emergency room just because we could not get an intravenous line in, which we couldn't get a line started even after several nurses had tried unsuccessfully but it was because he was rapidly declining. It was me; the Nurse Practitioner and I think the nurse all together making the last call. I don't know if he still would have passed but additional fluids sooner may have helped. On 10/22/25 at 3:58 PM, the Director of Nursing presented a Complaint/Grievance Report that she had received from Resident #1's Responsible Party, his daughter on 9/29/25 {name redacted. Per the report: the daughter voiced concern that the resident was becoming dehydrated, and when she visited her father, she observed a cup on his table with a lid but no straw and he was unable to drink from it. She requested supplemental shakes two (2) times a day and to be checked for a UTI (urinary tract infection). The Director of Nursing and Unit Manager investigated the daughter's concern and per their investigation the Nurse Practitioner Employee-D stated the resident was not dehydrated per lab tests and a urine test with culture and sensitivity was obtained with results showing no UTI (urinary tract infection). The Nurse Practitioner also started the resident back on supplements that was discontinued at the hospital. According to the Grievance report, the Unit Manager shared with the daughter that the resident had been taking his straw out of the cup himself. The report stated that the resident would be started back on supplement shake twice daily and had instructed the Certified Nursing assistants to check his beverage cups when going into his room to ensure he had a straw. Per the Grievance Report they discussed their investigative findings on 9/29/25 with the daughter and she expressed her satisfaction.Per clinical record review, there was no evidence that the facility staff continued to monitor Resident #1 for signs and symptoms of dehydration due to more frequent episodes of low urine output and poor oral intake both solid and fluid intake considering the concern voiced by the Responsible Party, his daughter and there was no evidence of supplement shakes started twice a day.On 10/22/25 per clinical record review (the Medication Administration Record and progress notes for October did not contain an entry for supplements) and according to interviews with the registered dietician, certified nursing assistants and nurses Resident #1 was given a Health Shake on his lunch tray daily, no evidence of amount consumed or any other supplements.On 10/22/25 at 4:21 PM a telephone interview was conducted with the Medical Director, Employee- E, who stated he had not seen Resident #1 as a patient but was aware of his care. He stated that Resident #1 had a decent amount of urine output, and the urine didn't show any concentration. He said they were monitoring his urine specific gravity on his urinalysis reports which were not indicative of dehydration. He also stated that Resident #1 was not showing clinical symptoms of dehydration. When questioned on his expectations of nurses completing assessments for dehydration, he stated he could not address nursing standards of care. On 10/22/25, a review of the clinical record, lab results for 9/13/25 urine specific gravity revealed, 1.013 (normal 1.010-1.030 and 10/8/25 urine specific gravity revealed, 1.016 (normal 1.010-1.030)On 10/22/25 at approximately 4:45 PM the Administrator and Director of Nursing provided a copy of a Complaint/Grievance initiated 10/15/25 from Resident #1's Responsible Party, his daughter stating patient passed away at the hospital. Daughter stated he had a UTI (urinary tract infection) and was septic. Doctor at the hospital told the family He hadn't had anything to eat or drink in 4 days She said she had not been informed about the urinalysis or antibiotic. The facility Administrator provided a copy of the Facility Reported Incident that she had completed and submitted dated 10/15/25 regarding daughter's allegation of neglect where he was transferred to the hospital on [DATE] and had passed away due to a urinary tract infection. According to the Administrator's investigation, she concluded that the allegation of neglect was unfounded as transfer to the hospital on [DATE] was a result of Resident #1's sudden clinical decline.On 10/22/25 a review of Resident #1's meal intakes for the 4 days prior to discharge to the emergency room was completed (fluid intake was not recorded):10/5/25 0-25% meal intake for breakfast and lunch meals, 51-75% meal intake for evening meal, 10/6/25 76-100% for breakfast and lunch meals, 0-25% for evening meal, 10/7/25 0-25% for breakfast, lunch and evening meal,10/8/25 76-100% for breakfast and lunch meal, 0-25% for evening mealPer the facility's policy on Ureterostomy Care, General Guidelines1. Determine if the resident is on intake or output before discarding urine.2. Check urine for unusual appearance and record findings.3. Maintain a daily record of residents' daily fluid output, as indicated. On 10/21/25 a review of Resident #1's clinical record (Treatment Administration Record) Monitor and Document urostomy output revealed holes/blanks for output on 9/28/25 on the day shift, 9/9/25 and 9/16/25 evening shift, and on 9/16/25 and 9/17/25 night shift.According to Lippincott's standards of practice for assessing dehydration in older adults, clinical assessments should include but not limited to: Oral mucosa and tongue: Look for dryness and stickiness. This is a more reliable sign in older adults than skin turgor.Mental status: Look for changes in mental status, such as dizziness, confusion, or delirium, which can be symptoms of dehydration in older adults.Urine color and output: Assess urine color (dark yellow may indicate dehydration) and monitor for decreased urine output. Note: While often used, urine color and output are considered unreliable markers when used alone in older adults. Laboratory assessments: Urine specific gravity: Elevated urine specific gravity (e.g., >1.020) can indicate dehydration but is unreliable when used alone in older adults.On 10/22/25 during the end of day meeting, the Administrator, Director of Nursing and the Regional Director Clinical Services were made aware of the concerns, and no further information was provided.

Based on staff interviews, clinical record review, and in the course of a complaint investigation, the facility staff failed to mitigate a known accident hazard for one Resident (Resident #1) in a survey sample size of 4 Residents. Specifically, Resident #1 needed assistance and guidance with dressing and had a known behavior of holding her [CONDITION(S)] catheter and picking at the [CONDITION(S)] catheter dressing. On the morning of 05/27/2022, Resident #1 was not assisted with dressing and found half-dressed, lying across the bed, no dressing on the [CONDITION(S)] catheter site, and one of the port caps removed resulting in Resident #1's death by exsanguination (severe loss of blood). This is harm. The findings included: On 06/08/2022, Resident #1's closed clinical record was reviewed. Resident #1's most recent Minimum Data Set with an Assessment Reference Date of 05/03/2022 was coded as a Significant Change in Status assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Functional status for dressing was coded as requiring limited assistance from staff meaning the resident was highly involved in activity and the staff provided guided maneuvering of limbs or other non-weight-bearing assistance with a one person physical assist. A review of the progress notes for April and May 2022 revealed that Resident #1 was admitted to the hospital on 04/21/2022 due to multiple abscesses on the left arm and returned to the facility on [DATE] with a double lumen catheter in the right internal jugular (IJ) for [CONDITION(S)] access. A physician's order dated 05/03/2022 documented Check access right double lumen IJ [internal jugular vessel] for bleeding, redness, tenderness, and swelling. The Treatment Administration Record associated with this order was signed off as administered on the night shift 05/26/2022 and on the day shift 05/27/2022. Resident #1's care plan was reviewed. The care plan did not document any behaviors pertaining to touching the [CONDITION(S)] catheter or disrupting the dressing. A progress note dated 05/27/2022 at 7:10 A.M. documented, Resident noted in bed asleep at present time. No distress noted. A progress note dated 05/27/2022 at 10:10 A.M. documented, CNA yelled for this writer to come to room [number]. Resident noted on bed on back with legs hanging off bed. Resident has pants on but no shirt noted on resident. Large pool of bright red blood noted on bed surrounding resident. Bright red blood noted on floor. [CONDITION(S)] double lumen catheter noted in right chest wall. No active bleeding noted from [CONDITION(S)] catheter. Blue cap from [CONDITION(S)] catheter noted beside resident. Checked carotid and radial pulse. Resident is a DNR. No pulse noted. No signs of life. Resident is pale and warm to touch. Ask floor tech supervisor to call nurses to [name of unit]. Central nurse RN arrive to access resident. All other facility nurses arrived to room to assist. DON informed of incident. NP informed of incident. Family called by Central nurse. They stated to call [name] funeral home. 911 called per protocol. EMT arrived stated that they spoke with [physician name] and he pronounced resident death at 0853. Funeral home called and body was release [sic] to them upon their arrival. On 06/08/2022 at approximately 3:15 P.M., CNA B working on the Memory Care unit was interviewed. CNA B verified they worked with Resident #1 the day before the incident on 05/27/2022. When asked about Resident #1's functional status for dressing, CNA B stated that Resident #1 needed assistance getting dressed but would, at times, get herself dressed. When asked if Resident #1 had any behaviors associated with the [CONDITION(S)] catheter, CNA B stated that Resident #1 would mess with it. CNA B stated if Resident #1 took notice of the catheter, she would hold it. CNA B stated that the day before the incident on 05/27/2022, CNA B observed Resident #1 holding the [CONDITION(S)] catheter. CNA B stated that they (1) told Resident #1 not to touch it and that Resident #1 was easily redirected. When asked if this was reported to the nurse, CNA B stated they did report it to the nurse but they could not remember the nurse's name because it was an agency nurse. When asked about the dressing for the [CONDITION(S)] catheter, CNA B stated that the site would usually have a dressing but the tubing was not wrapped. On 06/08/2022 at 3:45 P.M., LPN D was interviewed. LPN D verified she was an agency nurse working at the facility for the past three months. LPN D verified she was the nurse working with Resident #1 on the day of the incident. LPN D stated that Resident #1 could dress herself. When asked about the [CONDITION(S)] catheter dressing prior to the incident, LPN D stated usually the site was dressed but the tubing was not wrapped. LPN D stated that usually the tubing, the clamps, and the caps could be seen. LPN D stated Resident #1 had a double lumen [CONDITION(S)] catheter; one lumen with a red cap; one lumen with a blue cap. When asked about Resident #1's behaviors pertaining to the [CONDITION(S)] catheter, LPN D stated she personally did not ever see Resident #1 messing with her [CONDITION(S)] catheter. On 06/08/2022 at 4:25 P.M., CNA E was interviewed. CNA E verified she discovered Resident #1 on the morning of the incident on 05/27/2022. CNA E verified she was assigned to care for Resident #1 that day. CNA E stated that she got into work an hour late that day. CNA E stated she did call to let someone know she would be late but could not recall the name of the person she notified. CNA E stated that when she arrived on the unit, other staff members were passing breakfast trays so she also started passing trays. CNA E stated that 7:56 A.M., she entered Resident #1's room with the breakfast tray and found Resident #1 lying across her bed with blood all around. On 06/08/2022 at 4:35 P.M., the Director of Nursing (DON) was interviewed in the conference room with Surveyor B and Surveyor C present. When asked if the incident involving Resident #1 on 05/27/2022 was investigated, the DON stated it was investigated. When asked about the findings of the investigation and any changes made as a result of the investigation, the DON stated that all Residents with [CONDITION(S)] catheters were checked to ensure the [CONDITION(S)] catheter site was secured with gauze and tape. The DON stated that the orders were revamped to include calling the [CONDITION(S)] center if the [CONDITION(S)] catheter didn't have a dressing on. Also, the facility staff placed hemostats [a clamp] and dressing supplies at the bedside of all Residents with a [CONDITION(S)] catheter in case something was to happen and they needed something right then. When asked if staff received any education related to the incident, the DON stated that nurses and some aides received education to report it if the [CONDITION(S)] dressing is off. When asked for the in-service sheets, the DON stated that she remembers educating everyone but did not recall having them sign in-service sheets. When asked if Resident #1 had a dressing on her [CONDITION(S)] catheter the morning of the incident, the DON stated that Resident #1 did not have a dressing on that morning. The DON stated she checked the eMAR (electronic Medication Administration Record) and it was checked off as on there. The DON indicated that at some point, the dressing came off. When asked if Resident #1 had behaviors of touching her [CONDITION(S)] catheter or disrupting the dressing, the DON stated that Resident #1 would mess with it at times and the staff would remind her not to mess with it. The DON stated that Resident #1 would pick at the tape and the dressing. On 06/08/2022 at approximately 5:30 P.M., the administrator and DON were notified of findings. At approximately 6:15 P.M., the DON provided a copy of a written statement, signed by the DON, dated 06/08/2022 which documented the following excerpt: I was not made aware of resident's behavior of picking at her [CONDITION(S)] catheter site until the date of this incident. On 06/08/2022, the facility staff provided a copy of their policy entitled, Hemodialysis Access Care. Under the header, Care immediately following [CONDITION(S)] treatment in Section (1) and (2) documented, The dressing change is done in the [CONDITION(S)] center post-treatment. If dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. (Note: Check with State Nurse Practice Act to determine licensure and competency requirements). (1) Singular they (a generic third-person singular pronoun) is being used to protect anonymity. See https://apastyle.apa.org/style-grammar-guidelines/grammar/singular-they

Based on staff interviews, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure one Resident, Resident #1, of three residents in the survey sample was free from application of physical restraints. This resulted in psychosocial harm for Resident #1. The findings included: For Resident #1, the facility staff failed to prevent a CNA (Certified Nursing Assistant) from restraining Resident #1 in a wheelchair. Resident #1, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/18/2019 was coded as an entry assessment. Resident #1 was coded a BIMS (Brief Interview of Mental Status) score of 15/15 which indicated no cognitive impairment. Resident #1 required total dependence of one person for his activities of daily living and was always incontinent of bowel and bladder. He used a wheelchair to navigate through the facility. On 3/10/2020 at 12:15 PM an interview was conducted with Employee A, Administrator and Employee B, Director of Nursing during the complaint investigation. They stated that CNA A and LPN (Licensed Practical Nurse) A went into Resident #1's room on 2/5/2020 and found Resident #1 in his wheelchair with a seat belt and a sheet securing him to a wheelchair. They released the belt and sheet. CNA B was caring for Resident #1 at that time and they feared for reprisal from him if they reported the incident. On 2/17/2020 CNA A reported the incident to Employee B, Director of Nursing. These facts are supported by signed statements from CNA A and LPN A There was a statement from CNA B who stated that I got him (Resident #1) up off the floor to his wheelchair and put the seatbelt on him. Employee A, Administrator; Employee B, Director of Nursing: and Employee C, Staff Development Coordinator interviewed Resident #1 on 2/17/2020 at 9:45 AM regarding the incident. Resident #1 stated that (CNA B) put him on the floor on his fall mat and told him that you are going to sleep there tonight. Resident #1 also stated that he later came back in the room and body slammed me into the wheelchair and tied a sheet around me to keep me in the wheelchair. He denied any injuries or pain after the incident. Facility management instituted a Plan of Correction, thus making this violation a Past Non-Compliance deficiency. The Plan of Correction was as follows: 1. The facility failed to prevent, investigate, and report an allegation of physical abuse on or about 2/5/2020 for one resident. The resident is still a current resident in the facility. 2. All residents have the potential to be affected by this deficient practice. The facility conducted interviews screening for abuse and neglect. Residents with a BIMS score of greater than 8 were interviewed on 2/19/2020. Residents with a BIMS score less than 8 will have family interviews conducted screening for abuse. Any identified concerns that were discovered during the interviews will be immediately addressed according to the facility abuse and neglect policy. 3. Allegation of abuse was brought to the attention of the Director of Nursing on 2/17/2020 by the facility unit manager and reported to the appropriate agencies on 2/17/2020. The facility began an investigation of the allegation of abuse that had occurred on or about 2/5/2020. Education on Abuse and Neglect, Elder Justice Act, sexual abuse, and reporting requirements was conducted with the Interdisciplinary Team (IDT) on 2/19/2020 by the Regional Director of Clinical Services Facility staff to include the nursing department, respiratory therapy, dietary, housekeeping, laundry, administration, therapy, agency staff, and activity staff will receive training on Abuse and Neglect Policy, Prevention, sexual abuse, Elder Justice Act, and reporting requirements starting on 2/19/2020. Beginning 2/22/2020 no employees will be allowed to return to work until training has been completed. Administrator will attend resident council on 2/21/2020 and discuss abuse prohibition and reporting channels to ensure all residents are familiar with expectations. 4. Beginning on 2/22/2020 Administrator will monitor compliance with reporting suspected abuse. The Director of Social Service will interview a random sample of 5 residents weekly, conducting resident or family interviews as indicated of a BIMS score of 8 or above. Results of weekly audits will be submitted to the administrator weekly. Results will also be reported monthly to the QAPI (Quality Assurance Process Improvement) committee. The QAPI committee is responsible for ongoing monitoring of compliance. 5. Allegation of Compliance (AOC) 2/22/2020. The Plan of Correction was signed by Employee A, Administrator The survey team verified compliance on 3/10/2020.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #66) of 21 residents in the survey sample to prevent and identify an unable to stage sacral pressure wound resulting in harm. Resident #66's sacral wound was first identified as unable to stage with 100% slough (dead tissue) present in the wound bed. The findings included: Resident #66, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 12/19/17. She had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required extensive assistance with activities of daily living and was coded to be at risk to develop a pressure wound. On 1/24/18 at 10:30 a.m., an interview was conducted with Resident #66. She was lying in bed. She was observed to have a special air mattress. Resident #66 was asked if she had a current wound. She stated that she did not have a wound currently, but used to have a wound on her backside. She stated that staff do not get her up in the geri chair anymore and she would like to get up. A Risk For Pressure Ulcers assessment was completed on 4/4/17. Resident #66 scored a 15, indicating that she was at high risk for developing a wound. A review of Resident #66's clinical record revealed an abrasion on the left buttock identified on 5/6/17 and an unable to stage sacral wound identified on 5/15/17. Included in the clinical record was a form titled Wound Assessment Report. The form was dated 5/15/17. The wound type was described as Pressure Ulcer and the date the wound was identified was 5/15/17. The Assessment Occasion was documented as New Wound. The wound was staged as Unstageable due to slough/eschar. The wound bed was described as 100% slough and measured 0.5 cm (centimeter) X 0.5 cm x 0. A fax communication form was also included in the record. The form was communication from the wound care nurse to the doctor. The form was dated 5/15/17 and read Weekly Wound Update. New Sacrum 0.5 x 0.5 cm (centimeter) unstageable area (gray in color) [MEDICATION NAME] dsg (dressing) every 3 days + PRN (as needed). The MD (doctor) Response section read noted and included the doctor's signature. On 1/26/18 at 12:13 p.m., an interview was conducted with the wound care nurse and Director of Nursing (DON). The wound care nurse stated that she found the sacral wound on 5/15/17 when she was changing the dressing for the left buttock wound during the 7-3 shift. She could not provide an exact time. She stated that the left buttock dressing was last changed three days earlier on 5/12/17. The Treatment Administration Record (TAR) for (MONTH) (YEAR) was provided. It was reviewed with the wound care nurse and the DON that the weekly skin checks had not been completed by a nurse in the month of (MONTH) (YEAR). Skin checks were documented on the Nursing Weekly Summary form. Resident #66's record included a Nursing Weekly Summary dated 4/25/17 with no skin issues present and a Nursing Weekly Summary dated 5/30/17 that documented a sacral wound. During the interview, the DON stated that the weekly skin checks had not been completed. At the conclusion of the interview, the wound care nurse and DON were asked to provide information regarding the wound prevention interventions that were in place prior to the identification of the sacral wound and to provide all information they wanted to discuss regarding the wound. On 1/29/17 at 10:15 a.m. the DON provided the Daily Care Check List which was a document signed daily by the Certified Nursing Assistants (CNA). She stated that CNA D was Resident #66's usual CNA. The Daily Care Check List was signed as follows: 5/12/17: 7-3= CNA D, 3-11= blank, 11-7= CNA B 5/13/17: no sheet provided 5/14/17: 7-3= CNA F, 3-11= CNA E, 11-7= CNA E 5/15/17: 7-3= CNA D At this time, the DON stated that the facility completed pressure wound training in (MONTH) (YEAR). She provided the training sign in sheets. She stated that all the CNAs that had signed off on the Daily Care Check Lists from 5/12/17 to 5/15/17 had received the training. The sign in sheets were reviewed in the presence of the DON. The signatures of CNA E and CNA F were not on the sign in sheets. The DON stated that CNA E was an agency nurse. The DON was asked to provide any training that CNA E would have received. The Employee In-Service/ Continuing Education Record for CNA E was provided. It was documented that CNA E attended a 30 minute prevention of pressure ulcer training on 3/16/17. No pressure wound training documentation was provided for CNA F. The CNAs also completed the CNA ADL (Activities of Daily Living) Flow Record each day. The activities of bladder function (brief change) and bathing were opportunities for the CNAs to view Resident #66's skin. The record was completed as follows: 1. Bladder Function (total number of voids) 5/12/17: 7-3= 2 voids, 3-11= blank, 11-7= blank 5/13/17: 7-3= 4 voids, 3-11= blank, 11-7= blank 5/14/17: 7-3= 2 voids, 3-11= blank, 11-7= blank 5/15/17: 7-3= 2 voids 2. Bathing (How resident takes full body bath, gets in and out of tub, washes self) 5/12/17: 7-3= total dependence/ 1 person, 3-11= blank, 11-7= blank 5/13/17: 7-3= total dependence/ 1 person, 3-11= blank, 11-7= blank 5/14/17: 7-3= total dependence/ 1 person, 3-11= blank, 11-7= blank 5/15/17: 7-3= total dependence/ 1 person According to the CNA ADL Flow Record for the month of (MONTH) (YEAR), there was no documentation that any ADL care was provided for Resident #66 during the 3-11 or 11-7 shift on the days prior to the identification of the sacral wound (5/12/17-5/15/17). On 1/29/18 at 4:25 p.m. the missing documentation on the CNA ADL Flow Record was reviewed with the DON. When asked if documentation on the Flow Record was supposed to be completed, the DON stated yes. On 1/29/18 at 10:15 a.m., the DON and the wound care nurse were asked how long it took in hours for slough to develop in a wound. They did not give a time frame and stated that it depended on the individual's condition. When asked at what stage a wound should be found, the wound care nurse stated stage I. At this time, the wound nurse also reviewed the wound prevention interventions that were in place for Resident #66 prior to the sacral wound identification. The wound care nurse stated that the standard pressure reducing mattress was in place, the same mattress that all residents in the facility used. She stated that Resident #66 was administered a daily multivitamin, she was turned and repositioned and incontinence care was provided. It was reviewed with the DON and wound care nurse that Resident #66 was observed to currently use a specialty air mattress. The wound care nurse stated that the specialty air mattress was a pressure relieving mattress. The wound care nurse was asked why Resident #66 was not been on the specialty air mattress prior to the development of the sacral unable to stage wound, given that she had a history of [REDACTED]. The DON stated that in (MONTH) (YEAR), as part of an updated wound protocol, the facility began to use the specialty air mattress for residents who had the potential to develop a wound. According to the physician orders, the specialty air mattress was first ordered for Resident #66 on 12/1/17 after the development of a deep tissue injury to the left buttock on 11/27/17. No information was provided indicating that the specialty air mattress was ordered at the time of the sacral wound identification on 5/15/17. During the interview, the wound care nurse stated that Resident #66 did not want to get out of bed to participate in restorative activities and this contributed to the development of the wound. She was asked to provide documentation of the refusals. The Nursing Restorative Treatment Plan dated 4/24/17 was provided. The duration of treatment was four weeks, six times per day. The problem was positioning out of bed. An approach included Transfer to gerichair via lift- position to maintain upright midline posture. It was documented that Resident #66 refused treatment on 4/29/17, 5/6/17, and 5/13/17. She refused restorative care on three occasions prior to the identification of the sacral wound. As of 1/18/18, the facility had an order for [REDACTED]. CNA D was interviewed on 1/29/18 at 10:45 a.m. CNA D was asked at what time in her shift she signed off on the Daily Care Check List. She stated that she usually signed towards the end of the shift. When asked what her signature meant, she stated it meant that she had completed her duties for the resident such as answering call bells and changing the resident. CNA D was asked what she was supposed to do if she found an issue with a resident's skin. She stated that she was supposed to report the issue to the nurse. When asked what types of skin issues she reported, CNA D stated she reported bruises, scratches and breakdown. CNA D was asked if she regularly worked with Resident #66. CNA D stated yes. She stated that at the time Resident #66 developed the wounds, Resident #66 was getting up in the geri chair often and would want to stay up in the chair. CNA D stated that Resident #66 wasn't being changed as frequently because she wanted to stay in the chair rather than be in bed. CNA D stated that Resident #66 is changed more frequently now because she is in bed. The skin integrity care plan dated 4/21/16 was reviewed. The care plan read (resident) is at risk for impaired skin integrity R/T (related to) Aging process and immobility. She is incontinent of bowels and bladder. The plan also read 5/17/17 sacral unstageable area. The approaches included: turn and reposition during rounds, assess the skin weekly, apply protective ointment after each brief change, observe bony prominences for redness, dietary to assess nutritional needs, observe fluid intake, position with pillow as needed. The facility policy Pressure Ulcer/Skin Breakdown- Clinical Protocol was reviewed. The Assessment and Recognition section read 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and history of pressure ulcer(s). The rest of the policy explained the physician's role in wound management. In addition, the facility provided treatment protocols for wounds stage I-IV. No information was provide regarding unstageable wounds or deep tissue injuries. Guidance on pressure wound staging provided by the National Pressure Ulcer Advisory Panel website located at www.NPUAP.com was accessed on 1/31/18 at 11:19 a.m Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #66's sacrum was observed by the survey team on 1/25/18 at 9:15 a.m. The sacral wound was healed. Resident #66 stated that she did not have any pain. According to the wound care nurse, the sacral wound healed on 6/27/17. In summary, Resident #66's sacral pressure wound was not identified until it was unstageable. Weekly skin checks were not completed, CNAs did not document that they provided care for the resident, and a specialty air loss mattress was not used to aid in wound prevention for a resident who was assessed to be at high risk for wound development. On 1/26/18 and on 1/29/18, concern regarding Resident #66's sacral wound was discussed with the Administrator, DON and wound care nurse. The facility was given multiple opportunities to submit documentation regarding the sacral wound.

Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to provide an environment free from hazards, resulting in Immediate Jeopardy (IJ) and substandard quality of care for Residents #9 and #10. The Plan of Correction was created, implemented, and accepted. IJ was lowered to a D level deficiency. 1. The facility staff failed to ensure that open electrical wires were safely covered in Room (205) which housed Residents #9 and #10. 2. For Resident #12, the facility staff failed to ensure a shaving razor was not left out and available to wandering residents, in a resident room on the memory care dementia unit. 3. Resident #6's waist restraint was tied in a double knot behind the wheelchair. 4. The facility staff failed to ensure a large water puddle was cleaned up in a timely manner in the tub/shower room on the east wing. The findings included: 1. The facility staff failed to assure that open electrical wires were safely covered in Room (205) which housed Residents #9 and #10. Resident #9, an [AGE] year old female who resided in Room (205), was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #9's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/15/2015 was coded as an annual assessment. She was coded a BIMS (Brief Interview of Mental Status) score of 1/15, indicating severe cognitive impairment. She was coded as needing limited assistance of one person for her activities of daily living, and as being always continent of bowel and bladder. Resident #10, an [AGE] year old female who resided in Room (number), was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #10's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/6/2015 was coded as a quarterly assessment. She was coded a BIMS (Brief Interview of Mental Status) score of 3, indicating severe cognitive impairment. She was coded as being totally dependent on the assistance of one person for her activities of daily living, and as being always incontinent of bowel and bladder. During the initial tour of the facility on 12/15/2015 at 2:40 PM, Resident #10 was seen sitting in a bedside chair in Room 205, and Resident #9 was seen ambulating steadily around the room. Upon entering Room 205, exposed 220 volt electrical wires were observed in a power cord going to the air conditioning/heating unit. The air/heat unit is the type that goes through the wall to the outside and is approximately 6 inches off the floor. The original power cord was too short to reach the power outlet, so a power cord extension was fabricated by the facility. This outlet is 220 volts, which is required for high voltage equipment such as air conditioners, and is dangerous and possibly deadly, to be treated with care by a competent electrical professional. The cord that was fabricated consisted of a thick gauge wire with a three pronged plug at one end, designed to plug into a 220 volt wall receptacle. It was approximately three feet long with a standard wall receptacle on the other end. This wall receptacle was designed for use in a wall, and not as a standard extension cord, and was 2 inches x 4 inches x 2 inches, fitted with a three pronged receptacle to accommodate the plug from the air conditioner/heater. The wall receptacle was designed to be fitted with a plate to prevent access to the high voltage wires inside of the receptacle. This plate was missing and the entire device was plugged into the wall receptacle and connected to the air conditioning/heating unit. Excess wire length was lying on the floor. High voltage wires were visible in the receptacle, and could be potentially touched easily with a finger, resulting in an electric shock. Immediate Jeopardy chronology is as follows: 2:50 PM- Team meeting decided that this situation met all the requirements for Immediate Jeopardy. 2:55 PM-Director and Supervisors from Virginia Department of Health, Office of Licensure and Certification were contacted, and the IJ situation was described to them. 3:00 PM-Immediate Jeopardy was decided by the Team and Supervisors/Director. 3:09 PM- Meeting with Administrator and Director of Nursing to inform them of Immediate Jeopardy and to instruct on the process to abate it. 4:20 PM-Plan of Correction was given to the Team for review. 4:25 PM-Plan of Correction was accepted by the Survey Team. Immediate Jeopardy was abated. 4:30 PM-A visit to Room (2 ) confirmed that a proper electrical connection was installed on the heating/air conditioning system, confirming that residents were no longer in a dangerous situation. The Plan of Correction was submitted and accepted as follows: 1. Corrective action(s) accomplished for those residents found to have been affected by the alleged deficient practice: The extension cord going into the HVAC (Heating Ventilation and Air Conditioning) unit in room (205) has been removed. The correct receptacle has been installed into the outlet. 2. Identify other residents who have the potential to be affected by the same deficient practice and what corrective action taken: All resident rooms have the potential to be affected by the deficient practice. An inspection of all resident rooms has been completed to ensure no other units have exposed wires. 3. Measures/systemic changes put in place to ensure that the deficient practice does not reoccur: All managers have been assigned daily Angel rounds rooms along with other resident areas to inspect for physical plant and equipment in need of repair or replacement. Any damage to the building or equipment will be reported on the maintenance Request forms to be addressed promptly by the Maintenance Director. 4. Monitoring of corrective action to ensure the deficient practice will not reoccur: The Administrator (or designee) will report on the effectiveness of Angel rounds for 3 months at the Quality Assurance meeting. Report of findings and subsequent disciplinary action, if applicable, will be reported to the Quality Assurance Committee consisting of the Director of nursing, Medical Director, Pharmacy Consultant, Social Services Director, and Dietary Manager monthly to review the need for continued intervention or amendment to the plan. 5. Allegation of Compliance (AOC)-12/15/2015 4:25 PM 2. For Resident #12 the facility staff failed to ensure that a shaving razor was not left out and available to wandering resident's, in a Resident room on the memory care dementia unit. Resident #12, was initially admitted to the facility on [DATE], and readmitted after a hospitalization [DATE]. [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11-11-15 was coded as a quarterly assessment. The Resident was coded as having short and long term memory deficits and required extensive assistance with making daily life decisions. Resident #12 was also coded as requiring limited assistance of one staff member to perform activities of daily living (ADL's), and was coded as always continent of bowel and bladder. Observation of the memory care unit on 12-15-15, and 12-16-15, revealed numerous residents ambulating independently, and wheeling independently in wheel chairs around the unit. The residents were entering each others room at will without supervision. 4 doorways to rooms were found to have banners stretched across them which had written on them STOP in bold red letters. This was to keep wandering residents from entering these rooms. The rest of the 11 rooms on the unit had doors open with no banners, and were being entered by the wandering residents at will. These wandering residents were picking up items in the various rooms, which did not belong to them, and carrying them with them as they exited. Resident #12's room was observed on initial tour of the facility on 12-15-15, and again on 12-16-15. Resident #12 was not in the room, but was independently ambulating around the facility with a rolling walker. On 12-15-15 during initial tour, a shaving razor was found on the ledge by the sink in the 2 person resident room of Resident #12. The razor was open and available to the residents who were observed wandering freely up and down the halls and entering rooms at will without supervision. Review of the clinical record revealed a Mental Status Questionnaire completed 11-11-15, which documented Resident #12 as Severe brain dysfunction. Social work progress notes revealed that Resident #12 needed assistance and set up help with ADL's. The Resident's care plan review revealed that staff were to shave the Resident daily and as needed, as the Resident's dementia did not allow him to perform this task by himself. LPN B, the memory care unit manager was called into the room by 2 surveyors and asked if Residents on this unit were allowed to have razors without supervision, and her response was No. The Administrator and DON (director of nursing) were informed of the failure of the staff to ensure a hazard free environment for Resident #12, and other demented resident's on the unit on 12-16-15 at 11:00 a.m. No further information was provided by the facility. 3. Resident #6's waist restraint was tied in a double knot behind the wheelchair. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11/15/2015 was coded as a quarterly assessment. Resident #6 was coded as having a BIMS (brief interview of mental status) score of 1 out of a possible 15, or severe cognitive impairment. Resident #6 was also coded as requiring extensive to total assistance of one to two staff members to perform activities of daily living, such as bed mobility. The only behavior coded was wandering 1-3 days a week. The resident was also coded as using a restraint (chair prevents rising) every day. On 12/16/15 at 9:25 AM, Resident #6 was observed in the day room in a wheelchair. A soft waist restraint was around the resident's lower waist. The restraint was double knotted and was wrapped around the back and underside of the wheelchair. No behaviors were observed. On 12/17/15 at 10:25 AM, the resident was observed up in a merriwalker with the Activities staff assisting her with playing a keyboard. Review of the care plan dated 11/14/15 revealed the following: (name of resident) has a pomel (sic) cushion. She has a soft waist restraint when up in wheelchair. She has poor safety awareness. Risk for falls. Interventions included: · Apply restraint as ordered. · Have resident use wheelchair and alternating with merriwalker. · Place resident in restraint reduction program, review quarterly. · Give medication as ordered. · Remove restraint during mealtime. · Observe skin daily for signs of pressure areas. · Document and report any unusual findings · Obtain consent form RP (responsible party). · Check extremtities for impaired circulation and document. · Place the locks on the wheelchair when not in use. On 12/16/15 at 11:15 AM, CNA (certified nursing assistant) C untied the knot on the wheelchair; it took approximatley 10-15 seconds. The CNA stated, It is supposed to have a loop. On 12/16/15 at 11:45 AM, LPN (licensed practical nurse) C showed surveyor that two clips (pinch type) were added to the straps for quick release. On 12/16/15 at 2:15 PM, the DON (director of nursing) stated, That should not happen (tying restraints). Review of the facility's Use of Restraint Policy included the following: Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. On 12/17/15 at 12:05 PM, the DON and Administrator were notified of above findings. 4. The facility staff failed to ensure a large water puddle was cleaned up in a timely manner in the tub/shower room on east wing. During general observation tour, the tub/shower room on east wing was observed 12/17/15 at 8:28 a.m. A very large puddle of water was on the floor, opposite the shower. The shower entrance was only a few feet from the entrance to the tub/shower room. The surveyor had to hold her pants leg up, not to get the pants wet. LPN (licensed practical nurse) O, entered the tub/shower room 12/17/15 at 8:28 a.m. LPN O encouraged the surveyor not to fall in the water and be careful. LPN O stated the staff should have cleaned the water up prior to leaving the tub/shower room. No staff were in the tub/shower room and the rest of the room was dry. The administrator and DON (director of nursing) were informed of the failure of the staff to ensure the tub/shower room was safe, without a large amount of water on the floor, 12/17/15 at 1:40 p.m.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed for 1 resident (Resident #9) of 23 residents in the survey sample to ensure a restraint/ safety device was in place resulting in harm. Resident #9 fell head first from her wheel chair and sustained a laceration to the right forehead requiring 4 sutures. Her physician ordered lap buddy was not in place prior to the fall. The findings included: Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #9's most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 11/20/14. She was coded with a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment. She required extensive assistance with her activities of daily living. Resident #9 was observed sleeping in bed on 12/9/14 at 10:25 a.m. and 12/9/14 at 2:45 p.m. Her wheel chair and lap buddy were observed in her room. Resident #9's current physician order [REDACTED]." On 12/10/14 at 11:00 a.m., Registered Nurse A (RN A) was asked if she could find the original order for the lap buddy. RN A stated she had to look. RN A returned and stated that she could not find the original order. She stated that there would have had to be an original order so that the pharmacy would know to add the lap buddy to the physician order [REDACTED]. A "Pre-Restraining Evaluation" was completed for Resident #9. The "Referrals/ Recommendations" section of the form was completed on 2/3/14. The "recommendations" read "Lap buddy when up in w/c (wheelchair)." A "Physical Restraint Consent" form was completed. The "Restraint Type, Frequency" read "Lap buddy when up in w/c Release with meals + Q (every) 2 hours." The "Specific Target Behaviors" read "prevent resident from falling out of w/c (wheelchair)." The "Medical Symptoms" read "neuromuscular disease causing spastic movements Huntington's Chorea." The "Statement of Consent" section was completed. The "I DO" consent to the use of restraints check box was checked. Handwritten in below the box read, "Anything that keeps her from falling and hurting herself." The form was signed by the responsible party on 2/5/14. Resident #9's care plan information was reviewed. A care plan meeting summary dated 2/26/14 addressed restraint use. The meeting summary read "lap buddy when in w/c (wheelchair), helmet, low bed, mat on floor." The care plan meeting summary dated 8/27/14 read "Restraints lap buddy when up in chair" and the "meeting summary" section read "Lap buddy when up in chair. Wears safety helmet." The care plan meeting summary dated 11/25/14 read "Restraints mat on floor, pressure relieving pad in w/c, has lap buddy while up in w/c." The care plan documented the lap buddy use. The "problem" dated 1/1/14 read "____ is noted to have increased behavior. She will stand up and fall down, throws herself out of bed onto the floor mat, then onto the floor, cries. DX (diagnoses) psychosis, Huntington's Chorea, Progressive neurological deterioration, seizures, at risk for further falls." Handwritten on the "Approaches" list read "Lap buddy when in w/c (wheelchair)." During a review of Resident #9's clinical record, a nursing note documenting an injury was identified. The nursing note dated 8/12/14 read "Report received from ____ ER nurse- resident received four stitches to R forehead." A telephone order dated 8/12/14 read "Send to ER (emergency room ) for evaluation and possible sutures." A telephone order from the emergency room doctor dated 8/12/14 read "Cleanse sutures to R forehead with soap and H20 (water). Apply bandage qd (daily). F/U (follow up) with Dr.______ in 1 wk (week). Remove sutures in 1 wk." On 12/9/14, the Administrator was asked to provide the 8/12/14 incident report involving Resident #9. The Administrator provided a copy of the investigation during the afternoon of 12/9/14. According to the Resident Incident Report, a computerized report, the fall occurred on 8/12/14 at 3:30 p.m. The report read as follows: "Incident Type: Fall with head injury Type of Injury: Laceration- deep Location: Resident Room Equipment: wheel chair- non-motorized Witness: barber Narrative of incident and description of injuries: Resident was in a wheelchair getting a hair cut and had a spastic reflex that caused her to come out of the wheelchair and sustain a right forehead laceration. Right forehead laceration approximately 2 centimeters long and 0.3 centimeters wide requiring 4 sutures. Immediate Post-Incident Action: Resident will have someone to assist her when she is getting her hair cut to keep resident safe if spastic reflexes occur." Attached to the computerized incident report was a handwritten form titled "Resident Incident Report". The handwritten incident report was dated 8/12/14 1530 (3:30 p.m.) and was completed as follows: "Describe Injury: observed fall Equipment in use: wheelchair Activity: From chair without assist Location of occurrence: Resident's room Physical Restraints: "in use at time of incident" was checked Type of Restraint: chair alarm Narrative of incident and Description of Injuries: "Resident fell forward with spastic reflex OOw/c (out of wheelchair) while receiving a hair cut. Laceration to R forehead noted. moderate bleeding. pressure dressing applied. Sent to ER (emergency room ) for TX (treatment)." Handwritten at the bottom of the incident report form read "IDT (Interdisciplinary team) review staff + IDT intervention for this occurrence is to have someone to assist with hair cuts." An "Incident Statement" was completed by the barber on 8/12/14. The statement read " I was cutting ____ hair, then she jumped out of the chair, landed on head." An incident statement was also completed by the 3-11 shift nurse working at the time of the fall on 8/12/14. The statement read "Resident fell forward OO w/c (out of wheelchair) while receiving hair cut. Hitting head on floor." The "yes" box was checked next to the statement "I saw the incident." An incident statement was completed by Certified Nursing Assistant E (CNA E) on 8/12/14. The statement read "_____ were sitting in the wheel chair getting her hair cut. Next thing I know she just jumped out of the chair head first." The "yes" check box was marked next to the following statements: "I was assigned to this resident" "I saw the incident" "I am aware of assistive devices use by this resident" "If so, I saw the assistive device in place at the time of occurrence" Another form titled "Fall Investigation, Evaluation, and Interventions" was attached to the incident report. The form was dated 8/12/14. The form was completed as follows: Location of fall: room How did resident fall: fell out of chair Protective Devices: "Chair alarm" was circled. "Lap Buddy" was a choice, but it was NOT circled. Current restraint/protective device orders: chair, bed alarm In total, the investigation included three investigative forms and three witness statements. There is no mention of the use of the lap buddy anywhere in the investigation. The lap buddy was never indicated as one of Resident #9's current restraints or protective devices anywhere in the investigation. The investigation documented that Resident #9 used a chair alarm. A review of the clinical record revealed that the chair alarm had been discontinued on 7/18/14. The telephone order read "7/18/14 Per team discussion D/C (discontinue) chair alarm as resident no longer needs alarm." On 12/9/14 at 4:30 p.m., Resident #9's lap buddy use was discussed with the Administrator and Director of Nursing (DON). The DON was asked to look and see if she could find the original order for the lap buddy. On 12/10/14 at 9:15 a.m., the Administrator provided an order for [REDACTED]. It was dated 12/9/14 and signed by Registered Nurse A (RN A). The order read "Helmet to be worn daily, remove for bathing, skin assessments ETC. Lap buddy when up in w/c (wheel chair) R/T (due to ) muscle spasms. Clarification order." The original lap buddy order could not be located. On 12/10/14 at 10:25 a.m., the Administrator and DON were notified that Resident #9's fall was being considered as a situation of harm. They were asked to provide any further information regarding the incident. On 12/10/14 at 11:30 a.m., the DON provided a copy of the Resident Incident Report, the same report that had been provided by the Administrator on 12/9/14. The reports were compared. The copy provided by the DON had been altered. Additional information regarding the use of the lap buddy had been written into the report in two different locations. In addition, a witness statement was added to the investigation. The DON was informed that the two investigations were different. She was asked how that could happen. She stated that she did not know why the reports were different. The Quality Assurance Nurse (RN B), DON and Administrator met with the survey team at 11:45 a.m.. RN B stated she added the lap buddy onto the incident report after talking to staff member (LPN A) who had witnessed Resident #9's fall. RN B stated that she took LPN A's witness statement that morning (12/10/14). LPN A's witness statement was added to the second copy of the investigation. Although LPN A's witness statement was taken on 12/10/14, it was dated 8/12/14. LPN A was interviewed on 12/10/14 at 12:30 p.m. LPN A was asked to describe Resident #9's fall on 8/12/14. LPN A stated that the incident happened around shift change and she was still at the facility. She stated that all staff were standing behind the nursing station. Resident #9's room was directly in front of the nursing station. LPN A stated that Resident #9's wheelchair was near the doorway facing out of the door while she was getting her hair cut. LPN A stated that Resident #9 fell out of the wheelchair, hitting her head on the hallway floor. When asked if Resident #9 was wearing her lap buddy, LPN A stated she doesn't know if the lap buddy was on at the time but stated that staff had put it on her around 2:30 or 3:00 that day. LPN A stated that staff would have gotten Resident #9 up out of bed right before the barber arrived. CNA E, a staff member who gave a witness statement for the investigation, was interviewed on 12/10/14 at 11:30 a.m. CNA E was asked if she remembered the incident. She stated yes. CNA E was asked if she witnessed the fall. She stated yes. CNA E was asked if Resident #9 was wearing her lap buddy when she fell . CNA E stated she doesn't remember seeing the lap buddy but can not say for sure if it was on at the time. According to witness statements and the investigative forms completed as a result of the incident, there was no evidence that Resident #9 was wearing her lap buddy at the time of her fall.

Based on observation, staff interview, facility documentation and clinical record review, the facility failed for two residents (Resident #1 and Resident #3) in a survey sample of 22 residents, to prevent, assess and timely treat two residents with pressure ulcers. 1. For Resident #1 the facility staff failed to identify the resident as at risk for pressure ulcer development. Due to a lack of nursing assessments and care planning, Resident #1 developed eschar (dead tissue) at the base of the 3rd right toe on 4/25/13. 2. Resident #3's bilateral heel ulcers were not identified (assessed) until they were 'discolored'. Four days later the heels developed in to eschar (necrotic or dead tissue) on both heels. The findings included: 1. For Resident #1 the facility staff failed to identify the resident as at risk for pressure ulcer development. Due to a lack of nursing assessments and care planning, Resident #1 developed eschar (dead tissue) at the base of the 3rd right toe. Resident #1, a [AGE] year old, was admitted to the facility on [DATE] with a readmit on 1/1/13. Her [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 9/25/13. She was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required some assistance with her activities of daily living. Resident #1 was readmitted to the facility from the hospital on [DATE]. She was readmitted with a right foot sprain, right ankle sprain and [MEDICAL CONDITION] second toe. On 1/9/13 she was ordered to wear a Cam walker boot on the right lower leg. Nurse's Notes dated 1/9/13, 1:00 p.m. documented a consult from the orthopedic doctor. The note read, "Resident returned at this time n.o. (new order) elevate (R) foot/ ankle. ice pack to (R) foot/ ankle prn (as needed) for swelling, may wt. (weight) bear as tolerated on (R) leg, ordered tall CAM walker (R), will consult with orthopedic resident did not walk prior to this incident F/u (follow up) appt.(appointment) 3-4 weeks dx (diagnosis) (R) ankle sprain, (R) foot sprain (R) 2nd toe fx (fracture). clarified (R) CAM boot, take wrap off leg splint when CAM walker available." Nurse's Note dated 1/9/13, 2:45 p.m. read "order clarified from MD (doctor) wants to keep order for CAM walker boot. N.O. (new order) OT (occupational therapy) to eval (evaluate) + TX (treat) R/T (due to) CAM walker. Resident #1 was treated by Occupational Therapy (OT). The Cam walker boot was assessed. Assessments were documented on the following dates: 1/9/13 "Experienced right foot sprain, right ankle sprain and fracture of right second toe." "RLE (right lower extremity) is wrapped in half shell and bandage. Cam walker obtained and fitted." 1/10/13 "Pt (patient) was monitored for pressure and reddened areas with orthotic." 1/14/13 "Pt provided with RLE positioning with orthotic including donning and checking for reddened or pressure areas." 1/18/13 "Resident stated she was experiencing pain in foot at night. Reviewed wearing time and fit of boot. Pain reported to nursing." 1/30/13 Discharge Summary: Resident seen for evaluation and 11 treatment sessions to procure and fit Cam walker per physician's orders [REDACTED]. Resident refuses to wear boot at night in bed, so used when out of bed. Resident tolerates without difficulty, redness nor pain. Staff instructed in application, precautions and removal. Instructions placed in medical record. Discharge resident from OT effective 1/30/13." While there is no mention of drainage in the OT notes, a nursing note dated 1/23/13, 3P. read "Resident noted while in with therapy that clear drainage noted d/t (due to) [MEDICAL CONDITION] under boot, abd. (abdominal) pad applied to protect skin under boot will monitor. Dr.____ made aware." The wound care nurse (RN 2) first began treating Resident #1 for an area between the 3rd and 4th right toes on 1/27/13. RN 2's initial wound care note read "Resident has a very painful stage II ulcer between 3rd and 4th toe on R ft (right foot). R foot has 4+ [MEDICAL CONDITION] and red. Small amt (amount) of serosanguoneous drainage noted ulcer was cleaned with NS (normal saline) and [MEDICATION NAME] oint was applied." Nurse's Notes dated 2/6/13, 11:00 a.m. noted the right foot to be swollen. The notes read "Areas noted (R) foot swollen scabbed area noted between 3rd & 4th toe cleansed with wound cleanser open area noted." Another Nurse's Notes dated 2/6/13 at 12:00 p.m. read "To appt. to Dr.____ office for F/U appt. note attached to check between 3rd & 4th toe as well." An order was written for "[MEDICATION NAME] ointment between 3 & 4 toe q day until healed." RN 2's "Wound/ Skin Healing Record" was initiated on 1/27/13. On 1/27/13 RN 2 documented that the area between the toes was a stage II measuring 1.0 x 1.0 x <0.1 centimeters. RN 2 continued to assess and treat Resident #1's wound weekly. She completed assessments on 2/4/13, 2/11/13, 2/19/13, 2/25/13, 3/5/13, 3/12/13 and 3/18/13. She documented the area as healed on both her wound nurse's notes and the Wound/ Skin Healing Record on 3/18/13. An interview was held with RN 2 during the afternoon of 11/21/13. RN 2 was asked to review the pressure ulcer prevention interventions, skin assessments and skin treatments that were in place for Resident #1 at the time of the development of the toe wound. RN 2 stated that she identified the area between Resident #1's toes on 1/27/13 during her weekly wound rounds. RN 2 stated that the area was probably caused by Resident #1's gout. RN 2 stated that the area was a reoccurring area. During the interview, RN 2 was shown the nursing note dated 1/23/13 that documented the drainage observed by the OT. RN 2 stated that she had not been notified of the drainage and had identified the wound herself on 1/27/13 during wound rounds. RN 2 was asked again to provide the pressure ulcer prevention care plan that was in place for Resident #1 prior to the development of her toe wound. She was also asked to provide any skin related information, to include the nursing assessments of the skin. The Director of Nursing and Administrator were asked for the pressure ulcer prevention care plan and any other documents related to Resident #1's skin at the end of day meeting on 11/21/13. On 11/22/13 at 9:40 a.m., RN 2 provided documentation of the nursing skin assessments. When asked for the pressure ulcer prevention care plan, RN 2 stated that one had not been developed. RN 2 was asked if the use of orthotic equipment such as the Cam boot was cause for the development of a pressure ulcer prevention care plan. RN 2 stated yes. When asked how frequently the nursing staff should assess the resident's skin, RN 2 stated that skin should be checked every shift daily. The facility's "Prevention of Pressure Ulcers" policy was reviewed. The following information was from the "General Guidelines" section of the policy: "2. The most common site of a pressure ulcer is where the bone is near the surface of the body including back of head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes." And "3. Pressure can also come from splints, casts, bandages, and wrinkles in bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected." The facility completed a "Nursing Weekly Summary" form for each resident. The summary form included four diagrams of the body: front view, back view, right view and left view. The form read "Mark the locations of skin conditions/ wounds etc. on illustrations below." The form also allowed space for a narrative to be written. The following was a summary of the skin assessments completed in the Nursing Weekly Summary for Resident #1: 1/25/13 "Skin w/d (warm and dry) and intact." Nothing marked on the body diagrams. 2/1/13 "Skin w&d (warm and dry) to touch." Nothing marked on the body diagrams. 2/8/13 "No new breaks or bruises of the skin." Nothing marked on the body diagrams. 2/15/13 "Skin warm & dry to touch with several multiple healed areas observed to rt (right) side of face." "Continues wearing a brace to her (Rt) leg." The front view body diagram indicated "multiple healed areas to R side of face and "brace to (R) leg." 2/22/13 "Skin warm & dry to touch with no new open areas or bruises noted." The front view body diagram indicated "multiple healed areas to R side of face and "brace to (R) leg." 3/1/13 "Skin warm & dry to touch with no new broken areas or bruises." Written across the body diagrams read "No new open areas or bruises." 3/8/13 "Skin warm & dry to touch with no new open areas or bruises noted." Written across the body diagrams read "No new open areas or bruises." 3/15/13 "Skin warm & dry to touch with no new open areas or bruises noted." Written across the body diagrams read "No new open areas or bruises." 3/22/13 "No new open skin areas noted." Nothing marked on the body diagrams. 3/29/13 "Skin warm & dry to touch with no new open areas or bruises noted." Nothing marked on the body diagrams. The wound care nurse treated Resident #1 for the toe wound from 1/27/13 to 3/18/13. None of the Nursing Weekly Summaries completed during that time period indicated that Resident #1 had a wound between her right toes. The use of the CAM boot was mentioned in two notes, 2/15/13 and 2/22/13. An interview was held with Certified Nursing Assistant (CNA) 2 on 11/22/13 at 10:40 a.m. CNA 2 was asked when she was supposed to assess a resident's skin. CNA 2 stated that she was supposed to assess the skin when she gave the residents their baths. She stated that the skin check was a head to toe assessment to include the bottom, knees, feet and elbows. She stated that residents are to have bed baths every day. When asked what she was supposed to do if a resident wore a piece of therapy equipment or device, CNA 2 stated that she was supposed to remove the device and check under the device. She stated that if an area of issue was identified, she was supposed to report it to the nurse so the area could be assessed. When asked how she documented that care was provided, CNA 2 stated that the CNA's documented on the "ADL (Activities of Daily Living) Flow Record." When asked if she was supposed to sign the sheet, CNA 2 stated the CNAs were required to sign the back of the ADL Flow sheet everyday. Resident #1's ADL Flow Sheets were reviewed for January, February and March of 2013. CNAs did not sign the ADL Flow Sheet approximately 29 days for one or more shifts. The MDS completed after Resident #1's fall was reviewed. The MDS was a significant change MDS with an ARD of 1/3/13. Section M0150 asked "Is resident at risk of developing pressure ulcer?" The facility coded "No" as the answer to this question. The MDS coding was reviewed with RN 2 during the 11/22/13 interview. RN 2 stated that when a resident has a wound, the MDS staff would ask her about the resident's skin so that they could code the section. Section M, Skin Conditions, was signed as completed by the MDS staff. The 1/3/13 MDS was reviewed with LPN 1, MDS staff, on 11/22/13 at 10:10 a.m.. LPN 1 stated that if the Resident had an actual open area, then RN 2 would complete Section M on the MDS. If there was no open area, then LPN 1 stated that she would complete Section M. When asked how she determined which residents were at risk for skin breakdown, LPN 1 stated that "everyone is at risk for skin breakdown." When asked why she coded Resident #1 as "No" for the risk of developing a pressure ulcer, LPN 1 stated that Resident #1 was continent of bowel and bladder and therefore not at risk for a pressure ulcer. When asked about the lack of a pressure ulcer prevention care plan, LPN 1 stated that she included the pressure ulcer to an existing care plan after the wound area on the toe developed. A quarterly MDS with an ARD of 3/31/13 was completed for Resident #1. This assessment was completed after the wound nurse documented the stage II toe wound as healed on 3/18/13 and after the podiatrist documented an open area between the same toes on 3/25/13. Section M0150 asked "Is resident at risk of developing pressure ulcer?" The facility coded "No" as the answer to this question. Section M0210 asked "Resident has Stage 1 or higher pressure ulcers?" The facility coded "No" as the answer to this question. The facility form "Resident Data Set" was completed by the Unit Manager on 3/31/13. This was a quarterly assessment which aided the completion on the MDS. Section P was titled "Foot Problems and Care." Under "Infections of the Foot" the box "Open [MEDICAL CONDITION] on the foot"was checked. Under "Preventative or Protective Foot Care" the box "Application of dressings with or without medications" box was checked. The care plan that was updated by LPN 1 when the toe wound developed was dated 7/11/12. The problem for this page of the care plan read, "High risk for increase bleeding R/T Anti-coagulant: resident currently takes: 1.[MEDICATION NAME] 2. lovonox 3.[MEDICATION NAME] 4. ASA related to poor circulation." Handwritten under the problem section read "2/6/13 open area rt. foot between 3rd and 4th toe stage II." "3/5/13 stage II ulcer between 3rd and 4th toe improving (less than) <0.5x W0.5 x <0.1" And "3/8/13 DC (discontinue) tx (treatment) to R (right) toe ulcer healed." Handwritten under the "Approaches" section read "*monitor for swelling *To orthopedic clinic 2/6/13 *pain meds prn." Handwritten under the "Comments" section read: "2/7/13 seen by MD on 2/6/13 Apply [MEDICATION NAME] until healed. Return to appt (appointment) per orders." "2/7/13 Resident will not keep boot on at all times she taken it off because she said it hurts. will evaluate." "4/3/13 No prob noted" "7/3/13 no bleeding noted." After Resident #1's wound was documented as healed by the wound care nurse, Resident #1 was seen by the podiatrist on 3/25/13. The podiatry note read" Full thickness ulcer on lar. (lateral) aspect of base of 3rd right toe, within interspace. + redness surrounding ulcer and along dorsal foot + pink granular base and yellow crushing. + severe pain." "Prescribe Keflex 500 mg #14 1 tab po bid." "Recommend: Application of wound gel and ulcer medication daily." A Nurse's Note dated 3/27/13 9:30 a.m. read "N.O (new order) per Podiatrist keflex 500 mg (miligrams) #14 1 po (by mouth) bid (twice a day). Application of wound gel (decrease) ulcer medication daily w/ dsd. ulcer (R) between 3rd toe." A review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Both were continued through the end of March. The April 2013 MAR indicated [REDACTED]. No evidence was provided to suggest that the wound care nurse resumed following Resident #1's toe ulcer after the 3/25/13 podiatry visit when the physician documented an ulcer. Resident #1 visited the podiatrist on 4/25/13. "Reason for visit" read "Continuing care for ulcer R 3rd toe. Last eval 3/25/13." The assessment read "R 3rd toe laterally at base has firmly attached honey-colored eschar. + discomfort with compression of toe. + mild red discoloration. No obvious drainage. No active open lesion." "Other: Ulcer- R 3rd toe- stable." No evidence was provided to suggest that the wound care nurse resumed following Resident #1's toe ulcer after the 4/25/13 podiatry visit when the physician documented an ulcer with eschar. No evidence was provided by the facility to document what type of care was provided to the Resident's wound once identified by the podiatrist. Resident #1 visited the podiatrist on 7/23/13. The assessment read "Heavy debris between all toes (lotion, dead skin, lent) No open [MEDICAL CONDITION] of toes or feet. + severe pain." "Recommend: Wash and dry thoroughly between all toes." The issues with Resident #1's toe wound, to include lack of a pressure ulcer prevention care plan, MDS coding, timing of initial treatment, lack of assessment and treatment after doctor visits and lack of CNA documentation, was reviewed with the DON and Administrator at 11:45 a.m. on 11/22/13. No further information was provided regarding Resident #1's skin or wound. 2. Resident #3 was admitted to the facility 2/18/10. [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8/29/13 was coded as a quarterly assessment. Resident #3 was coded as having short and long term memory deficits and required total assistance in making daily life decisions. The resident was unable to understand others or make self understood. Resident #3 was also coded as requiring total assistance of one staff member to perform activities of daily living, such as bed mobility. Resident #3 was coded as being at risk for the development of pressure ulcers and one pressure ulcer was coded on the quarterly MDS assessment as being a stage 2. This was later determined to be a buttocks wound that had healed. On 11/19/13, during the initial tour, RN (registered nurse) 2 stated, "This resident has two heel pressure ulcers with eschar." The wounds were acquired." (occurred within the facility). The resident's heels were elevated, and bilateral heel boots were in place. On 11/20/13 at 10:00 AM, wound care observation was conducted by RN (2). Heel boots and soiled dressings were removed from both heels. On the right heel, an area of black, dry tissue (eschar) of approximately 4-5 cm (centimeters) was present. An area of similar size was on the left outer heel with dry, black eschar. The areas were treated with [MEDICATION NAME] spray. Review of the facility's clinical record revealed a nurse's note dated 10/10/13 at 10:40 AM, which read: "N.O. (new order) granulax spray to bilateral heels qd (every day) discoloration noted...orders also received for air mattress and heel protectors to both feet." On 8/29/13, a Braden risk assessment (assessment used to determine risk of developing pressure sores) was scored as a "13" or moderate risk. Review of the record revealed physician orders [REDACTED]. Air mattress on bed per protocol. Heel protectors to bilateral feet per protocol." Weekly skin assessment for the week of 10/4/13 read as followed: "No changes in skin, small areas on bottom dressed qd with coversite. No other open areas." The weekly skin assessment for the week of 10/18/13 (after the development of heel wounds ) read as followed: "Sacral dressing qd with Coversite." No mention was made of the heel wounds. Weekly wound assessment reports revealed the following: 10/14/13: Right heel- new wound, unstageable wound. 5.0 cm length, width 2.0 cm, depth 0.10 cm. 10/14/13: Left heel- new wound, unstageable wound. 5.0 cm length, width 2.0 cm, depth 0.10 cm. 11/11/13: Right heel. 4.0 cm length, width 2.00 cm, depth 0.10 cm. Improvement seen. 11/11/13: Left heel. 4.0 cm length, width 2.00 cm, depth 0.10 cm. Wound showing signs of improvement. Review of the care plan dated 4/11/12, under the heading of Incontinent of bowel and bladder, risk for pressure ulcers, revealed the following interventions: "Apply protective ointment to affected areas, wash and dry after each soiling, Nurse to report any skin breakdowns to MD, CNA (certified nursing assistant) to report any redness or skin breakdown to nurse, encourage resident to ask for assistance, place call light within easy reach, change briefs at frequent intervals, continue to monitor for signs and symptoms of infection, treatment per order, follow up appointment with MD per orders." There was no mention of protective measures for the heels, such as floating heels or heel boots. On 10/14/13, a new care plan was developed to include bilateral heel ulcers. Interventions included: "Use heel protectors, turn and reposition frequently, report any red or open areas to charge nurse, and follow facility protocol for treating breaks in skin integrity/pressure ulcers." On 11/20/13 at 10:20 AM, RN (2), the wound nurse was interviewed. She stated, "The CNA notified me, the wounds started off as unable to stage wounds (UTS)." She went on to state they were "dark" and that "heels were floated and heel boots were in place " prior to the development of heel wounds. Review of the care plan, TAR's (treatment administration record) did not contain documentation of heel boots or interventions to float heels. On 11/20/13 at 2:00 PM, an interview was conducted with LPN (licensed practical nurse) 4, the medication and treatment nurse for Resident #3. She stated, "We started the heel boots when her heels became discolored." On 11/21/13, at 9:45 AM, CNA (3) was interviewed. She stated, "She had the heel booties in place for a long time, I would put them on her." Guidance provided at www.NPUAP.com defined an unstageable pressure ulcer as follows: "The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Note the phrase "the base of the ulcer" is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (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." The article "Prevention of heel ulcers in an orthopedic unit", from Nursing Times .net, June 18, 2002, stated, "Although tissue breakdown is a complex multifactorial process, the focus with pressure ulcer development in the heels is on extrinsic factors such as pressure, shear and friction, with the most plausible explanation being the failure to relieve pressure. While many advances, such as pressure-relieving mattresses and beds, have greatly reduced the incidence of sacral ulcers (Blasczczyk et al, 1998). Krasner (1987) recognized that, even with pressure reduction, most support surfaces do not adequately relieve heel pressure." The NPUAP (National Pressure Ulcer Advisory Panel) advises "Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use." Review of the facility's policy for "Prevention of Pressure Ulcers", under general guidelines, Point 1 read as followed, "Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation to that area and subsequent destruction of tissue." Point 6 included the following: "The facility should have a system/procedure to assure assessments are timely, and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed." Under risk factor- Immobility, point C addressed "When in bed, every attempt should be made to float heels (keep heels off bed) by placing a pillow from knee to ankle or with other devices recommended by therapist and prescribed by the physician." On 11/21/13 at 3:30 PM, an interview was conducted with RN (2) and the DON (director of nursing). RN (2) stated, "The heel wounds occurred while we kept her in bed during the healing of the right buttocks wound." When asked if it is usual for wounds to be discovered with eschar, the DON stated, "no", and went on to state her expectation was for "CNA's to report changes in the skin." The DON was notified at this time of a potential harm level deficiency.

Based on observation, clinical record review and staff interview, the facility staff failed for one resident (Resident #1) of 22 residents in the survey sample, to prevent the development of a pressure sore and the facility failed to provide treatment and services to promote healing of an existing pressure sore. 1. Resident #1 developed a deep tissue injury wound on the left heel, which was noted on 1/6/12. 2. Resident #1 was observed without a dressing over the stage 3 sacral wound. The sacral wound was noted on 12/15/11 as a "shallow crater". The 12/19/11 measurement for the sacral wound was 2.0 X 1.0 cm (centimeters) and having a depth of 0.1 cm. with wound bed containing slough. On 1/6/12, the wound measured 2.0 X 2.0 cm, with a depth of 0.2 cm. 3. The facility failed to provide a specialty low air loss mattress as ordered on [DATE] by the physician for Resident #1. The findings included: Resident #1, an [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's most recent MDS with an ARD (assessment reference date) of 10/20/11 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 12 or being cognitively intact. Resident #1 was coded as requiring total one person assistance with activities of daily living. Resident #1 was also coded as having an indwelling catheter. The resident did not have a pressure ulcer coded on the MDS. On 1/15/12 at 8:15 AM, Resident #1 was observed during a bed bath. CNA (certified nursing assistant) (A) lowered the head of the bed and closed the curtains. The resident was not on a pressure relieving mattress. After the resident's face and front of the body was cleansed, the resident was turned to her side. A stage 3 pressure ulcer was observed on the sacrum without a dressing. There was no soiled dressing in the bed. The ulcer had yellow slough on the wound base. The CNA covered the resident and left the room. Upon re-entering the room the CNA stated, "the nurse told me to do this until she can do wound care. The CNA then covered the ulcer with a washcloth. A brief was applied. The CNA stated, "She had no dressing on at all this morning" when asked if she knew when the dressing was removed. According to the National Pressure Ulcer Advisory Panel, a stage 3 is defined as "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." Nurses notes, dated 12/15/11, described the sacral wound as a " shallow crater. " A new order for [MEDICATION NAME] every three days was initiated. The wound tracking for the sacral ulcer on 12/19/11 described the wound measurements as 2.0 X 1.0 cm (centimeters) and having a depth of 0.1 cm, with the wound bed containing slough. The wound was staged as a stage 3. The wound tracking for the sacral wound on 1/6/12 described the wound as measuring 2.0 X 2.0 cm, with a depth of 0.2 cm. CNA (A) proceeded to finish the bath. The resident's heels were resting on the mattress (not suspended off the mattress). The heels were covered by heel boots (Bunny boots), which the CNA removed. On the left heel's outer edge, an area of dark red to purple approximately 2 cm (centimeters) was present. The CNA cleaned the lower extremities and replaced the heel boots. On 1/6/12 at 8:15 AM, LPN (A) wrote the following weekly skin assessment documentation for the left heel as, " deep tissue injury left heel, dark purple in color- heel protectors and heels floated. " The National Pressure Ulcer Advisory Panel NPUAP) describes a deep tissue injury as" purple or maroon localized 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 preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. " The NPUAP describes the following use of support systems for the prevention of heel ulcers: 3.1. Ensure that the heels are free of the surface of the bed. 3.2. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. Hyperextension of the knee may cause obstruction of the popliteal vein, and this could predispose an individual to [MEDICAL CONDITION]. 3.3. Use a pillow under the calves so that heels are elevated (i.e., " floating " ). Using a pillow under the calves elevates the heels from the mattress. 3.4. Inspect the skin of the heels regularly. On 1/5/11 at 9:05 AM, LPN (licensed practical nurse) (A) went to Resident #1's room to do wound care. Supplies were brought into the room and placed on the bedside table. The table had not been cleaned or covered. Two tubes of ointment, Santyl and [MEDICATION NAME], were placed on the table. LPN (A) washed her hands, applied gloves, removed the washcloth, and cleansed the wound with wound cleanser. The gloves were removed and her hands washed. Santyl and [MEDICATION NAME] were applied to 4X4's and placed on the wound. The 4X4's were covered with a Coversite dressing. The tubes of ointment were replaced on the cart. The clinical record was reviewed. Nurses notes dated 1/4/12 documented a skin assessment which included "sacral ulcer 3 X 3 cm 1" (inch) depth. Cleansed and redressed with Santyl and [MEDICATION NAME]- position changed." There was no mention or wound tracking for the left heel wound. Wound tracking for the sacral ulcer revealed the resident developed a "shallow crater" on the sacrum on 12/16/11. On 12/19/11, the treatment protocol for a stage 3 and stage 4 ulcer was initiated. A Braden scale (risk assessment for pressure ulcers) was completed on 12/7/11 with a score 20 (15 or greater is at high risk). Review of the wound care management standard orders dated 12/19/11 for stage 3 and stage 4 ulcers with necrosis included the following and was signed by the physician on 12/19/11: 1. Dietary consult 2. Weigh weekly 3. Labs: [MEDICATION NAME] every 3 months until wound is healed 4. Initiate wound care documentation record 5. Reposition every 2 hrs. Avoid pressure to the affected areas 6. ZBEC vitamin 1 tablet by mouth 7. Provide low air loss mattress 8. Notify Responsible party 9. May insert Foley catheter to prevent contamination of wound. treatment of [REDACTED]. 1. Gently cleanse area with wound cleanser 2. Apply protective cream to wound edges 3. Apply thin layer of Santyl ointment to sterile 4 X 4. If yellow slough is present, apply antibiotic ointment such as [MEDICATION NAME]. Place antibiotic ointment against wound bed, then apply Santyl 4. Apply dressing loosely into wound bed, cover with 4X4's, ABD pad then secure with tape or Kling; date and initial 5. Change dressing every day and as needed On 1/5/12 at 11:00 AM, Resident #1 was observed up in the geri chair in the room. There was no specialty mattress on the bed. On 1/5/12 at 2:00 PM, the resident was observed in the bed. A low air loss mattress was present. The care plan dated 12/19/11 for a stage 3 pressure ulcer to the sacrum was reviewed. The interventions included "will apply an air mattress to the bed." An intervention dated 1/5/12 read: "Air mattress placed on bed." On 1/6/12 at 8:20 AM, the clinical record was reviewed. LPN (A) was writing a note regarding the deep tissue injury of the left heel. LPN (A) went to the room with writer, and the left heel was examined. LPN (A) stated, "The CNA did not tell me about the area, I did a body check today." The LPN stated, "the air mattress was not on until yesterday." On 1/6/12 at 11:50 AM, the DON (director of nursing) and Administrator were notified of harm level deficiency. On 1/6/12 at approximately 1:00 PM, the DON presented the following "Protocol for unavoidable acquired pressure deficits." dated 1/6/12. This included the following risk factors: incontinence of bladder and bowel, severe [MEDICAL CONDITION], depression, immobility, [MEDICAL CONDITION] medications and the HOB (head of bed) elevated due to medical necessity. Comments included "resident prefers to stay on back, and refuses to get OOB (out of bed) 3-4 days a week."

Based on observation, clinical record and facility document review, staff interview and in the course of a complaint investigation, the facility staff failed to prevent the development of pressure areas for 1 Resident (Resident #1) of 22 residents in the survey. This resulted in the amputation of Resident #1's leg. Resident #1 developed pressure areas on the left leg from a splint, which was left on after pressure areas were noted from the splint, resulting in an above the knee amputation of the left leg due to multiple pressure areas with eschar and exposure of bone. The findings included: Resident # 1, a [AGE] year old, was originally admitted to the facility on [DATE], with the most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), with an assessment reference date of [DATE], was completed for a quarterly assessment. Resident # 1 was coded as a "3" on the BIMS (brief interview mental status) or as being cognitively impaired. Resident #1 was coded as totally dependent on staff for all activities of daily living. The resident was coded as incontinent of bowel and as having a Foley catheter. Resident #1 was coded as having one stage 4 pressure ulcer measuring 4.0 cm by 4.5 cm (centimeter), with a depth of 0.8 cm. A stage IV pressure ulcer is described as a full thickness loss of skin and subcutaneous tissue, exposing muscle or bone (Clinical Practice Guideline, treatment of [REDACTED]. ,[DATE] pg. 1,2). On [DATE] at 8:15 AM, Resident #1 was observed sitting up in the bed, eating breakfast. The resident had a wound vac and an air pressure mattress. The Foley had a privacy cover. The spouse was at the bedside and stated, "She has been here about a year. She had her leg amputated because she had pressure sores under the splint." The resident was observed from 8:45 AM through 10:45 AM, at which time the resident was repositioned by staff. On [DATE], observation of the sacral wound treatment was done by RN (registered nurse) #1, designated as the wound nurse. The nurse began by cleaning the table and covering the table. Supplies were opened onto the clean area and a red bag was in place for the soiled items. The container for the wound vac drainage was emptied of a large amount of bloody fluid. The nurse removed her gloves, washed her hands and proceeded to remove the transparent dressing. The wound was noted to have a dark wound bed with some eschar and undermining present. The area surrounding the wound bed was red to approximately 3 cm from the wound. The nurse removed the gloves, washed her hands and asked the resident if she was OK, and the resident nodded. The wound was cleansed from inside to out, bone was visible. The nurse then cut black foam to fit the wound, and applied the transparent dressing over the wound. The suction tube was attached with good suction present. The nurse then disposed of unused items, and the scissors were cleaned. Privacy was maintained throughout the dressing change and the resident did not voice any pain during the procedure. Review of the clinical record revealed that on admission, the resident was noted to have a stage 1 on her sacrum and both heels were noted to be boggy and red. "Nonblanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, [MEDICAL CONDITION], induration, or hardness may also be indicators. " (Clinical Practice Guideline, treatment of [REDACTED]. ,[DATE] pg. 1). The resident had multiple risk factors including weight loss, low [MEDICATION NAME] of 2.9 (normal 3.2 to 4.5), and preference to stay on her back. On [DATE], the resident went out to an orthopedic appointment. She returned with a left leg immobilizer. The correspondence note read as follows: "Plan, Knee immobilizer LLE (left lower extremity, can remove immobilizer for skin care." On [DATE], a PT (physical therapy) note identified the risk of pressure ulcers related to it's use. It read as follows: "Pt (patient) new splint provides increase pressure secondary to nature of splint promoting extension and pt having constant muscle contraction toward flexed posture. Discussed this with nursing, but husband very intent that splint stay on per MD." On [DATE], a PT read, "when splint opened for exercise, pt had significant signs of pressure at patella (kneecap), post (posterior) calf, head of fibula and made nurse in charge as well as wound care nurse aware. Advised strongly that MD should be contacted due to skin integrity problems elsewhere that did not have the added pressure splint was providing. Padded splint with COTA (certified occupational therapy assistant) but advised that LPTA (licensed physical therapy assistant) felt risk of constant wear outweighed risk of hip integrity at this time. Nurse contacting pt's MD (name of attending physician). There was no note of discussion of pressure areas by splint, but an order for [REDACTED]. The orthopedic physician was not notified. Resident #1 ' s care plan contained an entry dated [DATE] for " immobilizer left leg. " There were no interventions included to address the immobilizer. On [DATE] (Saturday), a nurses note read: "Splint on left leg." No assessment of skin under splint was documented. On [DATE] (Sunday), noted, "brace on left leg." Again, no documentation of the skin under the brace was noted. On [DATE], a nurses note contained the following: "splint left leg new bruising to top of left knee, inner knee, and calf, ?? splint rubbing leg, OT (occupational therapist) to exam." A later note at 5:00 PM, in which the MD called that labs were received, and the [MEDICATION NAME] was decreased to once per day. "Res (resident) has multiple bruising to inner leg where immobilizer is stationed, immobilizer taken off at this time." Suspected Deep Tissue Injury: According to the AHCPR, "Purple or maroon localized 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 preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. In addition, Bruising indicates suspected deep tissue injury." On [DATE], a nurses note contained the following: "Therapy removed splint on left leg, they reported area red and starting to break down from pressure of this splint. Left lateral leg 4.0 X 3.5 w (width) brown skin intact. Red knee cap. Left lateral knee 1 X 1 red area, 4 X 3 area left lateral and posterior lower leg dark skin intact.... Dr. (name of attending physician) agrees no brace and notify ortho MD to schedule an appointment ASAP (as soon as possible)." There were no wound tracking or treatment orders at that time. The facility policy and procedure on splints defines a splint as a device used to support, immobilize, or correct a displaced or deformed joints. It also included the following: "observe for skin redness, discoloration, breakdown, swelling, or pain/discomfort before and after the use of the splint." On [DATE], the resident went to the orthopedic doctor. The correspondence report was as follows: "deep abrasions over the anterior knee/posterior knee thigh/posterior thigh/posterior calf/anterior aspect of distal third leg. Full thickness decubitus sore over the fibular head left. Stage 2 pressure sores over multiple areas of left foot. Stage ,[DATE] (,[DATE]) decubitus sore over the left heel. Treatment orders were written to clean areas of left leg with normal saline, apply [MEDICATION NAME] ointment, [MEDICATION NAME], cover with Kling. The wound tracking records dated [DATE] are as follows: left outer foot: 1.0 X 1.0, eschar (dead, devitalized tissue), onset [DATE] left outer ankle: 4.0 X 2.0, eschar, onset [DATE] left metatarsal joint: 0.8 X 0.8, eschar, onset [DATE] left top of foot: 2.0 X 2.0, eschar, onset [DATE] left outer knee: 2.5 X 2.0, eschar, onset [DATE] left knee: 3.5 X 1.0 , eschar, onset [DATE] left lower leg: 10.0 X 9.0, eschar, onset [DATE] left thigh: 6.0 X 4.0, eschar, onset [DATE] On [DATE], Resident #1 was admitted to the hospital for amputation of the left leg. The operative report for [DATE] detailed the following : "Has extensive stage 4 decubitus ulcers on this left lower extremity. The most significant decubitus ulcers on this left lower extremity are the left knee decubitus ulcer which has exposed bone (patella) and a large decubitus ulcer in the mid left foreleg overlying the calf area that goes down to the bone (fibula) and into the muscle which contained necrotic material and a deep abscess within the gastrocnemius muscle. Because of the extensive, multiple stage 4 decubitus ulcers down to the bone, tendon, muscle of the left lower extremity (more specifically the knee foreleg, ankle and foot), I have recommended a left above the knee amputation." On [DATE] at 8:00 AM, an interview was conducted with the Director of Nursing (DON), Assistant Director of Nursing (ADON), the wound nurse and the Administrator. The DON stated, "She came back from the orthopedic doctor with the splint. The spouse was adamant the doctor wanted the splint on at all times." The DON was asked if the orthopedic surgeon had been notified about the pressure areas, she stated, "I know we called him to schedule an appointment, I don't know what he was told." The wound care nurse was asked about wound documentation of these areas, to which she stated, "I don't measure stage I's, and the areas were not opened, we thought they were bruising." No wound care tracking or treatment for [REDACTED]. On [DATE] at 8:30 AM, the PTA (physical therapy assistant) stated, "She had rigid muscle tone in the left leg. Ortho ordered a splint for positioning that would keep the leg in neutral healing. The splint was opened and the leg had areas of pressure and redness. The splint was padded." On [DATE] at 10:30 AM, another interview was conducted with the DON, ADON and the Administrator. The DON stated, "PT notified nursing and nursing called the physician (attending) and the physician ordered blood work to rule out a clot. We thought the areas were bruising from the splint." When asked if she would expect nursing to check the area under the splint daily, the DON stated, "I would expect it to be removed for bathing." There was no documentation that the areas under the splint were assessed for continuing pressure until the following Monday ([DATE]). On [DATE] at 1:45 PM, an interview with CNA (certified nursing assistant) #2 was conducted as she had worked with the resident during the days of [DATE] through [DATE]. She stated, "She had a splint that went from her mid thigh to above the ankle. There were red areas where the "boning" in the straps were causing pressure. I showed these to her husband, and he said the doctor said I want that splint on." She went on to state there were "no changes during those days." When asked what her heels looked like, she stated, "there was nothing on her heels." It should be noted that the resident had eschar on both heels during this time. On [DATE] at 1:20 PM, the Administrator was notified of harm level deficiency. Complaint Deficiency