Every finding on record at Fredericksburg Health and Rehab

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to promote dignity for one of 4 residents in the survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to promote dignity. Resident #1 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1), hemiplegia (2) and hemiparesis (3) and aphasia (4). On the most recent minimum data set (MDS), a quarterly assessments with an assessment reference date (ARD) of 2/19/2026, the patient's BIMS (brief interview for mental status) score was assessed as ten out of fifteen, indicating moderate impairment for daily decision making. Section G coded R1 as dependent for showering and bathing. Section A coded R1's preferred language as English.On 5/5/2026 at 4:40 PM, an interview was conducted with R1. She stated, He told me I smell like fish. She stated there were two staff, but it was only the male who said she smelled like fish and Made fun of me. When asked she stated she reported the incident to her daughter. A follow-up interview was attempted but the resident was not available. On 5/6/2026 at 10:19 AM , an interview was conducted with CNA #3 (certified nursing assistant). She stated she recalled the incident that occurred with R1. When asked why do you feel R1 made the accusation. She stated because she and CNA #4 were talking in broken English, Creole. On 5/6/2026 at 11:27 AM, an interview was conducted with CNA#4. He stated he recalled the incident that occurred with R1. When asked if he laughed at her or said she smelled like fish, he said No. When asked what happened on that day, he stated that on the way to the shower, his coworker asked him, When are you going to cook us food. He said he told her he picked up fish and on Sunday he was cleaning fish for a couple of hours and he felt that his hands smelled like fish and the fish smell was on him. When asked why do you think R1 made the accusation he stated he did not know why but because of cultural differences sometimes when we speak the residents do not understand us. When asked how you can ensure a resident's dignity, he stated he was educated by his superiors, by not speaking in a foreign language while giving care to residents and being professional. On 5/6/2026 at 12:00 PM, an interview was conducted with LPN #6. When asked what steps were taken to investigate the allegation, she stated she and the director spoke to the R1 regarding the allegation and made sure R1was safe and they spoke to CNA#3 and #4 and educated themOn 5/6/2024 at 12:05 PM, an interview was conducted with the DON (director of nursing). When asked when were you notified of the allegation and by whom, she stated that the administrator received an email from corporate that notified us. When asked what steps were taken to investigate the allegation, she stated they narrowed it down to those who did showers on that day and were able to narrow it down to the two staff that showered R1. CNA#3 and #4 were called in and interviewed and the male staff was suspended. The DON was asked what actions were taken to prevent such further incidents. She stated they educated the two staff members and all staff not to speak in a different language and not to have personal conversations while taking care of residents as the perception of the resident can play a part in miscommunication. She further stated that she had the CNA #3 and #4 say to her what they were saying in their language at the time they were working with R1, and it was determined that one of the foreign language words could have sounded like R1's name. On 5/6/2026 at 1:15 PM, an interview was conducted with the Administrator. When asked how were you notified of the allegation and by whom, he stated he was notified by the Regional [NAME] President. He states that R1's daughter sent an email to corporate who then forwarded the email to him. When asked what steps were taken to investigate the allegation, he stated that he got with his team and interviewed R1. He further stated, the male staff was suspended and a facility reported incident was completed. He stated that educational in-services were completed to prevent further such incidents and they have tried to contact R1's daughter but she has not returned any calls. On 5/6/2026 at 1:20 PM, an interview was conducted with the DSS (Director of Social Services) and the SSA (social service assistant). When asked the SSA what was her involvement in the investigation, she stated I collected the resident's statement. When asked if she followed-up with R1, she stated that she had and she provided to the surveyor at approximately 1:40pm R1's Psychosocial Interview Tool, dated 4/29/2026. The DSS added that normally they would follow-up with a resident on the same day if they hear of it. When asked why are psychosocial assessments done, she stated because they do not know the impact an incident will have on a resident. A review of the facility's Resident Rights policy, effective 1/2017, revealed the resident has the right to be fully informed, in a language he or she can understand, of his or her total health status including, but not limited to, his or her medical condition. On 5/7/2026 at 2:40 PM, the Administrator, Director of Nursing, Unit Manager and the Regional Clinical Director were made aware of the concern. No further information was provided prior to exit. Reference:(1) Cerebral infarction- A cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. https://www.news-medical.net/health/Cerebral-Infarction.aspx(2)Hemiplegia- is the loss of muscle function in part of your body. https://medlineplus.gov/paralysis.html(3)Hemiparesis- Hemiparesis is one-sided muscle weakness. https://my.clevelandclinic.org/health/symptoms/24952-hemiparesis(4)Aphasia- Aphasia is a language disorder that makes it hard for you to read, write, and say what you mean to say. Sometimes it makes it hard to understand what other people are saying, too. Aphasia is not a disease. It's a symptom of damage to the parts of the brain that control language. https://medlineplus.gov/aphasia.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for two of six residents in the survey sample, Residents #2, and #3. The findings include:1. For Resident #2 (R2), the facility staff failed to post cautionary and safety signage, indicating the use of oxygen. A review of R2's clinical record revealed a physician's order dated 1/17/26 for oxygen at two liters per minute for shortness of breath. On 2/4/26 at 9:28 a.m., and 11:23 a.m., R2 was observed lying in bed, receiving oxygen at two liters per minute via a nasal cannula and oxygen concentrator. No cautionary and safety signs, indicating the use of oxygen, were observed at the resident's doorway or in the room. On 2/4/26 at 3:02 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated that when a resident is receiving oxygen, there is supposed to be a sign outside of the room door that documents oxygen is in use. LPN #1 stated the purpose of the sign is to alert staff that the resident requires oxygen, and for safety because oxygen is flammable. On 2/4/26 at 4:02 p.m., ASM (Administrative Staff Member) #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concern. The facility policy titled, Oxygen Administration documented, Safety and Storage: 1. Oxygen is considered a fire hazard and must be handled with caution .3. Post 'Oxygen in Use' signage where applicable. No further information was presented prior to exit. 2. For Resident #3 (R3), the facility staff failed to administer oxygen at the physician prescribed rate of two liters per minute. A review of R3's clinical record revealed a physician's order dated 1/30/26 for oxygen at two liters per minute for chronic obstructive pulmonary disease (lung disease). On 2/4/26 at 11:30 a.m., R3 was observed lying in bed receiving oxygen at a rate between three liters and four liters (as evidenced by the ball in the oxygen concentrator flow meter between the three-liter line and the four-liter line). On 2/4/26 at 2:14 p.m., R3 was observed lying in bed receiving oxygen at a rate between two and three liters (as evidenced by the ball in the oxygen concentrator flow meter between the two-liter line and the three-liter line). During both observations, the oxygen concentrator was not within the resident's reach. On 2/4/26 at 3:02 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated nurses should check the physician's order to ensure the correct amount of oxygen is administered to a resident. LPN #1 stated if a resident is supposed to receive two liters of oxygen, nurses should verify this by looking at the oxygen concentrator flow meter at eye level and making sure the middle of the ball runs through the two-liter line in the flow meter. On 2/4/26 at 4:02 p.m., ASM (Administrative Staff Member) #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concern. The oxygen concentrator manufacturer's instructions documented, 5. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate. The facility policy titled, Oxygen Administration documented, Administration Procedure: 2. Verify the physician's order prior to initiation .5. Apply the correct delivery device and prescribed flow rate. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of six residents in the survey sample, Resident #3. The findings include:For Resident #3 (R3), the facility staff failed to implement the resident's baseline care plan for oxygen administration. A review of R3's clinical record revealed a physician's order dated 1/30/26 for oxygen at two liters per minute for chronic obstructive pulmonary disease (lung disease). R3's baseline care plan dated 2/2/26 documented, I have alteration in Respiratory Status wheezing, SOB (Shortness of Breath), Obstructive Sleep Apnea. Administer oxygen as needed per Physician order. On 2/4/26 at 11:30 a.m., R3 was observed lying in bed receiving oxygen at a rate between three liters and four liters (as evidenced by the ball in the oxygen concentrator flow meter between the three-liter line and the four-liter line). On 2/4/26 at 2:14 p.m., R3 was observed lying in bed receiving oxygen at a rate between two and three liters (as evidenced by the ball in the oxygen concentrator flow meter between the two-liter line and the three-liter line). During both observations, the oxygen concentrator was not within the resident's reach. On 2/4/26 at 3:02 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated the purpose of the care plan is that it provides information so staff can meet residents' needs. LPN #1 stated nurses have access to look at residents' care plans to ensure they are implementing them. LPN #1 stated nurses should check the physician's order to ensure the correct amount of oxygen is administered to a resident. LPN #1 stated if a resident is supposed to receive two liters of oxygen, nurses should verify this by looking at the oxygen concentrator flow meter at eye level and making sure the middle of the ball runs through the two-liter line in the flow meter. On 2/4/26 at 4:02 p.m., ASM (Administrative Staff Member) #1 (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concern. The facility policy titled, Care Plan documented, 2. A Baseline Care plan must be developed within 48 hours of admission to insure that the resident's needs are met appropriately until the Comprehensive Care Plan is completed. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to manage pain for one of 13 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility failed to administer pain medication after an assessment was completed and the resident stated his pain level was a seven on a pain scale of one to ten, ten being the worse pain they had ever experienced. Resident #3 was admitted with diagnoses that included but were not limited to: post operative for a left calcaneus tuberosity (heel) fracture. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 11/16/23, the resident was coded as having no short or long term memory difficulties. R3 was coded as being independent for making cognitive daily decisions. An admission assessment, dated 11/15/23, documented the resident was assessed for pain. The resident stated his pain level was a seven at 6:07 p.m. The physician orders dated 11/15/23, documented, Acetaminophen Oral Tablet (used to treat mild pain) 325 MG (milligrams); Give 3 tablets by mouth every 8 hours as needed for pain. Hydromorphone HCL (hydrochloride) (used to treat moderate to severe pain) oral tablet 2 MG; Give 2 MG by mouth every 4 hours as needed for (moderate pain). Hydromorphone HCL oral tablet 4 MG; Give 4 MG by mouth every 4 hours as needed for (severe pain). The MAR (medication administration record) for November 2023 documented the above orders. The MAR failed to evidence documentation that the resident received any pain medication for his pain level of seven on 11/15/23 at 6:07 p.m. No pain medication was documented as having been administered on 11/15/23 after the resident was admitted at 12:50 p.m. The comprehensive care plan dated, 11/15/23, documented in part, Focus: Needs Pain management and monitoring related toL fracture. The Interventions documented in part, Administer pain medications as ordered. Review of the backup pharmacy list of medications available in the facility, documented the Hydromorphone was in the backup medication box. The Acetaminophen was documented as being in the facility as it is on the over-the-counter listing of medications. An interview was conducted on 7/2/24 at 12:44 p.m. with LPN (licensed practical nurse) #2, the unit manager. The above pain assessment was reviewed with LPN #2. When asked what she should do after assessing the resident's pain, LPN #2 stated to first look at the physician's orders and give medication accordingly. If there is no order for pain, we should contact the doctor and get an order to treat the resident's pain. The above MAR was reviewed with LPN #2. LPN #2 stated there is no documentation of any pain medication being administered. An interview was conducted with LPN #4, the nurse that completed the admission assessment on 11/15/23, on 7/2/24 at 2:02 p.m. LPN #4 could not recall the resident above. The admission assessment of 11/15/23 was reviewed with LPN #4. When asked if a resident has a pain score of seven out of ten, what should she do, LPN #4 stated if the resident has an order for pain medication, then you give that. If there is no order, she stated she would contact the doctor. The facility policy, Pain Management, documented in part, Treat the patient's pain as needed and ordered using nonpharmacologic or pharmacologic approaches. Base the treatment plan on evidence-based practice and the patient's clinical condition, past medical history and pain management goals .If the patient is allowed oral medications, begin with a nonopioid analgesic, such as acetaminophen or aspirin .If the patient needs more relief than a nonopioid analgesic provides, administer mild opioid (such as oxycodone or codeine) as ordered .If the patient needs still more pain relief, administer a strong opioid (such as morphine or hydromorphone) as ordered. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, ASM #6, the regional clinical director, RN (registered nurse) #2, the unit manager, and LPN #2, the unit manager, were made aware of the above findings on 7/2/24 at 4:36 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide the care and services to prevent pressure wounds for one of 13 residents in the survey sample, Resident #4. The findings include: The facility failed to document turning and repositioning of Resident #4 on the ADL (activities of daily living) form. Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Osteonecrosis, Syndrome of Inappropriate Secretion of Antidiuretic Hormone, Heart Failure, hypertension, aphasia, arthritis, malnutrition and respiratory failure. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 11/26/23, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not able to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring maximal assist for transfer, bathing; bed mobility, dressing, hygiene, toileting and dependent with feeding tube for eating. A review of the comprehensive care plan dated 10/26/23 revealed, FOCUS: I have altered skin integrity non pressure related to: Rash to my groin, abrasion to my forehead. I have a pressure to my sacrum. INTERVENTION: Conduct weekly skin inspection. Provide pressure reduction/relieving mattress. Treatments as ordered. Wound consult as needed. A review of the physician orders dated 10/26/23 revealed, Balsam Peru Castor Oil External Ointment (Balsam Peru Castor Oil) Apply to sacrum topically every day and evening shift for (Wound care). Treatment: Cleanse Sacrum with normal saline pat dry apply Hydrogel, Foam Border Dressing daily and PRN. APM2 air mattress setting of 2 check q shift for placement and functioning. every shift for promote wound healing. A review of the physician orders dated 11/1/23 revealed, Treatment: Sacrum: Cleanse with saline, pat dry, apply skin prep to surrounding intact skin and cover with Super Absorbent Gelling Fiber Foam every day shift every Tue, Thu, Sat for Wound Healing. A review of the physician orders dated 11/14/23 revealed, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacrum topically every day shift for Wound healing. Treatment: Cleanse Sacrum with normal saline pat dry apply Santyl Ointment as primary and cover with Foam Border Dressing daily and PRN every day shift for Wound Healing. A review of the October and November MAR-TAR (medication administration record-treatment administration record) did not evidence any missed medications or treatments to Resident #4. A review of Resident #4's October and November 2023 ADL (activities of daily living) document, reveals Roll Left and Right- coded as 01- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity Or, the assistance of 2 or more helpers is required for the resident to complete the activity missing documentation on night shift 10/25/23, 11/8/23, 11/12/23 and 11/19/23. A review of the progress note dated 10/26/23 at 4:31 PM revealed, Patient is [AGE] year-old male o as admitted from [NAME] hospital arrived at this facility to room [ROOM NUMBER] bed A for rehab. Admit Diagnosis: Sepsis, Aspiration Pneumonia, Hypertension, SIADH, [NAME] de [NAME] syndrome with behavioral issues, Dysphagia, CHF, acute hypoxic respiratory failure. Patient is full code. No known drug allergy. Resident on Jevity 1.5 tube feeding continues rate 50ml/hr., flushes 30ml every 4 hours. Patient alert to self, combative at times, scratches self. Wound observed on sacrum, redness on groin area. Incontinent of bowel and bladder. He denied pain during assessment. Medication lists were verified by NP. Bed placed at lowest position. Will continue to monitor resident for safety. Sacrum - Pressure: Length = 3.5cm, Width = 3cm, Depth = 0.1cm, - Stage Unstageable Drainage? No, amount of drainage with. No tunnelling or undermining present. A review of the weekly pressure ulcer measurement documents reveals: 10/26/24 sacral wound length 3.5 cm (centimeters) x width.3 cm x depth.1 cm. Treatment: Superabsorbent gelling fiber w/ silicone border & faced daily and as needed. A review of the Wound Physician's note dated 10/31/23 revealed, UNSTAGEABLE DTI SACRUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable DTI (deep tissue injury) within and around wound Duration > 10 days Objective Healing/Maintain Healing Wound Size (L x W x D): 3.5 x 2.3 x 0.1 cm Surface Area: 8.05 cm² Exudate: Moderate Sero - sanguinous Other viable tissues: 100 % (Dermis, Sub Q) DRESSING TREATMENT PLAN Primary Dressing(s) Superabsorbent gelling fiber w/ silicone border & faced apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Off-Load Wound ; Reposition per facility protocol. A review of the weekly pressure ulcer measurement documents reveals: 10/31/24 sacral wound length 3.5 cm (centimeters) x width 2.3 cm x depth.1 cm. Treatment: Superabsorbent gelling fiber w/ silicone border & faced daily and as needed. A review of the Wound Physician's note dated 11/7/23 revealed, UNSTAGEABLE (DUE TO NECROSIS) SACRUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable Necrosis Duration > 17 days Objective Healing/Maintain Healing Wound Size (L x W x D): 4.5 x 5.5 x 0.1 cm Surface Area: 24.75 cm² Exudate: Moderate Serous Thick adherent devitalized necrotic tissue: 100 % Wound progress: Exacerbated due to patient non-compliant with wound care EXPANDED EVALUATION PERFORMED The progress of this wound and the context surrounding the progress were considered in greater depth today. Thorough review of history performed, including review of Nursing Facility Records and through speaking with Nursing Staff. Coordination of care and plan for this wound discussed with Nursing Staff for further information. DRESSING TREATMENT PLAN Primary Dressing(s) Santyl apply once daily for 30 days Secondary Dressing(s) Gauze Island with border apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Off-Load Wound; Reposition per facility protocol; gel cushion to chair. A review of the weekly pressure ulcer measurement documents reveals: 11/7/23 sacral wound length 4.5 cm (centimeters) x width 5.5 cm x depth.1 cm. Treatment: Santyl and Superabsorbent gelling fiber w/ silicone border & faced daily and PRN. A review of the Wound Physician's note dated 11/14/23 revealed, STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage 4 Duration > 23 days Objective Healing/Maintain Healing Wound Size (L x W x D): 5.5 x 5.5 x 0.1 cm Surface Area: 30.25 cm² Exudate: Light Serous Thick adherent devitalized necrotic tissue: 80 % Other viable tissues: 20 % (Sub Q, Dermis) Wound progress: Improved evidenced by decreased necrotic tissue DRESSING TREATMENT PLAN Primary Dressing(s) Santyl apply once daily for 23 days Secondary Dressing(s) Gauze island with border, apply once daily for 23 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Off-Load Wound ; Reposition per facility protocol ; gel cushion to chair SITE 2: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE INDICATION FOR PROCEDURE Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Infected Tissue CONSENT FOR PROCEDURE Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 11/07/2023 to the health care surrogate; [NAME] Shook; who indicated agreement to proceed with the procedure(s) MDS 3.0 Post-stage: 4 ADDITIONAL NOTE Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration. PROCEDURE NOTE The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 3.02cm² of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 80 percent to 70 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. A review of the weekly pressure ulcer measurement documents reveals: 11/14/24 sacral wound length 5.5 cm (centimeters) x width 5.5 cm x depth.1 cm. Treatment: Santyl and Superabsorbent gelling fiber w/ silicone border & faced daily and PRN. A review of the 11/21/23 Wound physician report reveals, The patient's visit has been rescheduled. In therapy. 11/21/24 sacral wound length 5.5 cm (centimeters) x width 5.4 cm x depth.1 cm. Treatment: Santyl and Superabsorbent gelling fiber w/ silicone border & faced daily and PRN. A review of the progress note dated 11/26/23 at 4:13 PM revealed, Situation: Resident family member called 911 at 215pm. Resident family member sitting at bedside. Did not discuss any concerns with writer prior to calling 911. Paramedics stated to writer family wanting to send out r/t resident present wound to sacral region. Background: OSTEONECROSIS UNSPECIFIED, DYSPHAGIA UNSPECIFIED, SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE, MODERATE PROTEIN-CALORIE MALNUTRITION, ESSENTIAL (PRIMARY) HYPERTENSION, Full Code. Assessment: Resident provided with meds/flushes per feeding as ordered via g tube, provided with ADLs by staff, sacral patch in place, no signs/symptoms of pain or discomfort, no signs/symptoms of distress noted. Response: NP Chambers made aware; RP aware. A review of the progress note dated 11/26/23 at 7:53 PM revealed, Resident admitted to Hospital with diagnosis of: Leukocytosis, Hyponatremia, Osteomyelitis unspecified site. An interview was conducted on 7/2/24 at 7:15 AM with CNA (certified nursing assistant) #4, when asked about turning and repositioning the residents, CNA #4 stated, we turn and reposition them every two hours. When asked where this is evidenced, CNA #4 stated, we document all of our work on the ADL form. An interview was conducted on 7/2/24 at 11:50 AM with ASM (administrative staff member) #3, the wound care physician. When asked about Resident #4's wound, ASM #3 stated, he was admitted with the DTI (deep tissue injury) and as I told the mother, there is usually a lot under the surface that you do not see with a DTI. I saw him weekly and did not see any indication of osteomyelitis prior to him being admitted to the hospital. His syndrome contributed to his overall condition and difficulty to heal. On 7/2/24 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional [NAME] President of Operations and ASM #6, the regional director of clinical services was made aware of the above concern. A review of the facility's Pressure Ulcer policy reveals, Preventive measures include off-loading pressure, maintaining adequate nourishment and ensuring mobility to relieve pressure and promote circulation. Treatment includes methods to decrease pressure such as frequent repositioning to shorten pressure duration and the use of pressure reducing devices, such as special beds, mattress overlays and chair cushions. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications for one of 13 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to administer medications per the physician orders. A. Resident #3 was admitted with diagnoses that included but were not limited to: post operative for a left calcaneus tuberosity (heel) fracture, high blood pressure and chronic obstructive pulmonary disease (COPD). On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 11/16/23, the resident was coded as having no short- or long-term memory difficulties. R3 was coded as being independent for making cognitive daily decisions. The admission assessment dated [DATE], documented the resident arrived at the facility on 11/15/23 at 12:50 p.m. The doctor was notified of the admission at 1:30 p.m. The physician orders dated 11/15/23, documented, Carvedilol Oral Tablet (to treat high blood pressure) 6.25 MG (milligrams)l; Give 1 tablet by mouth two times a day related to essential hypertension (high blood pressure). Ipratropium - Albuterol Inhalation Solution (to treat asthma and COPD) 0.5 - 2.5 (3) MG/3 ML (milliliters); 1 vial inhale orally every 6 hours related to COPD. The November 2023 MAR (medication administration record) documented the above orders. The Carvedilol was scheduled for 9:00 a.m. and 5:00 p.m. There was no documentation that R3 received his 5:00 p.m. dose on 11/15/23. The square was blocked off. The resident did not have his 5:00 p.m. dose. The Ipratropium - Albuterol inhalation solution was documented in the MAR. It was scheduled for 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The first dose the resident received of this medication was on 11/16/23 at 12:00 a.m. The resident missed his 6:00 p.m. dose on 11/15/23. There were other medications scheduled for 5:00 p.m. that the resident received. The emergency backup medication box list documented the Carvedilol and the Ipratropium - Albuterol were both in the medication backup box. An interview was conducted with LPN (licensed practical nurse) #5 on 7/2/24 at 4:08 p.m. When asked if a medication is not available for administration when it is scheduled for, what do you do, LPN #5 stated, once they have an order, it is faxed to the pharmacy and if the medication is not here, we ask the pharmacy to send it stat and if it is not available we have to call the doctor and let them know. LPN #5 stated the facility had a backup medication box and it had some drugs in it. LPN #5 reviewed the MAR above. She noted that some 5:00 p.m. medication were administered. LPN #5 stated, she would have expected those medications to have been given since they were in the backup box. The facility policy, Ordering and Receiving Non-Controlled Medications, documented in part, Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery .Emergency/STAT medication orders: when a medication is available in the emergency kit remove the emergency/STAT dose needed for administration prior to the next pharmacy delivery. B. The facility staff failed to administer Hydromorphone HCL (used to treat moderate to severe pain) per the physician orders. The physician order dated 11/15/23 documented, Hydromorphone HCL (hydrochloride) (used to treat moderate to severe pain) Oral Tablet 2 MG; Give 2 MG by mouth every 4 hours as needed for (moderate pain). Hydromorphone HCL (hydrochloride) (used to treat moderate to severe pain) Oral Tablet 4 MG; Give 4 MG by mouth every 4 hours as needed for (severe pain). The November 2023 MAR documented the above orders. On 11/16/23, the Hydromorphone 2 MG tablet was administered at 5:04 p.m. for a pain level of five. At 8:20 p.m. the Hydromorphone 4 MG was administered for a pain level of seven. A time frame of three hours and 16 minutes. Review of the nurse's notes failed to evidence documentation that the physician was contacted to give the medication in a shorter time frame than what was ordered. An interview was conducted with LPN #2 on 7/2/24 at 12:44 p.m. When asked if a nurse can give a medication early if the order is for every four hours, LPN #2 stated the nurse would need an order from the physician to give it early. The above MAR was reviewed with LPN #2, she stated, the nurse should have called the doctor and written a note. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, ASM #6, the regional clinical director, RN (registered nurse) #2, the unit manager, and LPN #2, the unit manager, were made aware of the above findings on 7/2/24 at 4:36 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for the treatment of pain for one of 13 residents in the survey sample, Resident #3. The findings include: For Resident #3, the facility staff failed to implement the comprehensive care plan to administer pain medications as ordered. The comprehensive care plan dated, 11/15/23, documented in part, Focus: Needs Pain management and monitoring related to fracture. The Interventions documented in part, Administer pain medications as ordered. An admission assessment, dated 11/15/23, documented the resident was assessed for pain. The resident stated his pain level was a seven at 6:07 p.m. The physician orders dated 11/15/23, documented, Acetaminophen Oral Tablet (used to treat mild pain) 325 MG (milligrams); Give 3 tablets by mouth every 8 hours as needed for pain. Hydromorphone HCL (hydrochloride) (used to treat moderate to severe pain) oral tablet 2 MG; Give 2 MG by mouth every 4 hours as needed for (moderate pain). Hydromorphone HCL oral tablet 4 MG; Give 4 MG by mouth every 4 hours as needed for (severe pain). The MAR (medication administration record) for November 2023 documented the above orders. The MAR failed to evidence documentation that the resident received any pain medication for his pain level of seven on 11/15/23 at 6:07 p.m. No pain medication was documented as having been administered on 11/15/23 after the resident was admitted at 12:50 p.m. An interview was conducted with LPN #4, the nurse that completed the admission assessment on 11/15/23, on 7/2/24 at 2:02 p.m. LPN #4 could not recall the resident above. The admission assessment of 11/15/23 was reviewed with LPN #4. When asked if a resident has a pain score of seven out of ten, what should she do, LPN #4 stated if the resident has an order for pain medication, then you give that. If there is no order, she stated she would contact the doctor. When asked the purpose of the care plan, LPN #4 stated, it's to ensure the resident is properly taken care of. If pain medication was not administered and the care plan says to give pain medications to treat pain, is that following the care plan, LPN #4 stated, no. The facility policy, Care Plan documented in part, Care staff must be familiar with each resident's Care Plan and Approaches must be implemented. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, ASM #6, the regional clinical director, RN (registered nurse) #2, the unit manager, and LPN #2, the unit manager, were made aware of the above findings on 7/2/24 at 4:36 p.m. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to store medications in a secure location. The findings include: On [DATE] at approximately 3:00 p.m., an observation was made of a bathroom in the conference room where the surveyor was stationed. The door had a slide lock on the top of the door. Inside the bathroom were many binder books with documents, boxes of papers and a box, measuring 14 inches wide by 17 ,d+[DATE] inches deep by 14 ,d+[DATE] inches tall. The box contained the following: 174 medication cards with pill/capsules remaining in the card. Two insulin pen dispensers with insulin remaining in them. Eight Scopolamine Transdermal Patch - expired ,d+[DATE]. One bottle of Nystop Nystatin. One bottle of Calcium 500 mg (milligrams) capsules - expired ,d+[DATE]. One bottle of Zinc expired ,d+[DATE]. Two Flonase spray bottles opened [DATE] and expired ,d+[DATE]. One Azelastine, no date opened, dispensed [DATE]. One Visine eye drops, no open dated, expired ,d+[DATE]. Two bottles of Ibuprofen opened [DATE] and expired ,d+[DATE]. One Hyoscyamine 0.125 tablet, expired ,d+[DATE]. One box of Budesonide Inhalation Suspension, dispensed [DATE] and expired ,d+[DATE]. One box of Formoterol 20 mcg/2 ml (micrograms per milliliters) dispensed [DATE] and expired on ,d+[DATE]. One bottle of aspirin 81 mg, no expiration date or date opened. One Ipratropium Bromide and Albuterol Sulfate inhalation solution, dispensed [DATE] and expired ,d+[DATE]. One bottle of Docusate Sodium 100 mg capsules; opened [DATE] and expired ,d+[DATE]. One bottle of Folic Acid 400 mcg, opened [DATE], expired ,d+[DATE]. Insta - Glucose gel - partially opened with plastic dressing tape holding lid on. Expired ,d+[DATE]. One Budesonide Inhalation Suspension 0.5 mg/2 ml, dispensed [DATE], expired ,d+[DATE]. There were no residents in close proximetry to the conference room; nor was the conference room in an area used by the residents. An interview was conducted with RN (registered nurse) #2, the unit manager, on the process of returning medications to the pharmacy, RN #2 stated the overnight nurse scans the cards and puts them in a bag to send back to the pharmacy. An interview was conducted with OSM (other staff member) #1, the activities director, on [DATE] at 3:20 p.m. When asked if the conference room is locked when not in use, OSM #1 stated, no, not normally. The above box was shown to LPN (licensed practical nurse) #1 on [DATE] at 5:15 p.m. When asked if using the box was the proper way to store medications, LPN #1 stated, no. LPN #1 was asked if that was the proper way to discard medications, LPN #1 stated no. LPN #1 stated she had no clue as to why the medications were in there. The above box was shown to ASM (administrative staff member) #1, the interim administrator, on [DATE] at 5:45 p.m. She stated that she had no idea how they got there. The facility policy, Disposal of Medications, Syringes and Needles, Returning Medications to the Pharmacy, documented in part, 1. Medications, supplies, and any other medical products issued by the pharmacy will be accepted for return and credit, when required by the state, following proper storage and handling guidelines to assure maintenance of the product's strength, quality and purity. ASM #1, the interim administrator, and ASM #3, the administrator, were made aware of the above findings on [DATE] at 2:45 p.m. No further information was obtained prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one kitchen. The findings include: The facility staff failed to accurately label prepared food not stored in the original container, discard expired produce, store dry good scoops and thickener in a sanitary manner in the facility kitchen. On [DATE] at 8:30 a.m., an observation was conducted of the kitchen of the facility with OSM (other staff member) #4, dietary manager. Observation of the walk-in refrigerator revealed a four-shelf wire cart with a 5.2-quart plastic container with a white plastic lid on the third shelf labeled Ranch dressing with a prepared date of [DATE] and a use by date of [DATE]. The container was observed to contain a brown pudding like substance. OSM #4 identified the substance as chocolate pudding and stated that it was not labeled or dated accurately. She stated that the container should be labeled with the accurate contents, date it was prepared and a use by date of 3 days later. Further observation of the walk-in refrigerator revealed two cardboard boxes of fresh tomatoes stacked one on top of the other on the second shelf of a four-shelf wire cart. The bottom box of tomatoes was observed to contain tomatoes with visible white fuzzy substance on the surface of one tomato inside. The top box was observed to contain tomatoes with visible white fuzzy substance on the surface of three tomatoes inside the box, visible breakdown of the tomato skin with juice and seeds coming from the tomatoes and the base of the cardboard box was observed to be wet. OSM #4 observed the tomatoes and stated that the tomatoes were spoiled and needed to be discarded. She stated that they received produce every week and ordered them when they were on the menu, and these should have been discarded. Observation of the kitchen area revealed three large bins labeled flour, brown sugar and sugar. The bins were observed to contain scoops for the product located in scoop holders attached to the side of the bins. Observation of the scoop holders revealed multiple small black particles on the bottom surface of the holder. The scoops for the flour and the brown sugar were observed in the scoop holder resting on the black particles on the bottom of the holder. OSM #4 observed the black particle residue on the bottom surface of the holder and stated that the holders needed to be washed out and that it was probably coffee grounds in the holders. She stated that the scoop holders should be washed out regularly to keep residue from getting in there and touching the scoops. Further observation of the kitchen area revealed a 25-pound box of instant food thickener that was approximately one half full located on the bottom shelf of a metal table. The plastic bag containing the thickener was observed to be open to air. - bag is open to air. OSM #4 stated that the thickener should not be open to air to keep it clean, and they were working on getting a storage bin to keep it in. She stated that the bag containing the thickener should be kept closed. The facility policy Food Storage-Dry Goods dated [DATE] documented in part, Policy Statement: It is the center policy to insure [sic] all dry goods will be appropriately stored in accordance with guidelines of the USDA Food Code .The Food Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed . The facility policy Food Storage: Cold dated [DATE] documented in part, . The Food Services Director/Cook(s) insures [sic] that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . The facility policy Ice dated [DATE] documented in part, . The Food Services Director ensures that ice scoops are clean and stored in a separate container that limits exposure to dust and moisture retention . The policy failed to provide guidance for scoops used for dry goods. On [DATE] at 10:00 a.m., ASM (administrative staff member) #1, the interim administrator was made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care education for five of five staff reviewed. The findings include: During the course of an investigation of Resident #130's PTSD (post-traumatic stress disorder) / trauma informed care, five staff who were caring for Resident #130 were chosen to have their education files reviewed; RN (registered nurse) #1, LPN (licensed practical nurse) #5, LPN #11, CNA (certified nursing assistant) #5 and CNA #15. An interview was conducted on 10/25/23 at 3:00 PM with LPN #5. When asked if she had received any specific training for trauma informed care, LPN #5 stated, no, we have abuse training. An interview was conducted on 10/25/23 at 3:35 PM with RN #1. Asked what trauma informed care education he had received, RN #1 stated, my start date was just three to four weeks ago. There has been abuse education but no trauma informed care. I did have that education at my previous place. On 10/26/23 at 12:00 PM, ASM (administrative staff member) #2, the director of nursing stated, we do not have any education of staff on trauma informed care, nor any other information on PTSD this resident. We do provide abuse education and there is training related to trauma in the abuse training. On 10/26/23 at 1:40 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #5, the Regional [NAME] President of Operations and ASM #6, the Regional Director of Clinical Services were made aware of the finding. No further information was provided prior to exit.

Based on observations, staff /resident interviews and facility document review, it was determined the facility staff failed to develop/implement the care plan for four of 39 residents in the survey sample, Resident #130, Resident #6, Resident #79 and Resident #61. The findings include: 1. The facility staff failed to develop the comprehensive care plan for trauma informed care for Resident #130. Resident #130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder) and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 9/18/23, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating and limited assistance for bed mobility, transfer, walking and locomotion; extensive assistance for dressing and hygiene. MDS Section I: Active diagnosis: I 6100. Post Traumatic Stress Disorder coded as yes. A review of the comprehensive care plan dated 10/24/23, which revealed, FOCUS: Resident has an Alteration in Well-being related to PTSD. INTERVENTIONS: Assist resident with effective coping behaviors, try to maintain normal daily activities. Resident will be able verbalize feeling safe in her environment. Resident will openly discuss fear and triggers if able. A review of the physician's orders dated 9/6/23, revealed, Monitor for target behaviors of spitting, combativeness, refusal of ADL (activities of daily living) care, refusal of showers, refusal of medications and document. Demonstrating Sexual inappropriate behavior towards staff. Report behavior changes to NP/MD if behaviors arise. every shift for monitoring Document what behavior is observed. An interview was conducted on 10/25/23 at 8:05 AM with Resident #130. Asked if the facility had developed a plan of care for PTSD/trauma, Resident #130 stated, no. An interview was conducted on 10/25/23 at 3:00 PM with LPN (licensed practical nurse) #5. Asked the purpose of the care plan, LPN #5 stated, it is to set out the goals and interventions specific to each resident for their care. When asked if a resident with a diagnosis of PTSD a care plan addressing trauma should have, LPN #5 stated, yes, there should be a care plan. An interview was conducted on 10/25/23 at 3:15 PM with RN #3, the MDS coordinator. Asked when the PTSD care plan for Resident #130 was developed, RN #3 stated, yesterday, the director of nursing asked me to run a list of residents with PTSD and her name was on it and she did not have a care plan, so one was initiated. On 10/26/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the Regional [NAME] President of Operations and ASM #6, the Regional Director of Clinical Services were made aware of the finding. A review of the facility's Care Plan Preparation policy revealed, A care plan directs the patient's nursing care from admission to discharge. The written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings and it embodies the components of the nursing process. Update and revise the plan throughout the patient's stay, based on the patient's response. No further information was provided prior to exit. 32642 2. For Resident #79, the facility staff failed to develop a care plan for the resident's contractures (1). R79 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/9/23, the resident was coded as requiring the extensive physical assistance of two staff members for bed mobility, and as having impairment on both left and right sides of both her upper and lower extremities. On the following dates and times, R79 was observed lying in her bed, with contractions in both arms and both legs: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. On 10/25 at 2:30 p.m. and 10/25/23 at 9:44 a.m., there was a folded thin blanket between the resident's knees. No other devices, wedges, cushions, or splints were observed on or near the resident at any other observation. A review of R79's care plan dated 8/3/23 revealed no interventions to address the resident's contractures. On 10/25/23 at 1:21 p.m., RN (registered nurse) #3, the MDS coordinator, was interviewed. She stated she or the other MDS staff members are responsible for developing the comprehensive care plan when a resident is admitted . She stated she relies on clinical record documentation and the MDS triggers to determine which care plans are needed. When asked if a resident's contractures should be included in the care plan, she stated: Yes, I think so. Definitely. On 10/26/23 at 10:19 a.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. No further information was provided prior to exit. REFERENCE (1) A contracture develops when the normally stretchy (elastic) tissues are replaced by non-stretch (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. 3. For Resident #6 (R6), the facility staff failed to implement the care plan for a hand splint. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/18/23, R6 was coded as having impairment of an upper extremity on one side of her body. On the following dates and times, R6 was observed lying in bed and not wearing a left hand splint: 10/24/23 at 9:29 a.m., 9:31 a.m., 1:19 p.m., and 2:33 p.m.; and 10/25/23 at 9:36 a.m. and 11:16 a.m. A review of R6's orders revealed the following order dated 7/28/21: Apply hand and wrist splint daily to left hand in the morning related to CONTRACTURE, LEFT HAND. A review of R6's care plan dated 12/2/16 and updated 1/16/17 revealed, in part: Left hand splint as ordered for comfort and positioning. On 10/25/23 at 11:21 a.m., LPN (licensed practical nurse) #9 accompanied the surveyor to R6's bedside. When asked if the resident was wearing a hand splint, LPN #9 stated: No. When asked why the resident was not wearing a hand splint, he stated: I don't know. I think it was on her before they did her morning care. They must have taken it off when they did care. When asked if R6 had an order for a hand splint, he stated: I would have to check. I don't usually take care of her. When asked if the hand splint was anywhere in the room, LPN #9 opened all closets and drawers, and answered, No. I don't see one anywhere. On 10/25/23 at 2:31 p.m., LPN #9 was interviewed again. He stated the purpose of a care plan is to make sure a resident's needs are met. This includes all a resident's needs, and not just nursing needs. He stated the whole facility staff is responsible for implementing the care plan. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. No further information was provided prior to exit. 29125 4. For Resident #61, the facility staff failed to follow the comprehensive care plan for written communication with the dialysis center. A review of the comprehensive care plan revealed one dated 9/3/23 for I have alteration in Kidney Function Due to End Stage Renal Disease (ESRD), evidenced by hemodialysis. This care plan included an intervention dated 9/3/23 for Written communication form with review of weights and any changes in condition between dialysis provider and living center. A review of the clinical record for Resident #61 revealed a physician's order dated 9/3/23 for dialysis services every Tuesday, Thursday, and Saturday. A review of the dialysis communication book revealed the following: One communication sheet that was completed but was not dated. There was no way to know what dialysis visit the data on the sheet pertained to. Three communication sheets were not completed by the facility but was completed by the dialysis center. The facility did not provide pertinent data to the dialysis center. One of those sheets was also not dated. There was no way to know what dialysis visit the data from the dialysis center pertained to. All total, there were 22 opportunities for dialysis communication as of the survey review 10/25/23. There were 22 sheets in the book, including those with the noted missing information. On 10/26/23 at 9:58 AM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked if the care plan documented to provide written communication with the dialysis center and the facility did not complete a communication form, was the care plan followed, she stated that it was not. When asked what was the purpose of the care plan, she stated it was so that the can follow the plan of care for the resident and helps them follow the orders to take care of the resident. On 10/26/23 at 10:30 AM, ASM #1 (Administrative Staff Member), the Administrator, was made aware of the findings. No further information was provided by the end of the survey.

Based on a review of facility's documentation and staff interview, it was determined that the facility failed to convey personal funds in a timely manner for one of 39 residents in the sample, Resident #438. The findings included: Resident #438 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes mellitus (DM), bipolar and candidiasis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for bed mobility, transfer, walking, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated [DATE], which revealed, FOCUS: Long term care in a SNF (skilled nursing facility) is required due to my self-care and safety awareness deficits. INTERVENTIONS: Observe behavior changes/mental status changes/mood state changes. Provide emotional support to resident/family as needed. Refer for psych intervention services as needed. A review of Resident #438's medical record revealed the resident was transferred to the hospital on [DATE], where she expired. An interview was conducted on [DATE] at 1:35 PM with the RP (responsible party) of Resident #438. When asked if she had received the personal fund check, RP stated, they did not send us the personal fund check till mid-[DATE]. An interview was conducted on [DATE] at 12:25 PM with OSM (other staff member) #1, the business office manager. Asked the process to convey personal funds once a resident is discharged from the facility, OSM #1 stated, the process to return personal funds is to close the account and wait about a week to see if there are any additional charges. Once that is done, we cut a check and then wait for the appropriate people to sign the check before it is mailed. This usually takes about ,d+[DATE] days. Asked if the period from [DATE] to [DATE] was meeting the standard, OSM #1 stated, no, this was an extended period of time for return of personal funds. I will need to see if there are notes in the folder of the reason for the delay. On [DATE] at 5:08 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the Regional [NAME] President of Operations and ASM #6, the Regional Director of Clinical Services were made aware of the finding. A review of the facility's PFA (Patient Fund Account) Refund policy which revealed, Upon the death or discharge of a resident with personal funds on deposit with the facility that are less than the Medicaid Resource Level of $2,000.00 for a Medicaid resident, the Business Office must deliver all remaining monies to the appropriate person by processing a refund within thirty (30) days. (Federal Regulation 483.10). No further information was provided prior to exit.

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable and homelike environment for one of 39 residents in the survey sample; Resident #125. The findings include: On 10/24/23 at 10:32 AM, an observation was made of Resident #125's room. The base of the toilet around the area where the bolts hold the toilet to the floor had dark brown / black substance all over it. On 10/24/23 at 3:33 PM and 10/25/23 at 10:02 AM, there was no change to the above observation. On 10/26/23 at 9:34 AM, there was no change to the above observation. At this time, OSM #17 (Other Staff Member), a housekeeper, was asked about the substance on the toilet base. He said he would clean it now. He sprayed a cleaner on it and the substance immediately dispersed, indicating it was something that could easily be cleaned and was not a permanent stain. He stated it should have been cleaned before now. A policy was requested for clean/comfortable/homelike environment / housekeeping services. None was provided. On 10/26/23 at 10:30 AM, ASM #1 (Administrative Staff Member), the Administrator, was made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory services in a sanitary manner for one of 39 residents in the survey sample, Resident #138. The findings include: For Resident #138 (R 138), the facility staff failed to maintain and store nebulizer equipment in a sanitary manner. On the following dates and times, R 138 was observed in his room: 10/24/23 at 9:25 a.m. and 2:35 p.m.; and 10/25/23 at 9:40 a.m. At each observation, a nebulizer machine was positioned on the overbed table. The nebulizer tubing was dated 10/15/23, and the nebulizer mask was uncovered, and resting on top of a plastic bag on the overbed table. A review of R 138's orders revealed the following order dated 10/4/23: Budesonide Suspension 0.5 MG/2 ML (milligrams per milliliter) 1 vial inhale orally via nebulizer two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. A review of R 138's October 2023 MAR (medication administration record) revealed he had received the medication as ordered. On 10/26/23 at 9:00 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. She stated nebulizer tubing should be changed weekly, at a minimum, and more often if it gets dirty. She stated the date on the tubing should be the date the tubing was most recently changed. She stated the mask should be cleaned after each use, and stored in a plastic bag for infections control purposes. On 10/26/23 at 9:16 a.m., LPN #10 was interviewed. She stated nebulizer tubing should be changed every seven days, and the date on the tubing indicates the date it was last changed. She stated the nebulizer mask should be stored in a clean plastic bag between uses to prevent the spread of infection. On 10/26/23 at 10:19 a.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for storage of nebulizer equipment. No further information was provided prior to exit. REFERENCE (1) Bludgeoned ([NAME] EC) is used to treat Crohn's disease (a condition in which the body attacks the lining of the digestive tract, causing pain, diarrhea, weight loss, and fever). Budesonide (Tarpeyo) is used to decrease protein in the urine in patients with primary immunoglobulin A nephropathy (kidney disease that occurs in some people when too much immunoglobin A builds up in the kidney, causing inflammation). Budesonide is in a class of medications called corticosteroids. It works by decreasing inflammation (swelling) in the digestive tract of people who have Crohn's disease or in the kidney of people with nephropathy. This information is taken from the website https://medlineplus.gov/druginfo/meds/a608007.html.

Based on resident interview, staff interview and clinical record review, the facility staff failed to follow professional standards of practice for one of 39 residents in the survey sample, Resident #89. The findings include: For Resident #89 (R 89), the facility staff failed to administer the medication sodium bicarbonate per physician's order on multiple dates in October 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 10/24/23 at approximately 9:30 a.m., an interview was conducted with R 89. The resident voiced concern about not getting sodium bicarbonate. A review of R 89's clinical record revealed a physician's order dated 10/7/23 for sodium bicarbonate 650 mg (milligrams) by mouth two times a day for heartburn and indigestion. A review of R 89's October 2023 MAR (medication administration record) revealed the same physician's order for sodium bicarbonate. On 10/20/23 at 5:00 p.m. and 10/23/23 at 5:00 p.m., the MAR documented the code, 7= Other/See Nurse Notes. A nurse's note dated 10/20/23 documented, Pharmacy has been notified of need for this medication and will send tablets tonight. A nurse's note dated 10/23/23 documented, NP (Nurse Practitioner) has been notified of missed dose of this medication. A review of the facility OTC (Over the Counter) stock medication list revealed the facility was responsible for purchasing and supplying sodium bicarbonate. On 10/25/23 at 12:52 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the supply coordinator is responsible for ordering sodium bicarbonate. LPN #3 stated that when there are ten pills left in an over-the-counter medication bottle, she writes a note on the 24-hour report indicating the medication needs to be ordered then the management team discusses this during the morning meeting and the supply coordinator orders more medication. LPN #3 further stated that there is also a supply list on another unit and nurses can request OTC medications from that list. On 10/25/23 at 2:10 p.m., an interview was conducted with OSM (other staff member) #3 (the supply coordinator). OSM #3 stated she has a form the nurses are supposed to fill out if an OTC medication is needed but if a medication is due and not available, the nurses should tell her, and she can go to the store and purchase the medication. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on observation, staff interview, and clinical record review, the facility staff failed to follow a physician's order for one of 39 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility failed to apply compression stockings on the resident's legs as ordered by the physician. On the following dates and times, R79 was observed lying in her bed: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. At each of these observations, the resident was not wearing compression stockings on her legs. A review of R79's clinical record revealed the following order dated 8/3/23: Apply Compression Stockings one time a day. A review of R79's care plan dated 8/3/23 failed to reveal any information related to the compression stockings. On 10/25/23 at 2:18 p.m., CNA (certified nursing assistant) #14 was interviewed. She stated if a resident has an order for compression stockings, the order appears on the resident's electronic medical record the CNA is able to see. She stated the CNAs are usually responsible for applying compression stockings. She stated she cares frequently for R79, but did not realize the resident needed compression stockings. On 10/25/23 at 4:34 p.m., LPN (licensed practical nurse) #4 was interviewed. She stated if a resident needs compression stockings, the doctor or nurse practitioner will write an order for it. She stated nurses and CNAs together are responsible for making sure residents have compression stockings if ordered. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for the application of compression stockings. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions to prevent a decline in mobility for two of 39 residents in the survey sample, Residents #79 and #6. The findings include: 1. For Resident #79 (R79), the facility staff failed to implement interventions to prevent further loss of mobility related to her contractures (1). R79 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/9/23, the resident was coded as requiring the extensive physical assistance of two staff members for bed mobility, and as having impairment on both left and right sides of both her upper and lower extremities. On the following dates and times, R79 was observed lying in her bed, with contractions in both arms and both legs: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. On 10/25 at 2:30 p.m. and 10/25/23 at 9:44 a.m., there was a folded thin blanket between the resident's knees. No other devices, wedges, cushions, or splints were observed on or near the resident at any other observation. A review of R79's clinical record revealed no evidence of an assessment of her contractures or of any interventions to prevent further decline in her mobility due to the contractures. A review of the physical therapy screening dated 8/4/23 revealed either an n or n/a (not applicable) in all areas of the assessment, including, Does the potential exist for this patient to decline further without intervention? This review revealed, in part: Pt (patient) at baseline. No significant decline in functional status. Is total assist with bed mobility, ADL (activities of daily living). A review of an undated occupational therapy screening revealed no significant change in all areas of the assessment, including, Does the potential exist for this patient to decline further without intervention? This review revealed, in part: Pt at baseline of functional status. Nursing reported pt family has requested to take resident home for nights. Therapy for w/c (wheelchair) fitting to increase positioning. A review of the clinical record revealed no additional therapy evaluations of R79's contractures. A review of physician/extender progress notes revealed the following note dated 8/16/2023 NURSE PRACTITIONER PROGRESS NOTE .8/16/2023 .12 systems reviewed . Musculoskeletal-denies joint pain, swelling, stiffness, paresthesia . PHYSICAL EXAM .MUSCULOSKELETAL: Generalized weakness; no active joint swelling. This note was written by ASM (administrative staff member) #3, a nurse practitioner. A review of R79's care plan dated 8/3/23 revealed no interventions to address the resident's contractures. On 10/25/23 at 4:34 p.m., LPN (licensed practical nurse) #4 was interviewed. When asked if a resident with multiple contractures should be assessed for interventions to prevent further loss of mobility, he stated: The doctor or nurse practitioner usually does this. They will write an order for a splint or something. Sometimes therapy will do it. He stated he was not aware of any devices or interventions currently ordered for R79's contractures. On 10/26/23 at 8:22 a.m., OSM (other staff member), a physical therapist, was interviewed. When asked what is involved in an initial screening of a resident, he stated: It is not an evaluation. Sometimes we look at the resident. We go off what the nurses tell us. When asked if he had observed R79's contractures when he performed her initial screening, he stated he could not remember specifically. He stated: Nursing told me that she is bedbound with contractures. He stated he did not assess the resident's arm or leg contractures. He stated: I did not do a full eval. He stated: I think we may be picking her up for contractures this week. He added that no assessments or interventions to prevent further loss of mobility due to the resident's contractures had been put into place at the present time. On 10/26/23 at 9:00 a.m., LPN # 1, a unit manager, was interviewed. When asked what kinds of interventions should be put in place for a newly admitted resident who has contractures, she stated the facility protocol calls for a therapy screening for all new admissions. She stated: Those departments would do a screening and let us know if a person requires any kind of device. If a resident has a contracture, but does not have a device to prevent further contracture or skin breakdown, therapy will do a full evaluation and recommend whatever is needed. She stated: It's not okay for a resident to have contractures and for us not to do anything about them. On 10/26/23 at 9:16 a.m., LPN #10 was interviewed. She stated if a resident is admitted with contractures, the nurses should follow up with the doctor. She stated some residents already have positioning devices for the contractures, but if they do not have any devices or orders, the physician or nurse practitioner is responsible for ordering something. She added that sometimes the doctors rely on therapy to make recommendations, and that every resident with a contracture should at least have something attempted for them. On 10/26/23 at 11:20 a.m., ASM (administrative staff member) #3, a nurse practitioner, and ASM #4, a nurse practitioner, were interviewed. When asked what they do when they perform a resident's physical assessment, ASM #4 stated: We go in the room and look. We pull the covers back and look. When asked what her documentation revealed about what she saw regarding R79's contractures when she completed a physical assessment on 8/16/23, ASM #3 did not answer. ASM #4 stated: In my brain, this is 101 nursing. It is just routine. ASM #4 stated the nursing staff is responsible for initiating interventions to prevent a resident's loss of range of motion if a resident has contractures. ASM #3 was again asked what her documentation on 8/16/23 revealed about R79's contractures in both arms and both legs, she did not answer. ASM #4 interjected: Specific items for contractures are given to us through therapy. We have no reason to think that this resident is not getting the basics. Unless someone alerts us, we don't have any way of knowing. ASM #4 was asked to show evidence that either the physician or the nurse practitioners had noticed or assessed R79 for the contractures, she stated she would need to look. On 10/26/23 at 10:19 a.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for assessment/evaluation of residents with contractures. No further information was provided prior to exit. REFERENCE (1) A contracture develops when the normally stretchy (elastic) tissues are replaced by non-stretch (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement. This information is taken from the website https://medlineplus.gov/ency/article/003185.htm. 2. For Resident #6 (R6), the facility staff failed to apply a hand splint as ordered. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/18/23, R6 was coded as having impairment of an upper extremity on one side of her body. On the following dates and times, R6 was observed lying in bed and not wearing a left hand splint: 10/24/23 at 9:29 a.m., 9:31 a.m., 1:19 p.m., and 2:33 p.m.; and 10/25/23 at 9:36 a.m. and 11:16 a.m. A review of R6's orders revealed the following order dated 7/28/21: Apply hand and wrist splint daily to left hand in the morning related to CONTRACTURE, LEFT HAND. A review of R6's care plan dated 12/2/16 and updated 1/16/17 revealed, in part: Left hand splint as ordered for comfort and positioning. On 10/25/23 at 11:21 a.m., LPN (licensed practical nurse) #9 accompanied the surveyor to R6's bedside. When asked if the resident was wearing a hand splint, LPN #9 stated: No. When asked why the resident was not wearing a hand splint, he stated: I don't know. I think it was on her before they did her morning care. They must have taken it off when they did care. When asked if R6 had an order for a hand splint, he stated: I would have to check. I don't usually take care of her. When asked if the hand splint was anywhere in the room, LPN #9 opened all closets and drawers, and answered, No. I don't see one anywhere. On 10/25/23 at 2:18 p.m., CNA (certified nursing assistant) #14 was interviewed. She stated if a resident has an order for a hand splint, the order appears on the resident's electronic medical record the CNA is able to see. She stated the nurses are responsible for applying the hand splints. On 10/25/23 at 4:34 p.m., LPN (licensed practical nurse) #4 was interviewed. She stated if a resident needs a hand splint, the doctor or nurse practitioner will write an order for it. She stated nurses are responsible for applying the hand splints as ordered. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for the application of hand splints. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the care plan for one of 39 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to review and revise the resident's care plan to reflect the removal of a Foley catheter (1) and the addition of compression stockings. On the following dates and times, R79 was observed lying in her bed: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. At each of these observations, R79 did not have a Foley catheter, and the resident was not wearing compression stockings on her legs. A review of R79's clinical record revealed the following order dated 8/3/23: Apply Compression Stockings one time a day. Further review of R79's clinical record revealed she was admitted to the facility with a Foley catheter, but the catheter was discontinued on 8/11/23. A review of R79's care plan dated 8/3/23 failed to reveal any information related to the compression stockings. This review revealed, in part: I have a catheter .Catheter care daily and prn (as needed) .Change catheter as ordered by physician .Observe for pain near catheter and report to nursing .Observe urine output for dark color, presence of odor, blood, signs of infection and report to nursing .Position catheter below bladder, ensure tubing has no kinks, and secure for safety. On 10/25/23 at 1:21 p.m., RN (registered nurse) #3, the MDS (minimum data set) coordinator, was interviewed. When asked who is responsible for reviewing and revising care plans as residents' conditions and needs change, she stated: The MDS staff review them quarterly and yearly, but the floor nurses and unit managers review them in between. She stated the floor nurses and unit managers have access to the care plans on the electronic medical record and should be updating them regularly. She stated R79's care plan should have been updated to remove the information about the Foley catheter, and to include the information about the compression stockings. On 10/25/23 at 2:31 p.m., LPN (licensed practical nurse) #9 was interviewed. When asked who is responsible for updating the care plans, he stated: If we see something that needs to be changed, the unit managers are responsible for updating the care plans. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 9:00 a.m., LPN (licensed practical nurse) #1, a unit manager, was interviewed. When asked who is responsible for updating care plans, she stated the MDS staff is responsible for this. She stated changes in resident conditions or status are discussed every morning in the morning meeting. She stated: MDS takes it from there. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for reviewing and revising the care plan. REFERENCE (1) A urinary catheter (brand name Foley) is a tube placed in the body to drain and collect urine from the bladder. This information is taken from the website https://medlineplus.gov/ency/article/003981.htm.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one out of 39 residents in the survey sample, Residents #135. The findings include: The facility staff failed to complete an accurate MDS (minimum data set), a discharge assessment for Resident #135. Resident #135 was sampled during the closed record review for transfer to hospital. Resident #135 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, hemiplegia and end stage renal disease. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 8/2/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of Section A: Identification Information: A 2100. Discharge Status: 03. Acute Hospital. A review of the comprehensive care plan dated 4/17/23 revealed, FOCUS: The resident would like assistance in planning my next steps to be able to go home safely when my care/rehab goals are met. INTERVENTIONS: Appropriate referrals will be made to home health agencies and durable medical equipment companies prior to discharge. Help me get in touch with local contact agencies as needed. ' A review of the nursing progress note dated 8/2/23 at 6:31 PM revealed, Resident discharged home. Summary discharged and orders given to transporters per spouse request. Resident stable and no concerns voiced. Resident left facility via stretcher and accompanied by three transporters at 4:30 pm. A review of the physician discharge summary dated 8/3/23 at 7:30 AM revealed, discharged TO: x Home with family. An interview was conducted on 10/26/23 at 9:45 AM with RN (registered nurse) #3, the MDS coordinator. Asked to review the 8/2/23 MDS Section A for Resident #135 and the progress note for 8/2/23, RN #3 stated, yes, he was discharged home, it was coded as discharged to hospital. He went to the hospital the week before and came back. I will correct this in MDS. Asked what standard is followed for completing the MDS, RN #3 stated, we follow the RAI (resident assessment instrument). On 10/26/23 at 10:30 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the Regional [NAME] President of Operations and ASM #6, the Regional Director of Clinical Services were made aware of the finding. According to the RAI (resident assessment instrument) MDS Section A 2100 OBRA Discharge Assessment: Steps for Assessment: Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions: Select the 2-digit code that corresponds to the resident's discharge status. Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home. Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. Includes swing beds. Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide safe supervision for one of 39 residents in the sample, Resident #106. The findings include: For Resident #106 (R106), the facility staff failed to supervise him for safety when he independently walked into two commercial parking lots adjacent to the facility. R106 was admitted to the facility with a history of a traumatic brain injury. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/10/23, R106 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status. He was coded as exhibiting no behaviors during the look back period, including wandering. He was coded as requiring supervision, and the physical assistance of one staff member for locomotion off the unit. He was coded as having no psychological diagnoses. On 10/24/23 at 12:20 p.m., R106 was observed putting his name only (no time) on the sign out sheet at the receptionist's desk, and independently walking out the front door of the facility. He spoke to a visitor in the facility parking lot. He walked east through the facility parking lot, through a grassy area between the facility and an adjacent commercial lot, and into the commercial parking lot. The parking lot contained parking spaces for at least three stores, and a [NAME] Donuts with a drive through. As R106 walked through the parking lot, he approached and spoke to two individuals who were walking back and forth to their vehicles, and seven vehicle drivers as they sat in the parking lot. Two cars had to quickly put on their brakes as he walked in front of them. He walked to the drive through area of the [NAME] Donuts business, and wove through parked/moving cars, approaching and speaking to the drivers of three cars in the drive through. He returned to the facility at 12:42 p.m. On 10/25/23 at 8:05 a.m., R106 was observed leaving the facility through the front door. He walked west through the facility parking lot, crossed a grassy area between the facility parking lot and an adjacent commercial parking lot, and entered the commercial parking lot. The resident disappeared from observation behind a building in this parking lot. On 10/25/23 at 3:35 p.m., R106 was observed leaving the facility through the front door. He walked west through the facility parking lot and sat on a crate in the grassy area between the facility parking lot and the adjacent commercial parking lot. ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services joined in the observation. At the end of this observation, R106 was observed leaving the crate and walking into the adjacent commercial parking lot, disappearing behind a building. LPN (licensed practical nurse) #3 was asked to follow the resident by the management staff. A review of R106's clinical record revealed no details regarding the resident's traumatic brain injury. A review of the resident's hospital discharge note on the date of his facility admission, 5/26/22, revealed the traumatic brain injury was greater than [AGE] years old. A review of a facility Psychiatric evaluation dated 7/25/22 revealed, in part: Chief Complaint/Nature of Presenting Problem: refusal of care, irritability .He .has a history of TBI (traumatic brain injury. He is alert and oriented, he denied any psychiatric history. This is a consultation upon the request of staff who reported that patient has been refusing to take showers, and have his bed sheets changed. Upon interview today, patient with periodically irritable (sic) and stated 'I have the right to refuse showers. There are so many rules here' .Reinforced facility rules, patient verbalized understanding .Recommendations: Continue to reinforce importance of personal hygiene and facility rules. No psychotropic medications are warranted at this time. Monitor for changes in mood or behaviors and notify/page [name of physician practice] as needed. Will continue to follow and provide consultation. Further review of the clinical record revealed no evidence of psychiatric monitoring or follow up. A review of R106's Log of Patient Outings on 12/24/23 at 1:00 p.m. at the receptionist's desk revealed three entries on 10/23/23 beginning at 4:58 p.m. The resident's name was written in a different handwriting than the times of entry and exit. The log contained an additional five entries with no date, and with only one entry containing an exit time. All other date and time slots were blank. OSM (other staff member) #5, the receptionist, stated: [R106] does not like to write down the times. She stated the resident signs his own names, and she writes the times in and out when she is sitting at the desk. She added: I don't know what other receptionists do. A review of R106's orders revealed the following order dated 5/26/22: May go on pass and or LOA with responsible party with medications. Further review of R106's clinical record revealed no additional information regarding assessments of R106's safety to leave the building and to walk through adjacent commercial parking lots. A review of R106's care plan revealed no information related to R106's leaving the facility. On 10/25 23 at 1:33 p.m., OSM #2, the director of social services, was interviewed. When asked to describe R106 from a psychosocial perspective, she stated the resident is hyper, with short term memory deficits. She stated: He has the mind of a child pretty much, like a little kid. You tell them not to touch the hot stove, and they won't touch it right then. The next thing you know, they have forgotten what you said, and they touch the hot stove. She added: You have to try your best to protect them. She stated R106 understands in the moment, but is not going to retain instructions or requests. She stated R106's son felt his dad was a danger to himself living alone because R106 would walk out of the house, approach strangers in their cars, and would sometimes get in the cars with strangers. When asked if the resident is defiant, she stated he is not; he just cannot remember. When asked if the resident leaves the building independently, she said he does. When asked what he does when he leaves the building, she stated she is not sure. He is required to sign out when he goes out. She has seen him sitting on the crate in the grassy area to the left of the building. She stated she sees him every so often coming back into the building from across the way. When asked about the resident's safety awareness, she stated it is not good, and does not waver. She stated: A lot of times when he goes out, when we can, we try to monitor him and keep an eye on him to the best of our ability. When asked where those efforts are documented, she stated there was no documentation of this monitoring. When asked how the resident is safer at the facility than at home, given the fact that he is allowed to leave the facility unsupervised and wander through commercial parking lots, approaching strangers. She stated: That's a very good question. I had not thought about that. She stated she was not aware of any current safety assessments or psychological evaluations for R106. On 10/25/23 at 2:18 p.m., CNA (certified nursing assistant) #14 was interviewed. She stated she works day shift and often is responsible for caring for R106. She estimated the resident leaves the facility 8 or 9 times a shift. She stated she does not know what he does when he leaves, but that she has seen him walking through the [NAME] Donuts parking lot. She stated he tells her he is going out to get fresh air. On 10/25/23 at 2:31 p.m., LPN (licensed practical nurse) #9 was interviewed. When asked to describe R106, he stated: He's a lot. He estimated the resident leaves the facility at least five times during every day shift. When asked where the resident goes when he leaves the building, he stated: I'm not sure. I think he just walks around. I've seen him walking from the far parking lot toward the building. When asked if the resident is safe to leave the building unsupervised, he stated: I really don't know. He has been doing it ever since I started work here. On 10/25/23 at 2:54 p.m., ASM #2 was interviewed. When asked to describe R106 from a psychosocial perspective, she stated: He has the same affect all the time. He does say hi to me. He can make his needs known. When asked if R106 has memory problems, she stated: I don't see any evidence of it. When asked if the resident has been assessed for higher level thinking, judgment, and safety to leave the building alone, she stated he has not, that she knows of. When asked where the resident goes when he leaves the building, she stated: He goes off the property, right where the trees are, on the [west] side. When asked if the resident wanders through the adjacent commercial parking lots, she stated: I can't tell you if he goes in the parking lots. He just walks back and forth. When asked if the facility had ever received complaints about the resident's walking in the adjacent parking lots, she stated she thought one of the adjacent businesses had complained, and the administrator at that time took care of it. When asked who is responsible for the resident's overall safety, she stated: Technically, we are. But he is allowed to sign in and out, and go on LOA (leave of absence). On 10/25/23 at 3:45 p.m., after the management staff had observed the resident leaving the facility property and walking west into the parking lot, ASM #1, the administrator stated it is the resident's right to walk around the facility parking lot. She added: He is a 12 BIMS. I didn't know he was walking to other parking lots. On 10/26/23 at 11:20 a.m., ASM #3, a nurse practitioner, and ASM #4, a nurse practitioner, were interviewed. When asked if they had been aware that R106 was leaving the building and walking into the adjacent commercial parking lots, approaching strangers both inside and outside of cars, ASM #4 stated: We were not. We were not updated about these behaviors until yesterday. She added that when people have traumatic brain injuries, sometimes they are different. She stated: This change [in R106's behavior] is something acute. On 10/25/23 at 5:05 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #5, the regional vice president of operations, and ASM #6, the regional director of clinical services, were informed of these concerns. On 10/26/23 at 2:18 p.m., ASM #1 stated the facility did not have a policy for supervision of residents for safety. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the required assistance while providing ADL (activities of daily living) care which resulted in an injury for one of 11 residents in the survey sample, Resident #11. The resident sustained a laceration to the forehead requiring transport to the emergency room and sutures which constituted harm cited at past non-compliance. The findings include: For Resident #11 (R11), the facility staff failed to implement the plan of care while providing ADL care which resulted in the resident sustaining a laceration to the forehead requiring sutures at the emergency room . On the resident's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/7/2023, the resident was assessed as being severely impaired for making daily decisions. Section G documented R11 requiring extensive assistance from two or more persons for bed mobility, transfers and toilet use. R11 was assessed as always being incontinent of bowel and bladder. The MDS assessment, a quarterly assessment with an ARD of 11/6/2022 documented R11 being severely impaired for making daily decisions. Section G documented R11 requiring extensive assistance from two or more persons for bed mobility, transfers and toilet use. R11 was assessed as always being incontinent of bowel and bladder. The progress notes for R11 documented in part: - 12/15/2022 11:23 (11:23 a.m.) Situation: Staff reported resident rolled on her side during AM care and pulled the clothes bin and it tipped over and hit her on the left side of her head. Background: Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Assessment: Staff reported resident rolled on her side during AM care and pulled the clothes bin and it tipped over and hit her on the left side of her head. Upon assessment open area noted on left side of forehead measuring 1.5cm (centimeter) by 1.0cm .NP (nurse practitioner) on unit and assessed resident. Response: New order obtained to send resident to (Name of hospital) for evaluation. RP (responsible party) updated and made aware. - 12/15/2022 19:33 (7:33 p.m.) Note Text: Resident admitted under observation (Name of hospital). Has history of hydrocephalus (1) and upon completing CT (computed tomography) scan per hospital hydrocephalus is progression. Per hospital resident will stay for observation. - 12/22/2022 19:13 (7:13 p.m.) Note Text: Resident readmitted from (Name of hospital). 3 (three) stitches intact over left eye. Bruising and swelling noted at site. No facial grimacing or s/s (signs/symptoms) of pain when site was touched . The comprehensive care plan for R11 documented in part, I have a Self Care/ADL deficit related to: Self care impairment, Dementia, OA (osteoarthritis), muscle weakness. Date Initiated: 03/08/2022. The facility synopsis of events dated 12/16/2022 documented in part, .Thursday, December 15th, 2022 at approximately 10am, staff was proving [sic] ADL care which involved turning and reposition. (Name of R11) was in bed while CNA (certified nursing assistant) was attempting to provide peri-care, and the CNA rolled the resident on her side and the resident pulled on the lining [sic] trash bin and it tipped over and hit her on the head, and (Name of R11) sustained a laceration over her forehead. The resident was transferred to the hospital for evaluation, and remained in observation. Investigation initiated. The document contained a written statement from the assigned CNA on 12/15/2022 who no longer worked at the facility which documented in part, . After washing (Name of R11) and putting her blouse on, I was standing on the left side of (Name of R11) to roll her to the right and put her brief on. Then I pulled the brief threw [sic] her legs and walked to the right side to roll her to the left to connect the brief while rolling (Name of R11) pulled on the dirty lining [sic] trash bin in her room and it tipped over and hit her in the head. I ran to the other side to pick it up. I sat (Name of R11) up on the side of the bed and noticed she had a knot on her head. I went and notified my nurse (Name of LPN (licensed practical nurse) #1). I then went to get the instrument to get her vitals. The investigation summary documented in part, .the CNA (Name of CNA), did not follow the resident's Kardex (2) for bed mobility when providing peri-care. The Kardex shows that the resident requires two persons assisting her with bed mobility, and at the time of peri-care, the staff did not ask for assistance; however, the facility was not able to prove that the staff member actions was neglectful or abusive. The CNA (Name of CNA) was terminated from the facility for failure to comply with the resident plan of care . On 7/26/2023 at 11:10 a.m., an interview was conducted with CNA #1. CNA #1 stated that when they were providing care for residents who required two persons, they got help from another staff member. CNA #1 stated that they knew which residents required two persons for care by their report from the previous shift and looking at the Kardex in the computer. On 7/26/2023 at 11:15 a.m., an interview was conducted with CNA #2. CNA #2 stated that they checked the Kardex to know which residents required one- or two-person assistance. She stated that they also communicated between the shifts to the next nurse, so they knew. On 7/26/2023 at 11:30 a.m., an interview was conducted with CNA #3. CNA #3 stated that they used the Kardex to tell them the needs of the resident and it advised them if the resident required one- or two-person assistance with ADL's. On 7/26/2023 at 12:53 p.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had identified that R11 had been injured so they started an investigation and took a statement from the employee. He stated that they had the employee re-enact the situation and they had identified that R11 was a two-person assistance at that time and the CNA had not used two persons to perform the care. He stated that they had found that CNA did not act with the policy, so they had suspended them until they dug deeper into the investigation and found that the Kardex matched the chart and plan of care, so they had terminated the CNA based on the investigation. ASM #1 stated that the laundry bin in the room was metal and had a sharper edge than a normal bin and had some weight to it and the CNA had stated that the resident had grabbed for the bin, and it tipped over and hit her on the head. He stated that once they identified the laundry bin issue, they removed all metal bins from the facility. He stated that if the CNA had utilized the second person in the room that R11 could have potentially grabbed that second person rather than the laundry bin. He stated that R11 was sent to the emergency room and received sutures. ASM #1 stated that when they self- identify any issue, they bring the interdisciplinary team together to meet, bullet point their actions and make a plan to prevent recurrence. He stated that they had immediately removed one of the issues which was the bins, started education, performed audits, and did follow ups in QAPI (quality improvement performance improvement) meetings. On 7/26/2023 at 2:15 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that they were not assigned to R11 on 12/15/2022 but had come over to assist the nurse at that time. LPN #4 stated that they were told the resident had hit their head and they went in the room to find R11 sitting up in their wheelchair with a laceration on their forehead. She stated that the CNA told her that R11 had hit their head on the laundry basket which was beside the bed when she was getting her up during morning care. She stated that the CNA told her that she was rolling R11 over when the resident had grabbed the bin and it had fallen over and hit her on the head. On 7/26/2023 at approximately 2:20 p.m., an interview was conducted with LPN #1. LPN #1 stated that they were working with R11 on 12/15/2022 and had held pressure to the laceration after the injury. She stated that she had another resident having an emergency, so LPN #4 had taken over and sent R11 to the hospital. Review of the plan of correction provided by ASM #1 for R11's injury on 12/15/2022 documented a date of compliance of 12/19/2022. The plan of correction folder contained an ad hoc QAPI meeting dated 12/16/2022 for the incident and a performance improvement plan dated 12/16/2022. The plan included a 100% audit of current resident Kardex's completed 12/19/2022, 12/6/2022 [sic], 1/2/2023, 1/9/2023, 1/16/2023, 1/30/2023, 2/6/2023 and 3/6/2023, documentation of an audit of all resident rooms with removal of clothes bins dated 12/15/2022, the written CNA statement, evidence of education completed to all staff including the terminated CNA dated 12/16/2022, and a copy of R11's Kardex which documented in part, .Bed mobility: Extensive assistance, Two+ persons physical assist . The plan further documented QAPI improvement worksheets reviewing the incident on 1/27/2023, 2/28/2023, and 3/31/2023. Verification of the facility plan of correction was completed by observations, staff interviews and review of the facility audits, staff education and resident audits. No concerns were identified. Observations conducted of current residents receiving ADL care including turning and repositioning during the survey dates revealed no concerns with staff following the Kardex for one- or two-person assistance with ADL's. On 7/26/2023 at 12:20 p.m., the director of nursing provided evidence of education completed on 3/30/2022 for providing ADL care to residents including positioning, for the CNA terminated for the 12/15/2022 incident involving R11. On 7/26/2023 at 1:20 p.m., ASM #1, the administrator was made aware of the concern for harm. No further information was provided prior to exit. Based on the acceptable plan of correction, all components of the plan verified, and no concerns identified during the survey, this deficient practice is cited at past non-compliance. Reference: (1) Hydrocephalus is the buildup of too much cerebrospinal fluid in the brain. Normally, this fluid cushions your brain. When you have too much, though, it puts harmful pressure on your brain. This information was obtained from the website: https://medlineplus.gov/hydrocephalus.html (2) Kardex Originally, the proprietary name for a filing system for nursing records and orders that was held centrally on the ward and contained all the nursing details and observations of patients that had been acquired during their stay in hospital. Although this system is no longer used for nursing records, since care plans are now held at the patient's bedside rather than centrally, the term 'kardex' continues to be used generically, for certain centrally held patient record systems. This information was obtained from the website: https://www.oxfordreference.com/display/10.1093/[NAME]/authority.20110803100030337

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure a resident was free from accidents and hazards for one of 16 residents in the survey sample, Resident # 10. The facility staff improperly performed a one-person transfer for Resident # 10, and during the transfer, the resident sustained [REDACTED]. The findings include: Resident # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 10's most recent MDS (minimum data set), a 5-Day assessment with an ARD (assessment reference date) of 07/16/18, coded Resident # 10 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 10 was coded as requiring limited to extensive assistance of one staff member for activities of daily living and requiring extensive assistance of two staff members for transfers. Under G0300 Balance During Transitions and Walking coded Resident # 10 as Not steady, only able to stabilize with staff assistance for Surface-to-surface transfer. The comprehensive care plan for Resident # 10 dated 07/10/2018 documented, Focus. At risk for falls related to New environment, Use of medication. Date initiated: 07/10/2018. Under Interventions it documented, Two staff assist with transfers. Date initiated: 07/13/2018. The Physical Therapy Plan of Care for Resident # 10 dated 07/10/2018 documented, Functional Deficit: Transfers, Sit to Stand and Transfers, Stand to Sit. Current Level: Moderate Assistance x (times) 2 (two) persons (Routinely requires 50% phy (physical) assistance of 2 persons to transfer.) The facility's FRI (Facility Reported Incident) dated (MONTH) 13, (YEAR) for Resident # 10 documented, Injuries: Yes, laceration on right lower extremity resulting in 10 sutures. Under Describe incident, including location and action taken: Patient (Resident # 10), received laceration on right lower extremity during one person transfer. (Resident # 10) was sent to local hospital for medical treatment. Under Employee action initiated or taken: CNA received re-education on patient transfer status by therapy department prior to next scheduled shift. The facility's Nursing Home to Hospital Transfer Form for Resident # 10 dated 07/12/18 documented, Reason for transfer: Sutures to right calf. The facility's Statement by CNA # 5 dated 07/12/18 documented, I was called into the shower room to assist (Resident # 10) while using the bathroom. He had a big mess so I decided to give him a shower. While transferring him from the shower chair to his wheelchair with his walker his leg hit the side of the wheelchair causing the skin to break and bleed. The facility's Statement taken by ASM (administrative staff member) # 5, previous administrator, dated 07/13/18 Regarding Resident # 10 documented, This writer spoke with (CNA # 5) via (by) telephone, regarding incident which took place involving patient (Name of Resident # 10). When asked how (CNA # 5) would know (Resident # 10) was a two person assist (CNA # 5) replied, I would get it in report from the previous shift or if I saw one of the therapist I would ask them. When asked if she knew (Resident # 10) was a two-person assist (CNA # 5) replied 'I did not know that. I never would have thought that because he can stand and pivot with his walker. On 05/29/19 at 5:20 p.m., ASM (administrative staff member) # 1 (the administrator and ASM # 2, director of nursing, were informed of the above concern for harm. During the days of the survey, an attempt to interview CNA # 5 was unsuccessful due to her termination of employment from the facility on 10/29/18. On 05/30/19 at 8:15 a.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked if facility staff were provided training for transferring residents following Resident # 10's injury ASM # 2 stated, We completed education with the CNA involved in the incident and ongoing training regarding fall prevention, following the plan of care, following the Kardex, and discussed the action plan. ASM # 2 was then asked to provide a copy of the facility's action plan. On 05/30/19 at 8:45 a.m., an interview was conducted with OSM (other staff member) # 3, current rehabilitation director. When asked to describe what a two person transfer OSM # 3 stated, Its two staff on either side of the patient with a gait belt. Each staff should be holding the gait belt on each side of the patient, assist patient to a standing position and then taking a step or two toward the destination, the bed or wheelchair. OSM # 3 further stated, Transfer training is part is part of the CNAs basic training. When asked how a resident's transfer status is communicated to the nursing staff, OSM # 3 stated, We inform nursing after the evaluation and they put it on the care plan. On 05/30/19 at 10:20 a.m., ASM # 2, director of nursing, provided a copy of the facility's training and staff sign in sheet titled Fall Prevention and Education dated (MONTH) 2019. After reviewing the training and sign-in sheets ASM # 2 agreed that not all the facility staff had received training. When asked about the facility's action plan, ASM # 2 stated, It's more like an ongoing reminder of a safety awareness. When asked how they were ensuring facility staff were using the proper techniques for transferring residents, ASM # 2 stated, The transfer status is in the resident's Kardex and when there is a change in condition where they need additional assistance for a transfer we will update the care plan and get an evaluation by therapy. On 05/30/19 at approximately 5:50 p.m., ASM #1, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. (3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

Based on observation, resident interview, staff interview, facility document review clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to provide the necessary treatments and services to prevent, treat, promote healing and prevent infection of pressure ulcers for five of 32 residents in the survey sample, Resident #26, #7, #2, #19 and #13. 1 a. The facility staff failed to initiate and implement interventions on admission to prevent the development of a pressure ulcer and on 7/29/16 Resident #26 was documented by the facility staff as having a DTI* (deep tissue injury) on his left heel. The facility staff failed to initiate weekly skin assessments and wound evaluation sheets until 8/8/16. The weekly skin assessments and wound evaluation sheets that were completed did not document complete measurements or a description of the wound being assessed and failed to monitor the wound to determine if the wound was declining or improving. On 8/16/16 the facility staff documented that the left heel wound opened with purulent drainage, Bactrim (an oral antibiotic) was ordered by the physician on 8/17/16 to be administered for seven days. The facility staff failed to transcribe the order for Bactrim onto the MAR (medication administration record) and failed to administer the medication as ordered. Resident #26 was not administered an antibiotic until 8/29/16 following the results of a wound culture that was documented as positive for an infection. During the time period 7/29/16 - 9/16/16 facility documentation evidenced a worsening, odorous wound culminating into a Stage IV* ulcer described on 9/16/16 by a podiatrist as open to bone and Achilles tendon. Resident #26's left heel wound was subsequently diagnosed with [REDACTED]. 1 b. The facility staff failed to initiate and implement interventions on admission and failed to develop a care plan to prevent Resident #26 from developing an unstageable pressure injury to the right heel. The facility staff also failed to monitor and revise treatments to the wound on a continuous basis and to assess the effectiveness of the treatments in place. 2. The facility staff failed to implement measures to promote healing of a suspected deep tissue injury for Resident #7 on admission which declined to an unstageable wound on Resident #7's heel. The facility staff also failed to initiate and implement interventions recommended by the facility wound care physician for a period of 13 days. The facility staff also failed to float the residents heels. Resident #7's heels were observed directly on the mattress during the survey. 3.a. Resident #2 developed a pressure injury on the right calf on 3/9/17. The facility staff failed to implement treatment for [REDACTED]. 3.b. The facility staff failed to implement the wound care physician's recommendations for treatment of [REDACTED]. 3.c. Resident #2 developed a pressure injury on the right heel on 4/19/17. The facility staff failed to implement treatment until 4/25/17. 4. For Resident #19, facility staff failed to maintain infection control practices during a dressing change and promote healing of an unstageable (1) sacral pressure wound (2). 5. The facility staff failed to assess and appropriately treat Resident #13's pressure injury from her admission on 4/5/17 until 4/12/17, when she was seen by the wound specialist. The findings include: 1 a. The facility staff failed to initiate and implement interventions on admission to prevent the development of a pressure ulcer and on 7/29/16 Resident #26 was documented by the facility staff as having a DTI* (deep tissue injury) on his left heel. The facility staff failed to initiate weekly skin assessments and wound evaluation sheets until 8/8/16. The weekly skin assessments and wound evaluation sheets that were completed did not document complete measurements or a description of the wound being assessed and failed to monitor the wound to determine if the wound was declining or improving. On 8/16/16 the facility staff documented that the left heel wound opened with purulent drainage, Bactrim (an oral antibiotic) was ordered by the physician on 8/17/16 to be administered for seven days. The facility staff failed to transcribe the order for Bactrim onto the MAR (medication administration record) and failed to administer the medication as ordered. Resident #26 was not administered an antibiotic until 8/29/16 following the results of a wound culture that was documented as positive for an infection. During the time period 7/29/16 - 9/16/16 facility documentation evidenced a worsening, odorous wound culminating into a Stage IV* ulcer described on 9/16/16 by a podiatrist as open to bone and Achilles tendon. Resident #26's left heel wound was subsequently diagnosed with [REDACTED]. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*Note the resident was evaluated in the facility and found to have good blood flow to bilateral lower extremities. See the physician note dated 7/27/16)), [MEDICAL CONDITION] (low red blood cell count), [MEDICAL CONDITION] (an abnormal heart rhythm) and [MEDICAL CONDITION] (affecting the lungs). Resident #26's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/4/16 coded Resident #26 as a 0 (zero) out of a possible score of 15 on the BIMS (brief interview for mental status) indicating that Resident #26 was severely cognitively impaired with daily decisions about care. The resident was also assessed as requiring extensive to total assist from at least one staff person for transfers, dressing, eating, toileting, hygiene and bathing. Resident #26 was also coded in Section M, Skin Conditions, as having two unhealed pressure ulcers at the time of the assessment, an unstageable* wound with slough and/or eschar measuring 5.0 cm (centimeters) x 10.0 cm and an unstageable wound with suspected deep tissue injury. Resident #26's admission MDS with an ARD of 7/12/16 coded Resident #26 as being at risk of developing pressure ulcers with no admitted with or acquired existing pressure ulcers. Section V - Care Area Assessment (CAA) Summary of the admission assessment documented that 16. Pressure Ulcer was a triggered care area under column A and also checked under column B. Care Planning Decision. The instruction provided in Section V states, 2. For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. Check column B if the triggered care area is addressed in the care plan. Section V, Column B for Resident #26's MDS was checked for pressure ulcer. A review of Resident #26's clinical record revealed, in part, a facility document titled Clinical Health Status dated 7/5/16 at 1540 (3:40 p.m.), the box titled Admission was checked. Under the section titled Section B Skin Conditions a diagram of the human body had an arrow drawn, pointing to the back left hip and hand written beside the arrow was 38 staples. There were no other wounds/skin conditions documented. Under the section titled Braden Scale (9) for Predicting Pressure Sore Risk a score of 14 was documented, indicating moderate risk. Resident #26's comprehensive care plan dated on 7/5/16 was reviewed and did not include a care plan for skin or potential for pressure. On 7/29/16 a revision to the comprehensive care plan included the following documentation; Focus: Pressure ulcer actual due to: Pressure ulcer actual: DTI (deep tissue injury) Left heel. Date Initiated 7/29/2016. Interventions: Assist with Turning and repositioning as needed. Date Initiated 7/29/2016. Revision on: 8/9/2016. Bilateral calf support device while up in wheelchair to float heels. Date Initiated: 8/8/2016. Revision on 8/8/2016. Conduct weekly skin inspection Date Initiated: 8/31/2016. Revision on: 10/12/2016. Weekly Wound assessment: Date Initiated: 8/31/2016. Revision on: 10/12/2016. Dietary to implement prostat to aid in the healing process. Date Initiated: 8/3/2016. Extended bed. Date Initiated 8/3/2016. Heel elevator device in bed. Date Initiated: 8/3/2016. Revision on: 8/8/2016. Skin assessment to be completed per (name of facility) policy. Date Initiated: 7/29/2016. Treatments as ordered Date Initiated: 07/29/2016. A review of Resident #26's physician orders [REDACTED]. A nurse's note dated 7/27/16 at 2:07 a.m. documented, in part, LLE (left lower extremity) 2 + (two plus) [MEDICAL CONDITION] (swelling) noted and elevated on pillows, skin is warm to touch, site observed with no open areas. A physician order [REDACTED].@ (at) am (morning) on 7/27/16. An ultrasound report dated 7/27/16 documented, in part, the following findings; Clinical indication: Leg [MEDICAL CONDITION] and rule out [MEDICAL CONDITIONS]. Findings: There is no [MEDICATION NAME] (within the vessels) thrombus (blood clot) non-compressibility (blood filling issues) or other manifestation of deep vein thrombus in any of the vessels. The right common femoral vein is patent. Impression: Normal left leg vein ultrasound. No [MEDICAL CONDITION]. There is no further documentation on 7/27/16 or 7/28/16 regarding the status of the left lower leg. A nurse's note dated 7/29/16 documented, in part, Left heel mushy with moderate bleeding. Skin prep q (every) shift. Rehab (rehabilitation therapy) to eval (evaluate) for boots or pressure relieving device. RP (responsible party) and MD (medical doctor) aware of the new area. Resident #26's clinical record revealed, in part, a weekly skin review dated 7/26/16 at 11:00 a.m. There was no documentation on the assessment related to any skin concerns. Resident #26's TAR dated 7/1/16 - 7/31/16 documented that skin prep to the left heel was initiated and administered for a suspected DTI beginning on 7/29. There is no evidence in the clinical record that a weekly skin assessment or a wound evaluation sheet was completed when the SDTI (suspected deep tissue injury) was identified on Resident #26's left heel. A PT (physical therapy) Therapist Progress note dated 8/1/16 documented, in part, Pt (patient) was working towards his functional goals and the patient did not progress as anticipated during this progress reporting period. This is likely due to was (sic) making some progress until recent onset of left heel ulcer impacting standing/ WB (weight bearing) activities. During assessment pt's heel skin integrity and pain, pt. exhibited tendency to slide heels on bed in an effort to resist positioning performed by PT. Resident #26's clinical record revealed, in part, a weekly skin review dated 8/2/16 at 11:22 a.m. There was no documentation on the weekly skin review related to any skin concerns. A nurse's note dated 8/3/16 documented, in part, Left heel mushy with blackened area. There was no documentation to evidence that the facility staff conducted a wound evaluation assessment, staged the wound or obtained measurements of Resident #26's left heel wound. Review of Resident #26's clinical record revealed in part the following physician orders; - 8/3/16 Float heels. Document if patient refuses. Every shift for Preventative. - 8/4/16 Bilateral heels up device when in bed, every shift for Wound Healing. - 8/4/16 Prostat Max (a whey based liquid protein) two times a day for DTI left heel 30 ml (milliliters). - 8/4/16 House Supplement three times a day for DTI left heel 90cc (cubic centimeters) - Med Plus (a brand name of supplement). A review of Resident #26's MAR dated 8/1/16 - 8/31/16 evidenced that the physician orders [REDACTED]. The physician order [REDACTED]. A physician progress notes [REDACTED]. Receiving treatment. (L) heel decub (decubitus). Float heel. Nut (nutritional) support. Wnd (wound) MD (medical doctor) consult. A nurse's note dated 8/6/16 at 13:58 (1:58 p.m.) documented, in part, Blister area to left heel appears to be self-absorbing. A nurse's note dated 8/6/16 at 19:13 (7:13 p.m.) documented, in part, Blister is intact/closed. A nurse's note dated 8/16/16 documented, in part, the following; To resident (Resident #26) room for skin prep application to bilaterally (sic) heels. Strong odor noted when sock removed from left heel. Area open to left inner heel approx. 0.5 x 0.5 with purulent drainage. Therapy asked to look at wound for possible (sic) with recommendation to apply calcium alginate (7) to open area at present. MD (medical doctor) and RP (responsible party) made aware. A therapy note dated 8/16/16 revealed, in part, the following documentation; It was noted earlier by nursing that an area of the Pt's left heel wound had opened and was covered with necrotic tissue and had purulent drainage. Therefore PT has assessed wound is starting selective sharp debridement to remove necrotic tissue and promote healing. Necrotic tissue is present on the medial aspect of the left heel wound measuring 25 cm (centimeters) 2 (squared) in surface area and covered in 100% necrotic tissue. A physician ordered dated 8/16/16 documented, in part, Clean left heel daily, apply calcium alginate to open areas and then apply dressing every day shift. A review of Resident #26's TAR evidenced the initiation of this order starting on 8/17/16 and discontinued on 8/31/16. A weekly skin review completed by nursing on 8/17/16 documented, in part, the following; Site: Left heel. Wounds followed by wound nurse. There was no documentation describing the wound, wound stage and no measurements of the wound. A physician order [REDACTED]. A review of Resident #26's nursing notes revealed documentation stating that Resident #26 was taking an antibiotic from 8/18/16 to 8/26/16, a total of nine days. A review of Resident #26's MAR failed to reveal any documented evidence that the facility staff transcribed the order onto the MAR and did not evidence that Bactrim DS was administered to Resident #26 for seven days as ordered by the physician beginning on 8/18/16. A copy of the August pharmacy manifest was requested from ASM (administrative staff member) #2, the director of nursing on 4/26/17 at 6:10 p.m. at the end of day meeting, and on 4/27/16 at 10:15 a.m. This was not provided prior by the end of the survey process. A review of Resident #26's clinical record revealed a wound culture with a collection date of 8/18/16. The final report of the culture dated 8/23/16 documented, in part, HEAVY MIXED FLORA CULTURE (3). CONTAMINATION SUGGEST REPEAT CULTURE. Hand written below the report was the following documentation; Bactrim 8/17. Repeat cx (culture) in AM (morning) TO (telephone order) (name of physician). A physician order [REDACTED]. The facility staff had failed to administer the Bactrim to Resident #26 between 8/17/16 and 8/24/16. A physical therapy note dated 8/24/16 revealed, in part, Implemented selective debridement using scissors, tweezers and gauze to left heel wound for removal of non-viable blade escar (sic) tissue. Necrotic tissue is addressed by nursing. A wound evaluation assessment (one of three completed for Resident #26's left heel) dated 8/24/16 documented, in part, Wound Evaluation Week 3. Length. (no entry). Width (in cm) 3.2 Depth (in cm) 0 (zero). Current preventative interventions: Pressure redistribution mattress. W/C (wheelchair) cushion. Heel boots. The facility staff failed to document a description of the wound bed the stage of the wound and measurements of the wound. On 8/25/16 a wound culture was done as ordered for Resident #26's left heel wound. On 8/28/16 a report from the laboratory documented, in part, Source - Left heel. Organism 1 (one) - Heavy growth gram negative rods.(8) Hand written at the bottom of the laboratory report was the following:[MEDICATION NAME](an oral antibiotic) 500 mg (milligrams) PO BID x 5 (for five) days Lrg (large) growth in (L) ankle gram (-) (negative) rods. A review of the clinical record revealed, in part, a physician order [REDACTED]. May give am dose now. A nurse's note dated 8/26/16 documented, in part, Resident (Resident #26) left the facility for his wound appointment. The facility staff failed to provide any documentation from the wound clinic for this visit. A nutrition note dated 8/26/16 documented, in part; Left heel 8/15 (date) 9.2 x 15 (cm) 8/22 (date 6.0 x 11.0 (cm) SDTI (suspected deep tissue injury). Review of the clinical record revealed the facility staff failed to conduct wound evaluation assessments for Resident #26's left heel between 8/24/16 and 9/2/16 to evidence continuous monitoring of the wound. A nurse's note dated 8/29/16 documented, in part, Continues to monitored (sic) for excessive odor and drainage. There was no description of the wound, no wound stage and no measurements for this assessment. A wound evaluation assessment dated [DATE] documented, in part, Length. (no entry) Depth (in cm) 00 (zero). Width (in cm) 4. Wound bed warm to touch Skin 100%. Surrounding Tissue. Temperature warm. Current treatment: Apply skin prep q (every) shift. Date Treatment Ordered: 7/29/16. There was no documentation describing the wound bed or the stage of the wound. A physician note dated 9/7/16 documented, in part, (L) heel ulcer. There was no documentation describing the wound bed, the stage of the wound or the measurements of the wound. A physical therapy note dated 9/13/16 documented, in part, Pt (patient) has left heel wound unstageable w (with) total surface area of 50 cm 2 (squared) w depth 0 (zero) cm w minimal thin watery purple exudate (discharge), foul odor 95% necrotic, 5 % slough. On 9/14/16 Resident #26 was seen by a physician at the wound care clinic. The physician orders [REDACTED].#26's wound. A hand written physician order [REDACTED]. Santyl (an ointment used to treat infected wounds) to wound bed. Slightly moistened gauze. Kerlix/light coban or ace wrap. Continue to float heel and keep weight off at all times turning pt q (every) 2 hours. Increase protein. X-Ray of (L) heel. A review of Resident #26's 9/1/16 - 9/31/16 TAR revealed that the facility staff failed to administer the ordered dressing to Resident #26's left heel between 9/20/16 and 9/26/16. On these dates the facility staff documented that the dressing on Resident #26's left heel was as follows; Cleanse left heel ulcer with 0.125% Dakin's then apply moist-dry dressing with gauze soaked in 0.125% Dakin's Soln. Wrap with kerlix and light coban or ace wrap. Change qd (every day) and prn (as needed). Order date 9/19/16. There was no documentation in the clinical record regarding this order. Further review of the clinical record did not provide evidence that the facility staff were turning Resident #26 every two hours. Further review of the clinical record did not provide evidence that the facility staff had increased the amount of protein in his food. A physician progress notes [REDACTED]. Decubitus (a pressure injury). Float heels, wound care consult. [MEDICATION NAME](an oral antibiotic). X-ray reviewed. MRI (Magnetic resonance imaging). Continue [MEDICATION NAME] (an oral antibiotic ordered 9/8/16 to be administered for 14 days). A wound evaluation assessment dated [DATE] documented, in part, the following; Depth (in cm) 0 Staging: Suspected Deep Tissue Injury. Width (in cm) 4. Additional notes: Intact deep purple DTI. The documentation did not state the location of the wound described in the assessment such as left or right heel. A radiology report for Resident #26 dated 9/15/16 documented, in part, the following; Examination: Heel 2V (two views) Left. Results: No comparison study is available. Mild erosive change at posterior calcaneus (sic) is concerning for osteo[DIAGNOSES REDACTED]. Conclusion: Consider more sensitive imaging evaluation with MRI (magnetic resonance imaging) as clinically directed. Hand written at the bottom of the report is as follows; MRI Foot. Consult podiatry. Signed and dated by the facility physician on 9/15/16. A review of Resident #26's MAR dated 9/1/16 through 9/30/16 revealed that Resident #26 was administered [MEDICATION NAME] (an oral antibiotic) for 10 days starting 9/21/16 and ending on 9/30/16. A nurse's note dated 9/23/16 documented, in part; Wound has strong smell, when entering the room you can smell the odor even when the foot is wrapped. A nurse's note dated 10/4/16 documented, in part; Wound assessment. The left heel ulcer remains an unstageable pressure ulcer at 5.5 cm x 11 cm x unable to measure due to necrosis. 70% thick adherent necrotic and 30% granulation tissue is present on wound bed. Moderate serous exudate is noted with foul odor. Surrounding skin is macerated (the softening and breaking down of tissue in response to an infection). A wound culture collected on 10/4/16 and resulted on 10/8/16 documented, Heavy growth Proteus Mirabilis (4) (a gram negative bacilla). A physician's verbal order dated 10/4/16 documented, in part, PICC (5) (peripherally inserted central catheter- a long, thin, hollow tube placed into a vein above the bed of the elbow) line placement for infusion of ABT (antibiotic) therapy/infusion IV therapy. One time only until 10/4/16. A review of Resident #26's clinical record revealed, in part, a consent titled Peripherally Inserted Central Catheter (PICC) signed by Resident #26's RP on 10/4/16 that documented, in part, I consent to the placement/insertion of a PICC with catheter tip location at the superior vena cava level A report from an Infectious Disease consultant dated 10/6/16 documented, in part, History of Present Illness: Apparently PICC line was attempted at the NH (nursing home) but patient (Resident #26) was too combative to place a line. Discussion/Summary. Patient (Resident #26) has a large left heel necrotic decubitus ulcer with osteo[DIAGNOSES REDACTED] of the calcaneous (heel bone). This ulcer needs surgical debridement. I recommend that he see a podiatrist. Will order a PICC which he will likely need to have it placed at the hospital. After PICC line place, will empirically start meropenem (an IV (intravenous) antibiotic) 1 gm (gram) q 12 h (every 12 hours). Plan at least 6 weeks of IV antibiotics. A nurse's note dated 10/7/16 documented, in part, Spoke with RP regarding picc placement and haven't resent (sic) to IR ([MEDICATION NAME] radiology) for picc placement. Per RP she would like to think about it, I explained the benefits of obtain (sic) picc and what it could do regarding the wound to the res (resident) left foot. RP stating (sic) I need to think about it and I will let you know on Thursday after the resident podiatry apt (appointment). I also advise (sic) RP to follow up with (name of Infectious Disease physician) office regarding the picc placement. Further review of Resident #26's clinical record did not reveal that a PICC line was placed at the hospital and did not reveal that Resident #26 was started on an antibiotic between 10/1/16 and 10/17/16. Review of Resident #26's physician progress notes [REDACTED].#26's refusal of the PICC line or regarding an alternate antibiotic. Review of the clinical record revealed, in part, the following note from Resident #26's podiatrist dated 10/13/16; Ulcer on the left side is open to bone with Achilles tendon exposed and no palpable pulse to the left foot. A physician order [REDACTED]. Recommend; (L) AKA (left above knee amputation). Signed by physician. A nurse's note dated 10/17/16 documented, in part, the following; Situation: When nurse entered the residents (sic) room at 08:20 am to administer medication resident appeared slightly diaphoretic (sweaty) and not responding to his name resident and skin was warm to touch. Assessment: resident lying in bed with eyes closed resident did not respond to name alone nurse administered the sternum rub and resident did open his eyes however he appeared disoriented residents skin warm to touch vitals were as follows 102.4 (temperature), 98 (heart rate), 16 (respirations), 138/104 (blood pressure), 92% (oxygen saturation). Resident was transferred at 8:45 am via stretcher to (name of hospital). On 4/27/17 at 12:35 p.m. an interview was conducted with OSM (other staff member) #3, the therapy director. OSM #3 was asked if she remembered Resident #27. OSM #3 obtained the PT daily notes. OSM #3 stated, We did the initial evaluation on 7/6/16 and his participation was variable secondary to impaired cognition. He had surgery on his hip with anesthesia and was struggling to recover. He was having heel pain that was impairing his progression. We did start diathermy (8) (therapeutic treatment most commonly prescribed for muscle and joint conditions. It uses a high-frequency electric current to stimulate heat generation within body tissue) and ultra sound to assist with decreasing the pain. We started diathermy on 8/2/16 and it really was not helpful, especially with addressing pain with weight bearing activities. We had been asked by nursing to address the wound around 8/16/16 and we did some sharp debridement. He (Resident #27) continued to decline and we ended therapy on 9/30/16. On 9/13/16 the wound was huge, with a total surface area of 50 cm squared. It was totally covered in necrotic tissue. There was a definite foul odor. On 4/27/17 at 1:35 p.m. an interview was conducted with LPN (licensed practical) #4, a floor nurse. LPN #4 was asked what documentation she completed for a new admission. LPN #4 stated that she would complete the admission package. LPN #4 was asked if that included a skin assessment. LPN #4 stated, I do a head to toe assessment and document anything found. We do weekly skin assessments which used to be on the computer and now they are handwritten. LPN #4 was asked if she remembered Resident #26. LPN #4 stated that she did, he had a mushy heel, I saw it at that time, and we had a wound nurse so I told her to look at it. LPN #4 further stated, I don't think it was opened, they moved him, his heels were elevated and he was moved to another unit. LPN #4 was asked if she remembered any interventions or treatments. LPN #4 stated, I remember that the heel opened up, it had a foul odor and was full of infection. LPN #4 was asked to look at the documentation regarding the Bactrim order. LPN #4 was asked why the nursing staff would document the antibiotic as being given between 8/18/16 and 8/26/16 on the nurse's notes but not on the MAR. LPN #4 stated, I am not sure what happened there it should have been on the MAR. On 4/27/17 at 2:10 p.m. an interview was conducted with RN (registered nurse) #1, the staff development coordinator and assistant director of nursing. RN #1 was asked whether or not a care plan should have been in place when Resident #26 was admitted to address potential skin breakdown. RN #1 stated, The care plan should have been initiated on 7/5/17, admission, and interventions should have been put into place at that time to address his (Resident #26's) risk to develop a pressure ulcer. RN #1 was asked to explain when wound tracking would be initiated, RN #1 stated, Wound tracking begins once a wound is identified. For this resident (Resident #26) as soon as the wound on the heel was identified a wound tracking sheet should have been done. RN #1 was asked if she had any documentation to present regarding a care plan prior to the wound or any documentation evidencing ongoing measurements and monitoring of Resident #26's left heel wound. RN #1 stated she did not. On 4/27/17 at 2:55 p.m. an interview was conducted with LPN #9, Resident #26's admission nurse. LPN #9 was asked to describe her process on admission. LPN #9 stated, I do a complete skin assessment, head to toe, color, turgor and the Braden scale. LPN #9 was asked if she remembered Resident #26. LPN #9 stated that she was very familiar with the resident, but if she was busy she may have passed certain parts of the assessment on to another nurse. LPN #9 was unable to recall the circumstances of Resident #26's admission process. LPN #9 was asked if she was familiar with the Braden scale and if so what did a score of 14 indicate. LPN #9 stated, A score of 14 would mean at risk for developing a pressure ulcer. LPN #9 was asked if a Braden score of 14 would trigger for preventative measures to be put into place. LPN #9 stated, Yes, turn and reposition would be one thing we could do. LPN #9 was asked if she would put that on the care plan. LPN #9 stated, We (the nurses) sometimes do the care plan, generally it is the unit manager. On 4/27/17 at 3:00 p.m. an interview was conducted with RN #6, a floor nurse. RN #6 was asked how often weekly skin assessments were done. RN #6 stated, They are done by shift and by room. Back then (last year) we did them on the computer. RN #6 was asked if she remembered Resident #26. RN #6 stated, He was moved to my side and I remember a really bad wound on his heel. RN #6 was asked whether she remembered anything in particular about the wound / management of the wound. RN #6 stated, We had so many different wound nurses back then. I remember it got really smelly but other than that I don't really know the details. RN #6 was asked what she would do if she saw a Braden Scale of 14. RN #6 stated, We should start care planning for preventative measures. It really depends on their mobility. We would implement interventions if the resident was shown to be at risk. RN #6 further stated, Skin integrity is definitely something that should be addressed. The care plan is definitely important. On 4/27/17 at 3:55 p.m. an interview was conducted with RN #2, the MDS coordinator. RN #2 was asked to describe when a care plan would be initiated. RN #2 stated, On admission we have an interim care plan, this has to be done in the first 24 hours. Then we use the CAAs (care area assessments), medical [DIAGNOSES REDACTED]. RN #2 was asked who was responsible for the interim care plan. RN #2 stated that the nurse on duty at the time of the admission should do it. RN #2 was asked what was included on an interim care plan. RN #2 stated, (TRUNCATED)

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide adequate supervision to maintain and ensure a safe environment, for three of 43 residents in the survey sample, Resident #'s 17, 2 and 1; and failed to evaluate the continued use of an assistance devise to prevent accidents for one resident (Resident #10) in the survey sample of 43 residents. 1. The facility staff failed to manage Resident #17's aggressive behaviors towards other residents in the facility, and failed to provide adequate supervision of Resident #17 to prevent multiple incidents of Resident #17 striking other residents, creating an unsafe environment throughout the facility resulting in Immediate Jeopardy and substandard quality of care. Resident #17 was documented as striking Resident #21 on 11/22/15, Resident #38 on 12/29/15 with subsequent bruising and pain, Resident #41 on 4/22/16 and Resident #11 on 6/9/16. Resident #17's physician ordered a psychiatric evaluation to be completed in November of 2015 and May of 2016. The psychiatric consults were never implemented as ordered. On June 9, 2016 Resident #17 was placed on visual checks every 15 minutes following the incident with Resident #11. During the survey, Resident #17 was observed ambulating in the facility unsupervised. During an interview with LPN (licensed practical nurse) #2, she confirmed the visual checks every 15 minutes and stated she could not always watch Resident #17 but completed the log sheet for visual checks even when the visual checks were not completed. LPN #2 confirmed Resident #17 needed 1:1 (one to one) supervision or a someone is going to get hurt. During an interview with Resident #17's physician, who is also the facility medical director (ASM (administrative staff member) # 4) he stated, There is a chance of assault, we don't know what triggers him when he hits people. He needs to be in a higher level of care than can be provided here. Other residents are at risk I am worried he will hurt someone, make someone fall and break a hip or something. It worries me. The Administration was informed on 6/16/16 at 4:21 p.m. of the Immediate Jeopardy situation. Based on evidence provided by the staff Resident #17 was immediately placed on 1:1, with staff that were trained on supervision of the resident in regards to his aggressive behaviors and other residents' safety. The 1:1 supervision is ongoing. After the plan was reviewed, and verified through observation, interview and review of documentation, the plan was accepted. The Immediate Jeopardy was abated on 6/16/16 at 9:15 p.m. and the scope and severity of the deficiency was lowered to a level II pattern. 2. The facility staff failed to effectively assess the continued use of a merri walker (a restraint free walker that promotes independent ambulation) by Resident #10 following three falls. 3. The facility staff failed to ensure that interventions were implemented to address Resident #2 ' s aggressive behavior towards Resident #1, after altercations 6/15/15 and 8/9/15 when Resident #2 kicked Resident #1. 4. The facility staff failed to implement interventions for Resident #1 to ensure a safe environment, after Resident #1 was kicked by Resident #2 twice on 6/15/15 and 8/9/15 during resident to resident altercations. The findings include: 1. Resident #17, a [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 4/13/16. Resident #17 was coded on the Brief Interview of Mental Status as having a score of two out of a possible 15, indicating severe cognitive impairment with daily decision making. Resident #17 was also coded as not demonstrating behaviors during the 14 day look back period and was coded as wandering one to three days during the lookback period. Resident #17 was further coded as requiring supervision (oversight, encouragement or cueing) while ambulating on and off the unit. Resident #17 had full range of motion of upper and lower extremities. A review of Resident #17's quarterly assessment MDS with an ARD of 1/15/16 revealed, in part, that Resident #17 had not demonstrated any behaviors during the look back period and was coded as rejecting care for one to three days during the look back period. A review of Resident #17's admission assessment MDS with an ARD of 10/22/15 revealed that Resident #17 had not demonstrated any behaviors during the look back period and was coded as wandering for one to three days during the look back period. A review of Resident #17's admission assessment revealed, in part, that Resident #17 had no behavioral symptoms. A review of Resident #17's clinical record revealed behavior monthly flow sheets for the months of January, February, May and June, 2016. The following information was documented: · Behavior Monthly Flow Sheet January 2016 - 13 shifts out of a possible 93 shifts worked in the month contained an entry. Targeted behaviors were striking out/hitting and wandering. No behaviors were documented. · Behavior Monthly Flow Sheet February 2016 - 24 shifts out of a possible 84 shifts worked in the month contained an entry. Targeted behaviors were combative and wandering. No behaviors were documented. · Behavior Monthly Flow Sheet May 2016 - 22 shifts out of a possible 93 shifts worked in the month contained an entry. Targeted behaviors were not identified. No behaviors were documented. · Behavior Monthly Flow Sheet June 2016 - 30 shifts out of a possible 60 shifts worked in the month contained an entry (there were no entries for night shift). Targeted behaviors were false beliefs and fighting. On June 9, 2016 and June 13, 2016 behaviors were documented as X1 (occurred one time) and an intervention was put into place for 15 minute checks. A review of Resident #17's clinical record revealed that he had been seen by ASM #4 (Resident #17's physician, who is also the facility medical director) on the following dates: 10/15/15 for admission assessment; 1/5/16 assessment Dementia stable; 1/21/16; 2/3/16 assessment Dementia stable; 3/9/16; 4/6/16; 6/16/16 assessment Mental status changes. Mostly aggression; Keep pt (patient) close to nurses station: Needs higher level of care. A review of Resident #17's progress notes revealed, in part, a SBAR (situation, background, assessment, response) note documenting the following: 11/23/2015 00:08 (12:08 a.m.) Situation: Agitated with combative behavior towards his room mate (sic) after dinner. Background: H/O (history of) Dementia, HTN (hypertension), A-fib (atrial fibrillation) and heart failure. He is a DNR (do not resuscitate) status and under the care of (name of physician). Assessment: Resident was observed guarding the entry door to his room and waiving his cane in the direction of resident (Resident #21's medical record number). Screaming for him to stay out of his room. Further commenting that I hit him 3 times with my cane and if he comes back I'll do it some more. (Name of Resident #17) commented to nurse that his room mate (sic.) was condescending and he was sick of hearing him talk. Response: Son (name of son), (name of physician) and management have been notified of this occurrence. Residents were immediately separated and there have been no further events on this shift. This note was signed by LPN (licensed practical nurse) #16. Further review of Resident #17's progress notes revealed, in part, the following documentation: 11/23/2015 13:22 (1:22 p.m.). This writer spoke with the resident (Resident #17) regarding his former roommate (Resident #21). The resident stated, I hit him with my stick because he was attacking me. He was yelling at me and screaming at me. I took this thing (pointing to his cane) and knocked him down. No further comments or concerns were mentioned by the resident. Signed by OSM (other staff member) #4, the social worker. Resident #21 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD of 5/18/16. Resident #21 was coded as being severely cognitively impaired in ability to make daily life decisions, scoring a 3 out of a possible 15 on the BIMS exam. Resident #21 required total care for bathing; limited assistance for hygiene; supervision for transfers, ambulation, dressing, and eating; was usually continent of bowel and bladder; and had full range of motion of upper and lower extremities. A review of Resident #21's progress notes revealed, in part, a note for 11/22/15 (note dated 11/23/15 at 22 minutes after midnight), Resident (Resident #21) was involved in a physical altercation with his roommate (Resident #17) @ (at) 1800 (6:00 p.m.) .Assessment: Resident has normal ROM (range of motion) and there is no redness, lacerations or swelling R/T (related to) this occurrence. He was physically shaken by this event and reported that he had been struck 3 (three) times with a cane on his torso. VS (vital signs) (blood pressure, pulse, respirations and temperature) 164/72 - 78 - 22 - 98.2F (Fahrenheit) with a SPo2 (peripheral capillary oxygen saturation - an estimate of the amount of oxygen in the blood (1)) of 93% on RA (room air). Response: Daughter (name of daughter), Dr. (doctor) (name of doctor) and management were notified of this event. Residents were immediately separated and there have been no further events on this shift. New orders were rec'd (received) to administer Haldol 5 mg (milligrams) po (by mouth) daily and Benadryl 50 mg po daily after dinner x (times)30 days and then re-evaluate behaviors/rest patterns. Resident was placed in room (room number) for tonight and he has been resting quietly A review of the care plan for Resident #21 did not reveal any documentation regarding this incident. A verification of investigation was provided to this surveyor by ASM (administrative staff member) #2, the director of nursing that revealed, in part the following documentation; Provide a detailed description of event/allegation. (Name of Resident #17) struck resident (Resident #21's medical record #) with his cane 3 times after returning from dinner tonight. Assessment of resident/describe injury. Resident (Resident #17) was in an agitated state and commented that his room mate (sic) was condescending and that he was sick of hearing him talk. He added that if his room mate (sic) returned to the room he would hit him some more. Immediate resident protection initiated: Residents were immediately separated and have been monitored for location/safety. Son (name of Resident #17's son), (name of physician) and management were notified of this event. Resident (Resident #21's medical record #) has been relocated to another room. Causal / contributing factors and observations: Each male with psychological disorders with distinct preferences. (Name of Resident #17) prefers quite (sic) surroundings and the second male is extremely talkative w/o (without) boundaries. Specify recommendations / interventions take to prevent reoccurrence: Residents have been separated and monitored for location/safety. Rooms will be changed as indicated. Resident (Resident #21's medical record #) has been placed in a room on the east 1 hallway for the night this resident (Resident #17) became agitated (sic) and upset with the roommate being in his room and stated that he struck the resident with his cane and would do it again if he came back into the room. No one actually witnessed the roommate being struck nor were there any signs of injury but the roommate (Resident #21) also stated that he had been struck 3 times in the torso with this resident's (Resident #17) cane. This resident (Resident #17 will also be seen by psych (psychiatry), although he does have a care plan in place as he does get agitated (sic) and aggressive at times A review of Resident #17's care plan revealed, in part, the following documentation: Problem: I sometimes have behaviors which include hitting people and verbal aggression towards people entering my room. Date initiated 11/23/2015. Intervention: Please refer me to my psychologist/psychiatrist as needed. Date initiated 11/23/2015. Speak to me unhurriedly and in a calm voice. Date initiated: 11/23/2015. There was no evidence provided of a care plan addressing aggressive behaviors prior to 11/23/2015. On 6/20/16 at 11:00 a.m. an interview was conducted with RN (registered nurse) #3, the unit manager. RN #3 stated that she had created the care plan entries dated 11/23/15. RN #3 was asked why she had entered a care plan intervention to refer Resident #17 to his psychologist/psychiatrist on 11/23/15. RN #3 responded that she had spoken to Resident #17's physician following the incident with Resident #21 that had occurred on 11/22/15 and the physician had recommended that Resident #17 be seen by a psychologist / psychiatrist. RN #3 was asked whether or not an order had been entered directing staff to obtain a consult at that time. RN #3 reviewed the clinical record and stated that it did not appear that there was an order. RN #3 requested time to review the psychiatry book (a place where the nursing staff could list residents needing to be seen by psychiatry). On 6/20/16 at 11:20 a.m. RN #3 returned to this surveyor and stated that there were no psychiatric consults entered into the psychiatry book following the 11/22/16 incident as recommended on 11/23/16. A review of Resident #17's progress notes revealed, in part, the following documentation for 12/29/2015 at 3:30 p.m. Situation: Resident (Resident #17) reported to have hit another resident (Resident #38's medical record #) with his fist on the chest and right hand. Background: Resident has [DIAGNOSES REDACTED]. Assessment: Resident (Resident #17) refused total body assessment, however allowed this nurse to look at his arms and hands and no bruises noted. Response: Resident reminded and encouraged to stay apart for (sic) resident (Resident #38's medical record number) and not to hit anyone. MD (medical doctor) and RP (responsible party) notified. Signed by LPN #7. A Verification of Investigation was provided to this surveyor by ASM #2, the director of nursing. The Verification of Investigation revealed, in part, the following documentation: Provide a detailed description of event/allegation: This resident (Resident #17) is reported to have hit resident (Resident #38's medical record number) on right chest and right hand. Resident interview summary: Resident (Resident #17) states this has been going on since last week and I got tired of it so I punched her, resident became upset during interview and walked out. Immediate resident protection initiated: Residnet (sic) was assisted to his room to allow him time to calm down, reisdnet (sic) has dementia and short term memory loss and is not teachable, reminders offered. Causal/contributing factors and observations: Resident has dignosis (sic) of dementia and short term memory loss. Specify recommendations / interventions taken to prevent reoccurrence: Resident doesn't want to be bothered, resident is independent with ambulation around the center. Provide summary and outcome of investigative findings: Staff will continue to monitor location of resident and intervene when resident is noted becoming agitated and redirecting him accordingly. IDT (interdisciplinary team) discussed possible room change but will monitor to determine if room change is warranted or behavior continue. Resident #38 was admitted to the facility on [DATE] with a readmission of 10/13/15 with the [DIAGNOSES REDACTED]. The most recent MDS for Resident #38 was a quarterly assessment with an ARD of 4/20/16. Resident #38 was coded as being moderately cognitively impaired, scoring an 11 out of a possible 15 on the BIMS exam. Resident #38 required supervision and physical assistance of one person for ambulation, dressing and hygiene. Resident #38 had full range of motion of upper and lower extremities. A review of Resident #38's progress notes revealed, in part, the following documentation: 12/29/2015 23:48 (11:48 p.m.) Bruising noted on residents (Resident #38) right upper arm which she reports occurred during this physical contact today (with Resident #17). She has been OOB (out of bed) ad lib (as wanted) tonight and has been re-directed from making derogatory statements about male (Resident #17) involved in this event. No behavioral issues on this shift. Signed by LPN #16. Further review of Resident #38's progress notes revealed, in part, the following documentation: Resident alert and oriented x 3, ambulating around the center resident right hand, notably discolored and slightly swollen and painful to touch, right upper arm also has a very large bruise that resident reports is where she was hit. Resident (Resident #38) reports it feels sore, resident states she has not been around residne (sic) that hit her (Resident #17), states she is trying to stay away from him. Signed by RN #3. A review of Resident #38's comprehensive care plan dated 10/13/15 did not reveal any documentation regarding the incident with Resident #17 on 12/29/15 and did not provide any documentation of interventions placed on 12/29/15 for safety. A review of Resident #17's care plan revealed, in part, the following documentation following the incident on 12/20/2015: Problem: 12/29/15 Resident (Resident #17) struck another resident (Resident #38). There were no interventions listed. Continued review of Resident #17's progress notes revealed, in part, the following documentation: 4/22/2016 23:13 (11:13 p.m.) Type: SBAR - Change of Condition. Situation: At 3:28 p.m. resident (Resident #17) was sitting in front of nurse's station when he got up and hit another resident (Resident #41) who was walking in hallway. Background: Dementia w/o behavioral disturbance. HTN, [DIAGNOSES REDACTED] Atrial Fib, CHF. Assessment: No injury. Response: Resident (Resident #17) was removed from scene and redirected to his room. RP (responsible party), MD (medical doctor) and ADON (assistant director of nursing) aware. Resident #41 was admitted to the facility on ,[DATE] 14 with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date 5/25/16, she was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as having exhibited no behaviors during the look back period. She was coded as requiring supervision only from staff for bed mobility, transfers, walking and dressing. She was coded as being independent for eating, toileting and personal hygiene. She was coded as requiring the extensive assistance of one staff member for bathing. A review of the nurses notes for Resident #41 revealed the following note, written on 4/22/16 at 11:24 p.m. by LPN (licensed practical nurse) #2: Situation - At 3:28 p.m. resident (Resident #41) was walking in hallway when another resident (Resident #17) who was sitting in front of the nurse's station got up and walked up to her (Resident #41) hitting her twice on right arm. Background: Generalized pain, [DIAGNOSES REDACTED], Dysmetaboli[DIAGNOSES REDACTED], Depressive disorder, Huntingtons (sic) Chorea, chronic pain due to trauma, hearing loss, HTN (hypertension), constipation. Assessment: No redness or bruise noted on right arm. Response: Resident (Resident #41 was re-directed to her room. RP, (responsible party), MD (medical doctor) and ADON (assistant director of nursing) aware. A review of the comprehensive care plan for Resident #41 dated 10/29/14 and updated on 4/22/16 revealed, in part, the following: The resident (Resident #41) has the potential for injury. 4/22 hit by another resident (Resident #17) twice on right arm. Resident safety will be maintained through next review. Redirect resident to a safe place as needed. Remove sources of agitation as possible. A Verification of Investigation was requested for the incident involving Resident #17 and Resident #41 on 4/22/16 at approximately 3:00 p.m. from ASM #2, the director of nursing. ASM #2 stated that she did not have an investigation for that date. On 6/20/16 an interview was conducted with ASM #3, the ADON. ASM #3 was asked if she was notified regarding an incident between Resident #17 and Resident #41 that occurred on 4/22/16. ASM #3 stated that she was not notified by nursing on that date. A review of Resident #17's care plan revealed, in part, the following documentation: Problem: 4/22/16 resident (Resident #17) was sitting in front of nurse's station when he got up and hit another resident (Resident #41) who was walking in the hallway. Intervention: Remove sources of agitation as possible. Remove the resident from the area. Date initiated 4/25/2016. Further review of Resident #17's clinical record did not reveal any further documentation regarding the incident on 4/22/16 with Resident #41. A review of Resident #17's progress notes revealed, in part, the following documentation dated 6/9/16 at 16:06 (4:06 p.m.) SBAR - Change of Condition: Situation: (Name of Resident #11) was noted sitting upright in the hallway near the nurses station in her scoop and walk chair when this nurse observed resident (Resident #17's medical record number) hitting her (Resident #11) in a continuous motion his face appeared to be angry and this nurse ran and repeatly (sic) stated no. when (sic) I got in between (sic) them (name of Resident #11) then punched (Resident #17's medical record number) softly aprox (sic) two times he (Resident #17) then punched me like a punching bag on the left arm. (Resident #17's medical record number) then proceeded to the end of west 2 hallway and the PT (physical therapist) representative asked him if he wanted cookies and he proceeded to walk with her I stayed with (name of Resident #11) to prevent further altercations between the residents. A Verification of Investigation provided by ASM #2, the director of nursing, revealed, in part, the following documentation: Resident (Resident #17) observed by this nurse hitting resident (Resident #11's medical record number). Immediate resident protection initiated: separated from (Resident #11's medical record number) Q (every) 15 minute visual checks. A review of Resident #17's care plan revealed, in part, the following documentation: Problem: 6/19/16 resident noted to have altercation with another resident (he hit the resident, Resident #11, continuously until nursing staff separated him). Intervention: RESOLVED: monitor resident's whereabouts every fifteen minutes. Date initiated: 6/10/2016. A review of Resident #17's 15 minute check logs revealed the following information: 15 minute checks were initiated on 6/9/16 at 1500 (3:00 p.m.) and continued every 15 minutes with the following gaps in time when there was no documented 15 minute checks: · 6/12/16 11:00 a.m. - 6/12/16 12:00 noon (1 hour) · 6/12/16 1:00 p.m. - 6/12/16 3:45 p.m. (2.75 hours) · 6/14/16 12:30 p.m. - 6/14/16 2:45 p.m. (2.25 hours) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with assessment reference date 4/6/16, Resident #11 was coded as being severely cognitively impaired for making daily decisions, having scored six out of 15 on the BIMS (brief interview for mental status). She was coded as having demonstrated no behaviors during the look back period. She was coded as requiring the extensive assistance of staff for bed mobility, transferring from bed to chair, walking, toileting and personal hygiene. She was coded as being completely dependent on staff for bathing. A review of the clinical record revealed the following nurse's note written 6/9/16 at 4:02 p.m.: Situation: Resident (Resident #11) hit by (Resident #17). Background: Parkinson's, dementia with behavior. Assessment: (name of Resident #11) was noted sitting upright in the hallway near the nurses station in her scoop and walk chair when this nurse observed (Resident #17) hitting her in a continuous motion. His face appeared to be angry. This nurse ran and repeatedly stated no no (sic). When I got between them (Resident #17) then punched softly approx (approximately) two times. He (Resident #17) then punched me like a punching bag on the left arm. (Resident #17) then proceeded to the end of west 2 hallway and the PT (physical therapy) representative asked him if he wanted cookies and he proceeded to walk with him. I stayed with (Resident #11) to prevent further altercations between the residents. Response: No noted injuries at this time. Residents were separated. Resident (Resident #11) currently at nurse's station in a calm mood. (Resident #17) noted not in contact with her. Message was left for first and second contact to return call. 3-11 (3:00 p.m. to 11:00 p.m. shift) nurse caring for resident. Informed (name of attending physician) at 1507 (3:07 p.m.). No new orders. A review of the comprehensive care plan for Resident #11 dated 1/18/16 and updated on 6/10/16 revealed, in part, the following: My safety is at risk and there is potential for abuse due to: decreased physical ability, resident to resident altercation 6/9/16. I will be kept safe and free from abuse through my next review. Explain what you are going to do before providing care. Please remove me from potentially dangerous situations. A review of Resident #17's physician order [REDACTED]. Order Status: Active Order Date: 5/19/2016. Further review of Resident #17's clinical record revealed the following physician order [REDACTED]. (A facility to treat geriatric residents for psychiatric difficulties) Signed by ASM #4. A review of Resident #17's physician visits and consults did not reveal that Resident #17 had been seen by a psychiatrist. A document provided to this surveyor by ASM #2, the director of nursing, on 6/16/16 at 4:00 p.m. revealed that the psychiatrist had not visited the facility since 4/14/16. The psychiatry nurse practitioner had been in the facility on 5/12/16; 5/19/16, 5/26/16 and 6/2/16 but had not been asked to see Resident #17. Resident #17 was observed consistently by the survey team on 6/15/16 from 2:23 p.m. until 6:55 p.m. and on 6/16/16 from 2:45 p.m. until 3:12 p.m. During these times the following observations were made: · 6/15/16 2:33 p.m. - 2:56 p.m. Resident #17 was in his bathroom and room; no staff entered his room or looked into his room for a visual check. · 6/15/16 5:10 p.m. to 5:31 p.m. Resident #17 was lying across foot of bed, then up to his bathroom, back to sitting on edge of bed, left room and started ambulating down the hallway. No staff was observed to look into his room or check on Resident #17. At approximately 5:31 Resident #17 was intercepted in the hallway by staff. · 6/16/16 2:45 p.m. - 2:55 p.m. Resident #17 was ambulating in the hall without staff supervision, observed walking in hallway near the kitchen with a cup of coffee. Walked past a resident in a wheelchair prior to entering his room. Staff was not observed to intercept or be observing Resident #17 during this time. On 6/15/16 at 1:45 p.m. an interview was conducted with CNA (certified nursing assistant) #28, who was assigned to provide care to Resident #17 for dayshift. CNA #28 was asked how she was made aware of resident behaviors. CNA #28 stated that at the change of shift they did rounds and if anything was not normal she was made aware of it. CNA #28 was asked if there were other ways to get information regarding resident care and needs, CNA #28 responded that the information for each resident was on their Kardex. CNA #28 was asked whether she was aware of any specific residents that were known to have behaviors. CNA #28 responded, (Name of Resident #17) he gets agitated sometimes and hits at people. CNA #28 was asked how she was supposed to manage (name of Resident #17's) behaviors. CNA #28 responded, We don't have specific directions, we just keep him occupied. CNA #28 was asked if there were any residents that she had been instructed to watch all the time. CNA #28 responded, No, not anyone that's one to one or fifteen minute checks, not here on (name of nursing unit) and I work mostly on this side. On 6/15/16 at 2:20 p.m. an interview was conducted with LPN (licensed practical nurse) #18, an agency nurse responsible for the care of Resident #17 for day shift. LPN #18 was asked how she would learn about residents with behaviors. LPN #18 responded that she would be made aware in report of any behaviors and there was a log at the nurse's station. LPN #18 was asked how she would know about interventions in place for aggressive behaviors. LPN #18 responded that she would get the information at the change of shift report. LPN #18 was asked what she knew about Resident #17. LPN #18 responded, He is alert and oriented and likes to stay to his self and takes medications whole. LPN #18 was unable to provide any information regarding Resident #17's 15 minute checks or that he had been aggressive in the past with other residents. On 6/15/16 at 6:32 p.m. an interview was conducted with LPN #14, the nurse responsible for the care of Resident #17 on evening shift, in the presence of RN #5, the unit manager. LPN #14 was asked if Resident #17 was on 15 minute checks. LPN #14 responded yes. LPN #14 was asked to show the evidence of the 15 minute checks being completed. LPN #14 responded, I haven't written them down since I've been here. I haven't looked at him every 15 minutes. There were a few times when I did look at him. RN #5 stated, I've been here today, it's on the clipboard I showed it to you (name of LPN #14) remember? LPN #14 stated, No. RN #5 brought the clipboard to the desk and stated, I haven't done them today but I've been doing it (checking on Resident #17). On 6/15/16 at 6:35 p.m. an interview was conducted with CNA #21. CNA #21 was asked if she was aware of the 15 minute checks on Resident #17. CNA #21 responded, Yes, there were a few times when I did look at him, I had to go up front several times to speak to them (administration) so I couldn't watch him all the time. If he isn't bothering anybody we will let him sit at the nurse's station in the hallway otherwise keep him in his room if he looks like he's not in a good mood. On 6/16/16 at 2:00 p.m. an interview was conducted with ASM #4, the primary physician for Resident #17, (and also the facility medical director). ASM #4 was asked what information he could provide about Resident #17's aggressive interactions with other residents in the facility. ASM #4 responded that he needed to be placed in a geriatric psychiatric facility, a higher level of care. ASM #4 further stated that over the past 1 month period he had punched several other residents with minor consequences. ASM #4 stated, Once I saw a pattern of assault I knew he needed to go. ASM #4 was asked when the last incident occurred with Resident #17 hitting another resident. ASM #4 responded that Resident #11 was the last person he had struck but there were several other inciden

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to provide care and services to treat and prevent pressure ulcers* for one of 43 residents in the survey sample, Resident #42. * A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Also called bedsores. Pressure sores. (1) Resident #42 was admitted with an area on his sacrum/coccyx. No treatment orders were put in place for the wound and on 12/1/15 it was identified and documented as having declined into an unstageable wound * with yellow slough. On 12/8/15, the wound care specialist identified Resident #42 as having developed an Unstageable DTI (deep tissue injury) ** of the left heel. On 12/20/15, Resident #42 was identified as having developed an unstageable wound with tunneling where the scrotal sac attaches to the perineal area before the anus. There were no documented skin assessments for Resident #42, and no interim care plan to address his needs prior to the comprehensive assessment. There were no documents, other than the wound specialist's notes, regarding the assessment, measurements or treatments of wounds for Resident #42. * An Unstageable pressure wound is a known wound but not stagable due to coverage of wound bed by slough and/or eschar. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. (2) **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. (3) The findings include: Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 12/21/15, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating he was moderately impaired to make cognitive daily decisions. The resident was coded as requiring extensive assistance of one staff member for moving in the bed, transfers, locomotion, dressing, toileting, personal hygiene and was dependent for bathing. He was coded as requiring supervision of one staff member for eating. Resident #42 was coded in Section M - Skin Conditions as having one Stage 2 pressure ulcer * and one Unstageable pressure ulcer. The unstageable pressure ulcer was documented as being 0.5 x 0.5 cm (centimeters). The tissue was documented as slough. M0800 Worsening in Pressure Ulcer Status Since Prior Assessment documented, the resident's Stage 2 pressure ulcer was new since the last assessment. *A stage II pressure ulcer is described as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). May also present as an intact or open/ruptured blister. (4) The admission nursing assessment dated [DATE] at 2:45 p.m. documented, J(pressure ulcer according to the codes on the form) over the sacrum. The admission nursing assessment form documented, Date first observed - 11/24/15. Site - sacrum. Description - pink, boggy edges, granulation tissue noted to the center. The form documented a heading titled, Braden Scale for Predicting Pressure Sore Risk and a total score of 11 for Resident # 42. A score of 10-12 is indicative of a high risk for developing pressure sores. There were no further Braden Scales in the clinical record. The nurse's note dated 11/24/15 at 2:52 p.m. documented in part, Patient is incontinent of bowel and bladder, wound noted to the sacral area. Wound nurse to be notified. BLE (bilateral lower extremities) elevated, floating with pillows, heels intact at this time, scar to left groin area, firm and raised to touch, caregiver reports this was the result of lymph node removal. Skin is warm and dry to extremities, upper lower and mid back, excellent skin turgor. Review of the physician orders did not document any treatment for [REDACTED]. The physician order dated 11/24/15 documented, Weekly skin review, pressure redistribution mattress. The nurse's note dated, 11/25/15 at 1:11 p.m. documented in part, Patient is incontinent of bowel and bladder, skin is intact to all extremities. Bandage to sacrum removed and reapplied new after becoming soiled. A nurse's note dated, 11/26/15 at 10:04 p.m. documented in part, Resident's skin is dry and intact. There are no new areas of concern noted or reported at this time. The nurse's note dated, 11/28/15 at 1:08 p.m. documented in part, Incontinent of bowel and bladder, bandage to sacrum removed due to being soiled, area cleaned and new bandage applied and intact at this time. Patient is a total assist. A nurse's note dated, 11/29/15 at 2:27 p.m. documented in part, Bandage to sacrum intact .patient is incontinent of bowel and bladder, barrier cream applied to buttocks bilaterally. Heels are floating by use of pillows. The nurse's note dated, 11/30/15 at 11:07 a.m. documented in part, Skin is warm and dry, good skin turgor, nonblanchable, boggy, pink and moist area noted to the sacrum with some peeling, scant bleeding noted. Cleaned area with NS (normal saline), Duoderm * applied. Notified wound nurse. *DuoDERM® Dressings are modern [MEDICATION NAME] dressings for the management of light to moderately exuding wounds.DuoDERM® Dressings are versatile, easy to use and are suitable for managing different stages of wound healing and wound types in a protocol of care. (5) A nurse's note dated, 11/30/15 at 10:26 p.m. documented in part, Resident is incontinent of b/b (bowel and bladder), dressing intact to sacral area .assist of 1 provided by staff with care q2h (every two hours) and prn (as needed). Review of the TAR (treatment administration record) did not reveal any treatments ordered or administered for the month of November 2015. This was verified with RN (registered nurse) #1, the unit manager on 6/17/16 at 4:21 p.m. The nurse documented, in part, on 12/1/15 at 2:52 p.m., Resident skin is intact and warm to touch .Resident is incontinent of both bowel and bladder. Resident is dependent on all adl's (activities of daily living), one person assist. The Wound Evaluation Flow Sheet dated 12/1/15 at 5:05 p.m. documented, Is this continuing documentation of a wound tracked under a completed Wound Evaluation Flow Sheet? A circle next to No was documented. Site: coccyx; Type: Pressure; Length: 0.5 cm; Width: 0.5 cm; Depth: 0.0; Stage: Unstageable. Wound type: Pressure Ulcer (in-house acquired). When was the wound identified - 12/24/15 (sic). Additional descriptions: Further complicated by MASD (moisture associated skin damage), maceration, blanchable [DIAGNOSES REDACTED], boggy. Exudate: 1. Color/Type - Serous; 2. Consistency - thin, watery; 3. Amount - Small/minimal; 4. Odor - Not present. Wound bed: 3c. Slough - 100%. Wound color - yellow. Current treatment: Cleanse with normal saline, pat dry, [MEDICATION NAME] prep (skin prep)* surrounding skin, apply [MEDICATION NAME] (Duoderm like product) 2x (times) a week and PRN for strike through. Date Treatment Ordered - 12/03/2015. Current Wound Status/Additional Comments: Resident documented to have a wound upon admission by charge nurse. Wound evaluation by this nurse and wound care specialist on 12/01/15. This note was written by the wound nurse. She is no longer employed by the facility and was unable to be interviewed. *Skin-Prep is a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films. Skin-Prep can also be used to prepare skin attachment sites for drainage tubes, external catheters, surrounding ostomy sites and adhesive dressings. Helps tape and film adhesion. (6) The Wound Care Specialist Initial Evaluation dated, 12/1/15, documented in part, Unstageable (Due to Necrosis) of the Coccyx. Etiology: Pressure; MDS 3.0 stage: unstageable necrosis; Wound size: 0.5 x 0.5 x 0 cm. Exudate: light serous; Yellow necrotic: 50 %; Granulation tissue: 50 %. Dressing: [MEDICATION NAME] - Q TF (Tuesdays and Fridays). The nurse documented in part, on 12/2/15 at 6:21 a.m., He's incontinent of b/b, dressing intact to sacral area, turn and reposition as tolerated .assist of 1 provided by staff with care. The nurse's note dated, 12/2/15 at 3:25 p.m. documented in part, Resident dressing on sacral is intact .Resident is a two person assist. The physician orders dated, 12/3/15 at 1:03 p.m. documented, Cleanse wound to coccyx with NS, pat dry, [MEDICATION NAME] prep surrounding skin, apply [MEDICATION NAME] 2 x a week one time a day every Tues, Fri. 12/3/15 at 1:33 p.m. documented, Air mattress properly inflated Q (every) shift. MA 65 on a setting of 3 one time a day. The nurse's note dated, 12/3/15 at 1:42 p.m. documented in part, Incontinent of bowel and bladder, skin is warm and dry, bandage to sacrum is intact. Heels bilaterally are elevated and floating with use of pillows. The nurse documented in part on 12/3/15 at 11:55 p.m., Resident dressing on sacral is intact .Skin warm to touch and dry. Resident is incontinent of bowel and bladder. The nurse's note dated, 12/5/15 at 1:10 a.m. documented in part, Resident dressing on sacral is intact Resident is incontinent of both bowel and bladder. Resident is a two person assist. The nurse documented in part on 12/7/15, Wound noted to the sacrum, wound nurse is aware, cleaned area with NS, Duoderm applied. The nurse's note dated, 12/7/15 documented in part, Resident is incontinent of b/b, dressing intact to sacral area. The nurse documented in part on 12/8/15 at 2:36 p.m., Patient is incontinent of bowel and bladder at times, bandage to sacrum replaced, skin is warm and dry. The Wound Care Specialist Evaluation dated, 12/8/15 documented in part, Unstageable (Due to Necrosis) of the Coccyx. MDS 3.0 stage: Unstageable; Wound size: 0.5 x 0.5 x 0 cm; Exudate: light serous; Yellow necrotic: 50 %; Granulation tissue: 50%; Wound progress: no change. Dressing: [MEDICATION NAME] - QTF (Every Tuesday and Friday). Unstageable DTI (deep tissue injury) of the Left Heel: Etiology: Pressure; MDS 3.0 stage: unstageable DTI; Wound size: 2 x2x not measurable. Dressing: Skin Prep once daily. The nurse's note dated, 12/9/15 at 3:17 a.m. documented in part, Is incontinent of b/b, dressing intact to sacral area and no [MEDICAL CONDITION] to BLE (bilateral lower extremities) . assist of 1 provided by staff with care q2h and prn. A Late Entry dated, 12/9/15 at 7:27 a.m. was documented by the wound nurse. It documented in part, SBAR Change of condition. S - Situation: New area noted to resident left heel. B - Background: Resident presents with multiple comorbidities that may impact skin integrity and potential for healing; Adult T cell [MEDICAL CONDITION]/[MEDICAL CONDITIONS] CKD. A - Assessment: Left heel noted to present with a purple dusky area indicative of a suspected deep tissue injury that measures 2.0 x 2.0 x depth unknown. 100% skin/intact purple blister. No drainage, no odor, tender to touch. R - Response: Heel elevated with pillows. Call placed to RP (responsible party). Return call pending. MD (medical doctor) made aware. New orders noted for [MEDICATION NAME] skin prep Q day, air mattress MA 65* properly inflated Q shift on a setting of 3. *Air Mattress MA 65 is a fully-functional Alternating Pressure and Low-Air-Loss without the noise associated with the larger blower based systems. (7) A Late Entry dated, 12/9/15 at 6:14 p.m. documented, Assessed resident's left heel due to report of a new wound area. Upon inspection, the resident does present with a fluid filled blister, opaque in color indicative of a stage 2, that measures approx. (approximately) 2.0 x 2.2 cm. Periwound is WNL (within normal limits) .He is currently on an air mattress but heels were not floated. The charge nurse states that the resident does get up out of bed but usually wants to go back to bed almost immediately. He is being seen by therapy, has a [DIAGNOSES REDACTED].* boots to offload. He is not nutritionally compromised but was admitted with a wound to his sacral area. Order for skin prep every shift and to protect area. Wound sheet completed and CP (care plan). MD and RP to be made aware. This note was written by the former director of nursing, who was no longer employed at the facility and unavailable for interview. *Prevalon helps minimize pressure, friction and shear on the feet, heels and ankles of your non-ambulatory patients. By off-loading the heel, it delivers total, continuous heel pressure relief. Its unique design also helps reduce the risk of plantar flexion (foot drop). (8) The physician orders dated, 12/9/15 at 7:02 p.m. documented, Float heels while resident in bed as he will allow every shift. The nurse's note dated, 12/9/15 at 10:35 p.m. documented in part, Resident dressing on sacral is intact. The nurse documented in part on 12/10/15 at 2:31 a.m., Incontinent of both b/b, dressing intact to sacral, assisted with repositioning to off load pressure from buttom (sic) BLE elevated on pillows. Resident is a one person assist with adl's. The physician orders dated, 12/10/15 at 8:39 a.m. documented, Skin Prep to left heel Q day shift. The nurse's note dated, 12/10/15 at 4:19 p.m. documented in part, Patient is incontinent of bowel and bladder, bandage to sacrum intact, heels bilaterally floating with use of pillows. The nurse documented on 12/11/15 at 12:12 p.m., RP made aware of blister to right foot and stated that she had already knew and saw the blister. The nurse's note dated, 12/12/15 at 3:54 a.m. documented in part, Blister to right foot currently which remains intact and BLE elevated. The nurse documented in part on 12/12/15 at 1:34 p.m., Bandage to sacrum intact, heels bilaterally, floating with use of pillows. A Late Entry dated, 12/13/15 at 7:52 p.m. documented in part, Bandage to sacrum intact, heels bilaterally floating with use of pillows. A Late Entry dated, 12/15/15 at 2:03 a.m. documented in part, dressing is intact to sacral wound, resident T&R (turned and repositioned) Q2H (every 2 hours) heels floated. An eMAR (electronic medication administration record) Note dated, 12/15/15 at 9:15 a.m. documented in part, Wound MD rounding on unit with DNS (director of nursing services) will TX (treatment) at that time. The Wound Care Specialist Evaluation dated, 12/15/15 documented, Unstageable (Due to Necrosis) of the Coccyx. Wound size: 2x2x0 cm; Exudate: light serous; Yellow Necrotic: 50 %; Granulation Tissue: 50%; Wound Progress: No change. Dressing: Foam - Once daily; Santyl - once daily. Unstageable DTI of the Left Heel. Wound size: 2x2xnot measurable; Exudate: none; Wound Progress: No change; Dressing: skin prep - once daily. Assessment and Plan: Unstageable (Due to Necrosis) of the Coccyx - No change. Discontinue: [MEDICATION NAME] - QTF. Continue: Foam - Once daily, Santyl - once daily. A physician order dated 12/15/15, documented, Resident may discharge to home on 12/21/15 with referral for Home Health PT/OT (physical therapy/occupational therapy) skilled nurse for wound care treatments. Cleanse wound to coccyx with NS, pat dry, [MEDICATION NAME] prep surrounding skin, apply [MEDICATION NAME] 2X a week. This order was noted by the 11p.m. -7 a.m. nurse on 12/16/15. A nurse's note dated 12/16/15 at 3:57 p.m. documented, Wound dr (doctor) in to assess the resident NNO (no new orders). This note was signed by the former ADNS (assistant director of nursing services). This nurse is no longer employed by the facility and was unavailable for interview. The nurse documented in part on 12/17/15 at 11:57 p.m., Resident's skin is dry and intact. There are no new areas of concern noted or reported at this time. A nurse's note dated, 12/18/15 at 11:25 a.m., Wound care completed to sacrum and heels as ordered by MD. The nurse documented in part on 12/18/15 at 5:25 p.m., Dressing to sacrum change with no pain behaviors noted. Surround skin intact. A SBAR (Situation, Background, Assessment, Response) note dated 12/20/15 at 1:45 p.m. documented: Situation: nurse called to room by CNA (certified nursing assistant). Noted open area under scrotal area. Measures 1.8 x 1.5 cm with a 1.2 cm depth, noted yellow slough on wound bed, also posterior tunneling is 1.8 cm and anterior tunneling is 1.0 cm. Background: resident admitted to facility for cnf (sic) (skilled nursing facility) care under the services of (doctor). Resident is a full code. Assessment: resident is alert and verbal oriented x 3 (person, place and time) and able to voice need effectively. Skin w/d (warm and dry) resp (respirations) even and unlabored, no sob (shortness of breath) or dyspnea (difficulty breathing), abdomen is soft, with bowel sounds normative x 4 quads (quadrants) no n/v/d (nausea/vomiting/diarrhea) noted. Incontinent of b/b (bladder/bowel) assist of 1 provided by staff with care q2h (every 2 hours) and prn (as needed). Dressing is intact to sacral ulcer. Response: RP (responsible party) notified of new skin area as she was at bedside. (Name of doctor) notified and new treatment orders (sic) received and initiated. Resident continues to be pending discharge on 12/21. Review of the clinical record did not reveal any new orders documented in the record for treatment to this new area. A Late Entry dated, 12/21/15 at 10:27 a.m. documented in part, Patient is incontinent of bowel and bladder, has no complaints at this time .bandages to all wounds removed, areas cleaned as ordered and new bandages applied. Patient was assisted with packing all belongings RP transported patient home in a private vehicle. RP patient had no questions or concerns, medications and discharge instructions were reviewed with the patient. Patient left facility in good condition. The review of the physician progress notes [REDACTED]. The progress note dated, 12/14/15 documented, Wound: N/A (not applicable). Review of the clinical record did not reveal an interim care plan. The comprehensive care plan initiated on 12/3/15 documented, Focus: (Resident #42) presents with an altered skin risk and actual non pressure related to: MASD (moisture associated skin damage) to sacrum; diffuse excoriation, [DIAGNOSES REDACTED], Pressure ulcer to coccyx. 12/9/15 - Stage 2 fluid filled blister to left lateral heel. The Interventions documented in part, 12/3/15 -Complete Braden Scale per Living Center policy. 12/3/15 -Conduct weekly skin inspection. 12/3/15 - Monitor for signs and symptoms of infections such as swelling, redness, warm, discharge, odor notify physician of significant findings. 12/10/15 - Offload heels when in bed. 12/3/15 - Provide thorough skin care after incontinent episodes and apply barrier cream. 12/3/15 - Skin assessment to be completed per Living Center Policy. 12/10/15 - Treatments as ordered. On 6/17/16 at approximately 10:30 a.m. ASM (administrative staff member) #2, the director of nursing, was asked for any skin assessments completed for Resident #42. On 6/17/16 at 12:21 p.m. ASM #2 stated, I have no skin assessments for Resident #42. An interview was conducted with LPN (licensed practical nurse) #22 on 6/20/16 at 9:56 a.m. LPN #22 was shown one of her nurse's notes for Resident #42. When asked if she remembered anything about the gentleman, LPN #22 stated, I had just started here December 7th, I can't remember him. An interview was conducted with LPN #17, the current wound nurse at the facility, on 6/20/16 at 11:17 a.m. When asked who does the wound rounds with the wound doctor, LPN #17 responded that she did, she stated, He's here Tuesdays from 1:00 p.m. to 5:00 p.m. When asked who transcribes the orders, LPN #17 stated that she wrote the orders. This surveyor had LPN #17 read the nurse's note of 12/20/15. LPN #17 stated, I can't stage a wound. I have to get an RN (registered nurse), unit manager or wound doctor to look at it. When asked the process if a new area is found, such as the one described in the nurse's note of 12/20/15, LPN #17 stated, 'I would go look at the wound. Contact the primary physician; ask for an order for [REDACTED].#17 stated, Yes, it was stated it was a pressure ulcer on the admission assessment. When asked if you need an order for [REDACTED].#17 was asked if she had any further wound documentation for Resident #42. LPN #17 stated that she had already searched her office for any documentation regarding this gentleman and could not locate any wound documentation other that the 12/1/15 note and the wound specialist notes. An interview was conducted with CAN (certified nursing assistant) #23 on 6/20/16 at 1:11 p.m. regarding when she look at resident's skin. CNA #23 stated, On their shower days or if you give them a full bed bath and during incontinence care. When asked what happens if you find an open area, CNA #23 stated, I go straight to the nurse. When asked what the nurse does, CNA #23 stated, She has to come and assess it. An interview was conducted with CNA #24 on 6/20/16 at approximately 1:15 p.m. regarding when she observes the resident's skin. CNA #24 stated, Every day. When asked what is done if she found something that wasn't there before, CNA #24 stated, I go straight to the nurse and she comes and looks at it. An interview was conducted with LPN #26 on 6/20/16 at 1:19 p.m. When asked what she would do if a CNA reports a new open area on a resident's bottom, LPN #26 stated, First I'd assess it and decide on an immediate treatment. Then alert the treatment nurse and the doctor. I'd write the order for what the doctor tells me. When asked if there was a protocol for wound stages and what to suggest to the doctor, LPN #26 stated, I'd have to look that up in the computer. LPN #26 proceeded to go to the computer and attempt to pull up the information. She was unable to access the information she was looking for. When asked if this happens on a weekend or after the wound nurse leaves for the day, LPN #26 stated, We have a list of all staff phone numbers up at the front desk and I'd just call the wound nurse at home. An interview was conducted with LPN #9 on 6/20/16 at 1:28 p.m. When asked what she does if a CNA reports a new open area on a resident, LPN #9 stated, I call the doctor, get orders, do a SBAR (situation/background/assessment/response), notify the RP and wound nurse. Put it on the care plan. When asked who updates the care plans, LPN #9 stated, We do (nurses). On 6/20/16 at 2:58 p.m. ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing, were informed of the above concern for harm for Resident #42. The facts as documented above, and in the clinical record were shared and reviewed with them at this time. An interview was conducted on 6/20/16 at 3:34 p.m. with LPN #27. When asked to review her nurse's note in the clinical record, LPN #27 could not recall the resident. An interview was conducted on 6/20/16 at 3:54 p.m. with CNA #4, who was assigned to the resident during his stay. When asked when she observes a resident's skin, CNA #4 stated, Every time you provide care. When asked if she could recall the resident, CNA #4 stated, When he came, he was on an air mattress and a wound dressing on his bottom. I can't remember anything else about him. An interview was conducted on 6/20/16 at 5:12 p.m. with LPN #10, the nurse who wrote the note of 12/20/15. LPN #10 was asked to review her note of 12/20/15. LPN #10 stated, I remember him. The CNA, I can't remember who, called me that there was something there. I remember he had some testicular and scrotal swelling. You had to move his scrotum to clean under it. I found what I documented in the note. When asked if she had seen this before on the resident, LPN #10 stated, that was a new finding to me. LPN #10 stated, It was day shift and (Name of Doctor) was here. I got an order; put it in (name of computer program). When asked if she had to add it to the TAR (treatment administration record) too, LPN #10 stated, When you put an order in, you have to choose the box for which record you want it on. When LPN #10 was informed there was no documented order for any treatment put in place. LPN #10 stated, I'm pretty sure I put Santyl on it but I know I wrote an order. Sometimes the system kicks you out and you don't know what you've lost. When asked if she could recall what treatment was put in place upon admission, LPN #10 stated, I remember talking to (another LPN who is no longer employed at the facility) and saying that it's going to be something. LPN #10 was asked to clarify, LPN #10 stated, It was going to be a large pressure ulcer. An interview was conducted with administrative staff member (ASM) #2, the director of nursing; on 6/21/16 at 8:22 a.m. ASM #2 stated that there was not any interim care plan documented in the clinical record until 12/3/15 when the comprehensive care plan was initiated. ASM #2 stated, Unfortunately, there is nothing I can dispute of the things you have found in the clinical record. I have nothing further to present in relation to Resident #42. ASM #2 stated that the facility had initiated a Four Point Plan of Correction Action on skin concerns. A copy of the plan was requested. The facility policy, Skin Integrity Guideline documented, General Guidelines: Patients/Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission, quarterly, before transfer or discharge to any setting (unless emergent nature of transfer does not allow), and as necessitated by change in condition. Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings. DNS or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. The interdisciplinary plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Documentation and Care Interventions for Skin Integrity: Evaluation/Observation is to be completed within the first twenty-four hours of admission/quarterly/significant change of condition using the Weekly Skin Review and/or Wound Evaluation Flow Sheet. If identified risk present, the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan .Patients/Residents will be observed by the CNA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented .Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Week Skin Review. Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS). Each Living Center must create a manual tracking system to monitor completion of weekly WEFS. Care plan is to be implemented, evaluated and revised based on the needs of the resident. ASM #1, the executive director, presented credible evidence that a four point plan of correction had been put into place for skin integrity through their QA (quality assurance) program. The credible evidence included the following: 1. All residents with pressure ulcers will be reviewed and identified concerns will be addressed as indicated and plan of care reviewed and revised as indicated. 2. Nurse Leadership will complete weekly skin sweeps on all residents weekly x 1 month and then as needed. 3. Licensed nurses will receive education on skin integrity guidelines. Residents with pressure ulcers will be reviewed by the IDT (interdisciplinary team) weekly at the risk meeting. 4. DNS (Director of Nursing Services)/Designee will complete weekly skin audit review weekly x 6 weeks and results will be reported to QAPI (quality assurance program improvement). DNS/Designee will complete monthly quality review for pressure ulcers monthly for 3 months and will report to QAPI. Planned Date of Correction: 6/10/16. During the survey, there were no concerns identified by observation or record review of any current concerns for the care and services provided for pressure ulcer care and prevention. COMPLAINT DEFICIENCY PAST NON COMPLIANCE (1) Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Pages: 155, page 206. (2) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 July 2010, pages M-15, M-18, M-2. (3) This information was obtained from the website: npuap.org website (4) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 July 2010, pages M-15,M-18, M-2. (5) This information was obtained from the website: http://www.[MEDICATION NAME].com/wound-skin/duoderm-dressings (6) This information was obtained from the website: www.allegromedical.com (7) This information was obtained from the website: http://www.phc-online.com/microAIR_Mattress_p/invacare-ma65.htm (8) This information was obtained from the website: http://www.walgreens.com/store/c/sage-prevalon-heel-protector/ID=prod 06-product#!

Based on staff interview, facility document review, clinical record review, EMS (emergency medical services) records, and in the course of a complaint investigation, it was determined that the facility staff failed to preserve a resident's right to execute an advance directive regarding steps to be followed in the event he became without heartbeat and not breathing in the facility. The facility staff failed to honor Resident #24's advance directive instructing the facility staff to administer CPR (cardiopulmonary resuscitation) (1) to Resident #24 when he was found to be without a heartbeat and not breathing on [DATE]. He had signed a document on [DATE] stating that he wanted CPR to be administered in the event he was found to be without heartbeat and not breathing. He had a physician's order for CPR to be administered. He was pronounced dead by outside EMS (emergency medical services) personnel after they arrived at the facility and unsuccessfully attempted to resuscitate him. The findings include: . Resident #24 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a significant change assessment with assessment reference date [DATE], Resident #24 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #24's clinical record revealed a physician's order dated and signed by the physician on [DATE]. The order stated: Full Code. Further review of the clinical record revealed a document titled, Virginia Advance Directive for Health Care signed by Resident #24 on [DATE]. A date stamp on the document indicated that the facility received the document on [DATE]. Review of the document revealed a check mark in the box beside the following sentence: I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. Further review of the clinical record revealed a document titled, Patient Determination Checklist. The document stated, in part: Facility Policy: It is our policy that every resident will be resuscitated until a physician's DNR (Do Not Resuscitate) Order, signed dated, and is in place. In the event the heart stops beating - CPR will not be instituted and/or in the event that respirations cease the patient will not be intubated or placed on a respirator .I (name of resident) certify that I/We have reviewed the attached materials and had the resident rights explained to me (or as responsible party the rights of the resident) and the facility's medical self-determination policies. Please check appropriate boxes and complete. An X was written beside option #2, which stated: 2. Reject DNR. I direct the facility to administer all available indicated medical care. In the event of cardiac or [MEDICAL CONDITION] arrest, CPR shall be initiated if available. The facility may defer CPR to an emergency agency and reserves the right to do so. The document was signed by the resident and dated [DATE]. A review of the comprehensive care plan for Resident #24 dated [DATE] and most recently updated on [DATE] revealed, in part, the following: Will not have a decline in function related to cardiac conditions .Patient's wishes will be honored. A review of the nurses' notes for Resident #24 revealed, in part, the following: - [DATE] at 1:37 p.m.: Late Entry: Follow up to LATE ENTRY: Agency nurse left without documenting about Resident expiring in building on [DATE] between ,[DATE]:30 a.m. approximately with EMS on site. Resident pronounced by EMS. MD (medical doctor) notified. Body released to funeral home. - [DATE] at 11:45 a.m.: LATE ENTRY: EMS on site with resident and resident expired on [DATE] ,[DATE] (7:00 a.m. to 3:00 p.m.) shift. MD notified. Family notified. Body released to funeral home. A review of the FRI (facility reported incident) document received by the state agency on [DATE] revealed, in part, the following: This letter serves as a final notification for an incident that was reported on [DATE] at (name of facility). The resident involved was (name of Resident #24). It was reported that the resident was a full code and CPR was not initiated by staff .Conclusion: This allegation was investigated and was able to be substantiated. Protocol was not followed for this resident and EMS initiated CPR. Facility created a four point plan to correct the deficient practice .The agency nurse that was responsible for this event (LPN (licensed practical nurse) #24) is not allowed back into the facility. A review of the facility's investigative file about this incident revealed evidence that LPN #24, who was Resident #24's nurse on [DATE], had a valid nursing license and up-to-date healthcare provider CPR training and certification. On [DATE] at 3:00 p.m., OSM (other staff member) #1, the director of dining services, was interviewed regarding the events of [DATE] and Resident #24. She stated that she was the manager on duty on [DATE], and that it was the Sunday of Memorial Day weekend. She stated when she is the manager on duty, she typically walks the halls of the facility every hour to make rounds. She stated that around 10:15 a.m., Resident #24's wife, who is also deaf, met her in the hallway and grabbed her arm. The wife wrote the name of a local funeral home on a piece of paper and gave it to me (OSM #1). She stated that the wife was crying. OSM #1 stated she immediately walked to the nurses' station and observed LPN #2 on the telephone and LPN #24 standing close by. She stated she believed LPN #2 was on the telephone with Resident #24's physician, and LPN #2 was instructing LPN #24 to check the resident's pulse points. She stated she asked both nurses if anyone had called an RN (registered nurse), because, to her knowledge, there was no RN in the building. She stated she tried to reach ASM (administrative staff member) #3, the assistant director of nursing, by phone, but was unsuccessful. She stated OSM #19, the maintenance director, was also in the building and was trying to find Resident #24's wife. She stated she asked the nurses if anyone had called 911, and that the nurses stated they had not done so. She stated: I called 911 and they asked me what was his code status. I checked the chart and saw that he was a full code and that's what I told them. They said they were on their way. She stated the EMS personnel came right away. She stated she and the other nurses (she could not remember which specific nurses) attempted to reach both the son and the daughter of Resident #24, but could not reach them. When asked if, after checking the chart and validating that Resident #24 was a full code, she told any facility staff member about the code status, she stated: I told (LPN #24) and (LPN #2). She stated that neither nurse took any action. She stated EMS personnel arrived within a few minutes and began working on (Resident #24). She stated that they did CPR and administered four shocks with the AED (automated external defibrillator) (3). She stated that the uniformed police personnel and a detective arrived at the facility, and she believed a policeman declared Resident #24 dead. She stated the police took photographs and finally gave the facility staff permission to call the funeral home. When asked if facility staff from other parts of the building were aware of what was happening, she stated: Two nurses came from the other side (of the building) and asked why no one had called a code. I heard someone answer that it was because (ASM #4, the attending physician) said he was already dead. When asked if there was anything else she could remember about the incident, she stated: I got fussed at by the nursing staff for calling 911. But that's why we pay taxes. I asked them why none of them called 911, and they said it was because (ASM #4) said he was dead. On [DATE] at 3:20 p.m., LPN #9 was interviewed regarding the events of [DATE] and Resident #24. She stated she was working on the other side of the building when OSM #19 approached her and asked if there was an RN in the building. She stated that OSM #19 did not provide a reason for asking the question. She stated that another nurse approached her and asked her to print out Resident #24's medication list. When she asked why this was needed, the other nurse told her that Resident #24 had just died . She stated she went to the other side of the building, hoping to get to see Resident #24's wife. She stated the double doors to Resident #24's hallway were closed. When she opened the doors, she could see EMS personnel going in and out of Resident #24's room, and could hear sounds that led her to believe the EMS personnel were attempting to resuscitate Resident #24. She stated LPN #24 and LPN #2 were standing at the nurses' station. She stated she was shocked that a code had not been called on the overhead speakers. She stated an EMT (emergency medical technician) approached the desk and called the time of death at 11:19 (a.m.). She stated she walked back down to the nurses' station. LPN #24 was on the telephone and LPN #2 was looking through some papers. She stated that OSM #1 was also standing there. She asked them why a code was not called, and OSM #1 responded that she did not know a code was supposed to be announced. She said she left the unit and walked down the hall to the other nurses' station on that side of the building. She approached LPN #8 and asked her if she had heard a code called on the overhead speaker. LPN #8 told her that she did not, and asked which resident had coded. She stated that she told her that it was Resident #24 and that EMS had already arrived and pronounced him dead. When asked if she knew whether or not the nursing staff had started CPR prior to the arrival of EMS personnel, she stated: My impression was that they had started CPR prior to EMS getting here, but I can't be sure of that. On [DATE] at 3:30 p.m., OSM #19, maintenance director, was interviewed regarding the events of [DATE] and Resident #24. He stated he had been called to the building for a maintenance issue in the kitchen. He stated that he arrived around 10:15 a.m., and was walking the halls, making rounds, and waiting for some touch-up paint to dry. He stated when he entered Resident #24's hall, another resident's husband approached him and told him Resident #24's wife was trying to get staff members' attention to tell them that her husband had died . He stated he immediately walked to Resident #24's room, and he saw who he believes was LPN #24 leaving the room. He stated that his first thought was for Resident #24's wife, and he went to the nurses' station and asked about her. He stated he was told that the nurses had asked for her not to be in that area at that time. He stated he remembered asking: What are we doing here? At that time, OSM #1 approached the nurses' station. He asked whom had been called, and if anyone had called a code or 911. He stated OSM #1 asked him if he thought they should. He stated he told her that he did not know, but that he was aware, from experience, of other codes that had been called on the overhead pager. He stated LPN #24 arrived at the nurses' station and told them she had checked pulses. He stated that another nurse (he was not sure which one) asked if she had checked a certain pulse point (he could not identify which one), and LPN #24 stated she had not, and then LPN #24 left again to go and check that particular pulse point on Resident #24. He stated by that time, OSM #1 had called 911 and he saw the fire truck entering the facility parking lot. He stated he let the EMS personnel in through the side door and escorted them to Resident #24's room. He stated within a couple of minutes an EMT (emergency medical technician) walked to the nurses' station and asked for a staff member to go to Resident #24's room to provide assistance. He stated that his concern was still for Resident #24's wife, so he left the unit to try to find the wife. When asked if he knew whether or not facility staff had started CPR prior to EMS personnel arrival, he stated: No. There was absolutely no evidence of that. On [DATE] at 3:50 p.m., LPN #17, the nurse on call the weekend of [DATE], was interviewed. She stated LPN #24 had called her and told her that Resident #24 was dead, and told her that other nurses were initiating CPR. She could not remember an exact time for this phone call. She stated: I told her to call our ADON (assistant director of nursing) because we needed an RN to pronounce death. I am an LPN, not an RN. She stated she got dressed and drove to the facility. She stated she arrived at the facility around 11:20 a.m. She stated when she went to Resident #24's room, she saw Resident #24's wife sitting beside the body. The wife hugged and thanked her, then left the room with another person. She stated she called ASM #2, the director of nursing, on her way to the facility and after she arrived. She stated even though LPN #24 had told her that CPR had been initiated by facility staff, she did not believe this to be the case. ASM #2 instructed her to do in-services for all the nurses in the building regarding calling for help, checking for a pulse, checking the code status in a resident's chart, and then starting CPR if the resident is a full code. She stated that she educated all the staff in the building that shift, and also remained at the facility to educate oncoming staff for both the evening and night shifts. On [DATE] at 4:00 p.m., LPN #2 was interviewed. She stated she was working a more distant hallway on the same side of the building as Resident #24's room on [DATE]. She stated that sometime after 10:00 a.m., LPN #24 walked up to her and stated: (Resident #24) is dead. She stated she asked her (LPN #24) about the resident's code status, and that LPN #24 stated that she did not know. She stated they walked together back to LPN #24's nurses' station. She opened the chart and saw that resident was a full code. She stated: I told her (LPN #24) he was a full code. She stated she asked someone else (she could not remember who) to go and get a crash cart. She stated she assumed LPN #24 was going to Resident #24's room to start CPR. She stated she picked up the phone and called ASM (administrative staff member) #4, (Resident #24's physician and the facility medical director). She stated that it was a while before he called her back, but that when she did speak to him, she informed him that Resident #24 had passed, and that he is a full code. She stated that at that point, ASM #4 asked her if there was an RN in the building. She told him that she was not sure. ASM #4 instructed her that an RN should listen to the carotid pulse (4) for two minutes to be able to determine death. She stated when she got off the phone with ASM #4, LPN #24 approached the nurses' station again, and that she told LPN #24 what ASM #4 had just said. She stated: I told her that he wanted her to go and check the carotid pulse for two minutes. She stated that LPN #24 returned to Resident #24's room. She stated she was told at that time that another nurse had gone to get a crash cart. She had been off the phone for a short while when LPN #24 returned to the desk and stated that there was no pulse. She stated that during this time, OSM #1 and OSM #19 approached the desk and began discussing the need to call 911. She stated that OSM #1 ultimately called 911, and that she (LPN #2) called ASM #4 to let him know that EMS had now been called. She stated that once the EMS personnel arrived, an EMT approached the desk and asked who is in charge of this patient. She stated that ASM #4 spoke by phone to the paramedic. The paramedic told ASM #4 that Resident #24 was still warm and that he would have to start CPR. At this point, LPN #2 stated: (LPN #24) had told me that the resident was cold, not warm. She stated when the EMT made the request for a staff member, LPN #24 went in with the paramedics to assist them. On [DATE] at 8:30 a.m., LPN #8 was interviewed. She stated she was working on the other side of the building on [DATE] and was not aware of a code in the building until another staff member told her that EMS personnel had arrived and were working on Resident #24. She stated she walked over to the other side of the building and asked the nurses about the resident's code status. She stated that she believed that Resident #24's nurse was not a facility employee, but was a contract nurse for a temporary nurse agency. She stated she called ASM #4 and told him that there were at least one or two agency nurses working and that the EMS personnel were coding the resident. She stated that ASM #4 told her that he was already aware of it. When asked if she knew whether or not facility staff had started CPR before the arrival of EMS, she stated: If the agency nurses coded him, I did not know anything about it. On [DATE] at 8:50 a.m., CNA (certified nursing assistant) #2 was interviewed. She had worked with Resident #24 on the morning of [DATE]. She stated she delivered Resident #24's breakfast tray between 7:00 a.m. and 7:30 a.m. She stated the resident was awake, smiling, and sitting up in his bed. She stated he was eating a muffin when she left the room. She stated she returned to the room to pick up the tray around 8:30 a.m. Resident #24 was asleep at that time. She stated Resident #24 showed no signs of distress or discomfort. On [DATE] at 3:05 p.m., ASM #4, was interviewed regarding the events of [DATE] and Resident #24. He stated: I believe it was (LPN #2) who called me. She told me that the patient was not responding - that they had walked in and he was not breathing. I asked them to verify the heartbeat. I asked them to call 911. When asked whether or not he was aware that there was no RN in the building at the time, he stated: I knew there were multiple LPNs. I needed to know about the pulses. He stated: It looks like a sudden death to me. He stated that the resident's wife usually goes to the nurses to alert them about her husband's concerns or difficulties. He stated: 911 came and they started resuscitation. They didn't say if it was a flat line (without heartbeat). I think they declared the death themselves. When asked if he was aware of Resident #24's code status, he stated: We have not had any recent discussions. He was unable to hear or talk. We communicated by written means so it was harder. I don't think we had a code status discussion. When asked to verify exactly the order of what happened on [DATE], he stated: They called me and told me he was unresponsive/not breathing. I told them to check the pulse. Then the phone disconnected. Then she called me back. I told them to call 911. It was a code blue. When asked if he ever asked about Resident #24's code status, he stated: It was a weekend. I was not physically there. When asked if he instructed the facility staff to begin CPR immediately, he stated: They called 911. They came right away. I knew the EMS would start CPR when they arrived. A review of a memorandum written by OSM #20, a firefighter/medic from the local county EMS services on [DATE] revealed, in part, the following: On [DATE] at 1052 (10:52 a.m.), Medic ,[DATE], Wagon 6 and EMS 3 responded for a reported CPR call at (name and address of facility) .Upon arriving at the room it was noted that no staff responsible for the patient was in the room or in the vicinity of the room. As we entered the room I noted that the lights had been turned off, the curtain had been pulled completely around the patients (sic) bed so that you could not see him without opening the curtain. I requested staff several times to respond without any response. The patient was noted to be warm, with no rigor mortis or obvious signs of death. CPR was started since staff was not present to confirm DNR status of the patient. After ,[DATE] minutes a nurse did finally arrive, she confirmed that the patient had no DNR and was a full code. Her statement/report to me was that the last time the patient was seen normal was at 0830 (8:30 a.m.) when they gave him his breakfast. She stated that they came to check on him at 1015 (10:15 a.m.) and found him to be in this current state. The 911 phone call per the rip and run (a form used by the EMS service documenting the exact time and location of the emergency request) stated the call was not placed until 1049 (10:49 a.m.). The nurse had no explanation on why there was such a time delay from when they found the patient to when they called 911 other than she stated 'I called his doctor.' While working the arrest it was discovered that the patient's blood sugar was 10, which the nurse replied 'he is a diabetic.' Ultimately we were unable to revive the patient and the scene was turned over to Law Enforcement with report given to them on how the scene was found. I am writing to document as this seems well out of the normal standard of care for a patient. On [DATE] at 12:05 p.m., OSM #21, the chief of emergency services for the local county provider, met with the surveyor, and arranged for the surveyor to interview OSM #20 by phone. OSM #20 verified the events as documented in the above-referenced memorandum. He stated that the resident actually was covered from his toes to over the top of his head with a blanket when he and his partner arrived on the scene. He stated the staff told them that they had not called 911 sooner because they were getting the resident's paperwork ready. He added: CPR had not been initiated prior to our arrival. I know this because when I started, I broke ribs. If someone had already started CPR, his ribs would have broken then. When asked about the low blood sugar, he stated that this could have been a result of the resident being without pulse or breathing for over 30 minutes before CPR was started. On [DATE] at 6:35 p.m., ASM #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. They were informed that the survey team had a concern for harm related to these findings. ASM #1 stated that the facility had done a four point plan of correction related to this incident, and provided this documentation to the survey team. On [DATE] at 1:40 p.m., ASM #1 and ASM #2 were interviewed regarding this incident as it related to Resident #24's rights. Both staff members agreed that the facility staff had not honored the resident's right to receive CPR, as indicated in the Patient Determination Checklist referenced above. A review of the document titled, Admission Agreement and Notices Packet provided by the facility to all residents at admission revealed, in part, the following: Advance Directives and Refusal of Treatment and Experimental Research. You have the right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state law. The nursing home must provide you with written information regarding advance directives .What is an advance directive? Advance medical directives are instructions that state how you want decisions to be made for you if you become unable to make those decisions for yourself. In an advance medical directive, you can: Direct that a specific procedure or treatment be provided, such as artificially administered hydration (fluids) or nutrition (feedings) Will the (name of facility) follow my advance medical directive? It is the policy of the (name of facility) to implement a resident's advance medical directive to the fullest extent allowed under (name of state) law. A review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) Guideline revealed, in part, the following: In the event a resident/patient experiences [MEDICAL CONDITION] (cessation of pulse and/or respirations), cardiopulmonary resuscitation (CPR) will be provided in the absence of a valid Advanced Directive or a Do Not Resuscitate (DNR) order directing otherwise. Once emergency medical services (EMS) arrive, EMS will take control of the resuscitative effort and direct all related activities until either the resuscitative effort is ceased or the resident/patient is transported to an emergency center .If a patient/resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. w. Call out for help. Direct another staff member to announce the emergency per .protocol and call Emergency Medical Services (EMS-dial 911). Direct another staff member to bring the emergency supplies and AED to the scene. 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in facility, shall manage the physical efforts involved in resuscitation. 4. A staff member other than the one who is providing the resuscitative effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] places. 5. If DNR status is validated, do not initiate CPR. If CPR/Code Status is undetermined, CPR will be initiated and will continue until the arrival of EMS. A review of the document entitled 4-Point Plan of Corrective Action provided to the survey team by ASM #1 on [DATE] at 1:40 p.m. revealed, in part, the following: Description of event/deficient practice: Full code/DNR policy and procedure for nurses. What corrective action(s) will be accomplished for the residents found to have been affected by the deficient practice? DNS (director of nursing services)/Designee will complete quality system review for DNR/Full code status How will other residents having the potential to be affected by the same deficient practice be identified and what corrective action will be taken? All residents have the potential to be affected. Licensed nurses to be educated on DNR/full code policy and procedure and what nursing expectations are to include documentation and EMS notification. Nurses will be educated on remaining within scope of practice (RN pronouncement.) Nurses remaining in the room with resident through process until resident is transferred out with EMS or pronounce. Validate licensed nurses have up to date CPR cards. Review all of residents' code status. What measures will be put in place to ensure the deficient practice does not recur? Licensed nursing staff shall be educated on DNR/Full code policy upon hire, and/or new to the schedule. Mock code drill to be completed every shift for the next 24 hours, then daily until successful, then weekly X 4, and then monthly. Verification of credentials of agency nurses prior to working. Validate licensed nurses have up to date CPR cards. How will the corrective action be monitored to ensure the deficient practice will not recur (i.e. what quality assurance program will be put in place)? All Full code and DNR situations will be reviewed with daily start-up, any issues to be reviewed at QAPI (quality assurance performance improvement meetings). The planned date of correction for all items listed above was [DATE]. The facility staff provided the survey team with credible evidence, verified by staff interviews, that this plan of correction had been implemented as documented. During the survey no further concerns were identified for current resident reviewed, therefore, this citation will be cited as past noncompliance. No further information was provided prior to exit. PAST NONCOMPLIANCE COMPLAINT DEFICIENCY (1) CPR stands for cardiopulmonary resuscitation. It is an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped. This information is taken from the website https://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm. (2) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called [MEDICAL TREATMENT]. This information is taken from the website https://www.nlm.nih.gov/medlineplus/[MEDICAL TREATMENT].html (3) An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm. AEDs are used to treat sudden [MEDICAL CONDITION] (SCA). This information is taken from the website https://www.nhlbi.nih.gov/health/health-topics/topics/aed (4) The carotid arteries take [MEDICATION NAME] blood from the heart to the brain. The pulse from the carotids may be felt on either side of the front of the neck just below the angle of the jaw. This rhythmic beat is caused by varying volumes of blood being pushed out of the heart toward the extremities. This information is taken from the website https://www.nlm.nih.gov/medlineplus/ency/imagepages/ .htm.

Based on staff interview, facility document review, clinical record review, EMS (emergency medical services) records, and in the course of a complaint investigation, it was determined that the facility staff failed to provide care and services to promote the highest level of well-being for eight of 43 residents in the survey sample, Residents #24, #7, #9, #12, #3, #20, #10 and #23. 1. The facility staff failed to follow the physician's order to administer CPR (cardiopulmonary resuscitation (1)) to Resident #24 when he was found to be without a heartbeat and not breathing on [DATE]. He had a physician's order for CPR to be administered. He was pronounced dead by outside EMS (emergency medical services) personnel after they arrived at the facility and unsuccessfully attempted to resuscitate him. 2. The facility staff failed to assess Resident #7's pain level prior to administering pain medications on ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. 3. The facility staff did not administer a medication that was available in the stat (Immediate) box for Resident #9 per physician's order. 4. The facility staff failed to administer [MEDICATION NAME] XR per the physician order for [REDACTED].>5. The facility staff failed to administer a C-PAP machine per the physician order for [REDACTED].>6. The facility staff failed to follow the physician order for [REDACTED]. 7. The facility staff failed to administer the final dose of a five dose series antibiotic to Resident #10 as ordered by the physician on [DATE]. 8. a. The facility staff failed to follow physician's orders for the administration of insulin to Resident #23. The facility staff administered 15 units of [MEDICATION NAME] insulin* to Resident #23 on multiple occasions during May and June of 2016, when Resident #23's blood sugar was below the physician prescribed parameter of 126 and per the physician order the insulin should have been held. b. On [DATE], [DATE] and [DATE] at 0600 (6:00 a.m.) the facility staff failed to notify the physician of Resident #23's blood sugar readings below 90 as ordered. The findings include: 1. Resident #24 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a significant change assessment with assessment reference date [DATE], Resident #24 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #24's clinical record revealed a physician's order dated and signed by the physician on [DATE]. The order stated: Full Code. Further review of the clinical record revealed a document titled, Virginia Advance Directive for Health Care signed by Resident #24 on [DATE]. A date stamp on the document indicated that the facility received the document on [DATE]. Review of the document revealed a check mark in the box beside the following sentence: I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. Further review of the clinical record revealed a document titled, Patient Determination Checklist. The document stated, in part: Facility Policy: It is our policy that every resident will be resuscitated until a physician's DNR (Do Not Resuscitate) Order, signed dated, and is in place. In the event the heart stops beating - CPR will not be instituted and/or in the event that respirations cease the patient will not be intubated or placed on a respirator .I (name of resident) certify that I/We have reviewed the attached materials and had the resident rights explained to me (or as responsible party the rights of the resident) and the facility's medical self-determination policies. Please check appropriate boxes and complete. An X was written beside option #2, which stated: 2. Reject DNR. I direct the facility to administer all available indicated medical care. In the event of cardiac or [MEDICAL CONDITION] arrest, CPR shall be initiated if available. The facility may defer CPR to an emergency agency and reserves the right to do so. The document was signed by the resident and dated [DATE]. A review of the comprehensive care plan for Resident #24 dated [DATE] and most recently updated on [DATE] revealed, in part, the following: Will not have a decline in function related to cardiac conditions .Patient's wishes will be honored. A review of the nurses' notes for Resident #24 revealed, in part, the following: - [DATE] at 1:37 p.m.: Late Entry: Follow up to LATE ENTRY: Agency nurse left without documenting about Resident expiring in building on [DATE] between ,[DATE]:30 a.m. approximately with EMS on site. Resident pronounced by EMS. MD (medical doctor) notified. Body released to funeral home. - [DATE] at 11:45 a.m.: LATE ENTRY: EMS on site with resident and resident expired on [DATE] ,[DATE] (7:00 a.m. to 3:00 p.m.) shift. MD notified. Family notified. Body released to funeral home. A review of the FRI (facility reported incident) document received by the state agency on [DATE] revealed, in part, the following: This letter serves as a final notification for an incident that was reported on [DATE] at (name of facility). The resident involved was (name of Resident #24). It was reported that the resident was a full code and CPR was not initiated by staff .Conclusion: This allegation was investigated and was able to be substantiated. Protocol was not followed for this resident and EMS initiated CPR. Facility created a four point plan to correct the deficient practice .The agency nurse that was responsible for this event (LPN (licensed practical nurse) #24) is not allowed back into the facility. A review of the facility's investigative file about this incident revealed evidence that LPN #24, who was Resident #24's nurse on [DATE], had a valid nursing license and up-to-date healthcare provider CPR training and certification. On [DATE] at 3:00 p.m., OSM (other staff member) #1, the director of dining services, was interviewed regarding the events of [DATE] and Resident #24. She stated that she was the manager on duty on [DATE], and that it was the Sunday of Memorial Day weekend. She stated when she is the manager on duty, she typically walks the halls of the facility every hour to make rounds. She stated that around 10:15 a.m., Resident #24's wife, who is also deaf, met her in the hallway and grabbed her arm. The wife wrote the name of a local funeral home on a piece of paper and gave it to me (OSM #1). She stated that the wife was crying. OSM #1 stated she immediately walked to the nurses' station and observed LPN #2 on the telephone and LPN #24 standing close by. She stated she believed LPN #2 was on the telephone with Resident #24's physician, and LPN #2 was instructing LPN #24 to check the resident's pulse points. She stated she asked both nurses if anyone had called an RN (registered nurse), because, to her knowledge, there was no RN in the building. She stated she tried to reach ASM (administrative staff member) #3, the assistant director of nursing, by phone, but was unsuccessful. She stated OSM #19, the maintenance director, was also in the building and was trying to find Resident #24's wife. She stated she asked the nurses if anyone had called 911, and that the nurses stated they had not done so. She stated: I called 911 and they asked me what was his code status. I checked the chart and saw that he was a full code and that's what I told them. They said they were on their way. She stated the EMS personnel came right away. She stated she and the other nurses (she could not remember which specific nurses) attempted to reach both the son and the daughter of Resident #24, but could not reach them. When asked if, after checking the chart and validating that Resident #24 was a full code, she told any facility staff member about the code status, she stated: I told (LPN #24) and (LPN #2). She stated that neither nurse took any action. She stated EMS personnel arrived within a few minutes and began working on (Resident #24). She stated that they did CPR and administered four shocks with the AED (automated external defibrillator) (3). She stated that the uniformed police personnel and a detective arrived at the facility, and she believed a policeman declared Resident #24 dead. She stated the police took photographs and finally gave the facility staff permission to call the funeral home. When asked if facility staff from other parts of the building were aware of what was happening, she stated: Two nurses came from the other side (of the building) and asked why no one had called a code. I heard someone answer that it was because (ASM #4, the attending physician) said he was already dead. When asked if there was anything else she could remember about the incident, she stated: I got fussed at by the nursing staff for calling 911. But that's why we pay taxes. I asked them why none of them called 911, and they said it was because (ASM #4) said he was dead. On [DATE] at 3:20 p.m., LPN #9 was interviewed regarding the events of [DATE] and Resident #24. She stated she was working on the other side of the building when OSM #19 approached her and asked if there was an RN in the building. She stated that OSM #19 did not provide a reason for asking the question. She stated that another nurse approached her and asked her to print out Resident #24's medication list. When she asked why this was needed, the other nurse told her that Resident #24 had just died . She stated she went to the other side of the building, hoping to get to see Resident #24's wife. She stated the double doors to Resident #24's hallway were closed. When she opened the doors, she could see EMS personnel going in and out of Resident #24's room, and could hear sounds that led her to believe the EMS personnel were attempting to resuscitate Resident #24. She stated LPN #24 and LPN #2 were standing at the nurses' station. She stated she was shocked that a code had not been called on the overhead speakers. She stated an EMT (emergency medical technician) approached the desk and called the time of death at 11:19 (a.m.). She stated she walked back down to the nurses' station. LPN #24 was on the telephone and LPN #2 was looking through some papers. She stated that OSM #1 was also standing there. She asked them why a code was not called, and OSM #1 responded that she did not know a code was supposed to be announced. She said she left the unit and walked down the hall to the other nurses' station on that side of the building. She approached LPN #8 and asked her if she had heard a code called on the overhead speaker. LPN #8 told her that she did not, and asked which resident had coded. She stated that she told her that it was Resident #24 and that EMS had already arrived and pronounced him dead. When asked if she knew whether or not the nursing staff had started CPR prior to the arrival of EMS personnel, she stated: My impression was that they had started CPR prior to EMS getting here, but I can't be sure of that. On [DATE] at 3:30 p.m., OSM #19, maintenance director, was interviewed regarding the events of [DATE] and Resident #24. He stated he had been called to the building for a maintenance issue in the kitchen. He stated that he arrived around 10:15 a.m., and was walking the halls, making rounds, and waiting for some touch-up paint to dry. He stated when he entered Resident #24's hall, another resident's husband approached him and told him Resident #24's wife was trying to get staff members' attention to tell them that her husband had died . He stated he immediately walked to Resident #24's room, and he saw who he believes was LPN #24 leaving the room. He stated that his first thought was for Resident #24's wife, and he went to the nurses' station and asked about her. He stated he was told that the nurses had asked for her not to be in that area at that time. He stated he remembered asking: What are we doing here? At that time, OSM #1 approached the nurses' station. He asked whom had been called, and if anyone had called a code or 911. He stated OSM #1 asked him if he thought they should. He stated he told her that he did not know, but that he was aware, from experience, of other codes that had been called on the overhead pager. He stated LPN #24 arrived at the nurses' station and told them she had checked pulses. He stated that another nurse (he was not sure which one) asked if she had checked a certain pulse point (he could not identify which one), and LPN #24 stated she had not, and then LPN #24 left again to go and check that particular pulse point on Resident #24. He stated by that time, OSM #1 had called 911 and he saw the fire truck entering the facility parking lot. He stated he let the EMS personnel in through the side door and escorted them to Resident #24's room. He stated within a couple of minutes an EMT (emergency medical technician) walked to the nurses' station and asked for a staff member to go to Resident #24's room to provide assistance. He stated that his concern was still for Resident #24's wife, so he left the unit to try to find the wife. When asked if he knew whether or not facility staff had started CPR prior to EMS personnel arrival, he stated: No. There was absolutely no evidence of that. On [DATE] at 3:50 p.m., LPN #17, the nurse on call the weekend of [DATE], was interviewed. She stated LPN #24 had called her and told her that Resident #24 was dead, and told her that other nurses were initiating CPR. She could not remember an exact time for this phone call. She stated: I told her to call our ADON (assistant director of nursing) because we needed an RN to pronounce death. I am an LPN, not an RN. She stated she got dressed and drove to the facility. She stated she arrived at the facility around 11:20 a.m. She stated when she went to Resident #24's room, she saw Resident #24's wife sitting beside the body. The wife hugged and thanked her, then left the room with another person. She stated she called ASM #2, the director of nursing, on her way to the facility and after she arrived. She stated even though LPN #24 had told her that CPR had been initiated by facility staff, she did not believe this to be the case. ASM #2 instructed her to do in-services for all the nurses in the building regarding calling for help, checking for a pulse, checking the code status in a resident's chart, and then starting CPR if the resident is a full code. She stated that she educated all the staff in the building that shift, and also remained at the facility to educate oncoming staff for both the evening and night shifts. On [DATE] at 4:00 p.m., LPN #2 was interviewed. She stated she was working a more distant hallway on the same side of the building as Resident #24's room on [DATE]. She stated that sometime after 10:00 a.m., LPN #24 walked up to her and stated: (Resident #24) is dead. She stated she asked her (LPN #24) about the resident's code status, and that LPN #24 stated that she did not know. She stated they walked together back to LPN #24's nurses' station. She opened the chart and saw that resident was a full code. She stated: I told her (LPN #24) he was a full code. She stated she asked someone else (she could not remember who) to go and get a crash cart. She stated she assumed LPN #24 was going to Resident #24's room to start CPR. She stated she picked up the phone and called ASM (administrative staff member) #4, (Resident #24's physician and the facility medical director). She stated that it was a while before he called her back, but that when she did speak to him, she informed him that Resident #24 had passed, and that he is a full code. She stated that at that point, ASM #4 asked her if there was an RN in the building. She told him that she was not sure. ASM #4 instructed her that an RN should listen to the carotid pulse (4) for two minutes to be able to determine death. She stated when she got off the phone with ASM #4, LPN #24 approached the nurses' station again, and that she told LPN #24 what ASM #4 had just said. She stated: I told her that he wanted her to go and check the carotid pulse for two minutes. She stated that LPN #24 returned to Resident #24's room. She stated she was told at that time that another nurse had gone to get a crash cart. She had been off the phone for a short while when LPN #24 returned to the desk and stated that there was no pulse. She stated that during this time, OSM #1 and OSM #19 approached the desk and began discussing the need to call 911. She stated that OSM #1 ultimately called 911, and that she (LPN #2) called ASM #4 to let him know that EMS had now been called. She stated that once the EMS personnel arrived, an EMT approached the desk and asked who is in charge of this patient. She stated that ASM #4 spoke by phone to the paramedic. The paramedic told ASM #4 that Resident #24 was still warm and that he would have to start CPR. At this point, LPN #2 stated: (LPN #24) had told me that the resident was cold, not warm. She stated when the EMT made the request for a staff member, LPN #24 went in with the paramedics to assist them. On [DATE] at 8:30 a.m., LPN #8 was interviewed. She stated she was working on the other side of the building on [DATE] and was not aware of a code in the building until another staff member told her that EMS personnel had arrived and were working on Resident #24. She stated she walked over to the other side of the building and asked the nurses about the resident's code status. She stated that she believed that Resident #24's nurse was not a facility employee, but was a contract nurse for a temporary nurse agency. She stated she called ASM #4 and told him that there were at least one or two agency nurses working and that the EMS personnel were coding the resident. She stated that ASM #4 told her that he was already aware of it. When asked if she knew whether or not facility staff had started CPR before the arrival of EMS, she stated: If the agency nurses coded him, I did not know anything about it. On [DATE] at 8:50 a.m., CNA (certified nursing assistant) #2 was interviewed. She had worked with Resident #24 on the morning of [DATE]. She stated she delivered Resident #24's breakfast tray between 7:00 a.m. and 7:30 a.m. She stated the resident was awake, smiling, and sitting up in his bed. She stated he was eating a muffin when she left the room. She stated she returned to the room to pick up the tray around 8:30 a.m. Resident #24 was asleep at that time. She stated Resident #24 showed no signs of distress or discomfort. On [DATE] at 3:05 p.m., ASM #4, was interviewed regarding the events of [DATE] and Resident #24. He stated: I believe it was (LPN #2) who called me. She told me that the patient was not responding - that they had walked in and he was not breathing. I asked them to verify the heartbeat. I asked them to call 911. When asked whether or not he was aware that there was no RN in the building at the time, he stated: I knew there were multiple LPNs. I needed to know about the pulses. He stated: It looks like a sudden death to me. He stated that the resident's wife usually goes to the nurses to alert them about her husband's concerns or difficulties. He stated: 911 came and they started resuscitation. They didn't say if it was a flat line (without heartbeat). I think they declared the death themselves. When asked if he was aware of Resident #24's code status, he stated: We have not had any recent discussions. He was unable to hear or talk. We communicated by written means so it was harder. I don't think we had a code status discussion. When asked to verify exactly the order of what happened on [DATE], he stated: They called me and told me he was unresponsive/not breathing. I told them to check the pulse. Then the phone disconnected. Then she called me back. I told them to call 911. It was a code blue. When asked if he ever asked about Resident #24's code status, he stated: It was a weekend. I was not physically there. When asked if he instructed the facility staff to begin CPR immediately, he stated: They called 911. They came right away. I knew the EMS would start CPR when they arrived. A review of a memorandum written by OSM #20, a firefighter/medic from the local county EMS services on [DATE] revealed, in part, the following: On [DATE] at 1052 (10:52 a.m.), Medic ,[DATE], Wagon 6 and EMS 3 responded for a reported CPR call at (name and address of facility) .Upon arriving at the room it was noted that no staff responsible for the patient was in the room or in the vicinity of the room. As we entered the room I noted that the lights had been turned off, the curtain had been pulled completely around the patients (sic) bed so that you could not see him without opening the curtain. I requested staff several times to respond without any response. The patient was noted to be warm, with no rigor mortis or obvious signs of death. CPR was started since staff was not present to confirm DNR status of the patient. After ,[DATE] minutes a nurse did finally arrive, she confirmed that the patient had no DNR and was a full code. Her statement/report to me was that the last time the patient was seen normal was at 0830 (8:30 a.m.) when they gave him his breakfast. She stated that they came to check on him at 1015 (10:15 a.m.) and found him to be in this current state. The 911 phone call per the rip and run (a form used by the EMS service documenting the exact time and location of the emergency request) stated the call was not placed until 1049 (10:49 a.m.). The nurse had no explanation on why there was such a time delay from when they found the patient to when they called 911 other than she stated 'I called his doctor.' While working the arrest it was discovered that the patient's blood sugar was 10, which the nurse replied 'he is a diabetic.' Ultimately we were unable to revive the patient and the scene was turned over to Law Enforcement with report given to them on how the scene was found. I am writing to document as this seems well out of the normal standard of care for a patient. On [DATE] at 12:05 p.m., OSM #21, the chief of emergency services for the local county provider, met with the surveyor, and arranged for the surveyor to interview OSM #20 by phone. OSM #20 verified the events as documented in the above-referenced memorandum. He stated that the resident actually was covered from his toes to over the top of his head with a blanket when he and his partner arrived on the scene. He stated the staff told them that they had not called 911 sooner because they were getting the resident's paperwork ready. He added: CPR had not been initiated prior to our arrival. I know this because when I started, I broke ribs. If someone had already started CPR, his ribs would have broken then. When asked about the low blood sugar, he stated that this could have been a result of the resident being without pulse or breathing for over 30 minutes before CPR was started. On [DATE] at 6:35 p.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. They were informed that the survey team had a concern for harm related to these findings. ASM #1 stated that the facility had done a four point plan of correction related to this incident, and provided this documentation to the survey team. A review of the documentation by the survey team revealed that the four point plan of correction addressed only a physician's order regarding a resident's code status; the plan of correction did not address following ALL physician's orders and adittional findings had been found. On [DATE] at 1:40 p.m., ASM #1 and ASM #2 were informed that the plan of correction provided to the survey team was insufficient to cover all the required aspects of this F-tag. A review of the facility document entitled Physician Telephone Orders contained no information relevant to the issue of licensed staff following physicians' orders. A review of the facility policy entitled Cardiopulmonary Resuscitation (CPR) Guideline revealed, in part, the following: In the event a resident/patient experiences [MEDICAL CONDITION] (cessation of pulse and/or respirations), cardiopulmonary resuscitation (CPR) will be provided in the absence of a valid Advanced Directive or a Do Not Resuscitate (DNR) order directing otherwise. Once emergency medical services (EMS) arrive, EMS will take control of the resuscitative effort and direct all related activities until either the resuscitative effort is ceased or the resident/patient is transported to an emergency center .If a patient/resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. 2. Call out for help. Direct another staff member to announce the emergency per .protocol and call Emergency Medical Services (EMS-dial 911). Direct another staff member to bring the emergency supplies and AED to the scene. 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in facility, shall manage the physical efforts involved in resuscitation. 4. A staff member other than the one who is providing the resuscitative effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] places. 5. If DNR status is validated, do not initiate CPR. If CPR/Code Status is undetermined, CPR will be initiated and will continue until the arrival of EMS. No further information was provided prior to exit. (1) CPR stands for cardiopulmonary resuscitation. It is an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped. This information is taken from the website https://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm. (2) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called [MEDICAL TREATMENT]. This information is taken from the website https://www.nlm.nih.gov/medlineplus/[MEDICAL TREATMENT].html (3) An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm. AEDs are used to treat sudden [MEDICAL CONDITION] (SCA). This information is taken from the website https://www.nhlbi.nih.gov/health/health-topics/topics/aed (4) The carotid arteries take [MEDICATION NAME] blood from the heart to the brain. The pulse from the carotids may be felt on either side of the front of the neck just below the angle of the jaw. This rhythmic beat is caused by varying volumes of blood being pushed out of the heart toward the extremities. This information is taken from the website https://www.nlm.nih.gov/medlineplus/ency/imagepages/ .htm. In Fundamentals of Nursing, 6th edition, 2005, Patricia A. Potter and Anne Griffin Perry, Mosby, Inc; Page 419: The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients. COMPLAINT DEFICIENCY 2. The facility staff failed to assess Resident #7's pain level prior to administering pain medications on ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of [DATE] coded the resident as having a 15 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The resident was coded as needing assistance of two staff for all activities of daily living except for feeding which the resident could do after her meal tray was set up. Review of the physician's order sheet dated and signed on [DATE] documented, [MEDICATION NAME] (1) Tablet ,[DATE] MG (milligram) Give 2 tablet by mouth every 4 hours as needed for Pain. Start Date [DATE]. Review of the MAR (medication administration record) for [DATE] documented, [MEDICATION NAME] Tablet ,[DATE] MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 2 tablet by mouth every 4 hours as needed for Pain. Further review documented the [MEDICATION NAME] was administered on [DATE] at 7:50 a.m., on [DATE] at 8:36 a.m., on [DATE] at 8:26 a.m. and [DATE] at 8:45 a.m. In the box titled, Pain Level for each date there was an x. Review of the resident's chronic pain care plan revealed that the care plan was initiated on [DATE] documented,Focus Chronic Pai[DIAGNOSES REDACTED] and Backache. Interventions Administration Pain medication as ordered, observe for effectiveness. Evaluate and Establish level of pain on numeric scale/evaluation tool. On [DATE] at 3:55 p.m. an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked how staff assessed a resident's pain level, ASM #2 stated, They're supposed to use a pain scale. It should be the pain scale most appropriate for the resident. When asked why staff assessed pain, ASM #2 stated, The have to go back and assess the pain level (after they give the medication). On [DATE] at 4:15 p.m. an interview was conducted with RN (registered nurse) #5, the unit manager. When asked how staff assessed a resident's pain level, RN #5 stated, When a resident asks for a pain medication, ask them for a pain level. Go back within 45 minutes to an hour and ask if it was effective. RN #5 was asked to review the [DATE] MAR for Resident #7. When asked what the x marks in the Pain Level boxes meant for the dates documented above, RN #5 stated, They did not put in a pain level. An interview was conducted on [DATE] at 11:20 a.m. with LPN (licensed practical nurse) #7. When asked how staff assess pain, LPN #7 stated, First thing, I talk to the patient and find out if they are in pain. I ask them the location of the pain and for those who can rate pain have them rate their pain. LPN #7 stated that she used a pain score of one to ten with ten being the worst pain. When asked if the pain level was documented, LPN #7 stated, Yes, on the pain assessment (record). I'm going to wait an hour and check on how they're feeling. When asked why it was important to document the pain rating, LPN #7 stated, Rating of pain helps give us a record of how the pain is being controlled. Review of the facility's policy titled, Pain Management Guideline documented in part, GUIDELINE STATEMENT: To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life .GUIDELINE: Functions of appropriate pain management include, but are not limited to: Assessing pain and evaluation response to pain management interventions using a pain management scale based on patient/resident self-report or objective assessment for the cognitively impaired. Documenting pain assessment and interventions prior to giving medications. Assessment Pain assessment tools: Numeric Rating Scale . Numeric Rating Scale: The patient/resident identifies pain on a ,[DATE] scale, 0=no pain and 10=worst pain imaginable (very severe or horrible). On [DATE] at 5:30 p.m. ASM #1, the executive director and ASM #2, t

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to follow professional standards of practice for six of 29 residents in the survey sample, Residents #23, #16, #10, #7, #8 and # 22. 1. a. The facility failed to ensure staff were adequately trained in Cardiopulmonary Resuscitation (CPR) to provide initial emergency care to Resident #23 during a medical emergency and failed to ensure that CPR included usage of a back board or firm surface to ensure effective chest compressions; LPN (licensed practical nurse) #9 provided CPR to Resident #23 in the bed (a soft surface) without using a back board and was not certified with the required Health Care Provider CPR certification. The facility failed to ensure emergency equipment back board, oxygen, oxygen tubing and AED (automated external defibrillator) were stocked and available to nursing staff for use when Resident #23 was found in [MEDICAL CONDITION] (no pulse or respirations) a medical emergency at approximately 2:00 p.m. on [DATE]. Resident #23 died . b. The clinical record did not contain documentation of two conflicting verbally reported versions of Resident #23 being continuously monitored and assessed by a CNA (certified nursing assistant) and LPN (licensed practical nurse) throughout the day shift on [DATE], prior to being found in [MEDICAL CONDITION]. 2. During the medication administration observation for one of five residents, the facility staff crushed a medication that was an extended release tablet for Resident #16. 3. For Resident #10, the facility staff failed to clarify a physician's orders [REDACTED].*an antipsychotic). 4. For Resident #7, the facility staff failed to transcribe an order obtained from the physician on [DATE], for the use of a sling for a fractured humerus. 5. For resident # 8 facility staff failed to follow professional standards in the care of a [MEDICAL TREATMENT] AV (arterial - venous) fistula. 6. The facility staff failed to transcribe the hospital discharging physicians order for an antibiotic to the POS (physician order [REDACTED]. The findings include: 1. a. The facility failed to ensure staff were adequately trained in Cardiopulmonary Resuscitation (CPR) to provide initial emergency care to Resident #23 during a medical emergency and failed to ensure that CPR included usage of a back board to ensure effective chest compressions; LPN (licensed practical nurse) #9 provided CPR to Resident #23 in the bed (a soft surface) without using a back board and was not certified with the required Health Care Provider CPR certification. The facility failed to ensure emergency equipment back board, oxygen, oxygen tubing and AED (automated external defibrillator) were stocked and available to nursing staff for use when Resident #23 was found in [MEDICAL CONDITION] (no pulse or respirations) a medical emergency on [DATE]. Resident #23 died . Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of [DATE] coded the resident having no speech. The resident was coded as not being able to make himself understood and could not understand others. He was coded as having highly impaired vision. Resident #23 was coded as having both short and long term memory difficulties. He was coded as being severely impaired to make cognitive decisions. The resident was coded as having periods of inattention that was continuously present. Resident #23 was dependent of one or two staff members for all of his activities of daily living. He only required extensive assistance of two staff members for moving in the bed and dressing. Resident #23 was coded as having functional limitation in range of motion on all four extremities, both legs and both arms. Resident #23 was coded as being incontinent of both bowel and bladder. In Section K - Swallowing/Nutritional Status, the resident was coded as receiving all of his nutrition through a feeding tube. The physician order [REDACTED]. The comprehensive care plan dated, [DATE], documented, Focus: Patient has an advance directive as evidenced by: Full Code. The Interventions documented in part, CPR will be performed as ordered. The nurse's note dated, [DATE] at 14:49 p.m. (2:49 p.m.) documented, Situation: Resident noted to have decreased LOC (level of conscious) this AM (morning) upon arrival to shift. Continuous monitoring throughout shift by staff. Background: Resident is full code, no known drug allergies [REDACTED]. Assessment: Upon beginning of shift resident noted to have decreased LOC, resident responded to verbal and physical stimuli. vs (vital signs) ,[DATE], PR (pulse rate) 52, 18 (respirations) 97.9 (temperature) 95% (oxygen saturation level) Monitoring continued throughout entire shift. @ (at) 1345 (1:45 p.m.) during rounds, resident noted to have decreased LOC and VS were decreased. ,[DATE] (blood pressure) 40 (pulse). 911 (emergency services rescue) called at this time to send resident to ER (emergency room ) for further evaluation. At 1400 (2:00 p.m.) CPR (cardiopulmonary resuscitation) initiated. EMS (emergency medical services) arrived @ 1411 (2:11 p.m.) and pronounced resident deceased @ 1432 (2:32 p.m.). Response: MD (medical doctor) made aware, n.o. (new order) to release body to funeral home of choice. RP (responsible party) made aware and advised that (name of funeral home) will be picking up body. An interview was conducted with CNA (certified nursing assistant) #11, the CNA who cared for the resident on [DATE], on [DATE] at 10:41 a.m. CNA #11 stated, I went outside to the Spring Fling (at approximately 1:45 - 2:00 p.m.) and found (LPN #10) who was not on the time clock but was participating in the Spring Fling. I asked her to come and check on this resident that he wasn't right and the other nurse (LPN #9) was not doing anything and I've been telling her all day. (LPN #10) came in and told (LPN #9) to call 911. Then he coded and everyone was in the room, rescue came and he didn't make it. On [DATE] at 12:20 p.m., an interview was conducted with CNA #12 who was on duty during the day shift on [DATE]. When asked if the supplies were on the crash (emergency) cart when the code (for Resident #23) happened on [DATE], CNA #12 stated, I heard the Code Blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient especially when in [MEDICAL CONDITION]*) called and went to West 2 and two nurses were doing CPR on (Resident #23). They asked for oxygen, there wasn't anything there (on the crash cart). I had to run to West 1 to get oxygen tubing. Another nurse was behind me with an oxygen concentrator. I then left the room. On [DATE] at 3:37 p.m., an interview was conducted with LPN (licensed practical nurse) #11. LPN #11 stated she had been in another resident's room when the Code Blue had been called. LPN #11 stated I recall CNA #15 running in the hallway. She told me she was getting the AED (automated external defibrillator). I passed her again and she told me he (Resident #23) was gone. LPN #11 stated, The crash cart wasn't stocked with a back board or oxygen tubing. We wonder what we could have accomplished if it had been stocked. An interview was conducted with LPN #10, the nurse who came in from outside during the Spring Fling, on [DATE] at 4:51 p.m. When asked to describe her involvement with Resident #23 on [DATE], LPN #10 stated, I was outside at the festival doing barbeque. It was around 1:45 - 2:00 p.m. (CNA #11) came outside to me and told me (Resident #23) doesn't look good. She had told me that when she came in at 7:00 a.m. she had found him covered in tube feeding and throw up. She told the nurse (LPN #9). She (CNA #11) stated that the nurse (LPN #9) had been in and out. The O2 sat (oxygen saturation) was low and he wasn't looking good. She (CNA #11) told me how cold he was and that she had put blankets on him and kept telling the nurse (LPN #9) but she wasn't doing 'enough' for him. So I went in and the nurse (LPN #9) was at the nurse's station. I went in and he was dead, wasn't breathing and no heart rate. I yelled out to her (LPN #9) to call a code blue. I sent her (LPN #9) to do CPR and I went and called 911. The nurse told me she had taken his vital signs a couple of times and they were okay. When asked if the back board was used to perform CPR, LPN #10 stated, I can't swear to the board being there. An interview was conducted with CNA #15 on [DATE] at 5:02 p.m. When asked to describe her involvement with the code for Resident #23 on [DATE] at approximately 1:45- 2:00 p.m. CNA #15 stated, I heard (LPN #10) tell the nurse to call the Code Blue I went to the room; there was no board on the cart or under the resident. I saw the nurses doing compressions in the bed. There was no oxygen tubing going. I didn't see an oxygen tank on the cart either. Another nurse told me to go get the AED. I helped hook up the AED. Afterwards we were all upset because the cart didn't have what we needed on it. There was no board and no oxygen or tubing. On [DATE] at 5:20 p.m., an interview was conducted with LPN #9, the nurse caring for Resident #23 on the 7 a.m. -3 p.m. shift on [DATE]. When asked to describe her actions during that day, LPN #9 stated, When I came on duty that day I did my rounds. I work all over the place (facility) so I was not familiar with (Resident #23). I went in; he was sleepy, alert to verbal and physical stimuli. I completed my med (medication) pass. When asked if the CNA had told her that he had vomited that morning, LPN #9 stated, Not that I'm aware of. (CNA #11) told me he didn't look himself. I did a head to toe assessment; range of motion and his vital signs were within normal limits. He was not grimacing. I continued to monitor him throughout the day. When asked if she documented her assessments each time, LPN #9 stated, No, maybe on the shift to shift report. I had done his vital signs around 1:00 p.m. and had another nurse (who was unable to be reached) to look at him. I was getting him ready to send him out because he wasn't as alert. When I picked up the phone to call 911, (LPN #10) hollered to call a code blue. I called the Code Blue and went to do CPR. (LPN #10) called 911. When asked if a back board was utilized during CPR, LPN #9 stated, No, not that I can recall. LPN #9 was then asked again if she performed CPR on Resident #23 in the bed without a back board. LPN #9 stated, Yes. When asked if it is a standard of practice to perform CPR without a backboard, LPN #9 stated, No. It was my very first code ever. On [DATE] at 8:49 a.m., a copy of the list of supplies to be stocked and kept on the facility crash carts was requested and presented. Review of the list documented the following supplies were to be stocked on the facility crash carts: Drawer One: BP (blood pressure) Cuff Stethoscope Pulse Ox (oximeter - measures the amount of oxygen in the blood) Pen Light Glucometer Strips Lancets Alcohol Swabs Drawer Two: O2 (oxygen tubing) Nasal Cannula O2 mask face mask Non Re-breather mask [MEDICATION NAME] suction (catheter) Suction Catheter Kit Drawer Three: Face Masks Gloves Scissors Tape Drawer Four: Sharps Container Flashlight External Supplies: Ambu Bag with Mask (bag used to administer breaths during CPR) O2 key (to hang with Ambu bag) CPR board O2 tank with regulator Suction machine with tubing/canister attached [MEDICATION NAME] suction and suction cath (catheter) kit (attached to side of suction machine). On [DATE] at 11:10 a.m., two surveyors observed four crash carts in the building. All crash carts were secured with a fastener. All carts had a back board and documented supplies. One crash cart was capable of being opened without breaking the seal. Two surveyors verified the contents of the cart with the list in the binder on top of the carts. On top of all four crash carts was a sign off sheet. Only the month of [DATE] was in the binder. Administrative staff member (ASM) #3, the corporate nurse, informed this surveyor, on [DATE] at 3:37 p.m. that there was no policy on checking the crash cart. On [DATE] at 9:30 a.m., the facility provided copies of the logs to check the crash cart on West 2 for February through May of 2015. The logs documented the carts as having been checked. The [DATE] logs on the East 1 crash cart was only documented on [DATE] through [DATE]. The West 1 cart logs were complete. The West 2 cart logs were complete. The East 2 cart was documented from [DATE] through [DATE] and then only on [DATE]. On [DATE] at approximately 10:23 a.m. a copy of LPN #9's CPR certification was requested from the business office manager (other staff member (OSM)) #11. LPN #9 performed CPR on Resident #23 on [DATE]. On [DATE] at 11:23 a.m. OSM #11 stated, We do not have any documentation of her (LPN #9's) CPR certification. She is on her way with her card; she should be here in 30 minutes. On [DATE] at 11:35 a.m. a list of all licensed nurses employed by the facility since [DATE] was requested. A copy of all licensed nurses CPR certification was also requested. On [DATE] at 12:25 p.m., a second request was made for LPN #9's CPR card and a copy of her card was presented. LPN #9 did not have Healthcare Provider CPR certification. She had the general public Heart saver CPR. The card documented, Optional completed modules are those NOT marked out. All three of the optional modules were marked out indicating that the nurse did not have Child CPR/AED (Automated external defibrillator), Infant CPR and written test. On [DATE] at 1:00 p.m., the administrator, administrative staff member (ASM) #1, was informed of the concern that LPN #9 who performed CPR on a resident on [DATE] was not certified in Healthcare Provider CPR. ASM #1 was made aware of the request for the list of licensed nurses and a copy of their CPR certification. On [DATE] at 1:08 p.m. a list of licensed nurses and copies of CPR cards was received and reviewed. At this time, six (6) of 33 nurses had no documentation of CPR of any kind. Seven (7) of the 29 nurses who had CPR certification did not have the required healthcare provider CPR certification. Two more CPR certification cards were presented prior to exit, leaving four (4) nurses in the building with no documentation of CPR certification. An interview was conducted with administrative staff member (ASM) #2, the director of nursing, on [DATE] at 1:22 p.m., regarding the requirements for a licensed nurse to be employed at the facility. ASM #2 stated, They have to have a current license and current CPR. When asked if any specific CPR certification was required, ASM #2 stated, It has to be American Heart Association Adult CPR for the medical provider. The facility Job Descriptions for both the Charge Nurse - RN (registered nurse) and the Nurse Staff - LPN, documented, Qualifications: Must hold and maintain a current CPR certification. The facility policy, Emergency Care, General Guidelines for Documented in part, Procedure: 1. Observe condition of all resident by making rounds as soon as nursing report is completed. 2. If resident's condition has change, measure vital signs and note changes in condition. Call attending physician and report changes and nursing observations. Provide emergency care as necessary. The facility policy, Cardiopulmonary Resuscitation (CPR) Guideline documented, GUIDELINE STATEMENT: In the event a resident/patient experiences [MEDICAL CONDITION] (cessation of pulse and/or respirations), cardiopulmonary resuscitation (CPR) will be provided in the absence of a valid Advanced Directive or a Do Not Resuscitate (DNR) order directing otherwise. Once emergency medical services (EMS) arrive, EMS will take control of the resuscitative efforts and direct all related activities until either the resuscitative effort is ceased or the resident/patient is transported to an emergency center .GUIDELINE: If a patient/resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain Calm. 2. Call out for help. Direct another staff member to announce the emergency per Living Center protocol and call Emergency Medical Services (EMS - dial 911). Direct another staff member to bring the emergency supplies and AED (automated external defibrillator) to the scene. 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in the facility, shall manage the physical efforts involved in resuscitation. 4. A staff member, other than the one who is providing the resuscitative effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] placed. 5. If DNR status is validated, do not initiate CPR. If CPR/Code status is undetermined, CPR will be initiated and will continue until the arrival of EMS. American Heart Association, Heartsaver First Aid/CPR/AED Student Manual page 74, Make sure the person is lying on his back on a firm, flat surface. The Lippincott Manual of Nursing Practice, (Chapter 35, 8th edition) procedure guidelines for Cardiopulmonary Resuscitation documented equipment such as an arrest board, oral airway, bag and mask device, in addition to IV set up, defibrillator, . were to be available during CPR. It further documents in part: Nursing actions: . Place the patient supine on a firm flat surface . On [DATE] at 1:32 p.m. ASM #1, the administrator, was made aware of the concern above. No further information was provided prior to exit. * This information was obtained from the website: http://www.merriam-webster.com/medical/code%20blue b. The clinical record did not contain documentation of two conflicting verbally reported versions of Resident #23 being continuously monitored and assessed by a CNA (certified nursing assistant) and LPN (licensed practical nurse) throughout the day shift on [DATE], prior to being found in [MEDICAL CONDITION]. The clinical record was reviewed. The nurse's note dated, [DATE] at 14:00 (2:00 p.m.) documented, Situation: Witnessed fall from w/c (wheelchair) to floor next to bed in resident's room. Background: MR (mental [MEDICAL CONDITION]) anmia (sic) hypertension (high blood pressure) [MEDICAL CONDITION]. Assessment: Full body assessment done with no new areas of concern. Moves all extremities and nonverbal. ,[DATE] (blood pressure), 98.7 (temperature) 80 (heart rate), 18 (respirations), neuro (neurological) checks WNL (within normal limits), and no obvious signs of pain. Response: (Name of Doctor - administrative staff member #4) and resident's R/P (responsible party) notified and no new orders. The nurse's note dated [DATE] at 22:26 (10:25 p.m.) documented, Res (resident) alert and oriented to self, continue on skilled therapy signs of pain, yelling out loud, restlessness and guarding to BLE (bilateral lower extremities) observed assisted to reposition every 2 hours with 2 assist and LE (lower extremities) elevated on pillows with no effect prn (as needed) adm (administered) with effect pt (patient) in room incontinent of B&B (bowel and bladder) with 1 assist, peg site patent and intact all meds (medications) flushes and feeds adm (administered)and off as ordered afebrie (sic) bs (bowel sounds) present on all quad (quadrants) body warm to touch lungs fields clear bp (blood pressure) ,[DATE] rr (respirations) 20 auxt (axillary temperature) 97.8, p (pulse) 78 O2 (oxygen) ra (room air) 96%. This paragraph has been copied as it was written. There was no documentation in the clinical record the physician was notified of Resident #23's change in condition and symptoms of pain. The physician orders [REDACTED]. Review of the MAR (medication administration record) for [DATE] and [DATE] documented the resident had received the prescribed [MEDICATION NAME] on [DATE] at 4:50 a.m. and 8:32 p.m. and then on [DATE] at 7:43 a.m. The [MEDICATION NAME] was then administered on [DATE] at 7:28 p.m. There was no nurse's note for the night shift from [DATE] until [DATE] at 11:05 a.m. The nurse's note dated [DATE] at 11:05 a.m., documented, Resident continues to be alert with nonverbal expressions at this time. Resident remains skilled for PT (physical therapy) services. No complaints, no grunting or calling out noted this shift. Resident positioned q (every) 2 hrs (hours) with heels floated. PEG (feeding tube) patent and flushes without difficulty. Resident took all medications without difficulty. The nurse's note dated, [DATE] at 14:49 p.m. (2:49 p.m.) documented, Situation: Resident noted to have decreased LOC (level of conscious) this AM (morning) upon arrival to shift. Continuous monitoring throughout shift by staff. Background: Resident is full code, no known drug allergies [REDACTED]. Assessment: Upon beginning of shift resident noted to have decreased LOC, resident responded to verbal and physical stimuli. vs (vital signs) ,[DATE], PR (pulse rate) 52, 18 (respirations) 97.9 (temperature) 95% (oxygen saturation level) Monitoring continued throughout entire shift. @ (at) 1345 (1:45 p.m.) during rounds, resident noted to have decreased LOC and VS were decreased. ,[DATE] (blood pressure) 40 (pulse). 911 (emergency services rescue) called at this time to send resident to ER (emergency room ) for further evaluation. At 1400 (2:00 p.m.) CPR (cardiopulmonary resuscitation) initiated. EMS (emergency medical services) arrived @ 1411 (2:11 p.m.) and pronounced resident deceased @ 1432 (2:32 p.m.). Response: MD (medical doctor) made aware, n.o. (new order) to release body to funeral home of choice. RP (responsible party) made aware and advised that (name of funeral home) will be picking up body. Review of the comprehensive care plan dated, [DATE], documented, Focus: Impaired neurological status related to: [MEDICAL CONDITION] disorder. The Interventions documented in part, Monitor patient for change in condition. Monitor vital signs prn (as needed) and report abnormals to physician. Cognitive Loss: Resident has DX (diagnosis) [MEDICAL CONDITION](stroke) MR (mental [MEDICAL CONDITION] or intellectually disabled) and [MEDICAL CONDITION]. Exhibits severe cognitive loss. At risk for injury and decline. The Interventions documented, Monitor patient for change in condition. Monitor vital signs prn (as needed) and report abnormals to physician. The care plan dated, [DATE] documented, Focus: At risk for impaired communication. Resident has DX of [MEDICAL CONDITION], MR and [MEDICAL CONDITION]. Exhibits severe cognitive loss. His hearing is adequate. Is non-verbal. Is rarely/never understood and rarely/never understands. The Interventions documented, Consistent staff to work with patient.Listen carefully; validate verbal and non verbal expressions. The care plan dated [DATE] documented, Potential for impaired cardiovascular status related to: [MEDICAL CONDITION], malnutrition, hypertension, [MEDICAL CONDITION] (elevated fats in the blood),[MEDICAL CONDITIONS]'s. The Interventions documented, Observe for abnormal vital signs and report. Observe for change in condition. On [DATE] at 9:59 a.m., an interview was conducted with LPN (licensed practical nurse) #6, the nurse that took care of Resident #23 on [DATE] in the evening. When asked to describe her care on [DATE] for Resident #23, LPN #6 stated, He was very restless that evening. He would cry and yell out. He was guarding his lower extremities. We repositioned him. Care for his feeding tube, did his ADLs (activities of daily living). He continued to yell and cry. I gave him some pain medication ([MEDICATION NAME] sulfate). It was the only thing he had ordered. He's non verbal and can't tell us what's going on. He kept guarding his lower extremities. When asked if she had taken care of this resident before, LPN #6 stated, Yes, I had him every night I'm here. When asked to describe him, LPN #6 stated, He was so different that night. He continued to yell. Normally after we reposition him and clean him up, he normally settles down. When asked if she called and notified the doctor of Resident #23's change in status, LPN #6 stated, No, I didn't think to do it. On [DATE] at10:41 a.m., an interview was conducted with CNA (certified nursing assistant) #11, the CNA who cared for the resident on the 7 a.m. - 3 p.m. shift on [DATE]. When asked to describe the events of [DATE], CNA #11 stated, When I first came on duty, he (Resident #23) had vomited. It looked like his tube feeding, light creamy colored. I cleaned him up and notified the nurse (LPN #9). I told her (LPN #9) that he wasn't himself that morning. I went about my tasks of getting people up and feeding breakfast. I then went in and performed his ADLs, He was so cold. I put three blankets on him. I took his vital signs and got ,[DATE] and his pulse was 33. I told the nurse (LPN #9) again of my concerns for him. She went in and assessed him and retook his vital signs, manually. When asked if there has been any concern of the accuracy of the vital sign machine in the past, CNA #11 stated, No. CNA #1 stated, I kept on checking on him every hour. He was not getting better. He was just not himself. I work with him all the time and he just wasn't right. The nurse (LPN #9) was in the room and called for me to help her get his temperature. I helped turn him over to get a rectal temperature, it didn't register. He was stone cold but breathing. She (LPN #9) told me she was 'waiting for the doctor to call back.' I then went back to the Bistro to assist with feeding. After I finished that I went to check on him at approximately 1:20 p.m. His face was pale but taking breaths. I told her (LPN #9) again. I finally went outside to the Spring Fling (an event for facility residents) and found (LPN #10) who was not on the time clock but was participating in the Spring Fling. I asked her to check on this resident that he wasn't right and the other nurse (LPN #9) was not doing anything and I've been telling her all day. (LPN #10) came in and told (LPN #9) to call 911. Then he coded and everyone was in the room, rescue came and he didn't make it. I was upset because she should have done more and maybe I should have done more too but I was doing what I was supposed to do, notify my charge nurse. On [DATE] at 2:01 p.m. the administrator, director of nursing and corporate nurse were made aware of the above concern. On [DATE] at 4:51 p.m., an interview was conducted with LPN #10, the nurse who cared for the resident when he fell on [DATE] and the nurse who came in from outside during the Spring Fling (an event held for facility residents) on [DATE]. When asked to describe Resident #23's fall, LPN #10 stated, I was walking into the room when he was down on his knees out of the wheelchair but next to the bed. He was on the floor on his knees. He did not hit his head. A physical therapist walked by the room and I got him to help me get him into bed. I did a head to toe assessment and vital signs and he had no unusual findings. When asked to describe her involvement with Resident #23 on [DATE], LPN #10 stated, I was outside at the festival doing barbeque. It was around 1:45 - 2:00 p.m. (CNA #11) came outside to me and told me (Resident #23) doesn't look good. She told me that when she came in at 7:00 a.m. she had found him (Resident #23) covered in tube feeding and throw up. She (CNA #11) stated she told the nurse (LPN #9). She (CNA #11) stated that the nurse had been in and out of Resident #23's room. The (Resident #23's) O2 sat (oxygen saturation) was low and he wasn't looking good. She, (CNA #11) had told me how cold he was and that she had put blankets on him and stated she kept telling the nurse (LPN #9) but she wasn't doing 'enough' for him. So I went in and the nurse (LPN #9) was at the nurse's station. I went into the room and he (Resident #23) was dead, wasn't breathing and no heart rate. I yelled out to her to call a code blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to resuscitate a patient especially when in [MEDICAL CONDITION]*). I sent her to do CPR and I went and called 911. The nurse told me she had taken his vital signs a couple of times and they were okay. I wish (CNA #11) had come out earlier but she did what she was supposed to do, tell her nurse on duty. On [DATE] at 5:20 p.m., an interview was conducted with LPN #9, the nurse caring for Resident #24 on the 7 a.m. - 3 p.m. shift on [DATE]. When asked to describe what occurred during the day on [DATE], LPN #9 stated, When I came on duty that day I did my rounds. I work all over the place (facility) so I was not familiar with (Resident #23). I went in; he (Resident #23) was sleepy, alert to verbal and physical stimuli. I completed my med (medication) pass. When asked if CNA# 11 had told her that he had vomited that morning, LPN #9 stated, Not that I'm aware of, (CNA #11) told me he (Resident #23) didn't look himself. I did a head to toe assessment; range of motion and his vital signs were within normal limits. He was not grimacing. I continued to monitor him throughout the day. When asked if she documented the vital signs, LPN #9 stated, I don't think so. When asked if she documented her assessments and monitoring each time, LPN #9 stated, No, maybe on the shift to shift report. I had done his vital signs around 1:00 p.m. and had another nurse (who was unable to be reached) look at him. I was getting him ready to send him out because he wasn't as alert. When I picked up the phone to call 911, (LPN #10) hollered to call a code blue. I called the Code Blue and went to do CPR. (LPN #10) called 911. She wasn't on duty but was outside with the activity going on. I didn't know how she came about coming inside and seeing the resident. She was familiar with the resident. I went and performed CPR (cardiopulmonary resuscitation). When asked if a back board was utilized during CPR, LPN #9 stated, No, not that I can recall. LPN #9 was then asked again if she performed CPR on Resident #23 in the bed without a back board. LPN #9 stated, Yes. LPN #9's nurse's notes for [DATE] were reviewed with her. LPN #9 was then asked if she had contacted the doctor in the morning or at any time during the shift when the resident was assessed with [REDACTED].#11 reported to her that the resident was not himself. LPN #9 stated, No, his vital signs were stable and his condition was the same as when I saw him at the beginning of the shift. LPN #9 was asked when the physician was notified of the change in the resident's level of consciousness. LPN #9 stated, I didn't have time to call the doctor until after the incident (CPR) had occurred. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the corporate nurse, and ASM #5, the corporate director, was made aware of the above concern on [DATE] at 5:53 p.m. All documentation of asses

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide necessary care and services to attain or maintain the highest physical well being for one of eight residents in the survey sample, Resident #3. The facility staff failed to assess, document and provide the necessary care to promote healing of Resident #3's left leg venous stasis ulcer. Resident # 3 was admitted on [DATE], his left leg wound was not assessed and treatment was not performed until 8/11/13, at which time multiple open areas were observed with foul smelling green drainage and maggots in the wound bed. Resident # 3 was transferred and admitted to a local hospital for treatment. The findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 3's admission MDS (Minimum Data Set) with assessment reference date (ARD) of 8/11/13, coded the residents daily cognitive decision making skills as modified independence (some difficulty in new situations only). Resident #3 was coded as requiring limited staff assistance for bed mobility, transfers and dressing; requiring staff supervision for moving around the unit and eating; and requiring extensive staff assistance for toileting, personal hygiene; and being totally dependent for bathing. Resident #3's physician order [REDACTED].# 3's left venous stasis ulcer or any orders for a wound clinic consultation/appointment. A review of Resident #3's clinical revealed a listing of all orders written for Resident #3 during the time period 8/1/13 through 8/11/13, including discontinued and completed orders. This comprehensive list contained no mention of wound care until 8/11/13. A review of the Admission Nursing Assessment for Resident #3 revealed in the, "Signature/Title" box, the signature of LPN (licensed practical nurse) #9. In the "Sections Completed" box, the letter "B" was documented and in the "Date" box, was " 8/1/13." Section B, entitled: "Skin Conditions" revealed drawings of a human body with room for labels words, and letters to describe the skin of the assessed patient. On the drawing labeled "Anterior," (front view), a line was drawn horizontally at the knee. Underneath the line was drawn an "X" over the lower right leg. Also on the drawing, the left leg was labeled with a dot just above the left knee. Beside the dot, the word "Reddened" was written to indicate a red area just above the left knee. No other notations, drawings or other markings were present on the legs of the "Anterior" view or on any of the other body views in Section B of the admission nursing assessment. A review of Resident #3's progress notes revealed an admission note, dated 8/1/13 at 11:02 p.m., and signed by LPN #1 that documented in part the following: "Resident was admitted to the facility accompanied by family via wheelchair @ (at) 1:36 p (sic) (p.m.) under the services of (ASM (administrative staff member) #3, the facility medical director and Resident #3's attending physician). He is ... alert and oriented 70 yo (year old) male with an hx (history) of diabetes mellitus 2 (type 2). Residents (sic) speech is unclear due to being deaf but is able to write down what he needs so as to be easily understood. Resident is a right below knee [MEDICAL CONDITION]. Skin is noted to be warm, dry and intact with the presence of a scar on his chest. He also has a reddened area on his left knee. Resident is pleasant and cooperative with staff .... " This note contained no mention of a wound, dressing or device on Resident #3's left leg. A review of Resident #3's clinical record revealed a tabbed section entitled, "Admission" which contained an email, dated 7/8/13, from Resident #3's wife to Resident #3's primary care clinic staff. In the email, Resident #3's wife listed Resident #3's medications and stated, "Hope it will help and (Resident #3) has bad sores on his leg and my friend will call the wound clinic tomorrow." The email contained an undated hand-written notation on the right side as follows: "Check CBC/CMP (complete blood count, complete metabolic panel - blood tests) in AM (morning)." The notation was signed by ASM (Administrative Staff Member) #4, the nurse practitioner for Resident #3's attending facility physician. The facility admitting history and physical for Resident #3 signed by ASM #4 and dated 8/2/13 at 12:10 p.m. contained the following documentation: "History of Present Illness: 2. Diabetes: Associated symptoms include: blurred vision, hypoglycemic (low blood sugar) episodes - confusion and shakiness, slow healing wounds/sores and weight gain. Review of Symptoms: Dermatologic (skin) - Slow healing wounds/sores. Physical Exam: Skin - Normal - Inspection - Normal. Palpation/texture - Normal. Nails - Normal. Hair - Normal. Extremity - [MEDICAL CONDITION] (swelling) - Location: leg. Side: left. Severity: 4+, Type: non-pitting. Amputation - R AKA (right, above knee amputation). Assessment/Plan: "Continue using compression wrap on left lower extremity to help manage [MEDICAL CONDITION]." This section contained no mention of or plan of care for a wound on Resident #3's left leg. Resident #3's clinical record contained a document entitled, "Resident Discharge Plan," dated 8/2/13. The blank beside the phrase, "Community Services prior to admission," contained the following documentation: "Home Health (initials of the local hospital) for wound (name of Resident #3)." A review of Resident #3's care plan, with effective date 8/4/13, revealed no mention of or interventions for a wound on Resident #3's left leg until 8/11/13. A review of Resident #3's weekly skin assessment dated [DATE] and unsigned revealed no drawing or mention of a wound, dressing or appliance on Resident #3's left leg. A progress note dated 8/7/13 at 2:21 p.m. signed by LPN #6, documented, "Resident's wife gave this writer appointments that had been previously scheduled and transportation forms completed." Review of the clinical record failed to reveal any documentation or evidence of a wound clinic appointment. A review of Resident #3's bathing record revealed that Resident #3 was bathed with assistance of a staff CNA (certified nursing assistant) on the following days: 8/1/13 (CNA #4), 8/3/13 (CNA #1), 8/6/13 (CNA #3), 8/7/13 (CNA #5), 8/9/13 (CNAs # 2, 4, 6) and 8/10/13 (CNA #6). Review of a wound care progress note for Resident #3 from the local hospital's wound care center, dated 7/10/13, revealed the following: "Left lower leg ulceration measures 28 X 30 cm (centimeters) with yellow slough (dead tissue). There is a large amount of serosanguinous (blood mixed with light-color drainage) drainage noted with surrounding [DIAGNOSES REDACTED] (redness). There is +2 [MEDICAL CONDITION] noted to the lower leg. There is about 30% granular (healthy) tissue and 70% necrotic (dead) tissue." The note continues: "Assessment: *Venous stasis ulceration and **[MEDICAL CONDITION]. ***Calcium alginate and an Unna boot (a zinc oxide-impregnated bandage (1)) was applied to the left leg." Attached to the progress notes were photographs of Resident #3's left leg wound (taken on the day of the 7/10/13 visit). A review of a document from the local hospital's home care services entitled, "Documentation of Face-to-Face Encounter" regarding the need for Resident #3 to be the recipient of home health services revealed the following documentation: "The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care: (letter "L" with a circle around it, meaning left) leg venous stasis ulcers. My clinical findings support the need for the above skilled qualifying services because: Unna boot needs changed weekly to heal the ulcers." The unreadable signature was dated 7/10/13. A review of the nursing facility progress notes for Resident #3 revealed no mention of a left leg wound, left leg dressing or appliance, or of a wound care clinic consultation appointment for Resident #3 from 8/1/13 through 8/8/13. A progress note dated 8/9/13 and signed by ASM #2, the director of nursing, stated: "(Resident #3) has been seen prior to admission by (name and phone number of Resident #3's wound care clinic) and an appointment has been arranged for Wednesday, Aug. 14 at 1pm. (sic) Will speak with family regarding transportation needs. Course of treatment for [REDACTED]." Further review of the nursing facility progress notes for Resident #3 revealed the following entries, dated 8/11/13: - 9:48 a.m. signed by LPN #4: "Odor noted from left lower leg. Dressing removed, something resemblying (sic) maggots noted coming from wound. Nursing supervisor notified." - 11:00 a.m. signed by LPN #2: "Situation: Was notified by treatment Nurse, that orders for stasis ulcers of left lower extremity needed orders clarified, as Resident had wound clinic appt (appointment) last week, that family was to transport and could not make the appt. Wound clinic had applied Unna boot on appt prior to admission. Resident has appt rescheduled for upcoming week. Wound clinic was not open to clarify orders for wound until upcoming appt. In to assess wound with treatment Nurse, Unna boot was removed, and noted foul smelling green drainage, with multiple open areas and maggots in bed of wound. Area was immediately cleansed and soaked in Warm H2O (water), call placed to (ASM #3 the attending physician/facility medical director). Background: History of diabetes, right lower leg amputation, stasis ulcers of left lower extremity, that were being treated by wound clinic. Assessment: Foul smelling wound, with green drainage, multiple open areas left lower extremity, maggots are present in wound bed, skin is warm and surrounding tissue is discolored dusky, and purple, pedal pulse is present but faint, +2+3 [MEDICAL CONDITION] present. VS (vital signs) 131/86 (blood pressure), 78 (heart rate per minute), 22 (breaths per minute), 98.9 (temperature). Response: (ASM #3) was notified, and order obtained to send to ER for evaluation. Residents (sic) RP (responsible party) and Resident were notified. (name of ambulance service) arrived at approx (approximately) 10 a.m. Was called to room by Charge Nurse, she stated that Resident was refusing to go to the hospital. I wrote out on notepad to Resident the importance of going to hospital for evaluation, and that there may be a possible infection present that would lead [MEDICAL CONDITION] (infection in the blood), and other possible serious health issues. Resident nodded that he understood, but continued to Refuse (sic) to go. (name of ambulance service) transporters stated that he had a right to refuse and that that (sic) they could not transport. Transporters left and (ASM #3) was notified. He stated that we should call RP back and ask them to come in and talk to Resident about going to the hospital, and to express the importance to Son/RP. Message left for RP to call facility back as soon as possible, that Resident was refusing hospital transport. Treatment orders obtained from (ASM #3). (ASM #3) stated he would not give phone order for oral ABT's (antibiotics) as this would not be helpful. Resident needed to be admitted to hospital. Will continue to encourage Resident to go to hospital for eval (evaluation). Awaiting call back from Son, call placed to daughter earlier, with 0 (no) call back at this time." - 3:16 p.m. signed by LPN #2: "Resident agreed to transport to hospital, after wife returned from Church. (name of ambulance service) arrived and Resident transported, report called to ER (emergency room ) nurse (name of ER nurse) at 3pm." - 3:38 p.m. signed by LPN #3: "Late entry for 7-3 (first shift) on 8/10/13. Resident refused to allow skin assessment despite encouragement. Resident stated that he did not want it. Message given to wound nurse on 8/10/13 to call (phone number of wound clinic) regarding a change in treatment to ulcer on left leg. Wound nurse stated she would follow up." A verbal order unsigned by the physician for Resident #3 dated 8/11/13 documented: "Clean left lower leg with normal (sic). apply (sic) moist saline dressing to open areas and cover with kling (gauze bandage) BID (twice a day) until seen by wound clinic." A review of local hospital's emergency room physician report for Resident #3, dated 8/11/13, revealed the following: "Extremities: R AKA (right above knee amputation), left lower leg and foot have [MEDICAL CONDITIONS] (infection of the skin), and 2nd-4th toes are turning black at the tips. Leg has a foul odor." Review of the local hospital's admitting history and physical for Resident #3, dated 8/11/13, revealed the following: "Chief complaint: Left lower extremity redness and swelling. Skin: The patient has [DIAGNOSES REDACTED]tous (red) rash, swelling of left lower extremity with necrotic ulcers. Clinical impression: admitted . [MEDICAL CONDITION] of the left leg, left ankle, left foot and left toe(s)." In an interview on 8/21/13 at 8:30 a.m., OSM #5, an RN (registered nurse) and the clinical coordinator at the wound care clinic where Resident #3 was seen on 7/10/13, was asked about Resident #3's left leg wound and dressings. OSM #5 stated, "We put calcium alginate on there. Then an Unna boot, then a gauze wrap. Then he was to have home health come in to change the dressing. We wanted him to follow up with us in three weeks. Until then, he was to elevate his foot as much as possible." When asked how often the calcium alginate dressing and Unna boot dressings were to be changed, OSM #5 stated, "At least every week. More often if possible." When asked if, to his knowledge, anyone from the nursing facility had contacted the wound care center to inquire about Resident #3's orders or follow-up consults, OSM #5 stated, "No, we had not heard anything from them. And then we learned that (Resident #3) was in the hospital for it (the wound)." On 8/21/13 at 1:30 p.m., 1:35 p.m., 1:40 p.m., 2:15 p.m., and 2:45 p.m., CNA #2, CNA #6, CNA #1, CNA #3 and CNA #7 were interviewed about bathing Resident #3 on 8/3/13, 8/6/13, 8/7/13, 8/9/13, and 8/10/13. All CNAs when asked what they remembered about Resident # 3, stated one leg was amputated. One CNA stated they could not remember an issue with the other leg; the others stated there was a boot with sock, cast or soft material on his left leg or good leg. CNA #7 stated, "His wife wrote a note that the dressing could not get wet." On 8/21/13 at 11:05 a.m., an interview was conducted with LPN #4; the weekend wound nurse who first removed Resident #3's left leg dressing on 8/11/13. LPN #4 stated, "I went in to do a treatment on his arm because he had a skin tear on it. And he had an odor coming from his leg. He had a black kind of brace or boot on, and a black sock. I took those off and then I saw the Unna boot. I went to get the nursing supervisor. I showed her the Unna boot and the open areas he also had on his toes. I went to look for the orders for his leg, but we didn't have any. We did not have an order for [REDACTED]. " LPN further stated, "His wife did not want us to remove the dressing, but we told her that we had to look at it because of the terrible odor. So we took off the dressing. It smelled infected. I saw worm-like maggots in it. There were maggots on top of the foot and at the place where the Unna boot had been, and then all throughout his leg. I could see them moving around." When asked what the rest of Resident #3's left leg looked like, LPN #4 stated, "The rest of the leg was really, really dry. And red." When asked if LPN #4 recognized what the Unna boot was when she initially saw it, LPN #4 stated, "No, I didn't. I had never seen one before." When asked how she became informed about the Unna boot, LPN #4 stated, "Somebody told me since then that it was one. I really didn't know." When asked if LPN #4 was given any information regarding Resident #3 by the off-going nurse at the beginning of the shift, LPN #4 stated, "I knew that the Friday night nurse had left a note for the next nurse to call the wound clinic about him. The supervisor handed me the note on Saturday to call the wound clinic for a replacement for the Calcium alginate order because we didn't have any of that (Calcium alginate)." When asked what she did when she observed the maggots on the resident's legs and toes, LPN #4 stated, "I rinsed it off. The wife wouldn't let us get rid of the boot, so I double bagged it in a trash bag. It was so nasty. The supervisor called and got an order. I think it was for a wet to moist dressing and then wrap until the patient could get to the hospital." When asked what LPN #4's action would have been if she had admitted a resident with the Unna boot and underlying dressing, LPN #4 stated, "I would definitely have documented that there was something there, even if I didn't exactly know what it was. I would have gotten an order to treat it. I would have asked the nurse practitioner for the order. I think she is here all week. It is easy to get orders that way." In an interview on 8/21/13 at 11:55 a.m., LPN #3, who was Resident #3's assigned nurse on 8/11/13, LPN #3 stated: "I am only prn (as-needed). I did not know about his legs. I got in report from the Friday night nurse that they wanted the wound nurse to call and see if the dressing could get changed. I remember that on Saturday, I had given that number to the wound nurse. I don't think she (weekend wound nurse) was aware that (Resident #3) had a wound. I remember that he refused a skin assessment on one of those days - either Saturday or Sunday. I think the night nurse said they wanted to change the treatment from what was currently ordered. I didn't see any documentation regarding the leg wound. I went in to try to assess the wound on Saturday. He refused the skin assessment." And then on Sunday, I remember that we had a hard time convincing him to go to the hospital, too. I remember on Saturday, I asked the wound nurse what treatments she did and if I needed to do anything for the wound. The wound nurse said, 'I do all of them. I do all the treatments.' I remember that I looked on the MAR and the TAR, but there was nothing there about the wounds." In an interview on 8/21/13 at 12:30 p.m., LPN #1, the nurse who wrote the admitting progress note for Resident #3 on 8/1/13, LPN #1 stated: "The assessment was pretty much done when I got there, except for the skin part. (LPN #9) was working that night, and she offered to do the skin part of that assessment. She came to me and told me that he had refused to have his bandage taken off his leg. I went in later to look at his leg, but he refused." When asked if the presence of a wound and a resident's refusal of assessment of the wound are important to document, LPN #1 stated, "Yes." LPN #1 was shown the admission note she had written on 8/1/13 for Resident #3. When asked if the note included any information about the resident's left leg or about Resident #3's refusal of an assessment of the left leg, LPN #1 stated, "No, I didn't put it in there. " When asked if, once she found out that Resident #3 had a dressing/wound on his left leg, did she make any attempt to find out the reason and care needed for the left leg dressing, LPN #1 stated, "No, I didn't. It was a really busy evening." In an interview on 8/21/13, LPN #6 was shown the note she had written on 8/7/13 about scheduling transportation for Resident #3. LPN #6 stated, "I remember that it was with the endocrinologist, the cardiologist, and, I think, the eye doctor. I talked to his wife, and she gave me a list. Then she came to me later and said that (Resident #3) was supposed to go to the wound clinic. Then she came back later and said they needed to change the date. I told the wife that she should have given me the appointment slips when they first got here." When asked the responsibility the facility has regarding residents' outside appointments, LPN #6 stated, "They have to work through us. We have to know what is going on. I remember asking the wife who was going to transport them to the wound clinic and (Resident #3's wife) pointed and said, "Here." But then when she came back later, she gave me a note and said the wound clinic had cancelled." When asked if she took any action after learning this information, LPN #6 stated, "I said something to the wound nurse - (RN (registered nurse) #1, the weekday wound nurse) - she was the wound nurse that day. I asked (RN # 1) to go in to see the resident and she did." When asked what is the facility practice regarding assessments at the time residents are admitted to the facility, LPN #6 stated, "The policy is when anyone comes in, whoever is admitting the resident that day - whatever nurse it is - they are responsible for the head to toe assessment and for trying to get the information about the appointments." In an interview on 8/21/13 at 2:20 p.m., with RN #1, when asked if LPN #6 had ever asked RN #1 to go into Resident #3's room and assess his wound, RN #1 stated, "No. No nurse ever asked me to go in his room and look at the wound. I never saw it." In an interview on 8/21/13 at 2:25 p.m., LPN #2 stated, "I remember that he came and the nurse practitioner talked to family members and got the orders. I don't remember scheduling anything with the wound clinic." When asked about the events of 8/11/13, LPN #2 stated, "I think the nurse met me in the hall and said that there was a wound and that the doctor needed to be called. The nurse said something like, 'He has a wound on his leg and we need a treatment order.' She started cutting the bandage, and I saw the drainage immediately. It was dark green and it smelled so awful. There were maggots in the wound bed. They were moving around." When asked if LPN #2 was aware, until that moment, that Resident #3 had a wound on his left leg, LPN #2 stated, "No." When asked what the current order was when LPN #2 checked the orders, LPN #2 stated, "There were no orders." When asked about the progress note LPN #2 wrote at 11:00 a.m. on 8/11/13, LPN #2 stated, "I had talked to (ASM #2, the director of nursing) on the phone that morning and she told me that the family had told her the resident had missed a wound clinic appointment and that it was being rescheduled." LPN #2 stated, "(ASM #3 the facility medical director) told me that we had to call the family and convince the resident to go. The doctor told me he was not going to give any orders for antibiotics because the resident needed to go to the hospital and that we had to find a way to convince the resident to go. Finally, when the wife got home from church, she was able to convince (Resident #3) to go (to the hospital)." On 8/21/13 at 2:50 p.m., LPN #5 was interviewed regarding Resident #3's care. LPN #5 stated that she had been Resident #3's assigned nurse two times during his stay. LPN #5 stated, "I knew he had a healed amputation. I knew he had the boot, but nobody ever gave me any reason to investigate his leg. I know hindsight is always the best. I did wound care during the week before (Resident #3) went in to the hospital. I was the wound nurse. I remember the unit manager came up to me to start to say something about him, but I got called away. Later that night - maybe it was that Friday night before he went to the hospital, the DON called me and asked if the unit manager had talked to me. I said that I had to leave before the unit manager could tell me anything. The DON said that the wound center had been called and that they said he needed Calcium alginate for his wound. I remember being stunned to find out he even had a wound. If I had known it, I would have looked at it. I was the wound nurse a few days that week. I told the DON we didn't even have that dressing. And we didn't even have any Unna boots either. I remember the (ASM #2 DON) said for me not to worry about it - that she needed to call the wound center again and she would get back to me. The DON did not get back to me so I had to call her at home that night. She told me again not to do anything - to just put it on the 24-hour report for the night nurse to pass on for the Saturday nurse to call the wound clinic. I remember telling the DON that I thought the wound center would be closed on Saturday. The DON told me that it was okay - to just put it on the 24 hour report and she would follow up on Saturday. So I passed it to the night nurse. Then, they called me on Sunday, and I was like, 'Nobody followed up yesterday? That wound needs to be seen now." On 8/21/13 at 3:05 p.m., LPN #9, the nurse who signed off on the skin assessment portion of Resident #3's admission assessment, was interviewed. LPN #9 stated, "I just helped with the admission. I just did his skin assessment." When asked about Resident #3's legs, LPN #9 stated, "The biggest thing was a boot on the left leg. I would not take it off because they said it had just been changed." When asked who 'they' referred to, LPN #9 stated, "The resident and the wife." LPN #9 stated, "I asked the wife if there was an open wound, and she told me that it was just wet." LPN #9 stated, "Well, I wasn't sure. I asked his nurse to follow up on that boot. I wasn't sure what was under there." On 8/21/13 at 2:15 p.m., OSM (other staff member) #4, the facility admissions director, was interviewed about Resident #3's wound care needs. OSM #4 stated, "Unless there is a care need I can't meet, I bend over backwards to bring the resident in. I know the wound doctor was involved. I did not know to what extent. He had an appointment on 8/7/13 at the wound clinic. I think the POA (power of attorney) was arranging for transportation because (Resident #3) did not have Medicaid. He did not go to the 8/7/13 wound clinic appointment. The transportation did not come get him." When asked if OSM #4 notified the nursing staff about the 8/7/13 appointment or that the resident missed the 8/7/13 appointment, OSM #4 stated, "I felt it was not an issue because we have a wound nurse here." On 8/21/13, ASM #3 (medical director) was interviewed about Resident #3. ASM #3 stated that he was aware of Resident #3's multiple medical issues. ASM #3 stated, "I am also aware that (Resident #3) is passive and has been resistant to our efforts to assess the leg wound. You know we can't force treatment on him." When ASM #3 was asked about the events of 8/11/13, ASM #3 stated, "I think I saw (Resident #3) the night before. That night, I saw the resident, and the staff had no concerns about him. I noticed his wound dressing that night. (Resident #3)'s wife stated that her husband sees the wound clinic. Well, it turns out that they (Resident #3 and his wife) had re-scheduled the wound clinic appointment." When asked when ASM #3 became aware of the wound clinic appointment scheduled for Resident #3, ASM #3 stated, "Well, I know if he had not had some outside wound care, we would have had the resident see the wound physician who comes to the facility." ASM #3 stated, "I remember thinking, when I got the call, 'Wow that was pretty quick.' There wasn't an odor on Saturday. (Resident #3) had some [MEDICAL CONDITION] in his left leg, some mild [DIAGNOSES REDACTED] around the dressing. We called the son because the wife had been distraught about (Resident #3) going to the hospital. I remember I thought, 'Oh man, this is gangrene.' I feel sure (Resident #3) knew what was happening." When asked if ASM #3 was aware of Resident #3's wound, dressing and Unna boot at the time Resident #3 was assessed at facility admission, ASM #3 stated, "Well, I was aware of the Unna boot. Our efforts to take it off were resisted by the resident." When asked if ASM #3 knew how long the dressing and Unna boot had been applied to Resident #3's leg at the time of admission to the facility or at any point during Resident #3's stay, ASM #3 stated, "No, I didn't. I didn't know for sure. We assumed that it hadn't been on that long." When asked what ASM #3 considered to be standard practice for dressing and Unna boot changes, ASM #3 stated, "I don't like an Unna boot to be on even for 24 hours without assessing it. I try to look at the wound. The wound needs air." When asked why, at no time during Resident #3's stay, ASM #3 did not take the Unna boot and dressing off to assess Resident #3's wound, ASM #3 stated, "He was not going to let me very easily." On 8/21/13 at 3:25 p.m., ASM #2, the acting director of nursing, was interviewed. ASM #2 stated, "He was admitted from home, I think on the first. At some point, I became aware that he was a wound care clinic patient." ASM #2 stated, "Somebody told me, but I don't remember. I just remember calling the wound clinic on that Friday (8/9/13) to ask about his leg. I asked specifics about his wound. The nurse at the wound clinic provided me with the information. He (wound clinic nurse) told me that the resident had an appointment the previous Wednesday and that they (Resident #3 and his wife) called and cancelled the appointment because they could not get transportation. I told the wound clinic nurse that I would make another appointment for them. The clinic nurse gave me the treatment orders and measurements. He said the wound was 28 by 30 (centimeters). He said it was a venous stasis ulcer, and that it had a lot of drainage, and that the treatment order was Calcium alginate and an Unna boot. He said that Calcium alginate and an ace wrap would be all right. I made the appointment and put the note in and told the wound nurse. I told her that we needed the Calcium alginate and she said we didn't have it. So I asked her to call and get an order for [REDACTED].#2 was aware that the wound clinic would not be open on Saturday for order clarification, ASM #2 stated, "I meant I wanted her to call his attending physician - not the wound clinic. I thought it had been taken care of. Then the call or text came on Sunday. I called the building and talked to the nursing supervisor. She told me they had taken the Unna boot down and there was something in there like maggots. I asked if they cleaned it, and the supervisor said yes. She said they were calling the doctor and asking for an order to transport the resident to the ER. I asked about his clinical status. They told me he was stable, and they had cleaned it and wrapped it up. Later, they called me and told me that he had finally gone to the hospital." ASM #1, the facility administrator, and ASM #2 were made aware of the findings regarding Resident #3 on 8/21/13 at 3:40 p.m. On 8/22/13 at 9:45 a.m., ASM #1 and ASM #2 requested to speak with the survey team. ASM #1 stated, "We take this very seriously. We are trying to institute culture change and professional standards changes here. We have to look at what systems failed. Last week, we started with the re-education of our nurses regarding admissions because we noticed that we had missed some things." When asked what specifically triggered this re-education effort, ASM #1 stated, "Resident #3's chart." ASM #1 handed the surveyor a copy of the email from Resident #3's wife sent prior to admission to Resident #3's primary care clinic. ASM #1 stated, "See, our nurse practitioner wrote on this. She ordered the lab tests. She read the email and ordered the tests, so we knew about the wounds." ASM #1 also gave the surveyor a copy of the facility admitting history and physical, signed by the nurse practitioner. ASM #1 sated, "See, she (the nurse practitioner) noted that he has the slow-healing wounds and sores. And we have done some resea

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide services to ensure one of eight residents in the survey sample, Resident #3, was free from negligence in regards to care of a left leg venous stasis ulcer. The facility staff neglected to assess, document and provide the necessary care for Resident #3's left leg venous stasis ulcer. Resident # 3 was admitted on [DATE], and his leg wound was not assessed and treatment was not performed until 8/11/13, at which time multiple open areas were observed with foul smelling green drainage and maggots in the wound bed. Resident # 3 was transferred and admitted to a local hospital for treatment. The findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 3's admission MDS (Minimum Data Set) with assessment reference date (ARD) of 8/11/13, coded the residents daily cognitive decision making skills as modified independence (some difficulty in new situations only). Resident #3 was coded as requiring limited staff assistance for bed mobility, transfers and dressing; requiring staff supervision for moving around the unit and eating; and requiring extensive staff assistance for toileting, personal hygiene; and being totally dependent for bathing. Resident #3's physician order [REDACTED].# 3's left venous stasis ulcer or any orders for a wound clinic consultation/appointment. A review of Resident #3's clinical revealed a listing of all orders written for Resident #3 during the time period 8/1/13 through 8/11/13, including discontinued and completed orders. This comprehensive list contained no mention of wound care until 8/11/13. A review of the Admission Nursing Assessment for Resident #3 revealed in the, "Signature/Title" box, the signature of LPN (licensed practical nurse) #9. In the "Sections Completed" box, the letter "B" was documented and in the "Date" box, was " 8/1/13." Section B, entitled: "Skin Conditions" revealed drawings of a human body with room for labels words, and letters to describe the skin of the assessed patient. On the drawing labeled "Anterior," (front view), a line was drawn horizontally at the knee. Underneath the line was drawn an "X" over the lower right leg. Also on the drawing, the left leg was labeled with a dot just above the left knee. Beside the dot, the word "Reddened" was written to indicate a red area just above the left knee. No other notations, drawings or other markings were present on the legs of the "Anterior" view or on any of the other body views in Section B of the admission nursing assessment. A review of Resident #3's progress notes revealed an admission note, dated 8/1/13 at 11:02 p.m., and signed by LPN #1 that documented in part the following: "Resident was admitted to the facility accompanied by family via wheelchair @ (at) 1:36 p (sic) (p.m.) under the services of (ASM (administrative staff member) #3, the facility medical director and Resident #3's attending physician). He is ... alert and oriented 70 yo (year old) male with an hx (history) of diabetes mellitus 2 (type 2). Residents (sic) speech is unclear due to being deaf but is able to write down what he needs so as to be easily understood. Resident is a right below knee [MEDICAL CONDITION]. Skin is noted to be warm, dry and intact with the presence of a scar on his chest. He also has a reddened area on his left knee. Resident is pleasant and cooperative with staff .... " This note contained no mention of a wound, dressing or device on Resident #3's left leg. A review of Resident #3's clinical record revealed a tabbed section entitled, "Admission" which contained an email, dated 7/8/13, from Resident #3's wife to Resident #3's primary care clinic staff. In the email, Resident #3's wife listed Resident #3's medications and stated, "Hope it will help and (Resident #3) has bad sores on his leg and my friend will call the wound clinic tomorrow." The email contained an undated hand-written notation on the right side as follows: "Check CBC/CMP (complete blood count, complete metabolic panel - blood tests) in AM (morning)." The notation was signed by ASM (Administrative Staff Member) #4, the nurse practitioner for Resident #3's attending facility physician. The facility admitting history and physical for Resident #3 signed by ASM #4 and dated 8/2/13 at 12:10 p.m. contained the following documentation: "History of Present Illness: 2. Diabetes: Associated symptoms include: blurred vision, hypoglycemic (low blood sugar) episodes - confusion and shakiness, slow healing wounds/sores and weight gain. Review of Symptoms: Dermatologic (skin) - Slow healing wounds/sores. Physical Exam: Skin - Normal - Inspection - Normal. Palpation/texture - Normal. Nails - Normal. Hair - Normal. Extremity - [MEDICAL CONDITION] (swelling) - Location: leg. Side: left. Severity: 4+, Type: non-pitting. Amputation - R AKA (right, above knee amputation). Assessment/Plan: "Continue using compression wrap on left lower extremity to help manage [MEDICAL CONDITION]." This section contained no mention of or plan of care for a wound on Resident #3's left leg. Resident #3's clinical record contained a document entitled, "Resident Discharge Plan," dated 8/2/13. The blank beside the phrase, "Community Services prior to admission," contained the following documentation: "Home Health (initials of the local hospital) for wound (name of Resident #3)." A review of Resident #3's care plan, with effective date 8/4/13, revealed no mention of or interventions for a wound on Resident #3's left leg until 8/11/13. A review of Resident #3's weekly skin assessment dated [DATE] and unsigned revealed no drawing or mention of a wound, dressing or appliance on Resident #3's left leg. A progress note dated 8/7/13 at 2:21 p.m. signed by LPN #6, documented, "Resident's wife gave this writer appointments that had been previously scheduled and transportation forms completed." Review of the clinical record failed to reveal any documentation or evidence of a wound clinic appointment. A review of Resident #3's bathing record revealed that Resident #3 was bathed with assistance of a staff CNA (certified nursing assistant) on the following days: 8/1/13 (CNA #4), 8/3/13 (CNA #1), 8/6/13 (CNA #3), 8/7/13 (CNA #5), 8/9/13 (CNAs # 2, 4, 6) and 8/10/13 (CNA #6). Review of a wound care progress note for Resident #3 from the local hospital's wound care center, dated 7/10/13, revealed the following: "Left lower leg ulceration measures 28 X 30 cm (centimeters) with yellow slough (dead tissue). There is a large amount of serosanguinous (blood mixed with light-color drainage) drainage noted with surrounding [DIAGNOSES REDACTED] (redness). There is +2 [MEDICAL CONDITION] noted to the lower leg. There is about 30% granular (healthy) tissue and 70% necrotic (dead) tissue." The note continues: "Assessment: *Venous stasis ulceration and **[MEDICAL CONDITION]. ***Calcium alginate and an Unna boot (a zinc oxide-impregnated bandage (1)) was applied to the left leg." Attached to the progress notes were photographs of Resident #3's left leg wound (taken on the day of the 7/10/13 visit). A review of a document from the local hospital's home care services entitled, "Documentation of Face-to-Face Encounter" regarding the need for Resident #3 to be the recipient of home health services revealed the following documentation: "The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care: (letter "L" with a circle around it, meaning left) leg venous stasis ulcers. My clinical findings support the need for the above skilled qualifying services because: Unna boot needs changed weekly to heal the ulcers." The unreadable signature was dated 7/10/13. A review of the nursing facility progress notes for Resident #3 revealed no mention of a left leg wound, left leg dressing or appliance, or of a wound care clinic consultation appointment for Resident #3 from 8/1/13 through 8/8/13. A progress note dated 8/9/13 and signed by ASM #2, the director of nursing, stated: "(Resident #3) has been seen prior to admission by (name and phone number of Resident #3's wound care clinic) and an appointment has been arranged for Wednesday, Aug. 14 at 1pm. (sic) Will speak with family regarding transportation needs. Course of treatment for [REDACTED]." Further review of the nursing facility progress notes for Resident #3 revealed the following entries, dated 8/11/13: - 9:48 a.m. signed by LPN #4: "Odor noted from left lower leg. Dressing removed, something resemblying (sic) maggots noted coming from wound. Nursing supervisor notified." - 11:00 a.m. signed by LPN #2: "Situation: Was notified by treatment Nurse, that orders for stasis ulcers of left lower extremity needed orders clarified, as Resident had wound clinic appt (appointment) last week, that family was to transport and could not make the appt. Wound clinic had applied Unna boot on appt prior to admission. Resident has appt rescheduled for upcoming week. Wound clinic was not open to clarify orders for wound until upcoming appt. In to assess wound with treatment Nurse, Unna boot was removed, and noted foul smelling green drainage, with multiple open areas and maggots in bed of wound. Area was immediately cleansed and soaked in Warm H2O (water), call placed to (ASM #3 the attending physician/facility medical director). Background: History of diabetes, right lower leg amputation, stasis ulcers of left lower extremity, that were being treated by wound clinic. Assessment: Foul smelling wound, with green drainage, multiple open areas left lower extremity, maggots are present in wound bed, skin is warm and surrounding tissue is discolored dusky, and purple, pedal pulse is present but faint, +2+3 [MEDICAL CONDITION] present. VS (vital signs) 131/86 (blood pressure), 78 (heart rate per minute), 22 (breaths per minute), 98.9 (temperature). Response: (ASM #3) was notified, and order obtained to send to ER for evaluation. Residents (sic) RP (responsible party) and Resident were notified. (name of ambulance service) arrived at approx (approximately) 10 a.m. Was called to room by Charge Nurse, she stated that Resident was refusing to go to the hospital. I wrote out on notepad to Resident the importance of going to hospital for evaluation, and that there may be a possible infection present that would lead [MEDICAL CONDITION] (infection in the blood), and other possible serious health issues. Resident nodded that he understood, but continued to Refuse (sic) to go. (name of ambulance service) transporters stated that he had a right to refuse and that that (sic) they could not transport. Transporters left and (ASM #3) was notified. He stated that we should call RP back and ask them to come in and talk to Resident about going to the hospital, and to express the importance to Son/RP. Message left for RP to call facility back as soon as possible, that Resident was refusing hospital transport. Treatment orders obtained from (ASM #3). (ASM #3) stated he would not give phone order for oral ABT's (antibiotics) as this would not be helpful. Resident needed to be admitted to hospital. Will continue to encourage Resident to go to hospital for eval (evaluation). Awaiting call back from Son, call placed to daughter earlier, with 0 (no) call back at this time." - 3:16 p.m. signed by LPN #2: "Resident agreed to transport to hospital, after wife returned from Church. (name of ambulance service) arrived and Resident transported, report called to ER (emergency room ) nurse (name of ER nurse) at 3pm." - 3:38 p.m. signed by LPN #3: "Late entry for 7-3 (first shift) on 8/10/13. Resident refused to allow skin assessment despite encouragement. Resident stated that he did not want it. Message given to wound nurse on 8/10/13 to call (phone number of wound clinic) regarding a change in treatment to ulcer on left leg. Wound nurse stated she would follow up." A verbal order unsigned by the physician for Resident #3 dated 8/11/13 documented: "Clean left lower leg with normal (sic). apply (sic) moist saline dressing to open areas and cover with kling (gauze bandage) BID (twice a day) until seen by wound clinic." A review of local hospital's emergency room physician report for Resident #3, dated 8/11/13, revealed the following: "Extremities: R AKA (right above knee amputation), left lower leg and foot have [MEDICAL CONDITIONS] (infection of the skin), and 2nd-4th toes are turning black at the tips. Leg has a foul odor." Review of the local hospital's admitting history and physical for Resident #3, dated 8/11/13, revealed the following: "Chief complaint: Left lower extremity redness and swelling. Skin: The patient has [DIAGNOSES REDACTED]tous (red) rash, swelling of left lower extremity with necrotic ulcers. Clinical impression: admitted . [MEDICAL CONDITION] of the left leg, left ankle, left foot and left toe(s)." In an interview on 8/21/13 at 8:30 a.m., OSM #5, an RN (registered nurse) and the clinical coordinator at the wound care clinic where Resident #3 was seen on 7/10/13, was asked about Resident #3's left leg wound and dressings. OSM #5 stated, "We put calcium alginate on there. Then an Unna boot, then a gauze wrap. Then he was to have home health come in to change the dressing. We wanted him to follow up with us in three weeks. Until then, he was to elevate his foot as much as possible." When asked how often the calcium alginate dressing and Unna boot dressings were to be changed, OSM #5 stated, "At least every week. More often if possible." When asked if, to his knowledge, anyone from the nursing facility had contacted the wound care center to inquire about Resident #3's orders or follow-up consults, OSM #5 stated, "No, we had not heard anything from them. And then we learned that (Resident #3) was in the hospital for it (the wound)." On 8/21/13 at 1:30 p.m., 1:35 p.m., 1:40 p.m., 2:15 p.m., and 2:45 p.m., CNA #2, CNA #6, CNA #1, CNA #3 and CNA #7 were interviewed about bathing Resident #3 on 8/3/13, 8/6/13, 8/7/13, 8/9/13, and 8/10/13. All CNAs when asked what they remembered about Resident # 3, stated one leg was amputated. One CNA stated they could not remember an issue with the other leg; the others stated there was a boot with sock, cast or soft material on his left leg or good leg. CNA #7 stated, "His wife wrote a note that the dressing could not get wet." On 8/21/13 at 11:05 a.m., an interview was conducted with LPN #4; the weekend wound nurse who first removed Resident #3's left leg dressing on 8/11/13. LPN #4 stated, "I went in to do a treatment on his arm because he had a skin tear on it. And he had an odor coming from his leg. He had a black kind of brace or boot on, and a black sock. I took those off and then I saw the Unna boot. I went to get the nursing supervisor. I showed her the Unna boot and the open areas he also had on his toes. I went to look for the orders for his leg, but we didn't have any. We did not have an order for [REDACTED]. " LPN further stated, "His wife did not want us to remove the dressing, but we told her that we had to look at it because of the terrible odor. So we took off the dressing. It smelled infected. I saw worm-like maggots in it. There were maggots on top of the foot and at the place where the Unna boot had been, and then all throughout his leg. I could see them moving around." When asked what the rest of Resident #3's left leg looked like, LPN #4 stated, "The rest of the leg was really, really dry. And red." When asked if LPN #4 recognized what the Unna boot was when she initially saw it, LPN #4 stated, "No, I didn't. I had never seen one before." When asked how she became informed about the Unna boot, LPN #4 stated, "Somebody told me since then that it was one. I really didn't know." When asked if LPN #4 was given any information regarding Resident #3 by the off-going nurse at the beginning of the shift, LPN #4 stated, "I knew that the Friday night nurse had left a note for the next nurse to call the wound clinic about him. The supervisor handed me the note on Saturday to call the wound clinic for a replacement for the Calcium alginate order because we didn't have any of that (Calcium alginate)." When asked what she did when she observed the maggots on the resident's legs and toes, LPN #4 stated, "I rinsed it off. The wife wouldn't let us get rid of the boot, so I double bagged it in a trash bag. It was so nasty. The supervisor called and got an order. I think it was for a wet to moist dressing and then wrap until the patient could get to the hospital." When asked what LPN #4's action would have been if she had admitted a resident with the Unna boot and underlying dressing, LPN #4 stated, "I would definitely have documented that there was something there, even if I didn't exactly know what it was. I would have gotten an order to treat it. I would have asked the nurse practitioner for the order. I think she is here all week. It is easy to get orders that way." In an interview on 8/21/13 at 11:55 a.m., LPN #3, who was Resident #3's assigned nurse on 8/11/13, LPN #3 stated: "I am only prn (as-needed). I did not know about his legs. I got in report from the Friday night nurse that they wanted the wound nurse to call and see if the dressing could get changed. I remember that on Saturday, I had given that number to the wound nurse. I don't think she (weekend wound nurse) was aware that (Resident #3) had a wound. I remember that he refused a skin assessment on one of those days - either Saturday or Sunday. I think the night nurse said they wanted to change the treatment from what was currently ordered. I didn't see any documentation regarding the leg wound. I went in to try to assess the wound on Saturday. He refused the skin assessment." And then on Sunday, I remember that we had a hard time convincing him to go to the hospital, too. I remember on Saturday, I asked the wound nurse what treatments she did and if I needed to do anything for the wound. The wound nurse said, 'I do all of them. I do all the treatments.' I remember that I looked on the MAR and the TAR, but there was nothing there about the wounds." In an interview on 8/21/13 at 12:30 p.m., LPN #1, the nurse who wrote the admitting progress note for Resident #3 on 8/1/13, LPN #1 stated: "The assessment was pretty much done when I got there, except for the skin part. (LPN #9) was working that night, and she offered to do the skin part of that assessment. She came to me and told me that he had refused to have his bandage taken off his leg. I went in later to look at his leg, but he refused." When asked if the presence of a wound and a resident's refusal of assessment of the wound are important to document, LPN #1 stated, "Yes." LPN #1 was shown the admission note she had written on 8/1/13 for Resident #3. When asked if the note included any information about the resident's left leg or about Resident #3's refusal of an assessment of the left leg, LPN #1 stated, "No, I didn't put it in there." When asked if, once she found out that Resident #3 had a dressing/wound on his left leg, did she make any attempt to find out the reason and care needed for the left leg dressing, LPN #1 stated, "No, I didn't. It was a really busy evening." In an interview on 8/21/13, LPN #6 was shown the note she had written on 8/7/13 about scheduling transportation for Resident #3. LPN #6 stated, "I remember that it was with the endocrinologist, the cardiologist, and, I think, the eye doctor. I talked to his wife, and she gave me a list. Then she came to me later and said that (Resident #3) was supposed to go to the wound clinic. Then she came back later and said they needed to change the date. I told the wife that she should have given me the appointment slips when they first got here." When asked the responsibility the facility has regarding residents' outside appointments, LPN #6 stated, "They have to work through us. We have to know what is going on. I remember asking the wife who was going to transport them to the wound clinic and (Resident #3's wife) pointed and said, "Here." But then when she came back later, she gave me a note and said the wound clinic had cancelled." When asked if she took any action after learning this information, LPN #6 stated, "I said something to the wound nurse - (RN (registered nurse) #1, the weekday wound nurse) - she was the wound nurse that day. I asked (RN # 1) to go in to see the resident and she did." When asked what is the facility practice regarding assessments at the time residents are admitted to the facility, LPN #6 stated, "The policy is when anyone comes in, whoever is admitting the resident that day - whatever nurse it is - they are responsible for the head to toe assessment and for trying to get the information about the appointments." In an interview on 8/21/13 at 2:20 p.m., with RN #1, when asked if LPN #6 had ever asked RN #1 to go into Resident #3's room and assess his wound, RN #1 stated, "No. No nurse ever asked me to go in his room and look at the wound. I never saw it." In an interview on 8/21/13 at 2:25 p.m., LPN #2 stated, "I remember that he came and the nurse practitioner talked to family members and got the orders. I don't remember scheduling anything with the wound clinic." When asked about the events of 8/11/13, LPN #2 stated, "I think the nurse met me in the hall and said that there was a wound and that the doctor needed to be called. The nurse said something like, 'He has a wound on his leg and we need a treatment order.' She started cutting the bandage, and I saw the drainage immediately. It was dark green and it smelled so awful. There were maggots in the wound bed. They were moving around." When asked if LPN #2 was aware, until that moment, that Resident #3 had a wound on his left leg, LPN #2 stated, "No." When asked what the current order was when LPN #2 checked the orders, LPN #2 stated, "There were no orders." When asked about the progress note LPN #2 wrote at 11:00 a.m. on 8/11/13, LPN #2 stated, "I had talked to (ASM #2, the director of nursing) on the phone that morning and she told me that the family had told her the resident had missed a wound clinic appointment and that it was being rescheduled." LPN #2 stated, "(ASM #3 the facility medical director) told me that we had to call the family and convince the resident to go. The doctor told me he was not going to give any orders for antibiotics because the resident needed to go to the hospital and that we had to find a way to convince the resident to go. Finally, when the wife got home from church, she was able to convince (Resident #3) to go (to the hospital)." On 8/21/13 at 2:50 p.m., LPN #5 was interviewed regarding Resident #3's care. LPN #5 stated that she had been Resident #3's assigned nurse two times during his stay. LPN #5 stated, "I knew he had a healed amputation. I knew he had the boot, but nobody ever gave me any reason to investigate his leg. I know hindsight is always the best. I did wound care during the week before (Resident #3) went in to the hospital. I was the wound nurse. I remember the unit manager came up to me to start to say something about him, but I got called away. Later that night - maybe it was that Friday night before he went to the hospital, the DON called me and asked if the unit manager had talked to me. I said that I had to leave before the unit manager could tell me anything. The DON said that the wound center had been called and that they said he needed Calcium alginate for his wound. I remember being stunned to find out he even had a wound. If I had known it, I would have looked at it. I was the wound nurse a few days that week. I told the DON we didn't even have that dressing. And we didn't even have any Unna boots either. I remember the (ASM #2 DON) said for me not to worry about it - that she needed to call the wound center again and she would get back to me. The DON did not get back to me so I had to call her at home that night. She told me again not to do anything - to just put it on the 24-hour report for the night nurse to pass on for the Saturday nurse to call the wound clinic. I remember telling the DON that I thought the wound center would be closed on Saturday. The DON told me that it was okay - to just put it on the 24 hour report and she would follow up on Saturday. So I passed it to the night nurse. Then, they called me on Sunday, and I was like, 'Nobody followed up yesterday? That wound needs to be seen now." On 8/21/13 at 3:05 p.m., LPN #9, the nurse who signed off on the skin assessment portion of Resident #3's admission assessment, was interviewed. LPN #9 stated, "I just helped with the admission. I just did his skin assessment." When asked about Resident #3's legs, LPN #9 stated, "The biggest thing was a boot on the left leg. I would not take it off because they said it had just been changed." When asked who 'they' referred to, LPN #9 stated, "The resident and the wife." LPN #9 stated, "I asked the wife if there was an open wound, and she told me that it was just wet." LPN #9 stated, "Well, I wasn't sure. I asked his nurse to follow up on that boot. I wasn't sure what was under there." On 8/21/13 at 2:15 p.m., OSM (other staff member) #4, the facility admissions director, was interviewed about Resident #3's wound care needs. OSM #4 stated, "Unless there is a care need I can't meet, I bend over backwards to bring the resident in. I know the wound doctor was involved. I did not know to what extent. He had an appointment on 8/7/13 at the wound clinic. I think the POA (power of attorney) was arranging for transportation because (Resident #3) did not have Medicaid. He did not go to the 8/7/13 wound clinic appointment. The transportation did not come get him." When asked if OSM #4 notified the nursing staff about the 8/7/13 appointment or that the resident missed the 8/7/13 appointment, OSM #4 stated, "I felt it was not an issue because we have a wound nurse here." On 8/21/13, ASM #3 (medical director) was interviewed about Resident #3. ASM #3 stated that he was aware of Resident #3's multiple medical issues. ASM #3 stated, "I am also aware that (Resident #3) is passive and has been resistant to our efforts to assess the leg wound. You know we can't force treatment on him." When ASM #3 was asked about the events of 8/11/13, ASM #3 stated, "I think I saw (Resident #3) the night before. That night, I saw the resident, and the staff had no concerns about him. I noticed his wound dressing that night. (Resident #3)'s wife stated that her husband sees the wound clinic. Well, it turns out that they (Resident #3 and his wife) had re-scheduled the wound clinic appointment." When asked when ASM #3 became aware of the wound clinic appointment scheduled for Resident #3, ASM #3 stated, "Well, I know if he had not had some outside wound care, we would have had the resident see the wound physician who comes to the facility." ASM #3 stated, "I remember thinking, when I got the call, 'Wow that was pretty quick.' There wasn't an odor on Saturday. (Resident #3) had some [MEDICAL CONDITION] in his left leg, some mild [DIAGNOSES REDACTED] around the dressing. We called the son because the wife had been distraught about (Resident #3) going to the hospital. I remember I thought, 'Oh man, this is gangrene.' I feel sure (Resident #3) knew what was happening." When asked if ASM #3 was aware of Resident #3's wound, dressing and Unna boot at the time Resident #3 was assessed at facility admission, ASM #3 stated, "Well, I was aware of the Unna boot. Our efforts to take it off were resisted by the resident." When asked if ASM #3 knew how long the dressing and Unna boot had been applied to Resident #3's leg at the time of admission to the facility or at any point during Resident #3's stay, ASM #3 stated, "No, I didn't. I didn't know for sure. We assumed that it hadn't been on that long." When asked what ASM #3 considered to be standard practice for dressing and Unna boot changes, ASM #3 stated, "I don't like an Unna boot to be on even for 24 hours without assessing it. I try to look at the wound. The wound needs air." When asked why, at no time during Resident #3's stay, ASM #3 did not take the Unna boot and dressing off to assess Resident #3's wound, ASM #3 stated, "He was not going to let me very easily." On 8/21/13 at 3:25 p.m., ASM #2, the acting director of nursing, was interviewed. ASM #2 stated, "He was admitted from home, I think on the first. At some point, I became aware that he was a wound care clinic patient." ASM #2 stated, "Somebody told me, but I don't remember. I just remember calling the wound clinic on that Friday (8/9/13) to ask about his leg. I asked specifics about his wound. The nurse at the wound clinic provided me with the information. He (wound clinic nurse) told me that the resident had an appointment the previous Wednesday and that they (Resident #3 and his wife) called and cancelled the appointment because they could not get transportation. I told the wound clinic nurse that I would make another appointment for them. The clinic nurse gave me the treatment orders and measurements. He said the wound was 28 by 30 (centimeters). He said it was a venous stasis ulcer, and that it had a lot of drainage, and that the treatment order was Calcium alginate and an Unna boot. He said that Calcium alginate and an ace wrap would be all right. I made the appointment and put the note in and told the wound nurse. I told her that we needed the Calcium alginate and she said we didn't have it. So I asked her to call and get an order for [REDACTED].#2 was aware that the wound clinic would not be open on Saturday for order clarification, ASM #2 stated, "I meant I wanted her to call his attending physician - not the wound clinic. I thought it had been taken care of. Then the call or text came on Sunday. I called the building and talked to the nursing supervisor. She told me they had taken the Unna boot down and there was something in there like maggots. I asked if they cleaned it, and the supervisor said yes. She said they were calling the doctor and asking for an order to transport the resident to the ER. I asked about his clinical status. They told me he was stable, and they had cleaned it and wrapped it up. Later, they called me and told me that he had finally gone to the hospital." ASM #1, the facility administrator, and ASM #2 were made aware of the findings regarding Resident #3 on 8/21/13 at 3:40 p.m. On 8/22/13 at 9:45 a.m., ASM #1 and ASM #2 requested to speak with the survey team. ASM #1 stated, "We take this very seriously. We are trying to institute culture change and professional standards changes here. We have to look at what systems failed. Last week, we started with the re-education of our nurses regarding admissions because we noticed that we had missed some things." When asked what specifically triggered this re-education effort, ASM #1 stated, "Resident #3's chart." ASM #1 handed the surveyor a copy of the email from Resident #3's wife sent prior to admission to Resident #3's primary care clinic. ASM #1 stated, "See, our nurse practitioner wrote on this. She ordered the lab tests. She read the email and ordered the tests, so we knew about the wounds." ASM #1 also gave the surveyor a copy of the facility admitting history and physical, signed by the nurse practitioner. ASM #1 sated, "See, she (the nurse practitioner) noted that he has the slow-healing wounds and sores. And we have done some research

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to assess and implement interventions to prevent the development and promote healing of pressure sores and failed to re-evaluate treatment to prevent the development of additional pressure ulcers for two (2) of 36 residents in the survey sample, Residents # 3, and # 35. 1. For Resident # 3 who was admitted to the facility with a pressure wound (acquired in the hospital) DTI (deep tissue injury) located on the left inner heel, the facility staff failed to ensure pressure reliving positioning interventions were consistently and properly implemented and failed to evaluate, revise and implement new interventions to relive pressure and prevent further development of pressure sores. As a result of this failure Resident # 3 developed 3 additional DTIs, 2, stage II pressure sores and one stage I pressure sore. At the time of the survey the following 2 acquired pressure sores had not resolved: Right lateral ankle found as an unstagable DTI on 6/6/12 and Right hallux found as a stage II on 7/10/12. 2. a. The facility staff failed to ensure prevention, assessment, and treatment for [REDACTED]. Resident # 35 had physicians order for daily treatment to the second toe of the left foot, which was documented as being completed by staff. On 7/17/12 during an observation of Resident # 35's left foot the following pressure sores were observed and identified: an unstable DTI (deep tissue injury) was on the left lateral foot proximal; a second DTI closer to the fifth toe and an unsatagble eschar on the third toe of the left foot. The facility staff had not identified, assessed, measured or treated or the pressure sores on Resident # 35's left foot. b. Failed to identify and treat a pressure ulcer before it was observed at a stage III pressure ulcer on Resident # 35's mid sacral area and failed to do weekly skin assessments. A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Page 155. According to National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages: Suspected Deep Tissue Injury: 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. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. NPUAP defines pressure ulcer stages as follows: "Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: 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. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: 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." The findings included: 1. For Resident # 3 who was admitted to the facility with a pressure wound (acquired in the hospital) DTI (deep tissue injury) located on the left inner heel, the facility staff failed to ensure pressure reliving positioning interventions were consistently and properly implemented and failed to evaluate, revise and implement new interventions to relive pressure and prevent further development of pressure sores. As a result of this failure Resident # 3 developed 3 additional DTIs, 2, stage II pressure sores and one stage I pressure sore. At the time of the survey the following 2 acquired pressure sores had not resolved: Right lateral ankle found as an unstagable DTI on 6/6/12 and Right hallux found as a stage II on 7/10/12. Resident # 3 was admitted to the facility on [DATE] and again on 5/2/12 with [DIAGNOSES REDACTED]. Review of Resident # 3's MDS (minimum data set), a 60 day Assessment with an ARD (assessment reference date) of 6/27/12 coded Resident # 3 for Cognitive Skills for Daily Decision Making as Severely impaired. Resident # 3 was also coded as having short-term and long-term memory problems. Further review of this MDS assessment revealed that in Section G Functional status Resident # 3 was coded as being totally dependent with support of two for bed mobility, dressing, toileting, and personal hygiene. The resident was coded as requiring extensive assistance of one staff member for moving on the unit and off the unit and eating. The resident was coded as being totally dependent of two staff members for transfers from one surface to another, such as wheelchair to bed, and bathing. Resident # 3 was coded as having functional limitation of both lower extremities. Section H coded the resident as being always incontinent of bowel. Section M - Skin Conditions coded the resident as being at risk for developing pressure ulcers. Section M0210 coded the resident as having one or more pressure ulcers. Review of Section M0300 revealed the current number of unhealed pressure ulcers: 1 Stage I, 1 stage III, and 2 Unstageable-Deep Tissue. Review of Resident # 3's Significant change/readmission MDS with an ARD of 5/9/12 revealed for Section M Skin Conditions under M0150 coded "Yes" for "Is resident at risk for developing pressure ulcers." M0210 coded the resident as having one or more pressure ulcers. M0300 One unstageable - deep tissue that was present on admission. Review of Resident # 3's clinical record revealed that the Resident was admitted on [DATE] with a pressure wound (acquired in the hospital) this wound was located on the left inner heel and on admission it measured 2 x2. 5 cm and was determined to be a DTI (deep tissue injury). Further review of Resident # 3's clinical record revealed that the following wounds were discovered and classified as acquired wounds, meaning that they occurred while the Resident was in the nursing home: ? 6/6/12 - Right lateral ankle identified as a DTI measuring 3 cm (centimeters) long x 3 cm wide when found and not resolved. ? 6/6/12 - Right lateral distal foot identified as a DTI measuring 1 cm long x 0.7 cm wide when found and resolved 7/2/12. ? 6/10/12 - Coccyx identified as a stage II measuring 2 cm long x 0.8 cm wide x 0.2 cm deep when found and resolved 6/18/12. ? 6/13/12 - Right lateral heel identified as a DTI measuring 1.7 cm x 0.3 cm wide when found and resolved 7/5/12. ? 6/13/12 - Left hallux identified as a stage I measuring 1 cm long x 2 cm wide when found and resolved 7/5/12. ? 7/10/12 - Right hallux identified as a stage II measuring 1 cm long x 0.5 cm wide when found and not resolved. The human hallux is commonly called the big toe. This information was obtained from the website: <http://encyclopedia2.thefreedictionary.com/hallux> Measurements for the wounds that did not resolve according the documentation on the Wound Evaluation Flow Sheets were in part as follows: Right lateral ankle identified as a DTI: ? The day it was found- "6/6/12 -- DTI -- 3 x 3 cm 100% red/purple, exudate = none, peri wound =intact, treatment [MEDICATION NAME] film/spray. [MEDICATION NAME] form adhesive, heel lift wedge (6/6/12). " ? The last documented measurement- "7/9/12 UTS (unable to stage)-- 2 x 0.6 x 0.1, yellow - moderate thin, 100 % necrosis, periwound intact Tx Santyl oint, (ointment) moist gauze, Kling QD (7/5/12). " *Cellerate Rx is an activated collagen gel used to promote wound healing. Right hallux identified as a stage II on 7/10/12 - most recent measurement 1 x 0.5 cm At the time of the wound care observation on 7/12/12 at 8:08 a.m. the approximate size of the two wounds that had not resolved were as follows: ? Right lateral ankle- approximately 2 cm long x .5 cm wide ? Right hallux - approximately 1.2 cm long x .5 cm wide Observation was made of Resident # 3 on 7/12/12 at 8:08 a.m. accompanied by LPN (licensed practical nurse) # 6, the wound nurse. This wound observation revealed the wound to the right inner aspect hallux was a blister that LPN # 6 identified as "getting better." The wound to the right lateral ankle was observed to have necrosis in center of wound with yellow white necrosis that came out when the wound was cleansed. The right lateral ankle area was surrounded with pink healed tissues and outside of that area the tissue was dark. Wound care provided was observed as ordered by the physician. Physician telephone orders were reviewed and a signed order dated 7/5/12 documented: "Cleanse right lateral ankle w/NS, apply Santyl*oint. (Ointment) To wound, cover w/wet moist gauze, wrap w/Kling QD." The right hallux wound identified on 7/10/12 was also observed as a red fluid filled blister and LPN # 6 noted that it was "getting better." To the right hallux wound [MEDICATION NAME] protective barrier film/spray was applied in accordance with the physician order dated 7/10/12, "[MEDICATION NAME] protective barrier film/spray to right hallux blister Q shift." The Prevalon** boots ordered on [DATE] were observed to be in place. * According to Lexi-Comp's Drug Reference Handbooks: Drug Information Handbook for Nursing: 8th Edition 2007 pg. 301 "Santyl Enzyme topical debridement. Use- Promotes debridement of necrotic tissue in dermal ulcers..." **A pressure relieving heel protector boot. Resident # 3 was again observed on 7/17/12 at 9:30 a.m. accompanied by LPN # 6. The resident was positioned on her right side and all positioning devices were in place to include knee abductor wedge, pillows and wedge to back, and prevalon boots. An observation was made at this time to confirm areas identified as being resolved were resolved. These areas included: left inner heel, coccyx, right lateral heel, left hallux and the right lateral distal foot. The currently unresolved wounds were observed during the wound observation on 7/12/12. During an interview on 7/17/12 at 1:30 p.m. with ASM # 1, the administrator, ASM # 2, the DON, OSM # 11, a physical therapy staff member, and two surveyors, Resident # 3's wounds were discussed. OSM # 11 stated that, "(name of Resident # 3) was screened after admission on 5/2/12, all devices were in place and appropriate, positioning was good and I felt confident that all was correct and good. After 30 days there would be a referral to therapy if the wound was not progressing well. But we (therapy department) wait for nursing referral for devices and there was none so I (OSM # 11) felt devices were working." OSM # 11 stated, "I was not aware until yesterday (7/16/12) that the wound had not healed or that there were new wounds and I was called in to make an evaluation (on 7/16/12). Physical therapy started on 7/16/12 and sharps debridement is recommended." OSM # 11 stated, "(Name of wound nurse) felt the devices were working and that she (wound nurse) educated staff on proper placement of devices." OSM # 11 further stated, "(Name of wound nurse) reported that improper placement of (positioning) devices was a concern." ASM # 2, the DON, stated, "(Name of Resident # 3)'s wounds were discussed in risk management." ASM # 2 provided copies of the risk management notes with notations for Resident # 3's wounds and what treatment was in place. During an interview on 7/12/12 at 11:40 a.m. LPN # 6, the wound nurse, stated, "I have found pillows were not placed correctly or not at all. (Name of Resident # 3) is difficult to position she is challenge." LPN # 6 further stated that, "I don't work 24/7 and I can't guarantee that positioning is correct so that is why I went to Prevalon boots. I talk to CNAs randomly about positioning. Have not held a class that is not my responsibility to have classes." When asked about updating the care plan LPN # 6 stated, "The Unit Manager updates the care plan. I'm not responsible to update, the unit manager is to update." The typed up and copied Risk Management meeting notes provided on 7/17/12 at 1:30 p.m. by ASM # 2, the DON were reviewed. The notes revealed a hand written date of 6/18 with the initials of ASM # 2 next to the date. These notes pertained to Resident # 3's Right lateral ankle and right distal foot wounds (two wounds that were facility acquired and found at DTI), and revealed the following documentation, "Heel lift ordered to be placed under bilateral legs to float/elevate lower extrem. (extremities) when in bed but often found in early AM in w/c (wheelchair) beside bed." During the meeting on 7/17/12 at 1:30 p.m. ASM # 2 was asked a second time for any in-service training that was done for the education of staff in regards Resident # 3's positioning. The following is what was provided and left in the Activities Room on 7/17/12 for this surveyor. ? 4/12/12 - this in-service was for Resident # 3's positioning devices and monitoring of skin - review of this revealed that only two CNA signed the sign in sheet as having attended. ? 7/12/12 - this in-service was for all residents and discussed turning and positioning 32 CNA signed the sign in sheets as evidence that they attended. Prior to exit no other documentation was provided as pertains to positioning. During an interview on 7/12/12 at 2:45 p.m. with CNA (certified nurse's assistant) # 2 when asked how she would know how to care for a Resident and what positioning devices were to be used for a Resident, CNA # 2 stated ,"we look at the Kardex (care card). We can just look at it or carry it with us." During an interview on 7/17/12 at 1:30 p.m. with ASM # 1, the administrator, ASM # 2, the DON, OSM # 11 a physical therapy staff member and two surveyor's Resident # 3's nutritional status was discussed. Review of the nutritional notes revealed that Resident # 3 had a peg tube placed recently and that her weight was stable. A note dated 5/23/12 documented, "If continues to gain may need to adjust feeding." Review of recent labs (April 2012) revealed that Resident # 3's [MEDICATION NAME] was within normal limits Review of Progress notes dated 7/13/12 15:25, "New order obtained for Doppler to check out circulation. Doppler done came back negative. (Name of physician) notified and aware. Tried to call RP but not able to get a hold of them. Will let on coming (sic) nurse know." Review of the most recent Physical Therapy Plan of Care dated 7/16/12 provided by OSM # 11, on 7/17/12 at 1:40 p.m. revealed the following: Under "Reason for Referral: ...patient will benefit from skilled PT services to optimize positioning through education and safe positioning to prevent further contracture and skin integrity compromise. Also sharps debridement for removal of necrotic tissue and promotion of wound healing." Review of the physician signed telephone orders revealed the following interventions: ? 5/3/12 Heel lift wedge at foot of bed when resident in bed for pressure reduction to bilateral heels, check placement q shift - D/C 7/10/12 ? 6/11/12 MA-65 low-air loss mattress w/bilateral bed bolsters: maintained on setting # 3 Q shift for pressure reduction to boney prominences. Check for proper setting and bolster positioning Q shift ? 7/10/12 Prevlon boots to bilateral feet at all times when in bed Q shift for pressure reduction to feet, remove for skin inspection and tx Q shift then reapply All these orders were noted on the TAR (treatment administration record) plus the following interventions were noted on the TAR: ? Bed bolster when in bed for safety and positioning. Ordered 5/2/12 ? Ischial step cushion while in w/c foot rest strap/block in place as tolerated -- ordered 5/2/12 ? Repositioned q 2 hours ordered 5/2/12 ? Heel lift wedge at foot of bed when resident in bed for pressure reduction to bilateral heels, check placement q shift ordered 5/3/12 D/C 7/10/12 ? MA-65 low-air loss mattress w/bilateral bed bolsters; ordered 6/11/12 ? Prevlon boots to bilateral feet at all times when in bed Q shift ordered 7/10/12 Review of the TAR revealed that each intervention was noted to have been applied as ordered. No new positioning devices or documentation of evaluation of the ordered positioning devices was evidenced from 5/3/12 until the specialty mattress was ordered on [DATE] and no other evaluation or new positioning devices were noted or evidenced from 5/3/12 until 7/10/12. During this time period, between 6/6/12 to 6/13/12, three DTI were found. During an interview on 7/12/12 at 2:15 p.m. with OSM (other staff member) # 8 a physical therapist it was revealed that for Resident # 3, "We did a screen when she came back (from the hospital on [DATE]) but she had been discharged when she went out for the peg (feeding tube) and we did not pick her back up." The discharge summary, dated 4/11/12 was reviewed with OSM # 8. OSM # 8 stated that the positioning interventions would have been continued even after discharge from physical therapy. The positioning devices that were in place are documented in the next paragraph. Review of the Physical Therapy Notes on positioning for Resident # 3, provided by OSM # 8, a physical therapist, on 7/12/12 at 2:30 p.m. revealed: ? "Dated 4/12/12: Special adaptive equipment (heel floating device, wedge cushion and knee abductor wedge for patient's optimal positioning in lying in bed and sitting in wc (wheelchair) to maintain skin integrity." Review of the TAR (treatment administration record) revealed documentation that positioning devices were being used however documentation in the progress notes and staff interview revealed that they were not. Documentation in Progress Notes dated, "6/13/12 at 9:30 a.m. Upon providing wound care to residents' bilat. (bilateral) Lower extremities a stage 1 area was observed on the left hallux and a DTI to the right lateral heel as well. Heel lift wedge was not in place when resident was approached at start of shift. Wedge placed post wound care. Tx initiated to both new sites ..." Further review of the clinical record revealed an incomplete care plan in regards to skin integrity/pressure sores. Review of the care plan on 7/16/12 at 12:50 p.m. with LPN # 4 revealed a care plan with a focus area for altered skin integrity with an initiated date of 5/10/12 and another with a focus area of Pressure ulcer with an initiated date of 7/10/12. LPN # 4 could find no other care plans related to skin issues located within the clinical record. On 7/17/12 at 1:50 p.m. the rest of the care plan, with an initiated date of 5/10/12 and a print date of 5/10/12, was presented by the DON. When she was asked where it was found she stated it was in medical records department. The DON was asked if this care plan that was in medical records was part of the current active care plan she stated, "Yes." The complete current care plan was not available to facility staff. Review of the complete care plan that was provided on 7/17/12 by ASM # 2, the DON, revealed that the facility staff failed to update the care plan after each pressure area was discovered with the new interventions. Three care plans were presented one "Altered skin integrity: initiated on 5/10/12, a second on "Deep Tissue Injury" initiated on 5/10/12, and the third "Pressure Ulcer" initiated on 7/10/12. There were no notations on any of these care plans identifying the DTIs and pressure areas found 6/6/12 through 6/13/12. There were a total of five areas identified from 6/6/12 through 6/13/12 three DTI two Stage II and one Stage I. A review of the facility policy "Skin Integrity Guideline" that was presented on 7/11/12 at 12:00 noon by the Director of Nurses revealed the following: " Documentation of Weekly Skin Assessments/Observations: ? Determine care plans consistently implemented, evaluated and revised based on the needs of the resident. " During an interview on 7/12/12 at 5:45 p.m. with ASM (administrative staff member) # 2, the DON (director of nurses), and ASM # 5, the corporate nurse, Resident # 3's pressure wounds were discussed and ASM # 2 and # 5 were made aware of the above concerns. During the end of day interview on 7/12/12 at 6:45 p.m. with ASM (administrative staff members) # 1 the administrator, # 2 the DON (director of nurses), # 3 the assistant administrator and # 5 the corporate nurse, Resident # 3's pressure wounds and concerns were again reviewed. According to the U.S. Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guidelines, treatment of [REDACTED]. 95-0652 page 24: The Clinical Practice Guidelines treatment of [REDACTED]. Assessment of pressure sore healing. Progress toward healing should be evaluated weekly. If signs of ulcer deterioration are observed sooner (e.g. during daily dressing changes), steps to reverse them should be taken immediately. 9. Reassessment of Treatment Plan and evaluation of Adherence. If the ulcer is not healing, the clinician must reassess the treatment plan and determine whether it is being followed. In particular the clinician should assess whether tissue load management is adequate and should evaluate the extent of adherence to cleansing and dressing ...Necrotic tissue and or underlying abscessed should be suspected if the ulcer is not healing." 2. a. The facility staff failed to ensure prevention, assessment, and treatment for [REDACTED]. Resident # 35 had physicians order for daily treatment to the second toe of the left foot, which was documented as being completed by staff. On 7/17/12 during an observation of Resident # 35's left foot the following pressure sores were observed and identified: an unstable DTI (deep tissue injury) was on the left lateral foot proximal; a second DTI closer to the fifth toe and an unsatagble eschar on the third toe of the left foot. The facility staff had not identified, assessed, measured or treated or the pressure sores on Resident # 35's left foot. Failed to identify, measure, and treat pressure ulcers on the left foot for Resident # 35. Resident # 35 was admitted to the facility on [DATE] with a recent readmission on 03/13/12 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 06/08/12, coded the resident as usually understanding others, sometimes missing part/intent of the message but comprehends most conversations. He was coded as usually able to make himself understood and his needs known. Resident # 35 was coded as being severely impaired to make cognitive decisions. The resident was coded in Section E as rejecting care one to three days during the assessment period. Resident # 35 was coded as requiring extensive assistance of two staff members for moving in the bed, dressing, toileting, and personal hygiene. The resident was coded as requiring extensive assistance of one staff member for moving on the unit and off the unit and eating. The resident was coded as being totally dependent of two staff members for transfers from one surface to another, such as wheelchair to bed, and bathing. Resident # 35 was coded as having functional limitation of both lower extremities. Section H coded the resident as being frequently incontinent of bladder and always incontinent of bowel. Section M - Skin Conditions coded the resident as being at risk for developing pressure ulcers. Section M0210 coded the resident as not having one or more pressure ulcers. Section M0900 coded the resident as not having any pressure ulcers on the prior assessment. Observation was made of Resident # 35 on 07/17/12 at 2:25 p.m. accompanied by LPN (licensed practical nurse) # 6, the wound nurse. The resident was found lying in his bed on his left side. There were two pillows in the bed, one behind his head and one behind his back. His feet were resting directly on the surface of the bed. The resident had on socks. The resident's feet were observed. The left foot was observed with a dressing on the left heel. The wound nurse removed the dressing and the heel blanched. The left lateral foot proximal area was observed. The area was deep red/purplish in color and did not blanch. The wound nurse stated it was a deep tissue injury (DTI). The area was noted to be 0.3 by 0.7 cm (centimeters). There was a second area closer to the fifth toe that measured, 0.5 by 1.2 cm, again a deep red/purplish area. The wound nurse described it as a DTI. The third toe of the left foot had an area that was black, described by the wound nurse as "eschar"** measuring 0.8 by 0.8cm. The wound nurse was not aware of the left foot proximal area or the third toe. The second toe had a black "scab" on the knuckle of the toe. The wound nurse informed this surveyor that the area on the second toe was a known trauma injury, not pressure. LPN # 6 was asked if she was aware of the two deep tissue injuries and the third toe eschar, LPN # 6 stated, "I wasn't aware of these." When asked for the measurements of these areas, LPN # 6 stated, "I haven't measured them before as I was unaware of these new areas." **Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Review of the clinical record revealed the physician orders dated, 05/21/12 and signed by the physician on 07/04/12. The orders documented, "Apply [MEDICATION NAME]* protective barrier spray file to left 2nd toe affected skin q (every) shift. Allow to dry before covering with sock." An order dated, 07/10/12, documented, "[MEDICATION NAME] No Sting Spray barrier film, every shift; spray left outer foot by fifth toe reddened area q shift." * [MEDICATION NAME] No Sting Barrier Film is an alcohol-free liquid barrier film that dries quickly to form a breathable, transparent coating on the skin. It is designed to protect intact, damaged or 'at-risk' skin from urine, feces, other body fluids, adhesive trauma and friction. It comes in a variety of easy to apply formats: 1ml foam applicator, 3ml foam applicator, 28ml pump spray and a stoma wipe. It lasts for up to 72 hours, and will not sting, even when applied to broken, excoriated skin. Information obtained from the following website: http://solutions.3m.com.au/wps/portal/3M/en_AU/[MEDICATION NAME]/Home/Product_Info/No_Sting Resident # 35's TAR (treatment administration record) documented, "Apply [MEDICATION NAME] protective barrier spray/film to left 2nd toe affected skin q shift, allow to dry before covering with sock. Order date: 05/21/12. Also documented on the TAR, "[MEDICATION NAME] protective barrier spray/film; spray left outer foot by fifth toe reddened area q shift." Documentation revealed treatment was provided as ordered. The "Braden Score" was documented on 03/13/12 as a "10." A score of ten to twelve is "high risk" for developing pressure ulcers. A more current assessment was requested and was not provided by completion of the survey. A nurse's note dated, 07/10/12 at 6:47 a.m., documented, "Skin assessment done, no new areas of concern, complete ADLs (activities of daily living), staff propels W/C (wheelchair) thru facility, eats well, fed self." Review of the nurse's notes revealed a note dated, 07/10/12 at 11:37 a.m. that documented, "Situation: Resident has a small reddened area with white center left outer foot at fifth toe, skin intact. Background: Resident on a MA - 65 Mattress (Air mattress). Response: (name of physician's assistant) and daughter (name of daughter) notified and no new orders obtained. "Review of the skin assessment sheet revealed a skin assessment dated , 07/10/12, which documented, "No new areas, tx's (treatments) continue." Review of the comprehensive care plan dated, 03/21/12, documented, "Pressure ulcer actual or at risk due to Hx (history) of pressure ulcer, requires assistance with bed mobility, incontinence of bowel and bladder, lower extremity [MEDICAL CONDITION]." The "Interventions" documented, "Conduct weekly skin inspection. Treatments as ordered. Float heels. Turning and repositioning schedule per assessment." There was no documentation or measurements for the left foot lateral distal DTI and no documentation, measurements or treatment for [REDACTED]. An interview was conducted with LPN # 15 on 07/18/12 at 8:00 a.m. When asked what the nurses do when the wound nurse is not on duty and you find a concern on a resident's skin, LPN # 15 stated, "We measure it, and start treatment per our protocol." When asked who measures stage I and II's, LPN # 15 stated, "We do." An interview was conducted with LPN # 1 on 07/18/12 at 8:14 a.m. When asked to review her note of 07/10/12, LPN # 1 was asked if the nurses on the floor measure wounds, LPN # 1 stated, "We don't measure them in general. They don't let us stage them either." An interview was conducted with LPN # 5, the unit manager, on 07/18/12 at 8:45 a.m. When asked what the process is for identifying and initiating treatment for [REDACTED].# 5 stated, "The nurse should measure them, then the wound nurse will track them." When asked if the wound nurse should track deep tissue injuries, LPN # 5 stated, "Yes." An interview was conducted with LPN # 6 and administrative staff member (ASM), the corporate nurse consultant, on 07/17/12 at 3:15 p.m. LPN # 6 verified that there were no orders in place for Resident # 35's proximal left foot and the third toe." She also stated, "If I don't know about something, then I can't track it." An interview was conducted with the director of nursing (DON) on 07/18/12 at 9:35 a.m. When asked if the wound nurse is only to treat stage III and above pressure areas, the DON stated, "That is not true. She is the primary treatment nurse. She sees what she is directed to see." When asked if deep tissue injury wounds should be measured and followed, the DON stated, "Yes." When asked if the floor nurses can measure wounds, the DON stated, "They can measure them but currently can't st

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure physician ordered transfer equipment was used to prevent serious injury for one of three residents in the survey sample, Resident # 1, and failed to ensure physician ordered assistive devices were in place to prevent accidents for one of three residents in the survey sample, Resident # 3. 1. Resident # 1 was not transferred with the physician ordered mechanical lift, and suffered a laceration to her leg that required twenty staples. 2. Resident # 3 was observed attempting to climb out of the bed without the physician ordered mat on the floor next to the bed. The findings included: 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) (Version 3.0) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/15/10 coded Resident # 1 with short and long term memory difficulties. The resident was coded as being severely impaired to make cognitive decisions of daily living. Resident # 1 was coded as being totally dependent on the staff for all activities of daily living. The resident was coded as requiring extensive assistance of two or more staff members for moving in the bed and totally dependent of two or more staff members for transferring from one surface to another that included bed to wheelchair. The resident was coded as unable to stabilize their position during transfers without human assistance. The resident was coded in section J as having had a fall with injury, skin tears, lacerations and a second fall with major injury, broken bone. The previous MDS assessment (Version 2.0), an annual assessment, with an ARD of 08/16/10 coded the resident in section G 6. d, "Modes of transfer" as lifted mechanically. Resident # 1 was coded as being totally dependent of two or more staff members for bed mobility and transfers. Observation was made of Resident # 1 on 12/09/10 at 11:45 a.m. The resident was seated in a specialty wheelchair. The resident was asleep in the chair with head down. The chair had bilateral round trays coming from the sides and rested in front of the resident. The call bell was in place. The resident was again observed on 12/09/10 at 5:00 p.m. in bed and appeared to be asleep. The resident was positioned on her left side with bolsters on both sides of her. The bed was in the low position and the floor mats were in place on both sides of the bed. A specialty air mattress was noted on the bed. Review of the clinical record revealed the physician order summary sheet dated 11/28/10 and signed by the physician on 12/02/10 that documented, "03/06/2009: Resident to be OOB (out of bed) with a mechanical lift-every shift every day." Review of Resident #1's "Clinical Health Status" dated 08/16/10 revealed documented under the section entitled, "Braden Scale for Predicting Pressure Sore Risk" the following: ? "Sensory Perception: 2. Very limited: responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ? of body. ? Activity: 2. Chairfast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. ? Mobility: 2. Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently ? Friction and Shear: 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance." Section C of the "Clinical Health Status" dated 08/16/10 documented: ? "Can resident ambulate independently? A check was placed under No. ? Can resident transfer independently? A check was placed under No. ? Can resident ambulate with limited assistance? A check was placed under No. ? Can resident pivot transfer with limited assistance? A check was placed under No. ? If resident requires more than limited assistance with transfer refer to Lift Assessment." Further review of Resident #1's clinical record revealed a form titled, "Facility - Lift/Mobility Assessment for Residents". The form was dated 08/16/10 and signed by LPN (licensed practical nurse) # 1. ? Resident can bear weight on at least one leg? No was circled. ? Resident is able to follow simple instructions? No was circled. ? Resident is able to grip with at least one hand or a 2nd staff member is available to assist with the transfer? No was circled. ? Resident is able to undergo moderate pressure to the mid to lower back? Yes was circled. The form then documented, "If any of the four questions were NO, then the resident is not a SARA lift candidate. Proceed to the next questions for assessment of total dependent lift: ? Resident can undergo a semi-reclined position as shown in the picture to the right? Yes was circled. ? Resident weighs less than 420 pounds? - Marisa lift. Yes was circled." The form further documented, "Lift required: Marisa" was circled. Review of the comprehensive care plan dated, 09/01/10, documented, "Self care deficit: resident with DX (diagnosis) of Alzheimer's dementia with cognitive loss. Resident is dependent on all adls (sic) (activities of daily living)." The interventions documented, "Transfer with mechanical lift." The review of the nurse's notes dated, 09/01/10 documented, "The CNA (certified nursing assistant) was transferring the resident from her bed to her wheelchair and her the residents leg got caught on the wheelchair leg and tore the skin 7 cm (centimeters) full thickness on the back of her right lower leg.) In RESIDENT'S ROOM (The event occurred in room (number documented); injury: LACERATION on LEG (RIGHT)." Review of the ambulance record dated, 09/01/10, documented, "Nursing staff states Pt (patient) suffered a 3-4 cm (centimeter) laceration on back of the right lower leg when transferring from bed to wheelchair. Unknown what exactly caused the injury." "Nursing staff stated they had trouble controlling the bleeding, but eventually controlled with a pressure dressing." The hospital emergency room physician note dated, 09/01/10, documented, "Traumatic Lesions: Laceration - right leg, size- 14 cm; shape - V shaped, edge condition - with regular edges, location - posterior aspect, middle third." It further documented, "Laceration Repair - closure of skin with staples # 20." Nurse's note dated, 09/02/10 documented, "She also sustained a large skin tear on her right leg yesterday during transfer and has 20 staples in the area." Progression of the wound was reviewed. The wound care nurse became involved with the wound on 09/20/10. The wound evaluation flow sheet documented: "09/20/10: L (length) 6 cm, W (width) 4 cm, D (depth) 0 cm. Wound bed: eschar; Edges were approximated with staples." An interview was conducted on 12/09/10 at 5:45 p.m. with the Director of Nursing (DON). The investigation of the incident that occurred on 09/01/10 was presented. The investigative report documented, "Called to room by CNA. A 7 cm x 3 cm laceration noted on the back of resident's right leg." Review of the "Employee Memorandum" dated 09/01/10, documented, "Transferred (Resident # 1) without using lift as is ordered. She sustained a (sic) lg (large) skin tear as a result." Under the heading of "Corrective Action" the following was documented, "You must transfer those residents requiring a Hoyer lift as ordered. * See copy of care card." The copy of the attached care card documented under the heading, "Transfer" a picture of a lift was shown. The DON was asked what the resident's transfer status at the time of the incident was. The DON stated, "I attached the CNA care card to show to the employee that the resident was to be transferred by the mechanical lift." She further stated, "I think he thought because he was a big strong man that he could just lift her instead of using the lift." The employee file for CNA # 5, the CNA involved with the incident was reviewed. The employee was hired on 08/09/10 and terminated on 09/01/10. The review of the file revealed a "General Orientation Checklist" that documented a check mark next to, "Video: Safety Guidelines" (Safe-lifting Guidelines for all employees) and "Video: Give Yourself a Lift" (Mechanical Lifting Systems). On 12/09/10 at 6:00 p.m. an interview was conducted with the wound care nurse, LPN (licensed practical nurse) # 2. LPN # 2 was asked to describe the wound on the right lower leg of Resident # 1. LPN # 2 stated, "I was not involved with the wound until a few weeks after it happened. The wound was originally a simple dressing that the nurses did. I became involved on 09/20/10 when the area around the staples was noted to have necrotic tissue. The staples came out and the resident was sent to the wound clinic for debridement. The resident has been followed in the wound clinic since then for wound management. It is healing nicely at this point." Observation of the wound was made on 12/09/10 at 7:02 p.m. The resident was premedicated. The resident was lying on her left side. The leg was exposed. There was an upside down V shaped area of scar tissue. The area of the healing wound was approximately 8 cm in length and 6 cm in width. The area surrounding the wound was pink. There was an open area approximately 0.5 cm in length and 0.2 cm in width on the right border of the wound. The resident appeared comfortable throughout the dressing change. An interview was conducted with CNA # 1 on 12/09/10 at 3:09 p.m. When asked how a CNA finds out how a resident is transferred, CNA # 1 stated, "It's on a resident sheet in the CNA book." When asked how many staff members should transfer a resident using a mechanical lift, CNA # 1 stated, "Always have to have two staff members." Observation was made on 12/09/10 of a resident being transferred by a mechanical lift at 4:50 p.m. CNA # 2 and CNA # 3 transferred the resident using appropriate technique. An interview was conducted with CNA # 4 on 12/09/10 at 4:58 p.m. When asked if a male CNA can lift a resident instead of using the mechanical lift, when ordered, CNA # 4 stated, "No, if the order is for mechanical lift then you use the appropriate lift for that resident." When asked if a CNA can transfer a resident with a mechanical lift by themselves, CNA # 4 stated, "No, you can't do that, you must have two people at all times with the lift use. I didn't know that until I worked at a previous facility that you always have to have two people with a lift transfer." An interview was conducted with a physical therapist, other staff member (OSM) # 2 on 12/09/10 at 5:00 p.m. When asked who, in the facility, determines which residents should be lifted by a mechanical lift? OSM # 2 stated, "Usually the nursing staff sends a request for a therapy screen for transfers." When asked if all residents requiring a mechanical lift transfer need an evaluation or screening by the therapy department, OSM # 2 stated, "Yes, they should have had an evaluation." An interview was conducted on 12/09/10 at 7:39 p.m. with other staff member (OSM) # 1, the Rehabilitation Program Coordinator. OSM # 1 was asked if therapy screens all residents for the use of a mechanical lift. OSM # 1 stated, "We are involved but we are not the sole group to determine the Hoyer usage. The nurses can assess and evaluate a resident for Hoyer also." OSM # 1 was asked if therapy was involved with the orientation program. OSM # 1 stated, "I am at every orientation. I teach body mechanics. I demonstrate one and two person transfers. They have to watch the videos on body mechanics, safe transfers and gait belt usage." Review of the clinical record did not reveal an evaluation from therapy for the use of the mechanical lift. Review of the facility policy, "Lift, Transfer and Repositioning Policy" documented, "B. Resident Handling and Movement Requirements: 1. Transfer assistance, mobility assistance and other resident handling and movement tasks are to be carried out in accordance with the MDS, Care Plan and written implementing instructions pertaining to the individual resident. 5. Delegation of Authority and Responsibility: B: Supervisors will be responsible to: 1. Ensure resident handling tasks are assessed and are completed safely, using mechanical lifting devices and other approved resident handling aids and appropriate techniques. C: Employees will be responsible to: ....2. Use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of resident handling tasks." In "Fundamentals of Nursing" 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. "The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm clients." According to Fundamentals of Nursing, 6th edition, page 327, "A written care plan is designed to direct clinical care and to decrease the risk of incomplete, incorrect and inaccurate care. The plan is organized so that any nurse can quickly identify the client's nursing diagnosis, goals, and outcomes and nursing interventions to be delivered." The Administrator, Director of Nursing and Corporate Clinical Nurse were made aware of the concern for harm on 12/09/10 at approximately 5:55 p.m. No further information was provided prior to exit. 2. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) (Version 3.0) assessment, an annual assessment, with an ARD (assessment reference date) of 10/21/10 coded the resident as being severely impaired in cognitive skills for daily decision making. Resident # 3 was coded with inattention and disorganized thinking that were present but comes and goes. The resident was coded as requiring extensive assistance of one staff member for all her activities of daily living except bathing in which she was totally dependent of one staff member. Resident # 3 was coded as requiring extensive assistance of one person for bed mobility and for transferring from one surface to another. In section G300 the resident was coded as being not steady, only able to stabilize with human assistance for balance during transitions and walking. The resident was coded as being frequently incontinent of both bowel and bladder. Section J coded the resident as having had two falls without injury and one fall with injury. The resident was coded in section N as having received both antipsychotic and antidepressant medications in the past seven days. Under the Care Area Assessment Summary the resident had triggered for fall. Resident # 3 was observed on 12/09/10 at 12:13 p.m. sitting in her room in her wheelchair. Her feet were propped up on the edge of the bed. A chair alarm was in place on the wheelchair. The resident appeared to be asleep. The resident was observed on 12/09/10 at 3:10 p.m. The resident was in bed, the bilateral half side rails were up. The floor mat was observed folded up under the bed. An interview was conducted with CNA (certified nursing assistant) # 2 on 12/09/10 at 3:16 p.m. When asked how a staff member knows what assistive devices such as chair alarms and fall mats a resident needs, CNA # 2 stated, "The nurses tell us and we just know. Plus we have the aide work sheets in the front of the assignment book." CNA # 2 proceeded to show this surveyor the assignment book and the work sheet. The work sheet documented for Resident # 3 that she had bed and chair alarms and was on the falling star program. There was no documentation that the resident required a fall mat at the bedside. On 12/09/10 at 3:21 p.m. an interview was conducted with LPN (licensed practical nurse) # 1, the unit manager. When asked how the aide worksheets get updated, LPN # 1 stated, "I put them in on admission and I update them with new orders and after care plan meetings." On 12/09/10 at 3:40 p.m. the resident's room was observed and no fall mat was at the bedside. The resident remained in bed and appeared to be asleep. On 12/09/10 at 3:42 p.m. CNA # 3 was noted to enter Resident # 3's room and was passing ice to the residents in the room. On 12/09/10 at 3:51 p.m. Resident # 3 was heard stating, "Help". The resident was observed climbing out of the bed. No fall mat was at the bedside. LPN # 1 said to another nurse, "She's climbing out of the bed, find her CNA to help me." Review of the physician orders for the month of December 2010, documented, "11/04/10: Mat on floor and bed against wall - every shift - every day." Review of the comprehensive care plan dated, 11/04/09, documented, "Falls - Resident at risk for falls due to use of an antidepressant medication. Demonstrates impaired balance and unsteady gait." The care plan documented falls on 11/15/09, 01/13/10, 02/20/10, 06/07/10, 06/27/10, 07/05/10, 08/02/10, 08/30/10, 09/13/10, 09/17/10, 09/21/10, 10/08/10, 11/03/10, and 11/05/10. Fall mat at bedside was added as an intervention on 11/04/10. The fall on 11/03/10 was documented as, "Got self OOB (out of bed) and fell ." The review of the "Clinical Health Status" dated, 10/21/10 documented, "Risk for Falls" a score of "16". A total score of 10 or above deems the resident at risk. According to Fundamentals of Nursing, 6th edition, page 278; "The nurse applies the nursing process to provide appropriate and effective nursing care. The process begins with an assessment or gathering and analysis of information about the client's health status. The nurse then makes clinical judgments about the client's response to health problems, defined as nursing diagnoses. Once the nurse defines appropriate nursing diagnoses, a plan of care is developed. The plan includes interventions individualized to each of the client's nursing diagnoses. The nurse performs all planned interventions in an effort to improve or maintain the client's health. After administering interventions, the nurse evaluates the client's response and whether the interventions were effective." Page 966, "Falls account for up to 90% of all reported incidents in hospitals. The risk for falling is significantly higher in older clients. In addition to age, a history of previous falls, gait disturbances, balance and mobility problems, postural hypotension, sensory impairment, urinary and bladder dysfunction, and certain medical diagnostic categories (e.g., cancer and cardiovascular, neurological and cerebrovascular diseases) increase the risk. One of the more common factors precipitating a fall is a client's attempt to get out of bed to toilet. Drug use and drug interactions are also implicated in falls .....Falls that result in injuries can extend a client's length of stay in the health care environment, placing them at an even great risk for other complications." On page 969; "Risk for Falls: Assessment of a client's fall risk factors is essential in determining specific needs and developing targeted interventions to prevent falls. The nurse begins by asking clients if they have had a history of [REDACTED]. A client's risk of falling increases dramatically as the number of risk factors increases. Initial and daily assessment of fall risk is important in identifying clients who are at risk for falling." The Administrator and Director of Nursing were made aware of these findings on 12/09/10 at approximately 7:30 p.m. Complaint deficiency