Every finding on record at Freeman Nursing & Rehabilitation Community

Based on observation, interview, and record review the facility failed to recognize a change in condition for one Resident (Resident #2) of one resident reviewed for hospitalization. This deficient practice resulted in rehospitalization, insertion of an indwelling catheter, and intravenous diuretic therapy.(All times are recorded in Eastern Standard Time unless otherwise indicated.)Findings include:Resident #2 (R2)On 12/9/25 at 12:53 PM, an interview was conducted with R2 in their room while sitting in their recliner. R2 was asked if they had a recent hospitalization and replied, Yes, I needed diuretics because of having too much fluid on me. They even put a catheter in me because I was peeing so much. The food here is so salty. I asked not to have salt added to my tray and I will not eat gravy on my food because there is a lot of salt in gravy. I weigh myself every day at home and make sure I am not gaining too much weight because of my heart. R2's local hospital admission, dated 11/20/25, revealed in part, R2 was at the skilled nursing facility for rehab and presented to the emergency department on 11/20/25 with gradually worsening dyspnea (shortness of breath) for the past 1 to 3 weeks. R2's lab results revealed she was in fluid volume overload and was admitted to the local hospital for acute (rapid onset) respiratory failure secondary to exacerbation (worsening) acute congestive heart failure. R2 was placed on an intravenous diuretic (medication to help remove excess fluid from the body) drip, indwelling catheter, salt diet restrictions, fluid restrictions, and daily weights. R2 was discharged back to the skilled nursing facility on 11/25/25.Hospitalization records for R2 prior to her initial admission to the facility, dated 10/29/25, indicated she originally fell at her apartment and fractured her right femur. R2 had an emergency room base weight of 138.6 pounds with noted chronic congestive heart failure. There was a disposition note stating to anticipate discharge to skilled nursing facility tomorrow if bed is available. Follow-up with discharge planners. Plan: Orders - medications listed, heart healthy diet, and weight daily.On 12/10/25 at 10:30 AM, the Director of Nursing (DON) was asked for the original discharge paperwork from the hospital for R2 dated 10/30/25 and was not able to locate the discharge paperwork after looking in the electronic medical record and in R2's hard chart. Review of R2's facility documented weights revealed the following:a. 10/30/25 recorded as 139.2 pounds.b. 11/4/25 recorded as 141.0 pounds.c. 11/11/25 recorded as 148.0 pounds (a weight gain of 8.8 pounds since admission and gain of seven pounds in seven days).d. 11/13/25 recorded as 149.4 pounds.e. 11/14/25 recorded as 150.8 pounds.f. 11/15/25 recorded as 151.4 pounds (a weight gain of 12.2 pounds since admission).R2's progress note, dated 11/12/25 read in part .resident weight gain of 7 lbs. (pounds).Review of R2's progress note dated 11/13/25 read in part .Resident seems anxious regarding recent weight gain.3+ pitting edema (swelling from excess body fluid that leaves a temporary indentation [pit] when pressed) noted to BLE (bilateral lower extremities).SOB (shortness of breath) noted during conversation.Review of R2's lab for brain natriuretic peptide (BNP - a hormone released by the heart that helps diagnose heart failure when its levels rise due to heart working too hard) ordered on 11/13/25 and drawn on 11/18/25 disclosed a value of 32,600 pg/ml (picograms per milliliter - a unit of concentration used in medical tests). The BNP lab values normal range is less than 100 pg/ml, a very high range is considered to be greater than 900 pg/ml and is used to measure heart failure.R2's progress notes were reviewed between 11/15/25 and 11/20/25 and unfolded the following events: a. 11/15/25 read in part .some SOB while speaking.b. 11/17/25 read in part .Resident does c/o (complain of) feeling SOB and will begin to breath (sic) rapidly at times.c. 11/19/25 read in part .Resident has been experiencing SOB especially with exertion.d. 11/20/25 read in part .There is +2 edema in bilateral lower legs.sent her out to the ER (emergency room).family transported her to ED (emergency department).R2's most current weight on 12/10/25 was recorded as 147.2 pounds and reflective of a weight gain of 8 pounds over her normal base weight. R2's weight was approaching around the same weight she was sent out to the ER on [DATE] which was 149.6 pounds.Review of R2's progress note, dated 12/2/25 read in part Resident and family pleasantly expressed concern about any sodium intake d/t (due to) her CHF (congestive heart failure). Stated that she is very sensitive to sodium.R2's progress note dated 12/3/25 read in part Spoke with res. (resident) and her son today regarding her diet. Res. and family had concerns regarding her diet and our menu with sodium content. Res. has hx (history) of heart failure, HTN (hypertension) in the past. Res. use to following a very strict sodium restriction of her own at home and was concerned about her sodium intake here.Res. prefers to not have bacon, sausage, and ham when served . Review of R2's care plan, dated 10/30/25 declared a problem in part .Resident is at risk for complications related to diagnosis of hypertension, congestive heart failure. Goal: Resident's blood pressure will remain within normal limits and will be free of fluid and electrolyte imbalance this quarter. R2's care plan lacked any interventions to monitor for fluid volume overload such as daily weights or assessing for edema. Review of R2's face sheet revealed an admission to the facility on [DATE] with diagnoses including congestive heart failure, acute respiratory failure, and fracture of the right femur. Review of R2's admission minimum data set (MDS) assessment dated [DATE] revealed R2's brief interview for mental status (BIMS) reported intact cognition. Review of R2's facility census data unveiled an original admission to the facility on [DATE] and a discharge on [DATE] and a readmission on [DATE] back to the facility. On 12/10/2025 at 2:30 PM, the DON was asked to review weights for R2 since she was admitted , sent out to the hospital on [DATE], and her current weight gain following readmission to the facility. The DON stated, I can see where she has consistently gained weight. The DON was asked why R2 was not on daily weights at the time she was admitted like the hospital discharge paperwork indicated and replied, I don't know. The DON was asked what kinds of interventions were put in place to manage R2's CHF before she was sent to the local hospital for fluid volume overload and replied, I guess we should have been weighing her daily. I should have done a better job managing her.On 12/10/25 at 2:40 PM, an interview and observation were conducted with R2 in her room. R2 was observed to have 2+ pitting edema in her bilateral lower extremities and elevating her legs in her recliner. R2 voiced concerns about her weight gain. R2 was asked if the nurses listen to her lungs and assess her edema daily and replied, No, not consistently every day.Review of policy titled, Notification of Change, dated 01/2025, read in part, Introduction: The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death.Outcome Evaluation: Monitor and reassess the residents status and response to interventions. The physician should develop a working diagnosis and guide nursing staff in what to look for, what to monitor, and when to re-contact the physician if the resident progress deviates from the anticipated or expected course.

All times are Eastern Daylight Savings Time (EDST) unless otherwise noted.Based on observation, interview, and record review, the facility failed to perform hand hygiene during delivery of food which has the potential to result in the spread of illness and cross contamination among any or all 34 residents in the facility who receive meals.Findings include:During an observation on 12/10/25 at 9:06 a.m., Certified Nursing Assistant (CNA) A retrieved a tray from the food cart and delivered the tray of food to a resident in the dining room. CNA A then walked to the food cart and delivered another tray of food to a resident. CNA A continued to deliver two more trays of food to residents in the dining room and failed to use Alcohol Based Hand Rub (ABHR) [hand sanitizer] or wash her hands between meal tray delivery in the dining room.During an observation on 12/11/25 at 1:06 p.m., CNA A delivered a tray of food to a resident in the dining room and then used the resident's silverware to but up the baked potato. CNA A walked to the food cart and obtained another tray of food to a resident and used the resident's silverware to cut up the baked potato. CNA A walked to the beverage cart and obtained a drink for a resident. CNA A walked to the food cart and retrieved another tray of food and grabbed the handles of a wheelchair and moved another resident in the dining room. CNA A continued to deliver two more trays of food to the residents in the dining room. CNA A grabbed the handles of a wheelchair and moved another resident in the dining room. CNA A sat down next to a resident and started to feed the resident. CNA A did not use ABHR between delivery of food trays to the residents, after touching multiple wheelchairs in the dining room, or prior to assisting a resident with a meal.Facility policy titled Resident Dining Services last revised 4/21, read in part .Associates involved in dining services will wash their hands prior to distributing trays to the residents and when serving food to residents.Facility policy titled Hand Washing/Hand Hygiene last reviewed 1/25, read in part .Practicing hand hygiene is a simple effective way to prevent infections by preventing the spread of germs.During an interview on 12/11/25 at approximately 8:45 a.m., the Nursing Home Administrator (NHA) acknowledged the CNA did not perform hand hygiene during meal delivery in the dining room.

Based on interview and record review, the facility failed to ensure advance directives were reviewed in a timely manner for one Resident (#4) and failed to ensure the documentation of advance directives upon admission for one Resident (#33) of 16 residents reviewed. Findings include:All times recorded in Easter Savings Time (EST), unless otherwise noted. Resident #4 (R4) Review of the electronic medical record (EMR) on 12/9/2025 at 2:30 p.m., revealed R4 was designated as DNR (Do Not Resuscitate). Review of the Medical Treatment Decisions of Resident, signed and dated by R4 on 8/15/2024 revealed the following: I have been informed in writing, in language that I understand, of my rights and all rules and regulations to make decisions concerning medical care, include the right to accept or refuse treatment and the right to formulate and to issue Advanced Directives to be followed if i become incapacitated. In the absence of an advance directive, I understand that any and all life sustaining measures may be used. I may revoke any and all decisions at any time. The section of the form marked for Quarterly Review, held no documentation that care/advance directive had been reviewed with R4 or the resident representative, since originally signed on 8/15/2024. Resident #33 (R33) Review of the EMR on 12/9/2025 at 2:35 p.m., revealed R33 was designated as DNR. No signed document indicating R33 was informed of their right to formulate care/advance directives or designating wishes in the event R33 became incapacitated. The EMR indicated R33 was admitted to the facility on [DATE]. During an interview on 12/10/2025 at 9:25 a.m., the Social Services Designee, Staff B, reported she did not track the review of resident care/advanced directives. Staff B reported the responsibility for ensuring the resident care choices were reviewed fell upon nursing staff. On 12/10/2025 at 9:31 a.m., the Director of Nursing (DON) reported she would search the EMR for review dates and/or updated care/advance directives for R4 and R33. At 10:02 a.m., the DON reported she was unable to locate current documentation indicating R4 and R33's care directives were reviewed. The DON was queried as to the process for ensuring completion and timely review of resident's care directives to which she reported the process was under review. Review of the facility policy titled, Advance Directives, reviewed 1/2025, revealed the following: Upon admission the admission Director or designee will off the advanced directive form to the resident and/or the resident surrogate and request that the form be completed . The facility's Social Service Director will periodically discuss advance directives with the resident and/or the resident's surrogate upon a change in condition. During cardiac or respiratory arrest, the staff will reference and follow the resident's advance directive wishes as indicated on the advance directive form. Facility resident's advanced directives will be assessable for review .

Based on interview and record review, the facility failed to ensure the provision of dignified and respectful care and treatment for four Residents (R15, R24, R131, and R17) of 13 sampled residents reviewed for resident rights. This deficient practice resulted in resident dissatisfaction, frustration, and fear of mistreatment. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident R15 Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make their needs known. During an interview on 10/22/24 at 7:45 a.m., R15 said she had been told by CNA A that she was not a priority for [them] to provide care for. CNA B also present in the room providing care for R15 was asked if they had ever heard CNA A tell R15 that she was not a priority for [them] to care for. CNA B confirmed R15 had told her CNA A told her (R15) that she was not a priority to [them]. CNA B said CNA A had also directly told [CNA B] that R15 was not a priority to them in the provision of care. During an interview on 10/22/24 at 9:10 a.m., when asked about disrespectful and/or undignified treatment by staff, R15 stated, [Certified Nurse Aide (CNA) A] is mean. [They] yell at you. [They] get right in your face. You get so tired of [them] yelling in your face you agree with [them] so [they] get out of your room. [CNA A] is not a nice person . I have heard [CNA A] yelling at [R24], so I know [they are] mean to [R24], I have heard it. Resident R24 Review of R24's MDS assessment, dated 9/23/24, revealed R24 scored 13 of 15 on the BIMS, reflective of intact cognition. R24 had clear speech, understood others, and was able to make their needs known. During an interview on 10/22/24 at 9:00 a.m., R24 was asked if there were any staff that treated them disrespectfully. R24 stated, That big, fat [individual] (confirmed with R24 as CNA A). [They] treat me roughly. [They] have good moods, but when [they[ are in a bad mood . what happens then . I don't even want to tell you. [They] yell . If it (the facility) could be without [CNA A] it would be good. Everybody hates [them] . Resident R131 Review of R131's Face Sheet revealed they were a new admission to the facility. R131 was listed as their own responsible party, and was admitted for a short-term rehabilitation stay following a fall with fracture prior to admission. R131 had no diagnoses that indicated impaired cognitive function. The MDS assessment, dated 10/10/24, contained no documentation of cognitive function. During an interview on 10/22/24 at 9:45 a.m., R131 was asked if they had any concerns with the care provided by facility staff. R131 stated, Sometimes I have to wait an hour or an hour and a half to go to the bathroom. I have this hernia, and it starts pulsing when my bladder is full. I call them (CNA staff), a little before I really have to pee and sometimes, I have to wait an hour . I was actually crying. My hernia was pulsing, and it was hurting . During this interview R131 was able to clearly answer all questions without hesitation, or any indication of impaired cognition. During an interview on 10/23/24 at 1:41 p.m., CNA C was asked if they were aware of any staff member that had provided disrespectful or undignified care. CNA C stated, They (staff) call [them] 'The Creeper'. (It is) the way [CNA A] approaches the residents - [their] demeanor towards them (the residents) . There have been multiple times that residents have complained, and I reported to the [nurses] . With (resident who was) a constant ringer, CNA A would swing the door open and yell 'What are you doing ringing that bell all the time.' . [CNA A] boils my blood. I reported [CNA A] more than once. I yelled at the Director of Nursing (DON). I am not trying to get anybody fired, but where do you draw the line. [CNA A's] best intentions are not for the resident . I would rather have my residents safe that to have a resident look at me and say I don't want [CNA A] in my room. Resident (R25) has said they don't want [CNA A] in [their] room. [R2] has complained about [CNA A]. [R5] has complained about [CNA A]. I got mean enough that something needed to be done so they moved [CNA A] to afternoons, (from the night shift) so there were more people to watch [CNA A]. The nurse cannot babysit [CNA A]. We are adults here . It does not surprise me what they are investigating now .I took an oath to protect and make sure that these people are safe .[CNA A] got booted off (not working on) south because everyone was complaining about [CNA A] over there . I have reported [CNA B] (to facility administration) . 34568 Resident R17 An interview was conducted with R17 on 10/22/24 at 10:17 a.m. R17 stated that she has concerns with the care provided by CNA A. RN17 stated, (CNA A) is rude and inappropriate. I don't want [CNA A] to take care of me. Awhile ago I turned on my call light and (CNA A) told me to 'Find my own help' and turned off my call light and walked away. R17 stated that she did tell the DON about her issues.

Based on observation, interview, and record review, the facility failed to ensure disinfection of environmental surfaces, appropriate hand hygiene and donning and doffing of gloves to prevent the spread of infection for one Resident (R15) of three residents reviewed for wound care. This deficient practice resulted in the potential for increased transmission of infectious organisms between the environment and/or contaminated hands during wound care. Findings include: All times noted are Eastern Daylight Savings Time (EDST), unless otherwise noted. During observation of R15's thoracic (back) wound on 10/22/24 at approximately 7:50 a.m., revealed the dressing was dated 10/21/24. The dressing was bunched up on the bottom, and not properly sealed onto R15's skin. The black sweatshirt R15 was wearing was visibly soiled with the oozing drainage from the wound, which had saturated the dressing and spilled out onto the sweatshirt. During an interview at this same time, Licensed Practical Nurse (LPN) D was asked about the drainage that had escaped R15's wound dressing unto their clothing. LPN D said she was going to change the dressing today (10/22/24) because the dressing was not intact, and it was leaking drainage unto R15's clothing. Certified Nurse Aide (CNA) B held up R15's sweatshirt and showed the wound drainage stain on the clothing. CNA B confirmed R15's black sweatshirt was stained with the oozing drainage from R15's open, draining thoracic wound. Observation of wound care for R15 on 10/23/24 at 9:10 p.m., was performed by Registered Nurse (RN)/Nurse Manager F, with assistance from CNA B and CNA C. RN F brought wound dressing change supplies into R15's room on a small tray with extra gloves carried in her gloved hand. RN F set the clean gloves down on R15's dirty overbed table that was not disinfected prior to use. R15's back, thoracic wound was covered with a dressing dated 10/21/24, the same dressing as observed on the morning of 10/22/24 with LPN D. R15's thoracic dressing was fully saturated and dripping serosanguinous drainage as it was removed from R15's back. The skin under the saturated dressing appeared red and inflamed. RN F discarded the saturated dressing from R15's back. RN F picked up the wound cleanser container and clean gauze and was going to begin cleansing R15's open, thoracic wound when this Surveyor requested, she change her dirty gloves. RN F removed her dirty gloves and picked up a pair of gloves from R15's dirty overbed table. RN F was asked if she had disinfected the overbed table and acknowledged they had not. RN F threw the gloves that had been sitting on the overbed table away and started to don clean gloves from a box in R15's room. RN F was stopped and asked to perform hand hygiene by this Surveyor prior to donning clean gloves and continuation of wound care. Review of R15's Physician Orders on 10/23/24 at 9:20 p.m., revealed the following order, in part: Cleanse thoracic wound with NS, (normal saline) pat dry, apply DermaCol to wound bed, apply calcium alginate over DermaCol, cover with adhesive foam, change daily. Once a Day, 6:00 p.m. to 6:00 a.m. [Central Daylight Savings Time (CDST)] . Created 6/22/24. During an interview at this same time, when asked about the lack of a PRN (as needed) order for the thoracic dressing, the DON stated, That may be a problem. R15, present in the room stated, That is a problem for me too. [CNA B] tells them (the nurses) the dressing needs to be changed. [CNA B] has seen it ooze all the way down (my back) . During an interview on 10/23/24 at 11:23 a.m., the DON and Regional Clinical Manager K were asked about the infection control breaches observed during wound care for R15. The DON stated, They (staff) should remove their gloves and re-sanitize (their hands) and put on a fresh pair (of gloves). I would stop them if they didn't do those things. That is against infection control practices. If you are going to set your gloves down, you would want a barrier (on the overbed table). The DON confirmed there was no PRN order for change of R15's wound dressing, if it was not intact or the dressing was leaking until that day, 10/23/24. The DON said it would be a Standard of Practice to change the dressing if it was fully saturated and leaking. Review of the Centers for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, revealed the following, in part: Cleaning your hands reduces: The potential spread of deadly germs to patients. Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe . Know when to clean your hands: - Immediately before touching a patient . - After touching a patient or patient's surroundings. - After contact with blood, body fluids, or contaminated surfaces. - Immediately after glove removal. Know when to wear (and change) gloves: - If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. - Always clean your hands after removing gloves. - Remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil hands .

This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely and fully investigate an allegation of abuse for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on the ball, and I am hoping that they are not doing that to them, and they don't know . During an interview on 10/22/24 at approximately 7:55, a.m., CNA B was asked if R15 had reported to her that [CNA A] had poked her vaginal area with their gloved finger. CNA B confirmed R15 had reported the concern, and stated, I told the nurse four days ago - on Friday. During an interview on 10/22/24 at 1:28 p.m., the NHA was asked for any investigation documentation related to CNA A's treatment of facility residents. The NHA said they were in the middle of an investigation of a staff-to-staff incident with CNA A but had no investigations regarding inappropriate provision of care by CNA towards R15 or any other facility resident. The NHA acknowledged she had heard staff talking about a finger in someone's vagina but was unaware of any additional details. When asked if she had any previous or current resident or staff grievances related to CNA's treatment of facility residents, the NHA said she had not had any other concerns voiced by either facility residents or facility staff about CNA A. Review of the facility Abuse Prevention Program Policy & Procedure, reviewed 01/2024, revealed the following, in part: Staff to Resident Abuse: All staff are expected to be in control of their own behavior, are to behave professionally, and should appropriately understand how to work with the nursing home population . The Administrator and or Director of Nursing are to initiate and coordinate completion of a thorough investigation. Investigations must be initiated immediately and concluded as soon as possible not to exceed (5) days .Identify and interview (witness statements) all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) such as roommate . interview with co-workers or other supervisors in regard to the alleged perpetrator's work performance . In order to complete the Resident Abuse Investigation, all information must be gathered and reviewed, with a final summary analysis with an action plan to prevent reoccurrence . Residents are protected from physical and psychosocial harm during and after the investigation .

Based on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for an antidepressant medication for one Resident (R19) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted Resident #19 (R19) Review of R19's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including anxiety disorder, depression, and adult failure to thrive. Review of her 10/18/24 Brief Interview for Mental Status (BIMS) score on her Minimum Data Set (MDS) assessment revealed an 8/15, indicating moderately impaired cognition. Review of the Consultation Report from [Pharmacy Name} for 9/13/24 read, in part, (R19) has received Lexapro (antidepressant medication) 10 mg (milligrams) daily since Sept (September) 2022. Her last PHQ-9 score from July was 0 indicating no signs/symptoms of depression. According to the (name of Company) progress note from July it states that a GDR for Lexapro is overdue. Moods and behaviors are stable, and she does well with non-pharmacological interventions. It is time for a periodic review for a possible dose reduction. Recommendation: Please consider a lower dose such as Lexapro 5 mg daily. Further review of the Consultation Report dated 9/13/24 had Physician N respond I decline the recommendation .Resident doing well with dose reduction likely to lead to clinical decline Review of R19's Psychoactive Medication Quarterly Evaluation dated 10/15/24 read, in part, Dose: Lexapro 10 mg daily .comments/recommendations: Lexapro therapy started 6/2/22; CI (contraindicated) 9/23/24; next GDR evaluation due 9/23/25 . An interview was conducted with Physician N on 10/23/24 at 1:35 p.m. Physician N stated that R19 did not receive a dose reduction of her Lexapro because she had been functioning well on the medication. Physician N stated that she has known R19 in the facility for about two years and knew her in the community as well. When asked if Physician N ordered for R19 to be seen by (name of Company), she stated no. When asked if Physician N is aware of the facility's policy regarding GDR's, she stated no. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at approximately 1:45 p.m. The DON confirmed that R19 should have had an attempted GDR of Lexapro and would discuss the facility's policy with Physician N Review of R19's Physician Orders on 10/23/24 revealed she was still receiving Lexapro 10 mg every day since September 2022. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy reviewed on 1/2024 read, in part, .Psychotropic Drug is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics .Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters .

Based on interview and record review, the facility failed to ensure a resident/residents durable power of attorney (DPOA) understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for one Resident #19 (R19) of three residents reviewed for arbitration. Findings include: Resident #19 (R19) A review of R19's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included anxiety disorder, depression, and hypertension. R19 scored 6 of 15 on the Brief interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of facility arbitration document titled [NAME] Resolving Potential Disputes, revealed R19 signed the agreement on 12/29/22. Review of facility document titled Decision Making Capacity Determination, read in part . This form serves as documentation of the determination of [R19's] capacity to participate in medical treatment and decision following examination .this has been determined by two physicians .R19 has been evaluated and determined to lack capacity to make reasoned medical decisions. One signature was obtained by a physician on 7/26/24 and a second signature was obtained by a physician on 8/8/24. Review of facility arbitration document titled [Facility] Resolving Potential Disputes, read in part . Right to cancel agreement . the personal representative of the residents estate in the event of the residents death or incapacity as the right to cancel this agreement . During an interview on 10/23/24 at 12:24 p.m., Social Services Designee M acknowledged that the arbitration agreement was not revisited when R19 was determined not to have the capacity to make decisions for herself and R19's Durable Power of Attorney (DPOA) was activated.

Based on observation, interview, and record review, the facility failed to provide a comfortable mattress and functional, intact shelving for clothing storage for one Resident (R15) of 13 sample residents reviewed for comfortable and functional furniture. This deficient practice resulted in the use of an under-inflated, uncomfortable mattress and a built in four-shelf drawer unit with the third drawer missing. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 2:52 p.m., when asked about care received in the facility, R15 stated, I am laying on a bed right now, and the lady came in from [Facility Corporation] and said, 'What is wrong with your bed'. I am lying on the springs . They took my good mattress, and I have been laying on this Mattress and [Regional Clinical Director K] came in and said there is no air in there (the mattress) . I am laying on a flat (under-inflated) bed again and it hurts. What do you think about that? [The Director of Nursing (DON)] was in here today, and she said we have to get hoses for the bed . I thought the Maintenance guy (Maintenance Director J) would come in to look at the bed, and no - nothing. Now I am laying right back on the flat bed. They switched the mattress about three weeks ago at 1:00 a.m. in the morning. The (facility staff) told me to be quiet, it was the only time they had to switch the mattress . Observation of R15's dresser shelving unit found the third drawer missing, leaving an open space where the clothing below in the fourth drawer could be visualized. During an interview and observation on 10/22/24 at 7:45 a.m., R15 again complained that the mattress was not comfortable. Certified Nurse Aide (CNA) B, and Licensed Practical Nurse (LPN) D transferred R15 to a wheelchair. The mattress R15 had been laying on appeared indented and underinflated with air where R15's buttocks was positioned on the bed. The indentation did not change as time passed with R15 in the wheelchair. LPN D pressed down on the mattress at the indentation point, and confirmed there was no inflation of the mattress and stated, There is something hard here. CNA B, also pressed down at the point of indentation where R15's buttocks had been positioned and said there was no inflation that she felt in the mattress. Both LPN D and CNA B agreed that the bed frame and mattress tubing was felt, exactly as R15 had described. During an interview and observation on 10/22/24 at approximately 8:00 a.m., the DON, was asked to press on the mattress indentation. The DON pressed down on the mattress and said she didn't know anything about the bed, but it was supposed to work without air inflation. The DON said she believed the rental company brought the bed in, inflated it, and perhaps it was placed on her bed at a later time. During a telephone interview on 10/22/24 at 8:15 a.m., mattress manufacturer Director of Customer Services H was asked about the mattress delivery to the facility. Customer Services H stated, It was delivered October 5th 2024, a Saturday . There are 144 Roho cushion cells - on a foam base. Those cushions (cells) should be inflated. It was left in the hallway to be placed by the facility . It needs to be adjusted occasionally. Some of those can leak . There are three ports : one for the head section, middle section, and foot section. You can't inflate it if a hose isn't connected. Open the mattress - there is a fire barrier . you will see the external port and you will see the three hoses and it goes up the side of the mattress up by the rail and you can see where each section leads. You will be able to see the uninflated cells . During an observation and interview with the DON and Maintenance Director J on 10/22/24 at 8:31 a.m., both agreed that the middle section of air cells on the mattress appeared to be under-inflated in comparison to the foot section and the head section. Maintenance Director J said he was not responsible for the mattresses in the facility, and he did not have any idea how this (rented) mattress worked. The head section, upon palpation by this Surveyor also had under-inflated air cells as did the middle section where R15's bottom would have been positioned. The DON stated she would contact [the mattress manufacturer] and see if they could get someone there to inflate the mattress air cells. During an interview on 10/22/24 at 9:10 a.m., when asked if they had complained about the uncomfortable mattress, R15 stated, They would look me right in the eye and said that mattress was ok - so I just laid on it. I don't complain about too much of anything anymore. They don't do anything anyway . Maybe they just don't like me and my personality . During an interview and observation on 10/22/24 at 4:00 p.m., when asked about the mattress that was just removed from R15's bed, Customer Service I (who had been dispatched that day (to inspect the mattress by the rental company), stated, I think the mattress may have been inflated at a lower pressure for a different resident. The middle air cells were creased up on each other, collapsing some of the air cells so the [R15's] butt was going right down to the cushion (foam mattress). The creased air cells forced all the air to one side of the cushion, so it could not inflate all the cells. Customer Service I said that the mattress was an older mattress, so they had just replaced it with a newer model that day. During an interview and observation of R15's room during wound care on 10/23/24 at approximately 9:05 a.m., found the third shelf still missing from the built-in shelving unit in the room. When asked why the drawer was missing, R15 said they had told her someone needed a drawer, so they came and took the third drawer out of her shelving unit. R15 said it had been missing for a long time. The clothing in the bottom drawer was still visible. RN/Nurse Manager F, and CNAs B' and C were all present in the room at the time of the interview. Review of the [Model Name] LTC (long term care) 105 mattress manufacturer instructions, copyright 2008-2013, provided by Maintenance Director J revealed the following, in part: .Caregiver: Before using this product read these instructions and save for future reference . Cautions: CHECK EACH MATTRESS SECTION AND ACCESSORY AT LEAST ONCE PER DAY in order to make sure it is properly inflated, adjusted, and if applicable, snapped together . UNDER-INFLATION: DO NOT use an under-inflated product. Using a product that is under-inflated reduces or eliminates the product's benefits, increasing the risk to skin and other soft tissue. If the product appears under-inflated or does not appear to be holding air, check to make sure that all hoses are connected and refer to Troubleshooting section of this manual. If the product is still not holding air, contact your health care provider, distributor, or supplier or [Manufacturer] immediately. WEIGHT LIMIT: The mattress should be correctly sized to the end-user and the bed . DO NOT allow end-user to lie on an under-inflated or over-inflated mattress. Check at least once a day for proper adjustment .

This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on the ball, and I am hoping that they are not doing that to them, and they don't know . During an interview on 10/22/24 at approximately 7:55, a.m., CNA B was asked if R15 had reported to her that [CNA A] had poked her vaginal area with their gloved finger. CNA B confirmed R15 had reported the concern, and stated, I told the nurse four days ago - on Friday. During an interview on 10/22/24 at 9:10 a.m., R15 was asked about any further concerns related to mistreatment by staff. R15 stated, [CNA A] is mean. [CNA A] yells at you. [CNA A] gets right in your face. You get so tired of [them] yelling in your face you agree with [them] so [they] get out of your room. [CNA A] is not a nice person . [They are] sticking [their] finger in my vaginal area. [They] said there was poop in there . I don't know what [they were] trying to prove, but I know it hurt. When [they] went back again and poked me in the vaginal area. I had had it. I don't tell the DON (Director of Nursing) anything anymore, because she doesn't do a damn thing. When [the Nursing Home Administrator (NHA) ]was here yesterday, she asked if I wanted to file with the police . During an interview on 10/22/24 at 1:28 p.m., the NHA was asked if they had reported R15's allegation of potential sexual abuse to the State Agency. The NHA acknowledged she had heard staff talking about a finger in someone's vagina but was unaware of any additional detail. The NHA said the allegation of potential sexual abuse was not reported to the State Agency. Review of the facility Abuse Prevention Program Policy & Procedure, reviewed 01/2024, revealed the following, in part: All alleged or suspected violations are to be reported immediately to the Administrator or Director of Nursing, which are responsible to notify required officials, including to the State Survey Agency, Adult Protective Services, Local Public Safety, Licensure Boards, Regional Director of Operations or Regional clinical Directors and any other agencies in accordance with state law .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure a food preparation staff person washed their hands after being potentially contaminated. 2. Failing to demonstrate proper testing of the concentration of sanitizing chemicals in the three compartment sink and wiping buckets. 3. Failing to properly label and date food removed from the original packaging which was re-packaged and frozen. These deficient practices have the potential to result in food borne illness among any and all 26 residents of the facility. Findings include: (All times are reported in EST) 1. On 11/30/23 at approximately 11:45 AM, Cook B was observed wiping up something from the floor, with a paper towel, near the three compartment sink. Cook B disposed of the paper towel which was used to clean the floor, then donned a pair of gloves and began with food preparation duties without washing her hands. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 2. On 11/29/23 at approximately 12:10 PM, Certified Dietary Manager (CDM) A was requested to demonstrate the procedure for testing the quaternary solution for the wiping cloths bucket. CDM A removed a strip from the roll of QT 40 test strips, placed it in the bucket and dragged it through the solution, and removed it after 7 seconds. CDM A read the color change of the strip to show nearly 400 PPM (parts per million). CDM A was then asked to review the dispenser of strips. CDM A acknowledged the directions for use included specific language to hold the strip in the solution without agitation, hold it still for 10 seconds. Following these instructions, CDM A conducted the test again and demonstrated the solution contained approximately 150 PPM. The FDA Food Code 2017 states: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (C) Responding correctly to the inspector's questions as they relate to the specific FOOD operation. The areas of knowledge include: 11) Explaining correct procedures for cleaning and SANITIZING UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT; 3. On 11/29/23 at approximately 11:45 AM, the upright freezer, located in the storage room adjacent to the dietary office, was observed to have six gallon sized zippered closure bags of food. The bags were not labeled with the food product. An interview with CDM A at this time revealed the bags contained chicken thighs, and had been separated from a larger container of fresh (not frozen) thighs, then frozen. Numerous bags of ground beef logs were observed in varying sizes in the freezer. CDM A reported a similar scenario in which the product came in unfrozen, was portioned, wrapped and frozen. None of the re-packaged foods was marked with original expiration date and date the product was placed in the freezer, to establish the length of time the product could be held once it was thawed. The FDA Food Code 2017 states: The FDA Food Code 2017 states: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on observation, interview, and record review, the facility failed to implement a complete infection control program by failure to ensure social distancing of residents in COVID-19 isolation during communal dining, and failure to complete real-time tracking and surveillance of facility infections. This deficient practice resulted in the potential spread of infectious organisms within the facility, including COVID-19, and had the potential to affect all 46 residents. Findings include: All reported times are Eastern Standard Time (EST), unless otherwise noted. During a dining observation on 11/29/23 at 1:13 p.m., R15 was viewed sitting in communal dining room with food in Styrofoam containers, plastic cups, a washable coffee cup, and regular silverware. R15 was sitting with his back less than two feet from the unknown resident directly behind him. Certified Nurse Aide (CNA) O, wearing a surgical mask was observed sitting within three feet of R15. During an interview on 11/29/23 at 1:24 p.m., Registered Nurse (RN) R, who had been assisting residents with their lunch meals, was asked if R15, who was in isolation due to exposure from his current roommate to COVID-19, was allowed to eat in close proximity to other residents in the communal dining room. RN R stated, I asked RN D is [R15] was allowed in the dining room, and she said yes. I was told that it was his right to come down to the communal dining room and eat. During an interview on 11/29/23 at 1:27 p.m., RN R stated, R15 was looking for his mother and he wanted to go and eat in the restaurant - the communal dining room. I could not redirect him back out of the dining room. He refused wearing a mask. Although R15 did not test positive for COVID-19 RN R agreed that he was presumed positive due to his close exposure and isolation in the same room with his roommate who was positive for COVID-19. RN R agreed the resident should be positioned six feet from other residents. RN R stated, I did not go down there (communal dining room) and see how he was positioned. I would say he is probably at a normal table (near other residents). RN R confirmed they were using Styrofoam dishes for residents in quarantine for COVID-19 and agreed the CNA should be wearing an N95 if she is within six feet of the resident. RN R said the Director of Nursing (DON) was above her in the Infection Preventionist (IP) position, and RN R was still learning. RN R directed this Surveyor to the DON for any further questions. During an interview on 11/29/23 at 1:34 p.m., the DON/IP was asked about allowing R15 to eat in close proximity to other residents in the communal dining room. The DON stated, He is in considered a presumed positive. CDC recommends he should stay in isolation. If he is six feet away from others, he can be in the dining room. I would have rather distanced him from others, before trying to feed him in another room. Staff should be wearing an N95 mask. I was told they were 6 feet apart. When the position of R15 to other residents and staff was described, the DON stated, No six feet is six feet. The DON said she understood the concern and agreed the resident should have maintained a six-foot distance from all residents or staff, and staff should be wearing N95 masks. Review of the Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS), QSO-20-39-NH, revised 5/8/2023, revealed the following, in part: While the PHE (public health emergency) will end, CMS still expects facilities to adhere to infection prevention and control recommendations in accordance with accepted national standards . Nursing Home Visitation Frequently Asked Questions (FAQs) . 5. Should the facility pause communal activities and dining during an outbreak investigation? . Residents who are on TBP (i.e., isolation or quarantine) should not participate in communal activities and dining until the criteria to discontinue TBP has been met . A resident who is unable to wear a mask due to a disability or medical condition may attend communal activities, however they should physically distance from others . Review of the facility COVID-19 Visitation and Communal Activities/Dining, revised 10/2022, revealed the following, in part: . Residents who are on transmission-based precautions should not participate in communal activities and dining until the criteria to discontinue transmission-based precautions has been met . 40383 During an infection control interview on 11/30/23 at 11:30 PM, the Director of Nursing (DON) was asked about the system she used for surveillance of the facility infections and to present the 11/2023 data. The DON, who also functions as the Infection Preventionist, stated, I don't have the mapping ready. It is only 11/30/23. When asked about the tracking and trending of infections (also called mapping) the DON stated, The purpose of mapping is to find if there are clusters (of infected residents) and track infection and type of infection and monitor spread. I will present the mapping the first or second week of December and write the summary then. At this time, the DON revealed there were three Covid-19 positive residents in house. These residents had not been added to the November map as it had not been started. With this discussion, the DON said she understood the importance of continuous mapping (rather than waiting until the end of the month to track and trend infections) and that surveillance should be ongoing analysis and documentation of follow up. The facility policy titled Monitoring Infection Control Practices and dated as reviewed 3/2023, read in part: The facility's Infection Control Preventionist will conduct routine monitoring and surveillance to determine compliance with infection control policies and practices. The facility was asked to provide the policy for timely mapping, tracking, and analysis of infection. The Regional Clinical Director reviewed the manuals and responded there was not a policy for mapping and tracking of infection.

R229 Review of R229's partially completed MDS assessment, dated [DATE], revealed R229 was admitted to the facility on [DATE]. R229 was noted to be a Full Code and Diabetic. Review of R229's Admission Record revealed the following, in part: Type I (insulin dependent) diabetes mellitus with diabetic neuropathy, Type 1 diabetes mellitus with ketoacidosis without coma (Admission), dehydration, and anoxic (lack of oxygen) brain damage, not elsewhere classified - r/t (related to) severe hypoglycemia. Review of R229's Care Plans revealed the following, in part: Problem: Resident is at risk of complications R/T DX (diagnosis) diabetes mellitus. Interventions included: [DATE] - Administer medications as ordered. [DATE] - Monitor blood glucose as ordered. [DATE] - Monitor for signs of hyperglycemia (blood glucose elevated; increased thirst; increase urination; increase appetite followed by lack of appetite; nausea, vomiting). [DATE] - Monitor for signs of hypoglycemia (low blood glucose; sweating; cold, clammy skin; numbness of fingers, toes, mouth; rapid heartbeat; nervousness, tremors, faintness, dizziness). Review of R229's Physician Orders revealed the following, in part: [DATE] - Insulin lispro solution; 100 unit/mL (milliliter); amt (amount); per sliding scale; subcutaneous Special Instructions . [Sliding Scale number of units to administer based on blood glucose levels]. [DATE] - Lantus U-100 Insulin (insulin Glargine) solution; 100 unit/ml; amt: 8 units; subcutaneous. Special Instructions: Give 8 units of Lantus Q (every) PM (evening). [DATE] - Lantus U-100 Insulin (insulin Glargine) solution; 100 unit/mL; amount 10 units; subcutaneous. Special Instructions: Give 10 units daily every AM . No order was present in Physician Orders or in the facility Standing Orders for administration of glucagon as a treatment for hypoglycemia for R229. Review of R229's Progress Notes revealed the following, in part: [DATE] 2:29 p.m. (CST), Res (resident) has a hx (history) of hypoglycemic/anoxic encephalopathy. Resident was currently in the hospital for diabetic ketoacidosis. Resident is a full code at this time . Res on Lantus, sliding scale insulin and scheduled Synthroid at this time . [DATE] 11:33 a.m. (CST), Resident blood sugar at 1100 (11:00 a.m. CST) = (equals) 582 (hyperglycemic) . [DATE] 2:31 a.m. (CST), Resident is receiving skilled nursing care r/t DM (diabetes mellitus) ketoacidosis, anoxic brain damage, cardiomyopathy . at around 2300 (11:00 p.m. CST), resident started using call light, asking for assistance but unable to state with what, c/o (complained of) all over body aches requesting Tylenol. Writer brought in PRN (as needed) Tylenol and noted resident was sweating profusely. Accu check was taken at this time was 51. Resident given 2 snacks. Accu-Chek redone at 2330 was 97 . [DATE] 6:55 a.m. (CST), MD updated about low blood sugar via phone call, MD aware of the low blood sugar reading and snacks provided. MD acknowledged, no new orders and MD to see resident in facility today, signed by the Director of Nursing (DON). [DATE] 4:46 p.m. (CST), MD contacted for blood sugar of HI (number unable to be registered) on meter at 4 PM check . During observation of the facility medication room on [DATE] at 8:30 a.m., the DON was asked to find any available back-up glucagon for administration to insulin-dependent diabetics for a severe hypoglycemic event. The DON looked through the back-up medication boxes and was not able to find the glucagon by the names of the medications on the back-up boxes. A medication named Gvoke was listed, and the DON was unsure of the type of medication it was. Upon searching through that specific medication back-up box, it was identified as an emergency dose of glucagon. When asked if the DON would have been able to find the glucagon in an emergency, the DON stated, No, because I didn't know what the Gvoke stood for. I didn't know it was glucagon. The nurse would not have been able to find it in an emergency. During an interview on [DATE] at 9:45 a.m., when asked if it was important for a newly admitted Type I diabetic to have an order for glucagon for treatment of severe hypoglycemia, Physician Q stated, Yes, I believe that is a policy here. They (residents with insulin-dependent diabetes) should have an order for glucagon when they are admitted . Physician Q aid he was unaware that R229 did not have an order for glucagon upon admission. Physician Q stated, I will make sure there is an order for glucagon for [R229] today. Physician Q agreed that there may not be time to call 911 with a severe hypoglycemic event. Observation of the [NAME] Hall medication cart on [DATE] at approximately 9:50 a.m. found no glucagon in the medication cart for administration to R229 in the event of a severe hypoglycemic event. Review of the Diabetic Management Program policy, reviewed ,d+[DATE], revealed the following, in part: Procedure: All residents with orders for insulin or oral diabetic medications should have orders for blood glucose monitoring and treatment for hypoglycemia . 49302 Based on observation, interview, and record review, the facility failed to provide the necessary standards of care and services for diabetes management in four (Resident #3, #18, #27 and #229) of seven residents reviewed for diabetic management. This deficient practice resulted in the potential for diabetic related complications including organ damage, stroke, and death. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Review of facility policy titled, Care Standards: Diabetic Management Program reviewed ,d+[DATE] read, All residents with orders for insulin or oral diabetic medications should have orders for blood glucose monitoring and treatment for hypoglycemia (low blood sugar). Resident #27 (R27) Review of R27's electronic medical record (EMR) revealed readmission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, and sepsis. Record review of R27's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Review of R27's Medication Administration Record (MAR) revealed the following: Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL (milliliter); Amount to Administer: 5 units; subcutaneous (under the skin), before meals. Lantus Solostar U-100 (100 units of insulin per milliliter of fluid) Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Amount to Administer: 18 units; subcutaneous, once a day. Glucagon (medication used to treat low blood sugar) Emergency Kit (human) (glucagon) recon (reconstituted) soln (solution); 1 mg (milligram); Amount to Administer: 1mg; injection, as needed. Special instructions: If UNCOOPERATIVE/UNCONSIOUS (sic) patient: If BS (blood sugar) <70mg/DL (deciliter) Give 1mg IM (intramuscular). May cause N/V (nausea/vomiting); Keep HOB (head of bed) elevated or position resident on either side. Notify physician for further orders. Fasting Accu (a device used to measure blood glucose levels) Checks x 3 days, once per morning. R27's fasting blood glucose levels from [DATE] to [DATE] were recorded as 349mg/dL, 131mg/dL, and 100mg/dL, respectively. Review of R27's Progress Notes (nursing), revealed the following: [DATE] 6:49 AM [CT (Central Time)] (5:28 AM CT) Writer was called to resident's room by Certified Nursing Assistant (CNA), reports that resident is unresponsive. Sternal rubbing and shaking would not arouse resident. Resident's eyes were rolled back in her head and pupils were responsive (constricted in response to light). VS (vital signs): T (temperature) 98.5, P (pulse) 69, RR (respiratory rate) 5 apneic (a temporary stop in breathing), B/P (blood pressure) ,d+[DATE], O2 sat (oxygen saturation) 91% on RA (room air), blood sugar read Lo (Manufacturer's Instructions indicated Lo meant the blood sugar sample tested was less than 20 mg/dL.) (5:40 AM CT) 1mg of glucagon was administered SQ (subcutaneous), 911 was called. (5:45 AM CT) CNA notified writer that resident had no pulse. (5:46 AM CT) ambulance arrived at facility and CPR was initiated. (6:07 AM CT) ambulance left the facility with the resident, resident had a pulse. On [DATE] at 3:26 PM, a phone interview was conducted with CNA E regarding finding R27 unresponsive. CNA E stated, I was the CNA who found her. I went in there and I looked at her and her eyes were rolling back in her head, and I called her name quite a few times and did the sternal rubs with no response. I ran and got the nurse . it seemed like she was doing better and all of a sudden, she just stopped breathing. I ran and got the nurse again .and he called 911, he called [the DON] .We knew she was sickly. I had gotten her up to go to the bathroom, she was telling us that she just didn't feel right. That was about 1:00AM or 1:30AM [CT]. We let [Registered Nurse (RN) G] know that she didn't feel right . On [DATE] at 6:59 AM, an interview was conducted with CNA F. CNA F stated, Me and [CNA E] went in to .check on her [R27] .She was laying back over to the left side and it appeared that her eyes were rolled back. She was breathing labored and fairly slow. We both went and got [RN G] to come down and check her . On [DATE] at 4:23 PM, a phone interview was conducted with RN G. RN G stated R27's respirations were initially, really high. RN G reported he subsequently called the DON who directed him to call 911. RN G stated after he called the DON, he remembered R27 was diabetic which prompted him to check her blood glucose levels. RN G reported that the monitored read, Lo which indicated R27's blood sugar was less than 20 mg/dL. RN G reportedly administered Glucagon at that time. Shortly after, RN G said the CNAs informed him that R27 no longer had a heartbeat. RN G indicated that Emergency Medical Services (EMS) then arrived and initiated cardiopulmonary resuscitation (CPR) before transporting R27 from the facility. RN G verified there was no active order for blood sugar monitoring for R27. Review of R27's EMR revealed no record of RN G conducting an assessment after it was reported she felt unwell. Review of R27's EMR revealed no standing order for blood glucose monitoring following [DATE]. Review of R27's MAR did not indicate that physician ordered Glucagon Emergency Kit was administered on [DATE]. Resident #18 (R18) Review of R18's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension, and chronic kidney disease. Review of R18's MAR revealed physician orders with [DATE] start date, insulin glargine insulin pen; 100 unit/mL (3 mL); Amount to Administer: 20 units; subcutaneous, once per morning. Review of progress note dated [DATE] read, Received verbal order to discontinue Accu checks as blood glucose is stable, resident has had no s/sx (signs and symptoms) of hypo/hyperglycemia. Review of R18's blood glucose levels for approximately 60 days prior to the progress note to discontinue Accu checks ([DATE] to [DATE]) revealed blood glucose levels ranging from 164mg/dL to 483mg/dL. On [DATE] at 11:41 AM, an interview was conducted with the DON regarding stable blood sugar levels. DON considered R18's blood glucose levels to be, unstable. Review of R18's MAR revealed no orders, including frequency or method, to monitor blood glucose levels after [DATE]. On [DATE] at 10:08 AM, an interview was conducted with Registered Nurse (RN) D who confirmed R18 was diagnosed with type II diabetes with orders for insulin. RN D identified signs and symptoms of hypoglycemia and verified resident had no orders for hypoglycemic management. RN D reported in the event of a hypoglycemic episode, she would call the attending physician for glucagon orders, if needed, and EMS. RN D verified there was no glucagon located on the unit medication cart. RN D was unable to locate glucagon in medication contingency room and relied on DON for assistance. On [DATE] at approximately 8:27 AM, R18 was observed with brown sugar and syrup on their breakfast tray. R18's tray card read, SS (sugar substitute) diet. Review of facility policy titled, Dietary Manual: Suggested Diets for Long-Term Care Facilities, revised ,d+[DATE] read in part, Regular with Sugar Substitute: This diet should be ordered for those residents with unstable blood sugars. Examples of unstable blood sugar are Fasting BS (blood sugar) over 150mg/dL, non-fast BS over 180mg/dL. Review of R18's care plan read, Problem: Resident is at risk of complication R/T (related to) DX (diagnosis) diabetes mellitus and, Approach Start Date: [DATE]. Diet as ordered. Resident #3 (R3) Review of R3's EMR revealed admission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and moderate dementia. Review of R3's physician orders with a start date of [DATE] revealed, Farxiga (dapagliflozin propanediol); 10 mg; amt (amount): 10 mg; oral, once a morning with orders to, notify physician for blood glucose readings less than 70 mg/dL or greater than 300 mg/dL, as needed. Review of R3's care plan identified problem, Resident is at risk of complications r/t DX diabetes mellitus with a goal that read, Resident will have blood glucose WNL (within normal limits) and absence of signs of hypoglycemia or hyperglycemia. An approach with the start date [DATE] read, monitor blood glucose as ordered. Review of R3's MAR revealed no orders, including frequency or method, to monitor blood glucose levels nor orders for treatment of hypoglycemia.

Based on observation, interview and record review the facility failed to provide the appropriate treatment and services to restore oral eating skills of one Resident (R12) of one who was maintained on enteral feedings. This deficient practice resulted in resident dissatisfaction with his quality of life and resorting to stealing of food from the dietary department so he could eat food by mouth rather than via a tube. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Review of R12's EMR (Electronic Medical Record) revealed the most recent admission to the facility as 7/31/23 with diagnoses including dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, gastrostomy status (a surgical procedure to insert a tube through the abdomen and into the stomach for feeding), diabetes mellitus and myocardial infarction (heart attack). The Care Plan for R12 revealed a Nutritional Status Problem: (R12) is at Nutritional / Hydration risk and receiving 100% of nutrition and hydration via tube feeding as well as po (by mouth) intake. This problem was initiated on 9/19/23 and included approaches of: - Diet per doctors order. Mech (mechanical) soft, thick liquids, no straws - Offer me a PB&J (Peanut Butter and Jelly) sandwich . pudding - Give Tube Feeding per doctors order Glucerna 1.5 (type of feeding flowing at) @ 120 cc (1/2 cup per hour) from 10 pm to 6 am The tube feeding provides 1440 calories per day during the night hours. On 11/29/23 at 08:38 AM, R12 was observed in the dining room and had only crusts of a sandwich left on his plate. He said he was not very hungry at breakfast. (His tube feeding runs all night and finishes in the morning.) R12 reported he did get peanut butter and jelly per his request, and he had consumed the entire sandwich except some of the crust. On 11/29/23 at 1:19 PM, R12 was observed in the dining room with a straw in a tumbler of chocolate milk. The chocolate milk had been consumed and only a splash of it remained at the bottom of the tumbler. R12 was eating his meal slowly. The EMR revealed a 11/15/23 Therapy Communication Note for R12 which read as follows: Recommendation: ST (Speech Therapy) Recommendation for Weaning patient off of peg tube: - Consult with dietician to begin reducing peg (percutaneous endoscopic gastrostomy) tube supplements to allow patient to begin eating more food. - Encourage snacks through out the day. - Encourage patient to increase water intake. This Communication Note indicated Therapy provides copies to the following: DON (Director of Nursing) and Dietary if related. The following day on 11/16/23 at 9:19 PM, the Registered Dietitian (RD) progress note read as follows Met with resident regarding current nutrition regimen. Resident receiving nocturnal TF (tube feeding) regimen of Glucerna 1.5 TF via PEG tube, 120ml [milliliters (1/2 cup)] from 10p-6a, with additional 100ml free water flush Q (every) 4. Total TF regimen provides 1440 kcal (kilocalorie)/day (calories per day), 78 gms (grams) protein/1420 ml free water/day, along with mechanical soft/thin liquid diet. PO (by mouth) intake had improved, d/t (due to) to upgrade in liquid status from nectar to thin. Avg. (average) intake 50-75% at this time with meals. Breakfast continues to be less than 50%, however, resident remarks that he has never been a big breakfast eater, intake at lunch and supper avg. 75%. RD and CDM (Certified Dietary Manager) met with resident to go over food preferences, in attempt to enhance kcal/protein options of choice, with meal card updated, dietary staff aware. Resident has had positive weight gain since admission (approximately 12.6lbs (pounds)x last 4 months (13.7%) however BMI(Body Mass Index) remains below average at 17. Resident remains risk for malnutrition at this time. Desires return to home. IDT (Interdisciplinary Team) to meet regarding outcome and RD continues to follow. The RD progress note did not address the ST communication even though it was written the day before. No reduction of the tube feeding per recommendation of the ST was considered. Calorie needs to continue to promote improved BMI and maintain this resident were not assessed. On 11/30/2023 at 9:02AM, the CDM progress note read as follows: This writer witnessed resident observing our food delivery over the last couple of weeks. I had asked res. (resident) if he was looking for anything in particular and he stated, no, I'm just looking. Yesterday afternoon I saw resident back down by the stock order. I walked away for a time and came back to have another staff member tell me that the res. had taken two 4 packs of chocolate pudding out of the case that was sitting there. I saw the resident going up the hall and I went to ask him if he had taken the pudding. He told me yes, two packs. I explained to him that if he wanted such things to ask me or other staff for them and that I needed to be accountable for all of the items in the order. He said ok. I will continue to monitor. During an interview on 11/30/23 at 1:50 PM, the recommendation from the ST was reviewed with the DON and the CDM. The DON stated recommendations go to the IDT and are discussed. The DON stated a previous recommendation on 11/7/23 had been discussed but she did not receive the 11/15/23 recommendation, so there had not been follow through. The CDM remarked she had observed R12 was stealing pudding. During an interview on 12/01/23 at 9:25 AM, R12 stated he was tired of the tube feeding and wishes it would go away.

Based on interview and record review, the facility failed to add or revise nutritional interventions in a timely manner for one (Resident #20) of twelve residents reviewed for care plans. This deficient practice resulted in the potential for unnecessary weight loss. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of R20's Minimum Data Set (MDS) Significant Change assessment dated [DATE] indicated R20 weighed 121 lbs. (pounds). A quarterly MDS assessment dated [DATE] indicated R20 weighed 112 lbs. which represented a 7.44% weight loss in approximately 30 days. Review of Dietary Progress note by the Registered Dietitian (RD) dated 9/19/23 read in part, Wt (weight) review: current wt 111#, signif (significant) wt loss 30, 90, 180 days, 13.4%, 17.2%, 23% respectively. wts have declined over the the (sic) last 6 months, po intake varies25-100% .no recommendations at this time, will continue to monitor. May be candidate for Hospice Services. Review of R20's nutrition care plan identified, Problem: Resident is at Nutritional/Hydration risk d/t (due to) cognitive impairment r/t (related to) Dementia with a goal that read in part, Resident will have adequate intake AEB (as evidenced by) no noted significant weight loss. R20's care plan revealed one updated goal since the Significant Change Assessment on 9/7/23 reading, Approach Start Date: 9/29/29. DPOA (durable power of attorney) wishes for resident have clothing protector on during meals. No other updates were evident on the care plan despite a documented 13.4% weight loss over the previous 30 days. Review of facility policy titled, Dietary Manual, Nutritional Assessment revised 4/21, read in part, Once a problem has been identified and the Dietitian has been consulted, the primary nurse should work with the Dietitian and resident in setting realistic goals and identify approaches to be used . No updated goals were evident in the care plan.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent new pressure ulcers from developing for one Resident (R14) of one resident reviewed for pressure ulcer care. This deficient practice resulted in two new, facility-acquired pressure injuries to R14's coccyx. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. During an observation and interview on 11/28/23 at 2:41 p.m., R14 was asked about the presence of any pressure ulcers. R14 stated, I don't know if I have any open areas on my bottom today . My rear is sore . During an observation of her bottom with Certified Nurse Aides (CNAs) L and M, the presence of one Stage II pressure injury to R14's coccyx was observed. CNA L and M said R14 had repeatedly complained about the presence of a hole in the air mattress. CNA M felt underneath the air mattress and stated, I found the hole here, as she guided this Surveyors hand to an under-inflated area in the middle of the bed where R14's buttocks was positioned. Review of R14's Minimum Data Set (MDS) assessment, dated 9/20/2023, revealed R14 was admitted to the facility on [DATE] with current, active diagnoses that included: neurogenic bladder, diabetes mellitus, paraplegia, anxiety disorder, depression and depression. R14 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The MDS assessment, Section M - Skin Conditions identified a risk for the development of pressure ulcers, with no Stage I or higher unhealed pressure ulcers present at the time of the assessment. During an interview on 11/29/23 at 1:44 p.m., when asked if she had observed R14's bottom (buttocks and coccyx) the Director of Nursing (DON) stated, No, I have not looked at her bottom at all. I have it scheduled for today. The DON confirmed R14 had previously complained about not being checked and changed (for incontinence and brief changes) and lack of repositioning. During an observation and interview on 11/30/23 at 8:49 a.m., the DON observed R14's bottom and confirmed the presence of two new Stage II coccyx pressure ulcers. Observation of R14's coccyx found two separate coccyx slits: two separate skin openings. R14 said it was because she had been left in wet and/or soiled incontinence briefs for too long. When asked who had removed the old air mattress, that R14 alleged had a hole in the middle of the mattress, the DON said Maintenance Staff C had removed the mattress from the bed on 11/28/23 after the start of the recertification survey. During an interview and observation on 11/30/23 at 8:58 a.m., Staff C observed the lavender colored air mattress removed from R14's bed on 11/28/23 in a back storage room with this Surveyor. Staff C unzipped the air mattress cover to reveal the air baffles inside the mattress. Staff C closely examined the 11th inflatable baffle (from the bottom of the mattress) and confirmed there was a hole in the baffle which would not allow the mattress to properly inflate with air. Staff C confirmed the lack of air in the 11th baffle would feel like a hole in the mattress to a resident laying on the mattress. Staff C documented the air mattress manufacturer and model number and said he would provide the Manufacturer's Instructions for Use for the air mattress removed from R14's bed. During an interview on 11/30/23 at 12:11 p.m., CNA L was asked if R14 had complained about the air mattress on the bed. CNA L said R14 had repeatedly said it felt like she was laying on the bed frame. R14 had complained about that for about a month. CNA M, also present during the interview, said she was present when [R14] complained about the discomfort of laying on the under-inflated air mattress. CNA M stated, I told the nurses, and we told [Staff C] . The afternoon aide [CNA N] . got [Staff C] and they looked at the bed. He said nothing was wrong with the bed. She would bring it up every so often. I think she just got tired of talking about it . I kept telling them she (R14) was sitting on the bed frame. Review of R14's Care Plans revealed the following ADL/Skin Integrity Approach: Approach Start Date 02/17/2023, Use pressure reducing air mattress . Review of the [Name Brand] 8 Alternating Pressure Mattress Replacement system with Low Air Loss User Manual, by [Corporation Name], dated 9/2020, revealed the following, in part: Pressure injuries are defined as localized injuries of the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear. Support surfaces or specialized mattress systems are used as part of an overall, multi-disciplinary, multi-dimensional care plan intended to prevent and treat pressure injuries . If the pressure is consistently low, open the zipper and confirm that all the hoses are properly connected. Then check for any noticeable leakage in any of the tubes. If necessary, contact your local dealer to replace any damaged tubes or hoses.

Based on observation, interview, and record review, the facility failed to provide care to prevent contamination of the urinary drainage system for one Resident (R15) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms between the floor and R15's urinary drainage system. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. Observation on 11/30/23 at 2:17 p.m., found R15 self-propelling in a wheelchair with the urinary drainage bag lying flat on the floor as he moved between several hallways in the facility. The urinary drainage bag was not placed in a dignity cover, and it loudly swished on the floor as the wheelchair made each roll forward. R15 moved from the dining room door entrance on the service hall to his room on the [NAME] Hall of the facility. No staff intervened to reposition the urinary drainage bag off the floor during his locomotion between the hallways. Review of R15's Minimum Data Set (MDS) assessment, dated 11/6/2023, revealed R15 was readmitted to the facility on [DATE] with active diagnoses that included obstruction uropathy, Alzheimer's disease, and dementia. R15 scored 99 (unable to complete) on the Brief Interview for Mental Status (BIMS) and was documented with Severely impaired cognition. R15 had an indwelling catheter. During an interview on 11/30/23 at 2:15 p.m., Certified Nurse Aide (CNA) M, standing outside of R15's room door with CNA L, stated, I just seen (sic) that. [CNA O] was supposed to switch (R15's urinary drainage bag to a leg bag). CNA M said CNA O was no longer working in the building that day. CNA M and CNA L both confirmed that R15's urinary drainage bag should not have been dragging on the hallway floors as he self-propelled in the building. CNA M said the urinary drainage leg bag was supposed to be put on when R15 was up in the wheelchair. Review of R15's Physician Order Report: 10/30/2023 - 11/30/2023 revealed the following, in part: CENA Flow Sheet: Order Type: General, Start Date: 1/30/2023 - Open Ended; Resident to have urine leg bag applied every AM and changed to a foley bag at HS (hour of sleep) every day. Twice a Dat: Days 07:00 AM - 11:00 AM [Central Standard Time (CST)], Evenings 08:00 PM - 10:00 PM (CST). Prescription: Start Date: 11/28/2023 - 12/04/2023, Sulfamethoxazole-trimethoprim tablet; 400-80 mg, amt: 1 tag; oral. Special Instructions: Per urology for UTI (Urinary Tract Infection). [DX (diagnosis): Urinary tract infection . During an interview on 11/30/23 at 2:15 p.m., the Director of Nursing and the Regional Clinical Director were asked about any concerns with R15's catheter urinary drainage bag dragging on the floor for an extended amount of time during locomotion in his wheelchair. The DON confirmed R15 was supposed to have a leg bag (for urine drainage) when up in the wheelchair. The DON said infection control was the concern and stated, (We) can't have it (urinary drainage bag) dragging on the floor. Review of the Incontinence Management Policy, reviewed 1/2022, revealed the following, in part: Staff will be educated to the infection control aspects of incontinence care as well as promoting the resident's dignity, privacy .

Based on interview and record review, the facility failed to implement nutrition interventions for two (Resident #12 and Resident #20) of twelve residents reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss and the potential for choking and aspiration. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of the weight history revealed R20 weighed 117.0 lbs. (pounds) on 9/3/23 and weighed 110.6 lbs. on 10/2/23, for a total weight loss of 6.4 lbs. This resulted in a 5.47% weight loss within a 30-day period. On 7/5/23, R20 weighed 132.4 lbs., which represented an additional 15.4 lb. weight loss equating to a 16.47% weight loss in 90 days. Furthermore, R20 weighed 141.2 lbs. on 4/2/23, an additional 8.8 lb. weight loss in 180 days. This represented a 21.67% in a total of 180 days. Review of the policy titled, Care Standards, Weight Monitoring reviewed 1/2023 read, The RD (registered dietitian)/CDM (certified dietary manager)/RDT must document on weight gains and losses of those residents that experience 5% for 30 days, 7.5% for 90 days, and 10% for 180 days in the medical record to meet the professional standards for Dietitians. Review of R20's medical records did not reveal documentation by dietary staff regarding weight loss in the month of October 2023 despite meeting the criteria stated in the facility policy. Review of R20's physician orders dated 10/6/23 revealed, administer 60mL (milliliters) of (Brand Name) supplement with medications BID (twice a day) daily. Review of R20's Medication Administration Record (MAR) dated 11/1/23 - 11/30/23 revealed 60mL (Brand Name) supplement was not administered from 11/7/23 to 11/14/23 with the reason listed as, Drug/Item Unavailable. On 11/30/23 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). When asked why R20 was not administered (Brand Name) supplement as ordered from 11/7/23-11/14/23, the DON stated either the facility was out of (Brand Name) supplement or the vendor was late with delivery. The DON stated that in these circumstances, the kitchen should have offered a replacement. On 11/30/23 at 12:19 PM, an interview was conducted with the Certified Dietary Manager (CDM). CDM A stated on the days (Brand Name) supplement was unavailable, she doubled R20's house supplement order as a substitute. CDM A was unable to provide documentation that indicated a substitute had been offered. Review of R20's Care Plan revealed, Problem: Resident is at Nutritional/Hydration risk d/t (due to) cognitive impairment r/t (related to) Dementia with listed goal as, Approach: encourage snacks between meals; assist as needed with start date of 6/6/23. Review of R20's Intakes (including AM snack, PM snack, bedtime snack, and supplements) revealed one snack and/or supplement was offered in the month of November (11/2/23), five in October (three snacks on 10/25/23, 10/16/23, 10/12/23), three in September (9/13/23, 9/6/23, 9/3/23), six in August (8/23/23, 4 snacks on 8/16/23, 8/3/23), four in July (7/26/23, 7/13/23, 7/9/23, 7/8/23), and two in June (6/23/23 and 6/7/23). No snack or supplement refusals were documented in the given period. On 11/30/23 at 1:44 PM, an interview with the DON was conducted regarding implementation of R20's care plan nutritional goal. The DON stated that patient should be offered a daily snack at minimum. When questioned why R20 was only offered one snack in the month of November the DON stated, I'm not sure, maybe the nursing staff aren't documenting correctly. The facility was unable to provide further documentation that snacks were offered to R20 according to the care plan. 40383 Resident #12 (R12) Review of R12's EMR revealed the most recent admission to the facility was 7/31/23 with diagnoses including dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, gastrostomy status (a surgical procedure to insert a tube through the abdomen and into the stomach for feeding), diabetes mellitus and myocardial infarction (heart attack). The Care Plan for R12 revealed a Nutritional Status Problem: (R12) is at Nutritional / Hydration risk and receiving 100% of nutrition and hydration via tube feeding as well as po (by mouth) intake. This problem was initiated on 9/19/23 and included approaches of: - Diet per doctors order. Mech (mechanical) soft, thick liquids, no straws - Offer me a PB&J (Peanut Butter and Jelly) sandwich . pudding - Give Tube Feeding per doctors order Glucerna 1.5 (type of feeding flowing at) @ 120 cc (1/2 cup per hour) from 10 pm to 6 am On 11/29/23 at 8:39 AM, R12's bedside table in his room was observed to contain a foam cup of water with a straw inserted. On 11/29/23 at 1:19 PM, R12 was observed in the dining room with a straw in a tumbler of chocolate milk. The tray card for R12 read in part, NO STRAWS. On 11/29/23 at 2:28 PM, R12's bedside table in his room was observed to contain water in a foam cup with a lid and a straw. During an interview on 11/29/23 at 1:30 PM, the Director of Therapy (Staff H) reviewed the EMR for R12 and confirmed the Speech Therapist notes indicated R12 was at risk for swallowing difficulties and should not have straws. In an email dated 12/1/23, the Speech Therapist (Staff P) confirmed the plan for R12. The email read in part: I made the no straws recommendation on 11/7/2023 when I re-evaluated him and upgraded him to thin liquids. I have continued to use the current plan of care since that time. To answer your question: ' So you recommended a continuation of the no straw recommendation for the reasons listed below. Correct? ' Yes, I recommend continuation of no straws. Review of the EMR revealed R12 weighed: - 97.6 lbs. on 11/11/23, - 104.6 lbs. on 11/16/23, - 95.8 lbs. on 11/25/23 No other follow up weights were observed. An interview was conducted on 11/30/23 at 2:00 PM, the DON and CDM stated reweights should occur if there was a 3 lb change in weight for a resident weighing less than 100 lb. and a reweight should also occur if there was a 5 lb. change in weight for a resident over 100 lbs. The EMR was reviewed with the DON and CDM for R12 and no reweights had been taken to verify the accuracy of the weights. The facility policy titled Monthly and Weekly Weights dated as reviewed on 1/2022, read in part: Reweights: conducted on resident that: a. Have experienced a 5% weight gain or loss from the previous month if current weight is over 100 lbs. b. Have experienced a 3 lb. weight loss or gain from the previous month if current weight is under 100 lbs. If a re-weigh is required it should be conducted in the presence of a licensed nurse and the weight recorded with the nurse's initials in the medical record, re-weights should be done within 48 hours .

Based on interview and record review, the facility failed to implement written Quality Assurance and Performance Improvement (QAPI) policies and procedures for adverse event monitoring after an insulin dependent Resident #27 (R27) became unresponsive, was sent to the emergency room , and expired that day. This deficient practice resulted in failure to determine root cause of significant change in condition and hospitalization to improve outcomes which could affect the entire facility population. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #27 (R27) Review of R27's electronic medical record (EMR) revealed readmission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, and sepsis. Record review of R27's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. Review of R27's Medication Administration Record (MAR) revealed a regular regime of two types of insulin: - Humalog KwikPen Insulin (insulin lispro) insulin pen; .before meals and - Lantus Solostar -subcutaneous, once a day The Physicians Orders for R27 included: - Glucagon (medication used to treat low blood sugar) Emergency Kit (human) (glucagon) recon (reconstituted) soln (solution); 1 mg (milligram); Amount to Administer: 1mg; injection, as needed. Special instructions: If UNCOOPERATIVE/UNCONSIOUS (sic) patient: If BS (blood sugar) <70mg/DL (deciliter) Give 1mg IM (intramuscular). May cause N/V (nausea/vomiting); Keep HOB (head of bed) elevated or position resident on either side. Notify physician for further orders. and - Fasting Accu (a device used to measure blood glucose levels) Checks x 3 days, once per morning. Review of R27's Progress Notes (nursing), revealed the following: - [DATE] 6:49 AM [CT (Central Time)] (5:28 AM CT) Writer was called to resident's room by Certified Nursing Assistant (CNA), reports that resident is unresponsive. Sternal rubbing and shaking would not arouse resident. Resident's eyes were rolled back in her head and pupils were responsive (constricted in response to light). VS (vital signs): T (temperature) 98.5, P (pulse) 69, RR (respiratory rate) 5 apneic (a temporary stop in breathing), B/P (blood pressure) ,d+[DATE], O2 sat (oxygen saturation) 91% on RA (room air), blood sugar read Lo (Manufacturer's Instructions indicated Lo meant the blood sugar sample tested was less than 20 mg/dL.) (5:40 AM CT) 1mg of glucagon was administered SQ (subcutaneous), 911 was called. (5:45 AM CT) CNA notified writer that resident had no pulse. (5:46 AM CT) ambulance arrived at facility and CPR was initiated. (6:07 AM CT) ambulance left the facility with the resident, resident had a pulse. - [DATE] 02:09 PM [CT (Central Time)] Per (Named Hospital) update resident passed away while at their care. DON (Director of Nursing) and MD (Medical Director) updated. On [DATE] at 10:00 AM, an interview was conducted with the Nursing Home Administrator (NHA) regarding the QAPI policy to determine the facility's procedure on data collection and monitoring for improvement including adverse events. The NHA presented the facility process on scope, feedback, monitoring, and activity of the Quality Assurance team. The NHA presented the QAPI committee meeting dates and sign in sheets for [DATE] and [DATE] (following the adverse event concerning R27). This insulin dependent Resident became unresponsive, noted was without pulse, CPR (Cardio -pulmonary Resuscitation) was initiated, was sent to the emergency room , expired that day, and was not reviewed in the QAPI process. The NHA stated there was not an investigation or an incident and accident report written regarding this event in the facility and emergency transport with death following the same day. The NHA stated she was called at home regarding R27 being sent to the hospital and agreed this was an adverse event. With regards to the QAPI procedure, the NHA said, No one identified there was an event that needed to be discussed. During an interview on [DATE] at 10:27 AM, the Director of Nursing (DON) was asked why a statement was not taken from the aides who were present after the adverse event regarding R27. The DON provided no answer. During further discussion, the DON stated deaths were reviewed. The question was posed, if there was a formal meeting after the resident death of R27 (i.e. a ground huddle, team meeting, a QAPI discussion, an all-staff meeting) to discuss the incident, the outcome, and ways to improve in the future? The DON responded No. When asked if this event could have been used to identify gaps in the diabetic management system, she replied, Yes, I can see that. The facility policy titled: Quality Assurance and Performance Improvement dated as ,d+[DATE] was reviewed. This policy read in part: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: . b. Systems and reports demonstrating systematic identification, reporting, investigation, analysis and prevention of adverse events. An Adverse Event was defined in the policy as an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof. The policy included guidelines which read in part: 3. A. The facility maintains procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. b. The facility draws data from multiple sources including . viii. Incident and accident reports, including reports of adverse events . 4. Program Activities - b. Medical errors and adverse events are routinely tracked. i. Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event. ii. An investigation will be conducted on each identified medical error or adverse event to analyze causes. iii. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education .

Based on observation, interview and record review the facility failed to follow established vendor provided menus on two of two days meals were observed. This deficient practice has the potential to result in inadequate meal nutrition for any and all 26 residents. Findings include: (all reported times are in EST) On 11/29/23 at 1:00 PM observations of the noon meal were made. The steam table contained stainless steel pans with mashed potatoes and a meat/gravy mixture. An interview with CDM (Certified Dietary Manager) was conducted and was learned the meal being served was shepherd pie as the main course. A review of the menus provided revealed the menu for 11/29 was scheduled to be meat loaf, mashed potatoes, gravy, and peas. On 11/30/23 at 9:00 AM, it was observed the steam table contained croissant sandwiches, Canadian bacon, oat meal, and toast. A review of the menu for this specific day identified waffles and French toast as the meal. On 11/30/23 at 1:00 PM it was observed the steam table contained fish nuggets as the main course. A review of the menu provided for 11/30 showed that sweet and sour chicken thighs was scheduled. A review of all menus provided to the survey team, none corresponded to the meals being observed to be served for two days. These menus were titled with the facility's parent corporation name, with individual columns identifying the day of the week (Sunday through Saturday), with each day's column specifying the date the meal was to be served. On 11/30/23 at 1:45 PM, an interview was conducted with CDM A related to the menus and food being served. CDM A stated We have a five week menu cycle but only use 4 weeks. We flex the last week. When asked to explain what flexing the menu meant., CDM A was unable to explain. The menus were shown to CDM A with the actual dates of the month (i.e. 11/29 and 11/30) written at the top of the column for each day, with the menu items listed in a box/cell for each respective meal, CDM A stated, Oh, those dates don't mean anything. When asked what that meant, CDM A again stated the facility flexes the menu. A review of menus in the kitchen, located in notebooks, from which the cooks worked, had only four weeks. Every day of every week had some menu item scratched out and a new item hand written in. There was no evidence the registered dietitian was evaluating and approving the menus or the daily changes being made.

This citation pertains to Intake #MI00132859. All times are Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to prevent verbal abuse for two Residents (#21 and #25) of nine residents reviewed for abuse during resident to resident incidents. This deficient practice resulted in psychosocial harm for Resident #21, with feelings of fear, helplessness, and vulnerability. Findings include: Review of Resident #21's Minimum Data Set (MDS) assessment, dated 06/20/22, revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including paraplegia (paralysis of lower extremities), pressure ulcer, kidney disease, anxiety, and depression. Resident #21 required extensive two-person assistance for bed mobility, and was dependent for transfers, toileting, and locomotion (bed dependent). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15, which showed Resident #21 had intact cognition. Review of the Resident #25's MDS assessment, dated 08/27/22, revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including heart failure, liver disease, dementia, bipolar disorder, psychotic disorder, delusional disorder, intellectual disability, and somatoform disorder (neurological symptoms without medical explanation). Resident #25 was independent with bed mobility, transfers, locomotion (wheelchair mobility), and toileting. The BIMS assessment revealed a score of 15/15, which showed Resident #25 had intact cognition. The Behavioral Assessment showed Resident #25 had physical behavioral symptoms directed at others four to six days during the assessment period, and verbal behavioral symptoms directed at others one to three days during the assessment period. Review of an investigation summary provided via email on 12/01/22, by the Nursing Home Administrator (NHA), revealed a Resident to Resident verbal altercation between Resident #21 and Resident #25, on 09/02/22. Resident #21 reported to her son, Family Member (FM) AA, Resident #25 was calling her negative names. The Social Services (SS) Director, Licensed Practical Nurse (LPN) Z, interviewed Resident #21, who reported Resident #25 had entered her room on 09/02/22 and called her something like old lady motor mouth. The Administrator (former) was notified, and when interviewed Resident #21 reported Resident #25 had called her a big lady motor mouth [expletive]. FM AA reported they observed Resident #25 backing out of Resident #25's room (upon their arrival to the facility), and heard Resident #21 yell for Resident #25 to leave their room. Registered Nurse (RN) P was walking towards Resident #21's room with FM AA, and reported they heard Resident #21 state, [Resident #25]; get out! Resident #25 was interviewed, and denied the incident, but reported she did not like Resident #21. Resident #21 reported Resident #25 left the room when asked, but did not understand why Resident #25 did not like her. The intervention was Resident #21 was reminded to use their call light when needed, and was provided with a wrist whistle additionally for assistance. The facility administration concluded Resident #25 did enter the doorway of Resident #21's room and called her names. During an observation on 11/30/22 at 1:58 p.m., Resident #25 was observed wheeling her wheelchair quickly down the hallway from the dining room, and reported she was headed to her room to get a sweater. During an observation on 12/01/22 at 9:08 a.m., Resident #21 was laying in their hospital bed. Review of LPN Zs interview/witness statement, dated 09/09/22, revealed the NHA (former) reported, [ .Resident #21 reported feeling unsafe as she is bedbound [bed dependent] and cannot move if [Resident #25] were to ever lay hands on her . Review of Resident #21's interview/witness statement, dated 09/02/22 at approximatley 4:30 p.m., revealed, .[Resident #21] doesn't understand why [Resident #25] won't leave her alone, but [sic] doesn't know what [Resident #25] is capable of. [Resident #21] said she has heard stories of [Resident #25] hitting other people, and [Resident #25] makes her nervous. [Resident #21] told me that she did not like that [Resident #25] had called her a big lady motor mouth [expletive]. [Resident #21] said that [Resident #25] had done this on numerous occasions. [Resident #21] said she doesn't know why [Resident #25] is after her and won't leave her alone. [Resident #21] has the feeling that [Resident #25] may do something to her, and [Resident #21] is incapacitated and unable to defend herself . Review of the Electronic Medical Record (EMR) showed Resident #21 and Resident #25 had been roommates prior to this incident, which Resident #21 confirmed. Review of Resident #25's current Care Plan revealed, Problem: Resident is unable to make consistent daily decisions without cues/supervision for safety R/T [related to] DX [diagnoses] intellectual difficulties, bipolar disorder with restlessness and agitation at times .Approach: In new situation, provide support and reassure to reduce stress and potential agitation .Approach: Give feedback to resident when inappropriate decisions are made .Approach: Determine if decision made by the resident may be negative to the resident or others . Review of Resident #21's current Care Plan revealed no interventions to address Resident #21's reported feelings of fear, helplessness, and vulnerability from the verbal incidents perpetrated towards her by Resident #25, or interventions to provide support, monitoring, or prevention of these occurrences. During an interview on 11/28/22 at 1:58 p.m., Resident #25 was asked about her involvement in any resident to resident incidents. Resident #25 denied any incidents with other residents, and showed Surveyor her room, and how well she made her bed. During an interview on 12/01/22 at 9:09 a.m., Resident #21 reported Resident #25 was a meanie (a mean person), Resident #21 reported when Resident #25 came to their room as a new roommate Resident #25 said, 'I don't like you .', and called her a motor mouth [expletive]. Resident #25 reported Resident #21 said this to her repeatedly and added, It was a daily thing [occurrence]. Resident #21 reported to management staff and Resident #25 was moved to the end of the hall. Since then Resident #25 still came to her door and repeatedly called her a motor mouth [expletive]. Resident #25 stated, It happened this week .They [staff] got me a whistle . Resident #25 showed Surveyor a whistle on her nightstand, but reported this still did not make her feel comfortable with Resident #25, as Resident #21 heard Resident #25 slapped one of the residents. Resident #21 added, [Resident #25] is only two doors down, and [the former NHA] said it was verbal abuse .Yes, that's what I would call it. Surveyor confirmed Resident #25 was two doors down, on the same side of the hall. During further interview (per Resident #21's request) on 12/01/22 at 9:25 a.m, Resident #21 reported Resident #25 also started holding up her middle finger [a rude gesture] to her in the last month, and was giving her the Sign of the Cross [a religious prayer gesture]. Resident #21 reported [LPN Z] said to her, Be very careful, as that woman [Resident #25] doesn't like you. Resident #21 stated, I am being targeted . Resident #21 reported more incidents [including a similar 11/24/22 verbal incident, and the gestures] occurred two days this past week. Resident #25 said she started to shake when the recent incidents occurred, and said, I was scared. Resident #21 further reported FM AA says, 'It's dangerous, and they [staff] don't watch her.' Resident #21 stated, What happens if [Resident #25] gets up at night? There is always a first time [clarified as a physical incident], and I don't sleep well at night [due to fear of Resident #25]. Resident #21 shared she was fearful of what Resident #25 could do to her, such as punching or a physical assault, and was fearful of an injury, given her health problems. Resident #21 reported FM AA was scared for her, and both had talked to management, yet the incidents were still occurring. Resident #21 reported she had filed a grievance. During a phone interview on 12/01/22 at 09:41 a.m., FM AA stated there were several verbal incidents perpetrated towards his mother by Resident #25. FM AA reported Resident #25 would give Resident #21 inappropriate hand gestures, including the finger, and yelled at Resident #21, saying, I'm going to get you, motor mouth. FM AA clarified they had heard Resident #25 say this to Resident #21, and staff gave Resident #21 a whistle to alert staff, which Resident #21 did not use. FM AA reported Resident #21 was upset and fearful of Resident #25, including of a physical altercation. FM AA reported they had spoken to current and past administrators, nursing management staff, and social services staff, with no change in Resident #25's behaviors towards Resident #21. Staff told them Resident #25 was redirectable. FM AA reported they did not agree, as Resident #25's verbal behaviors towards his mother had continued. FM AA stated sometimes they [nursing management] have one aide working in the whole place, and cannot provide adequate supervision of Resident #25, especially when they are short staffed. FM AA reported they told a nursing staff person [who they declined to name] they were going to report the incidents (to the State Agency), and the staff asked them not to report, stating they would face retaliation. FM AA reported these incidents towards Resident #21 by Resident #25 had been going on for months, as well as towards other facility residents. FM AA reported they spoke to the NHA a few days ago with their concerns, and were again told Resident #25 was redirectable. Review of Resident #25's progress note, dated 08/12/22, revealed, .Asked resident [#25] if she called her roommate [Resident #21] 'motor mouth [expletive].' [Resident #25] replied 'Yes, but I won't do it again'. [Resident #25] also confirmed that she takes [Resident #21's] newspaper without asking 'but I give it back when I am done' Inquired what [Resident #25] should do differently in these instances. [Resident #25] replied, ' .I should ignore [Resident #21] instead of calling her names .' Review of Resident #21's Grievance Complaint Form, dated 08/12/22, revealed, .[Resident #21] upset; reported that her roommate [Resident #25] called her a 'motor mouthed [expletive]' several times. Per [Resident #21], 'That is the last straw.' Other complaints including her roommate taking her newspaper without asking. Keeping the bathroom door open when using the bathroom, and general rudeness.IDT [Interdisciplinary Team] met and decided to move the roommate [Resident #25] .[Resident #25] confirms each complaint did occur. [Resident #25] moved to room [#] . The grievance was signed by LPN Z on 08/12/22, and addressed by 08/14/22. Review of Resident #25's Behavioral Care provider summary, dated 02/15/22, revealed, XXX[AGE] year old female is seen for depression and delusions .staff agree [Resident #25] does better without a roommate .Previous history of aggression or violence: Yes . Review of Resident #25's Behavioral Care provider summary, dated 04/15/22, revealed, XXX[AGE] year old female is seen for bipolar and delusions .[Resident #25] fixates on her next door neighbor [unnamed roommate] repeating things throughout the day, this irritates her . Review of Resident #25's Behavioral Care provider summary, dated 06/30/22, revealed, .[Resident #25] had a recent altercation with another resident and had to move rooms. [Resident #25] fixates on her new roommate [Resident #21, per census], says [Resident #21] talks on the phone a lot and it frustrates [Resident #25] at times . Review of Resident #25's Behavioral Care provider summary, dated 09/02/22, revealed, .[Resident #25] continues to fixate on other residents and their noises and lights at night. Says they irritate [Resident #25] . Review of Resident #25's Behavioral Care provider summary, dated 10/17/22, revealed, .[Resident #25] has been bothering her old roommate [Resident #21], will purposely go into [Resident #21's] room down the hall however says [Resident #25] wants nothing to do with her . Review of Resident #25's Behavioral Care provider summary, dated 10/28/22, revealed, .Staff state [Resident #25] was seen spitting her medications into the toilet, they [staff] have been closely monitoring [Resident #25's] medication administration since . Review of Resident #25's progress notes revealed Resident #25 had physical altercations where she was the perpetrator with another facility resident on 05/19/22, 06/10/22, and 07/12/22. Review of Resident #25's progress note, dated 11/24/22 at 3:23 p.m., by RN P , revealed, .I was informed by [Resident #21] as soon as her son left, [Resident #25] came to [Resident #21's] doorway, and called her a 'motor mouth'. I approached [Resident #25], who was at the nurses station at this time, if [Resident #25] had gone past [Resident #21's] room and [Resident #25] said, 'Yes'. I then repeated what [Resident #21's room] said and [Resident #25] said, 'I apologize; I don't want to be in trouble. I won't do it again' .As I [RN P] am writing this, I heard [Resident #25] say to another resident, 'Get away from me,' and as I turned, [Resident #25] pushed the handle on the back of the resident's chair as she [Resident #25] made her way to her own room. Review of Resident #25's progress note, dated 06/09/22 at 7:08 a.m., revealed, [Resident #25] does have a hx [history] of verbal and physical behaviors particularly towards current and past roommates. Behaviors typically occur when she is upset with current and past roommates . Review of Resident #25's progress note, dated 03/08/22, revealed, .[Resident #25] does have a hx of verbal and physical behaviors towards current and past roommates . Review of Resident #25's behavioral tracking logs (for 15 minute checks) showed no behavioral monitoring/tracking on 11/15/22 from 7:00 a.m. to 5:00 p.m., on 11/16/22 from 7:00 a.m. to midnight, and on 11/17/22 through 11/31/22. During an interview on 11/30/22 at 12:47 p.m., RN P confirmed Resident #25's behavioral management tracking logs should have been completed by staff on the missing dates, as behavioral incidents were occurring, including a resident to resident incident involving Resident #25 towards Resident #21 a week ago [on 11/24/22], when RN P was working. Review of Resident #25's behavioral tracking log, dated 11/24/22, was not completed, when a similar verbal abuse incident occurred perpetrated by Resident #25 towards Resident #21. During an interview on 11/30/22 at 12:47 p.m., the NHA confirmed the behavioral management tracking logs for Resident #25 were accurate, including the missing entries during November, 2022. During an interview on 12/01/22 at 10:37 a.m., the DON and LPN Z acknowledged verbal abuse had occurred to Resident #21, post review of the resident to resident incidents (which Resident #25 perpetrated towards Resident #21) . Both understood the need for increased supervision and effective interventions for Resident #25, as evidenced by the missing behavioral tracking logs and several resident to resident incidents towards Resident #21, which continued to recur. Both acknowledged Resident #21 would benefit from additional support and monitoring when they understood Resident #21 experienced psychosocial harm as a result of the repetitive, multiple resident to resident verbal abuse incidents. During an interview on 12/01/22 at 8:30 a.m., the Regional Operations Director, NHA S, and the NHA acknowledged the concerns with the multiple, ongoing resident to resident verbal altercations (which Resident #25 perpetrated towards Resident #21), the missing behavioral monitoring tracking during November, 2022, and Resident #21's adverse psychosocial outcomes of fearfulness and vulnerability, given the resident, family member, nursing staff, social services staff, and administration were reporting and documenting verbal abuse. Both reported they understood the deficient practice. Review of the policy, Abuse Prevention Program Policy and Procedure, reviewed 01/2022, revealed, Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse .[Facility Organization] has abuse prevention programs in which policies and procedures safeguard our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint .verbal, mental and sexual [abuse] . A resident to resident altercation should be reviewed as a potential situation of abuse .Investigations for potential abuse will not be dismissed in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. During the investigation, it will be identified that the actions were willful were deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm .Mental or Verbal Abuse: Mental abuse is the use of verbal or nonverbal actions, which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, agitation, or degradation .

Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent falls for three Residents (#1, #2 and #4) from three reviewed for falls. This deficient practice resulted in a fracture of the pinky finger for Resident #2, a fracture of the left arm for Resident #4 and a fall with hospitalization for Resident #1. Findings include: Resident #1 According to electronic medical record (EMR), Resident #1 was admitted to the facility on [DATE], with dementia, hearing loss, urine retention with long term use catheter, high blood pressure, hand contractures, acute kidney failure, history of falls, weakness and unsteady gait. An Event Report, dated 8/7/22 revealed Resident #1 fell from bed when he rolled over. The Resident suffered a bruise with a bump to the right forehead and was sent to the hospital and diagnosed and admitted with [CONDITION(S)] and urinary tract infection ([CONDITION(S)]). The investigation revealed the Resident wore a strap type catheter secure device, in contrast to the Care Plan, which instructed an adhesive secure device only. The strap device cut off the circulation, according to hospital records, to the right leg, which became numb, causing an apparent fall from bed, and subsequent circulation problems resulting in necrotic toes and comfort measures only. The Care Plan was updated on 8/12/22 to place a fall mat on the floor next to the bed when the Resident was in bed. Several observations during the survey, including on 9/28/22 at 10:20 a.m. and 1:15 p.m., 9/29/22 at 7:50 a.m. and 8:28 a.m. and 9:30 a.m., revealed no floor mat in the room or in place on the floor when the Resident was in bed. The Care Plan also instructed to maintain frequently used items within reach, dated 8/21/22, and lock wheel chair brakes when transferring, dated 5/26/22, and one person assist with transfers with walker and gait belt, as well as with ambulation and toileting, dated 5/26/22. Resident #1 had two subsequent falls on 8/21/22 and 9/20/22. The Resident, according to the Event Report, was reaching for something from bed on 8/21/22. On 9/20/22, according to the Event Report, the Resident was returning from the bathroom, transferring to bed, alone. Resident #2 According to the EMR, Resident #2 was admitted on [DATE], was moderately cognitively impaired, with diagnoses including [CONDITION(S)], [CONDITION(S)], progressive [CONDITION(S)], depression, anxiety, hallucinations, weakness, tardive dyskinesia (involuntary movements secondary to certain medications) and others. The Resident required assistance with walking, toileting, and transfers. Resident #2 had 8 falls between 8/1/22 and 9/19/22, on 8/1/22, 8/4/22, 8/5/22, 9/2/22, 9/7/22, 9/15/22, 9/17/22, and 9/19/22. On 9/28/22 at 10:35 a.m., Resident #2 was observed in her room leaning over the right side of the wheel chair. The Resident had no activity or busying items in the room and paced in the chair around the room. The Event Report for the fall on 8/1/22 revealed Resident #2 was trying to pick up something from the floor. The Witness Statement, dated 8/1/22 authored by Staff G confirmed the Resident was trying to pick up a puzzle piece from the floor. The Witness Statement, dated 8/1/22, authored by Certified Nurse Aide (CNA) H revealed Resident #2 was anxious and wandering in and out of rooms and pulling at the bottom of the bed frame looking for the dog. The facility investigation revealed the Resident was sent to the hospital for evaluation following confusion, increased tardive dyskinesia symptoms, cold and clammy skin and was diagnosed with a concussion. The Care Plan instructed provide diversional activities, dated 8/4/22 and monitor, redirect and anticipate increased agitation, dated 2/24/22. The Event Report for the fall on 8/4/22 revealed the Resident was with family prior to the fall, and then found at the foot of the roommate's bed on the floor. The Witness Statement, dated 8/4/22 and authored by Licensed Practical Nurse (LPN) I, revealed the Resident went to look out the window at family leaving prior to the fall. The Care Plan instructed diversional activities following family visits. On 8/5/22 Resident #2 was self transferring, according to the Event Report, dated 8/5/22. The Care Plan instructed assist of one with transfers, dated 6/17/22. On 9/2/22, Resident #2 was trying to pick up food from the floor and fell . On 9/7/22, Resident #2 said she tripped over the fall mat while trying to walk to the bathroom. On 9/15/22, Resident #2 was walking back to bed from the bathroom when she fell . On 9/17/22, Resident #2 could not remember what she was doing when she was found on the floor in the room. The progress note, dated 9/17/22, revealed, .was on floor with feet toward door and head toward window, lying on her right side, there was an area of pooling blood under her head .right hand .Large hematoma rose beneath middle knuckle on dorsal side of hand and resident was unable to squeeze my fingers with that hand. Sent to [hospital] . The progress note, dated 9/18/22, revealed a fracture of the right pinky as a result of the fall. The investigation following the fall with fracture did not discuss prior falls at all, nor analyze time of day, staffing, visitations (problematic trigger according to the care plan) or other possible root causes. On 9/19/22, Resident #2 was trying to pick up her spoon when she fell . None of the above events demonstrated sufficient root cause analyses to determine why Resident #2 continued to fall or interventions to prevent repeated falls based on a root cause. Resident #4 According to the EMR, Resident #4 was admitted on [DATE] with diagnoses including dementia with behavior, weakness unsteady on feet, chronic obstructive pulmonary disease, anxiety, [CONDITION(S)] disorder, depression, and was severely cognitively impaired. The Resident required extensive assistance for transfers, walking and toileting. The Event Report, dated 8/21/22, revealed Resident #4 was found on the floor on his knees, leaning on the bed with his left arm between the bed and the recliner. The left arm was painful and the Resident would not allow assessment by the nurse. The Resident had no footwear on. The Witness Statement, dated 8/21/22, authored by CNA J revealed transferring the Resident was more difficult since 8/19/22 and he reported increased back pain. The Witness Statement, dated 8/21/22, authored by CNA K also revealed Resident #4 had increased back pain for several days prior and nursing was aware. The Witness Statement, dated 8/21/22, authored by CNA L also noted decreased mobility over the previous couple of weeks. The progress note, dated 8/21/22, authored by Registered Nurse (RN) B, revealed, .Resident was found on his knees next to bed and recliner, with his left arm between the bed and recliner .was crying out My arm! I can't move it, it hurts! The facility investigation revealed R #4 had a fractured left arm, and was returned to the facility from the hospital, with a sling. The investigation concluded a fall with fracture but did not address the decreased mobility in the investigation or show that during the prior weeks when the decrease was known, any new interventions were put into place to prevent a fall. During an interview on 9/28/22 at 1:36 p.m. the Director of Nursing (DON) said the social services designee had access to care plans and she herself updated them after falls, but to be honest with you, I don't know who else does this. The DON confirmed floor nurses did not update care plans following falls. During an interview on 9/29/22 at 9:40 a.m., RN B said she remembered vividly Resident #4's fall on 8/21/22. RN B confirmed the Resident was never independent with transfers and usually needed assistance of one or two staff with the sit to stand lift. RN B described the fall and her response, which was congruent with the investigation. The policy Fall Prevention and Management, dated 1/2022, revealed, .to assess resident risk for falls and implement interventions to reduce the incidence of falls and/or mitigate the risk of injury related to falls .Licensed nurses will complete fall risk assessments on residents upon admission, quarterly, and [as needed] .The Director of Nursing of clinical leader will review post-fall documentation to ensure .contributing factors have been identified .If intervention/preventive measure is appropriate based on the root-cause of the fall .care plan has been updated .Communication to direct care staff .complete an evaluation detail and investigation analysis summary .

Based on observation, interview and record review, the facility failed to identify and monitor a change of condition and follow the care plan regarding catheter secure device, for one Resident (#1), from three reviewed for change in condition. This deficient practice resulted in a urinary tract infection, with [CONDITION(S)] (a life threatening blood infection), endocarditis (a life threatening heart valve infection caused by [CONDITION(S)]) and necrotic (dead) untreatable toes, with admission to the hospital, and resultant end of life comfort care. Findings include: According to the electronic medical record (EMR), Resident #1 was admitted to the facility on [DATE], with dementia, hearing loss, urine retention with long term use catheter, high blood pressure, hand contractures, acute kidney failure, history of falls, weakness and unsteady gait. According to the Event Report, dated 8/7/22, Resident #1 fell out of bed on 8/7/22 at 1:15 a.m. The Resident stated he turned over in bed and fell out. The Resident suffered a large bruise to the right forehead. Vital signs at that time revealed Resident #1 had a temperature of 101.4, a lying blood pressure of 155/67, and a pulse of 153 (all indicative of early [CONDITION(S)]). The Report confirmed contributing factors including a urinary tract infection ([CONDITION(S)]), cognitive impairments, hearing loss, and balance problems. The Report indicated Resident #1 was sent to the emergency department for evaluation, due to the bruise on the forehead, elevated temperature and pulse. The report further indicated the Resident was admitted for [CONDITION(S)] and [CONDITION(S)]. The Witness Statement, dated 8/7/22, indicated Resident #1 toileted himself independently. The root cause analysis indicated the Resident was self transferring, but that was not congruent with the Resident's statement. The Care Plan instructed monitoring for changes in condition, dated 6/3/22. The Care Plan also instructed to monitor blood pressure for high blood pressure problem, dated 5/26/22, instructed to assist to bath room for safety, dated 5/26/22, a one person assist for transfers and ambulation, dated 5/26/22. The Care Plan also instructed the following, dated 5/26/22, Use adhesive leg anchor to secure (catheter) tubing NOT leg strap. dated 5/26/22. The hospital emergency room triage note, dated 8/7/22, revealed, .Chief Complaint: Altered mental status and confused and fall .was found on the floor in the nursing home, he has a [history] of dementia, but his mental status is altered .has a bruise and bump above right eye .has a [catheter] in place from nursing home .right leg is discolored/bluish from tight band around his upper thigh, left leg is warmer to touch than right leg .had fever, weakness, and trouble walking .[CONDITION(S)] screen positive . The Discharge Summary from the hospital, printed 8/12/22, revealed [CONDITION(S)] (new diagnosis), endocarditis mitral valve (new diagnosis), and others. The education provided on discharge included a drawing with explanation of a catheter strap acting like a tourniquet resulting in loss of circulation to the toes causing infection and gangrene, not a candidate for surgery, with [CONDITION(S)], [CONDITION(S)] and endocarditis, not a candidate for surgery, on comfort care. The Summary also showed an echocardiogram finding of, .Anterior Mitral Leaflet is very much thickened with 1.5 cm (centimeter) diameter VALVE VEGETATION .Moderate Mitral Regurgitation present . (new findings). The facility investigation of a complaint related to Resident #1's care revealed allegations of catheter secure device was too tight and caused foot problems, the facility did not identify a [CONDITION(S)], the facility did not change the catheter since admission, and the facility did not supervise the resident to prevent a fall. The investigation revealed the Resident told the nurse on duty (Now the Director of Nursing (DON)) his right leg was numb, after he fell from bed. The DON observed the right leg to be discolored. The DON checked the strap and did not find any concerns. (However, the care plan clearly instructed no strap device to be used.) The investigation confirmed a temperature of 101.6 and rapid pulse following the fall on 8/7/22. The DON said in the investigation there were no signs of infection prior to the fall. But, the hospital emergency room note of 8/7/22 noted the Resident was on [MEDICATION(S)] 100 mg (milligrams) twice daily for [CONDITION(S)]. The investigation confirmed the catheter was not changed since admission from 5/26/22 to 7/4/22, when the order for monthly changes was discontinued. The rationale was the monthly change did not comport with CDC (Centers for Disease Control) guidelines. The investigation did not account for clarifying the order with the ordering provider. The order was simply not followed. During an interview on 9/29/22 at 10:32 a.m., Registered Nurse (RN) F confirmed no catheter changes were performed since admission on 5/26/22. The physician order, dated 5/26/22 instructed a change of the urinary catheter monthly. A statement as part of the facility investigation, dated 8/21/22, revealed, .He (Resident #1) is independent and self transfers . This was incongruent with the care plan. The statement was authored by CNA D an agency staff. The Interview, undated, with the DON, revealed the DON checked Resident #1's blood pressure on the shift of the fall on 8/7/22. But, the EMR revealed no vital signs documented since 8/4/22. The progress note, dated 8/7/22 revealed a temperature of 101.6 and pulse of 153, but no other vital signs. During an interview on 9/29/22 at 8:45 a.m., the DON confirmed she was the nurse on duty on 8/7/22 when Resident #1 fell from bed. The DON was asked about the condition and vital signs of the Resident when he fell . The DON did not directly answer. When asked if there was a [CONDITION(S)] protocol in place, the DON was confused and did not understand the question. When asked if there was a procedure to follow to detect early [CONDITION(S)], the DON said she didn't think so. When asked what early [CONDITION(S)] signs and symptoms were the DON could not say except that blood pressures and temperatures could vary. When asked about the catheter secure device as an adhesive versus a strap design, the DON said she was not aware at the time it was supposed to be an adhesive device. On 9/28/22 at 1:15 p.m., Resident #1 was in the room in a wheel chair with the right foot uncovered. The entire foot was purple red with blotchy patches up to the mid shin. The second and third toes were black and stuck to the adjacent toes which were fluid filled and had excoriating skin. The toes were clearly infected and deadened. The Resident said he could not eat his lunch on the tray because he had to look at his foot and lost his appetite. During a follow up interview on 9/28/22 at 1:36 p.m., the DON was asked about a [CONDITION(S)] screening tool and whether one was used in the facility, and replied there was a McGeer's criteria used. The DON said she thought the McGeer's criteria was the [CONDITION(S)] screen but wasn't sure. Then, the DON said she didn't know what a [CONDITION(S)] screen was and none was used in the building, and she never was educated on using one as a floor nurse. On 9/29/22 at 9:30 a.m., Physician (Staff) E was at the bedside in Resident #1's room with Family Member (FM) C and this Surveyor. Staff E confirmed the Resident's right toes were necrotic and infected and dying due to a circulation (arterial) problem, not venous stasis, and that the Resident was not a surgical candidate for amputation of the foot. On 9/29/22 at 10:26 a.m., Resident #1 was observed asleep in the bed, with no mat on the floor (per care plan). FM C was in the room and said there was an indentation on the leg from the strap in the hospital and provided pictures taken by hospital staff confirming the indentation with markings where the strap was and included the discoloration of the right leg. FM C said the very next day after the Resident was readmitted to the facility the strap was back on the leg, and provided a picture of the same. The Care Plan revealed a problem of open area to right foot on 9/15/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/29/22 at 11:25 a.m., the DON was asked what the wounds (necrosis) of Resident #1's toes were, and responded they were arterial ulcers from PVD. When asked why the care plan said they were venous ulcers, the DON did not know. When asked if there was a difference in treatment and care for arterial versus venous ulcers, the DON stated, I don't know. The Event Report, authored by the DON, dated 9/13/22, revealed a venous ulcer on the top of the right second toe, with a scab. The policy Notification of Change, dated 2/2022, revealed, .The Licensed nurse will use professional judgement any time that in their opinion the resident requires immediate medical attention .When made aware of a change in condition of a resident the Licensed nurse will perform and assessment based on their professional judgement that may include: vital signs, mental status, major diagnosis, current pertinent medications .skin assessment .

Based on observation, interview and record review, the facility failed to assess and treat pressure ulcers for one Resident (#6) from three reviewed for pressure ulcers. This deficient practice resulted in the worsening of the Resident's pressure ulcers to stage 4 with hospitalization , a wound vac system and pain. Findings include: During an interview on 9/28/22 at 3:46 p.m., Registered Nurse, (RN) A confirmed Resident #6 returned from the hospital on 9/27/22 with wound clinic orders for wounds to both hip wounds and two wounds to the back that had a wound vac system in place. RN A said the pharmacy did not yet have the ordered medication, but it would arrive the following day. RN A said she contacted the wound clinic who clarified the care could be done the following day for the wound vac. RN A confirmed she was the wound nurse in the building as of about one week after her hire the month prior. RN A said she took the certification classes, but was as yet unable to test for wound care certification. RN A said when she first saw Resident #6's wounds in August 2022, she was horrified; they were necrotic, infected and had an odor that forced her to use an [MEDICATION(S)] under her nose while in the room. RN A said she insisted on sending the Resident to the emergency department to be evaluated and told facility leadership This is gonna kill him. According to the electronic medical record (EMR) Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/28/22 at 3:55 p.m., wound care was observed provided by RN A with the Director of Nursing (DON) assisting. Resident #6 was uncovered to expose the wound vac tubing lying over the abdomen, indented into the very fragile, thin skin. Both RN A and the DON confirmed education was needed for all staff, visitors and the Resident regarding the tubing positioning as the observed situation would likely cause more wounds. Both hip trochanter bones had stage 4 approximately 4-6 cm (centimeter) round wounds with brown/gray wound bases that appeared dying and had areas of green, and were odorous. Both dressings were saturated with a brown exudate. RN A said the wounds were unstageable or stage 2 when the Resident left for the hospital and were most likely debrided to reveal the current wounds. RN A said the first time she saw the wounds the odor was unbearable and the wounds were clearly infected and uncared for. RN A provided care per orders, but did not treat the two back wounds that had the wound vac system in place. The Resident had a new deep tissue injury to the coccyx. RN A said the Resident was very difficult to reposition as he had rigidities and an uncooperative family member who came to reposition him incorrectly. The Resident's skin was very fragile, thin and translucent. The DON leaned her weight on the Resident's legs and this Surveyor had to ask twice before she lifted her weight from the Resident. RN A confirmed the wounds to the back were almost twice as large as prior to hospitalization and had significantly worsened from lack of appropriate care. The wound vac was not observed changed. During an interview on 9/29/22 at 11:44 a.m., RN A said she didn't know how Resident #6's wounds got so bad, but when she was hired on 8/22/22 and saw them she insisted he go out to the hospital. RN A said the DON was the wound nurse then and no treatments for the infection was being provided; only dressings applied to control the drainage. The wounds were full of necrotic tissue. RN A said the corporate RN was in and saw the wounds and agreed to send the Resident out to the hospital. RN A said the DON was not doing the assessments and measurements weekly. During an interview on 9/29/22 at 11:48 a.m., RN F confirmed she saw Resident #6's wound with RN A and was immediately concerned and agreed to call the physician for an order to send the Resident to the hospital. RN F said the Resident's wound to the back was narrower, but slightly longer than a hand, half the size visualized dressed with the wound vac system. Weekly skin assessments revealed the following: 9/27/22: Stage 4 pressure ulcers to back and bilateral hips 9/12/22: No new areas. Pressure areas being monitored by treatment nurse. No areas of the body were marked. 9/6/22: Area on Left hip is beginning to open. 8/30/22: No areas of skin impairment was checked. 8/25/22: No new skin alterations noted. 8/19/22: No new shin alterations noted. 8/1/22: No changes noted to skin at this time. Wound to coccyx and back remain unchanged with [treatment] in place. 7/28/22: Pressure ulcers continue to coccyx and spine. Redness noted to right hip. 7/15/22, 7/12/22, 7/5/22 and 7/19/22: No areas of skin impairment. Weekly Pressure Ulcer Progress Reports revealed the following: 9/28/22 by RN A in house acquired stage 4 pressure ulcer to left hip (trochanter) with moderate (#4) pain, 5.3 X 6.1 X 1 cm with copious drainage, wet to dry dressings and deterioration noted, wound was stage 2 when resident was sent and admitted to hospital for wound infection. Resident returned with stage 4 with exposed muscle tissue Physician, dietician and family notified. In house acquired right hip stage 4 with moderate pain, 4.3 X 5 X 0.8 cm, with copious drainage, deteriorated. 9/9/22 By RN A right side spine unstageable admitted with wound, with moderate pain, 13.7 X 6.6 cm, copious drainage, purulent foul odor, deteriorated and a mid spine unstageable 11.8 X 4.3 with copious drainage, purulent and foul odor On 9/9/22 both hip wounds were staged at 2. From 8/9/22 to 9/28/22 all wounds almost doubled in size and went from stage 2 or unstageable ulcers to stage 4 ulcers. Resident #6's Care Plan revealed pressure ulcers to the back that were present on admission. The goal was to heal the ulcers without complications, target date 10/1/22. The Plan instructed assessments, dated 7/26/22, and skin inspections per protocol on 7/26/22. The Care Plan noted at risk for skin breakdown, with goal of skin remaining in tact, target date 10/1/22. The Care Plan had no mention of stage 4 pressure injuries to bilateral hips. The Care Plan was absent specific positioning instructions for the Resident's wounds. The policy Pressure Injury Prevention and Care, dated 1/2022, revealed, .To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution .Physician/provider will be notified if pressure injury shows sings of deterioration, infection, or no improvement for further evaluation and recommendations regarding treatment and interventions .Update the resident care plan to address the areas of pressure injury, and approaches initiated .

Based on observation, interview and record review, the facility failed to appropriately assess, monitor and care for a urinary catheter, for one Resident (#1), from three reviewed for catheter care. This deficient practice resulted in repeated urinary tract infections ([CONDITION(S)]), circulatory deficiency, [CONDITION(S)], with endocarditis (a life threatening heart muscle infection), hospitalization with necrotic toes, and subsequent end of life comfort care. Findings include: According to electronic medical record (EMR), Resident #1 was admitted to the facility on [DATE], with dementia, hearing loss, urine retention with long use catheter, high blood pressure, hand contractures, acute kidney failure, history of falls, weakness and unsteady gait. According to the Event Report, dated 8/7/22, Resident #1 fell out of bed on 8/7/22 at 1:15 a.m. The Resident stated he turned over in bed and fell out. The Resident suffered a large bruise to the right forehead, had a temperature of 101.4, a lying blood pressure of 155/67, and a pulse of 153 (all indicative of early [CONDITION(S)]). The Report confirmed contributing factors including a urinary tract infection ([CONDITION(S)]), cognitive impairments, hearing loss, and balance problems. The Report indicated Resident #1 was sent to the emergency department for evaluation, due to the bruise on the forehead, elevated temperature and pulse. The report further indicated the Resident was admitted for [CONDITION(S)] and [CONDITION(S)]. The Witness Statement, dated 8/7/22, indicated Resident #1 toileted himself independently. The root cause analysis indicated the Resident was self transferring, but that was not congruent with the Resident's statement. The Care Plan instructed monitoring for changes in condition, dated 6/3/22. The Care Plan also instructed to monitor blood pressure for high blood pressure problem, dated 5/26/22, instructed to assist to bath room for safety, dated 5/26/22, a one person assist for transfers and ambulation, dated 5/26/22. The Care Plan also instructed the following, dated 5/26/22, Use adhesive leg anchor to secure (catheter) tubing NOT leg strap. dated 5/26/22. The hospital emergency room triage note, dated 8/7/22, revealed, .Chief Complaint: Altered mental status and confused and fall .was found on the floor in the nursing home, he has a [history] of dementia, but his mental status is altered .has a bruise and bump above right eye .has a [catheter] in place from nursing home .right leg is discolored/bluish from tight band around his upper thigh, left leg is warmer to touch than right leg .had fever, weakness, and trouble walking .[CONDITION(S)] screen positive . The Discharge Summary from the hospital, printed 8/12/22, revealed [CONDITION(S)], endocarditis mitral valve, and others. The education provided on discharge included a drawing with explanation of a catheter strap acting like a tourniquet resulting in loss of circulation to the toes with infection and gangrene, not a candidate for surgery, with [CONDITION(S)], [CONDITION(S)] and endocarditis, not a candidate for surgery, on comfort care. The facility investigation of a complaint related to Resident #1's care revealed allegations of catheter secure device was too tight and caused foot problems, the facility did not identify a [CONDITION(S)], the facility did not change the catheter since admission, and the facility did not supervise the resident to prevent a fall. The investigation revealed the Resident told the nurse on duty (Now the Director of Nursing (DON)) his right leg was numb, after he fell from bed. The DON observed the right leg to be discolored. The DON checked the strap and did not find any concerns. (However, the care plan clearly instructed no strap device to be used.) The investigation confirmed a temperature of 101.6 and rapid pulse following the fall on 8/7/22. The DON said in the investigation there were no signs of infection prior to the fall. But, the hospital emergency room note of 8/7/22 noted the Resident was on [MEDICATION(S)] 100 mg (milligrams) twice daily for [CONDITION(S)]. And the facility Event Report, authored by the DON, noted a [CONDITION(S)] as a contributing factor in the fall. The investigation confirmed the catheter was not changed since admission from 5/26/22 to 7/4/22, when the order for monthly changes was discontinued. The rationale was the monthly change did not comport with CDC (Centers for Disease Control) guidelines. The investigation did not account for clarifying the order with the ordering provider. The order was simply not followed. Resident #1's Care Plan revealed .signs of [CONDITION(S)] (acute confusion .fever .) During an interview on 9/29/22 at 10:32 a.m., Registered Nurse (RN) F confirmed no catheter changes were performed since admission on 5/26/22. The physician order, dated 5/26/22 instructed a change of the urinary catheter monthly. A statement as part of the facility investigation, dated 8/21/22, revealed, .He (Resident #1) is independent and self transfers . This was incongruent with the care plan. The statement was authored by CNA D an agency staff. The Interview, undated, with the DON, revealed the DON checked Resident #1's blood pressure on the shift of the fall on 8/7/22. But, the EMR revealed no vital signs documented since 8/4/22. The progress note, dated 8/7/22 revealed a temperature of 101.6 and pulse of 153, but no other vital signs. During an interview on 9/29/22 at 8:45 a.m., the DON confirmed she was the nurse on duty on 8/7/22 when Resident #1 fell from bed. The DON was asked about the condition and vital signs of the Resident when he fell . The DON did not directly answer. When asked if there was a [CONDITION(S)] protocol in place, the DON was confused and did not understand the question. When asked if there was a procedure to follow to detect early [CONDITION(S)], the DON said she didn't think so. When asked what early [CONDITION(S)] signs and symptoms were the DON could not say except that blood pressures and temperatures could vary. When asked about the catheter secure device as an adhesive versus a strap design, the DON said she was not aware at the time it was supposed to be an adhesive device. On 9/28/22 at 1:15 p.m., Resident #1 was in the room in a wheel chair with the right foot uncovered. The entire foot was purple red with blotchy patches up to the mid shin. The second and third toes were black and stuck to the adjacent toes which were fluid filled and had excoriating skin. The toes were clearly infected and deadened. The Resident said he could not eat his lunch on the tray because he had to look at his foot and lost his appetite. The catheter drainage bag was hanging on the wheel chair arm above the level of the bladder. During an interview on 9/28/22 at 1:33 p.m., RN A confirmed the catheter drainage bag should always be below the level of the bladder and not on the floor. During an interview on 9/28/22 at 1:36 p.m., the DON confirmed the catheter drainage bag should always be below the level of the bladder and not on the floor. The DON said Resident #1 would throw his drainage bag on the floor. When asked if any education or care plan interventions for education/explanation of the drainage bag was in place or happened previously, the DON confirmed it was not. During a follow up interview on 9/28/22 at 1:36 p.m., the DON was asked about a [CONDITION(S)] screening tool and whether one was used in the facility, and replied there was a McGeer's criteria used. The DON said she thought the McGeer's criteria was the [CONDITION(S)] screen but wasn't sure. Then, the DON said she didn't know what a [CONDITION(S)] screen was and none was used in the building, and she never was educated on using one as a floor nurse. On 9/28/22 at 2:55 p.m., CNA M was observed performing catheter care with Resident #1. There was white pus at the insertion site, which CNA M confirmed was not normal. RN A and the DON came to assess and both confirmed the pus was not normal. The DON, also the Infection Preventionist, said there was a urine analysis and culture awaiting results. The DON later confirmed a positive [CONDITION(S)]. The Resident's urine was orange/yellow and clear in the drainage bag. The Resident's penis was deeply split at least two inches below the meatus and had a side insertion site for the catheter. There was a streak of bright redness in the penial tissue from the head to the catheter insertion site. On 9/29/22 at 9:30 a.m., Physician (Staff) E was at the bedside in Resident #1's room with Family Member (FM) C and this Surveyor. Staff E confirmed the Resident's right toes were necrotic and infected and dying due to a circulation (arterial) problem, not venous stasis, and that the Resident was not a surgical candidate for amputation of the foot. On 9/29/22 at 10:26 a.m., Resident #1 was observed asleep in the bed, with no mat on the floor (per care plan). The catheter drainage bag was on the floor not covered by a dignity bag. FM C was in the room and said there was an indentation on the leg from the strap in the hospital and provided pictures taken by hospital staff confirming the indentation with markings where the strap was and included the discoloration of the right leg. FM C said the very next day after the Resident was readmitted to the facility the strap was back on the leg, and provided a picture of the same. During an interview on 9/28/22 at 2:07 p.m., RN A confirmed she was the wound nurse and Resident #1's toes were arterial wounds that started as a small scabbed wound to the second right toe on re-admission from the hospital. At that time, the right second and third toes were blackened and stuck to the adjacent toes, which were pus filled with macerated skin. RN A said cleaning between the toes was not possible due to the toes would most likely fall off if moved. The right foot was cold according to RN A. The entire foot was reddened to the ankle. The Care Plan revealed a problem of open area to right foot on 9/15/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/29/22 at 11:25 a.m., the DON was asked what the wounds (necrosis) on Resident #1's toes were, and responded they were arterial ulcers from PVD. When asked why the care plan said they were venous ulcers, the DON did not know. When asked if there was a difference in treatment and care for arterial versus venous ulcers, the DON stated, I don't know. The Event Report, authored by the DON, dated 9/13/22, revealed a venous ulcer on the top of the right second toe, with a scab. During an interview on 9/29/22 at 9:20 a.m., the DON confirmed she checked the drainage bag strap for tightness on the day of the fall, but didn't know then that the secure device was supposed to be an adhesive device, not a strap. On 9/29/22 at 9:30 a.m., Resident #1 was in the room with Staff E and Family Member (FM) C. The catheter drainage bag was on the floor. The Care Plan had no documented education of Resident #1 explaining the importance of keeping the drainage bag off the floor or below the bladder, or the medical need for the catheter. The policy, Incontinence Management, dated 1/2022, and confirmed by the DON on 9/29/22 at 3:28 p.m. as the only policy addressing catheter care, revealed, .Care planned approaches for catheter usage will include avoidance of infection, signs and symptoms of infection including pain, medical necessity for ongoing usage .avoidance of problems resulting of continued catheter usage .Based on current professional standards of practice, information and education for the resident .on the identification of risks and benefits for the use of a catheter must be documented .

This deficiency is related to Intake #MI 036. Based on interview and record review, the facility failed to provide adequate supervision during transfer from bed to wheelchair which resulted in harm with a fractured femoral head ([CONDITION(S)]) for one Resident (#8) of four residents reviewed for falls. This deficient practice resulted in harm as evidenced by an unassisted fall to the floor, left femoral head (hip) fracture, lack of a complete post-fall assessment, delayed diagnostic x-ray evaluation of Resident #8's left leg/hip, and a significant increase in pain. Findings include: Review of Resident #8's Minimum Data Set (MDS) assessment, dated 2/22/22, revealed Resident #8 had been a long-term resident in the facility and had active diagnoses that included: mild intellectual disabilities, [CONDITION(S)], and non-Alzheimer's dementia. Resident #8 required extensive, one-person physical assistance with bed mobility and transfers between surfaces and scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderately impaired cognition. Pain assessment on the MDS assessment documented no pain in the last five days. Review of a 4/17/22 Fall Event Report for Resident #8 revealed the form was completed by the Director of Nursing (DON) on 5/2/22. The Event Report revealed Resident #8 was transferring from bed, right knee buckled and was lowered to floor with immediate post fall complaints of right knee pain. The fall was witnessed by Certified Nurse Aide (CNA) H. During an interview on 5/2/22 at 12:24 p.m., Licensed Practical Nurse (LPN) C was asked about Resident #8's fall in the facility. LPN C said Resident #8 had cried in pain for days until a second order for an Xray of the left hip/leg was obtained by a facility nurse. LPN C said his left leg/hip was broken for a week before the x-ray on the left side was completed. Review of Resident #8's nursing progress notes revealed the following: 4/18/22 5:45 a.m. [Central Daylight Time (CDT)]- Resident had complaints of right knee pain. 4/17/22 he was being transferred from bed to w/c (wheelchair) when his right knee buckled, and he was lowered to the ground. No c/o (complaint of) pain at the time. This am resident had c/o right knee pain nursing gave resident Tylenol. Right knee palpated and resident did not c/o (complain of) pain. Right knee is free of visible injury no redness no bruising no [CONDITION(S)] . 4/20/22 8:10 a.m. (CDT) - Resident having increased pain to both left and right thighs from knees to hips related to recent fall .fax sent . to (physician) office requesting increase in pain medication and x-rays ., written by Licensed Practical Nurse (LPN) B. 4/20/22 9:13 a.m. (CDT) - New order for Xray to right femur, knee, and hip . No orders for Xray to left knee, femur, hip at this time ., written by LPN B. 4/20/22 5:33 p.m. (CDT) - Xray's completed at facility, all views are negative (of right hip/leg/knee) . 4/22/22 12:54 p.m. (CDT) - Resident continues to receive PT (physical therapy) services . Therapy reports decreased in tolerance d/t (due to) pain of BLE (bilateral lower extremities) . 4/23/22 9:50 a.m. (CDT) - Resident (#8) continues to have pain down both thighs. Greater pain noted to left thigh, hip, and knee. [MEDICATION(S)] in place, bio freeze applied, [MEDICATION(S)] given . 4/24/22 10:22 a.m. - [Resident #8] continues to have pain down left thigh this morning . 4/27/22 8:58 a.m. - Pain noted to lower back and left thigh this AM . 4/28/22 1:37 p.m. - New order received . X ray left hip, thigh, and knee. Xray lumbar back related to increased pain post being lowered to the floor incident . 4/30/22 5:21 a.m. - Resident x-rays sent 5am. The results are: X-ray of Femur = (equals) Acute Left Femoral Neck FX (fracture). X-Ray of Hip and Pelvis show femur FX . 4/30/22 7:09 a.m. - New order to send to . ED (Emergency Department) to have pinned (surgical repair of left hip) . Resident continues to have increased pain. Ambulance called for transfer . 5/3/22 9:08 a.m. - .resident (#8) had surgery yesterday (5/2/22) to left femur fracture, area pinned . Review of Resident #8's Physical Therapy Treatment Encounter Notes, dated 4/14/22 through 4/29/22, revealed the following physical therapy documentation: Date of Service 4/21/22 - Clinical approached Patient twice to participate in skilled therapy services, w/Patient agreeing second attempt. Patient reported he was in (sic) experiencing pain in L (left) hip/thigh area and was in tears. Clinical assisted Patient in static stands at parallel bars x 2 w/Moderate physical assist and consistent verbal cueing for sequencing. Patient was visibly in pain. Clinical reported findings to DON and is going to look future into pain. Patient had Xray on RLE (right lower extremity - came back negative - Patient is telling clinician L side . Date of Service 4/27/22 - Patient reported pain in L hip/thigh/knee area - CENA staff reporting Patient c/o of only L sided pain. DON was informed and contributes it to being arthritis or possible sciatica . Date of Service 4/28/22 - Patient performed static stands at parallel bars x 2 w/Patient complaining of slight discomfort of L hip/thigh area .Patient reported pain in L hip/thigh/knee area in which Clinician has been talking with nursing about this ongoing pain. Today nursing reached out to Physician to investigate further Xrays. During an interview on 5/3/22 at 11:16 a.m., Physical Therapist (PT) O and Physical Therapy Assistant (PTA) N confirmed Resident #8 had continued to participate in physical therapy following the fall with fracture on 4/17/22. Both staff confirmed they were aware of his increased pain, and reported it to the DON and nursing staff, until an x-ray was finally obtained of Resident #8's left leg/knee/hip on 4/29/22 (12 days post fall), identifying the left femur fracture. Review of Resident #8's April 2022 Medication Administration Records (MARs) revealed the following pain documentation: [MEDICATION(S)] ([MEDICATION(S)] adhesive patch for pain) was added to Resident #8's MAR on 4/23/22 - for increased complaints of pain. [MEDICATION(S)], as needed for pain was started on 4/19/22, with doses administered on 10 of 12 days between 4/19/22 and 4/30/22. Acetaminophen 325 mg, 2 PO (by mouth) for mild discomfort was initiated 7/1/16, but in April of 2022, doses were administered on 4/17 through 4/30/22. On 4/17 the Pain Location was documented on the MAR as l (left) leg. Bio freeze topical gel 0.5% was started on 4/22/22 to apply to bilateral knees for pain. Pain Assessments for Resident #8 between 4/1/22 ant 4/16/22 revealed assessments were completed three times daily with a pain rating of 2 out of 10, on four individual assessments. Beginning on 4/17/22 (day of fall) through 4/20/22, Resident #8's pain was documented between 2 to 5 out of a scale of 10, on 25 separate pain assessments. Review of Resident #8's Radiology Reports revealed x-rays of the right femur, right knee, and right hip and pelvis revealed no fractures on 4/20/22, three days post fall (fall on 4/17/22). Radiology Reports of x-rays completed on 4/29/22 (12 days post fall) revealed Acute left femoral neck fracture. During a telephone interview on 5/3/22 at 8:00 p.m., CNA H confirmed she had been assisting Resident #8 with a transfer from bed to the wheelchair on 4/17/22 when he fell to the floor with an unidentified injury. CNA H confirmed she did not use a gait belt to assist Resident #8 with the transfer, was not standing within reach of the Resident, and did NOT lower the resident to the floor. Resident #8 fell to the floor when his legs buckled. CNA H said she repeatedly told nursing staff she had not lowered him to the floor, but it remained in the progress notes. When asked about a post fall physical assessment, CNA H said Registered Nurses (RNs) T and D did not complete a head-to-toe assessment, compare leg lengths, or assess for internal/external rotation of the legs prior to moving the Resident from the floor back into bed. CNA H said by Friday, 4/22/22, Resident #8 was screaming and crying in pain. He could not get out of bed and when he was rolled in bed he was crying out in pain. During an interview on 5/4/22 at 10:14 a.m., RN T said she had heard CNA H calling for help on 4/17/22 when Resident #8 was on the floor. RN T said it was not a fall - because the CNA was behind him holding him. RN T said when RN D returned from a break the post fall assessment had been completed by RN D. RN D denied having completed a post fall assessment, because she thought it had been done by RN T. RN T said they did not apply a gait belt prior to lifting Resident #8 from the floor back into the bed, and she did not check for any injuries. During an interview on 5/4/22 at 10:48 a.m., the DON and Regional Clinical Nurse K were asked about the nursing note that stated Resident #8 was lowered to the floor. The DON said that RN D had reported that when she called and informed the DON of the situation. When the DON was asked what the definition of a fall was, she stated, Anytime it is an unintentional position change. Review of the facility Fall Prevention and Management Policy, revised 2/2020, revealed the following, in part: .Procedure: . 2. When a fall event occurs, a licensed nurse will: A. complete an immediate physical assessment of the resident . B. Complete a fall event/incident report. C. Notify the physician and responsible party. D. Initiate orders from the physician, if indicated E. Interview or obtain staff statements to determine events surrounding the fall E. (SIC) Implement an appropriate intervention/preventive measure F. Document the occurrence and any follow-up in progress notes G. Communicate the fall on the 24-hour report H. Monitor the resident and follow-up if indicated . 4. The Director of Nursing of clinical leader will review the fall, events surrounding the fall, intervention, and post-fall documentation with the IDT during morning clinical meeting to elicit IDT input and recommendations, and determine if additional investigation is needed. 5. The director of Nursing or clinical leader will complete an evaluation detail and investigation analysis summary . During an interview on 5/4/22 at 11:27 a.m., Regional Clinical Director K, in the presence of the DON was asked about the lack of supervision and failure to follow the facility fall policy regarding Resident #8's fall with major injury (femur fracture) on 4/17/22. Regional Clinical Director K acknowledged staff education would be provided to timely report to the nurse, assess the resident for injury before removing from the floor, completion of notification to the responsible party, follow up with any physician order, and implement interventions based on the cause of the fall. Regional Clinical Director K confirmed an incident report should have been completed timely, with statements from witnesses, and a gait belt or Hoyer lift should have been used to remove Resident #8 from the floor.

Based on interview and record review, the facility failed to ensure critical services were provided for an acute change in condition for one Resident (#111) of ten residents reviewed for advance directives. This deficient practice resulted in delay in Resident #111's treatment for [REDACTED]. Findings include: On [DATE] at 11:21 a.m. an interview with Family Member (FM) G revealed the following: I called (facility) to talk to (Resident #111) and (Licensed Practical Nurse (LPN) H) goes (Resident #111)'s been unresponsive .and we don't know what's happening. So then I called my son, and then the emergency room . (The emergency room ) advised me to call an ambulance, so I did that, and the facility turned it away. When asked why the ambulance was turned away, FM G stated the ambulance agency stated LPN H told emergency personnel not to come, because Resident #111 was a No Code, and he was dying. So (the facility) must have found out (Resident #111) didn't have a Do Not Resuscitate order in place. So then (the facility) called the ambulance back and then sent (Resident #111) to the hospital. Then I went up to the hospital and (Resident #111) was completely unresponsive .Then they took (Resident #111) to (Regional Acute Care Medical Center) later that day or the following day because (Resident #111) had a really bad infection. (Resident #111) was up there for two weeks, and then he died [MEDICAL CONDITION] (whole body infectious process) .his blood pressure dropped and they couldn't get it back. The ambulance people were the ones who told me the facility turned them away. FM G provided the ambulance agency and staff member's name. FM G stated she had documentation from the local emergency service provider which stated, LPN H informed the emergency services personnel Resident #111 was recently released from the hospital where he had signed a DNR order. So I am assuming (LPN H) is the one who turned (emergency services personnel) away. Then they had to call them back (when it was known Resident #111 was a full code). Review of the face sheet provided by the facility for Resident #111 dated [DATE] revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a History & Physical dated [DATE] provided by the facility revealed Resident #111 had a fall down multiple stairs on [DATE] and underwent spinal neck surgery to address the fractures sustained from the fall. Review of the Discharge Summary provided by the facility dated [DATE] revealed a full code status (all life saving measures necessary to sustain life). A review of the Progress Notes from admission on [DATE] through discharge on [DATE] provided by the facility revealed the following: [DATE] 1:15 p.m. (CST) Patient non verbal this morning, unable to answer questions appropriately. VS (Vital Signs) BP (Blood Pressure) ,[DATE], P (Pulse) 60, R (Respirations) 18, T (Temperature) 97.5 SPO2 (Oxygen Saturation) 95% on room air .New order to send to ER for a A psychiatric evaluation. (Local Ambulance) here at 12:15 p.m. (CST) (written by LPN H) [DATE] 8:09 a.m. (CST) Called (Local Hospital) for update on resident (#111) and was informed he had been transferred to (Acute Care Regional Health Center) for [MEDICAL CONDITION]. (Written by RN O) Resident #111 Readmitted to the facility on [DATE] at 6:00 p.m. (CST) according to the face sheet dated [DATE] provided by the facility. Review of the Patient Discharge Instructions provided by the facility from the Acute Care Regional Health Center dated [DATE] revealed Resident #111 was discharged as a Full Code. A Progress Note dated [DATE] at 6:55 p.m., for Resident #111, read as follows: (Physician) notified. New orders given for [MEDICATION NAME] (Sedative) 1 mg (milligram) by mouth twice a day prn (as needed). [MEDICATION NAME] (antipsychotic) 0.25 mg by mouth twice day. [MEDICATION NAME] (Antidepressant) 30 mg by mouth once a day for one week and then increase to 60 mg once a day. Document behaviors and notify (Physician) of increased behaviors. The above Progress Note was written by LPN H within an hour of the time of readmission, indicating LPN H was part of the readmission process for Resident #111. Review of Progress Notes for Resident #111 since readmission on [DATE] through [DATE] at 2:04 a.m. (CST) revealed no significant concerns or signs of decline. Review of a Progress Note dated [DATE] at 4:25 p.m., revealed the following: Patient was non responsive this shift, with periods of apnea. Unable to arouse with verbal commands and a sternal rub. (FM G) called. (FM G) called the police and stated we were refusing to send him to the hospital. (Physician) notified and gave orders to send him to the hospital. (Local Ambulance) called and were here at 4:15 p.m. (CST). (Written by LPN H) Review of a Progress Note dated [DATE] at 9:16 p.m. revealed the following: Phoned ED (Emergency Department) for update on resident (#111). Was admitted to ICU (Intensive Care Unit) [MEDICAL CONDITION], altered mental status and fever. Will follow up with (Local Hospital) at a later time. (Written by RN N) On [DATE] at 11:59 a.m. an interview with Emergency Services Personnel (ESP) J revealed the following: ESP J stated he remembered the incident surrounding FM G who had called for a transfer to the hospital for Resident #111. ESP J stated the local Public Safety Officer (PSO) K had relayed communication he had with (LPN H) at the facility who stated (Resident #111) was a DNR (Do Not Resuscitate). ESP J stated the Emergency Services stood down at that time. ESP J stated they were called back to transport (Resident #111) via 911 for emergent transfer to the hospital later. ESP J stated, I told (PSO K) something is fishy about this one, you better write a good report. ESP J was aware of Resident #111 dying at the Regional Medical Center due to complications [MEDICAL CONDITION]. On [DATE] at 12:09 p.m., an interview with PSO L revealed the following: It was at 3:59 p.m. We received a call on [DATE] from (FM G) who called dispatch and advised us (Resident #111) was not being allowed to go to the hospital. Our officer called the facility and spoke with (LPN H) who was a nurse at the facility. (LPN H) stated (Resident #111) was recently released from the hospital, and (Resident #111) had signed a DNR. (LPN H) also advised there was no power of attorney, and (Resident #111) was on his death bed. We then got another call from . our dispatch, and we then transported (Resident #111) to the hospital later. On [DATE] at 2:20 p.m., an interview with LPN H revealed the following: (Resident #111) was fine most of the day, I had tried to get a hold of (Resident #111) family, and when I finally got a hold of (FM G), she wanted him to go to the hospital, and while we were getting (Resident #111) ready to go, the police station called and said (FM G) was reporting we were refusing to send (Resident #111) to the hospital, which wasn't the case. So (Resident #111) vitals were stable. (Resident #111) was responding but lethargic. I had given (Resident #111) an [MEDICATION NAME] (sedative/hypnotic) because he was flip flopping in bed. (Resident #111) was stable up until we sent him out. (Resident #111) kind of went unresponsive for like a five minute period, so we decided to send him out. I called (Physician I), and (Physician I) decided to send (Resident #111) out (to the acute care hospital for evaluation). We weren't going to send (Resident #111) out when (Emergency Services) called, and then (Resident #111) went unresponsive, so we decided to call 911 and send (Resident #111) out (to the acute care hospital for evaluation). When asked why PSO L would have stated LPN H declared Resident #111 was a DNR and declined the need for emergency services, LPN H stated, See that's the thing, one place said (Resident #111) was a DNR (in the EMR (electronic medical record)) and the physical chart said (Resident #111) was a full code. I went with what I saw first which was (Resident #111) was a DNR. When asked if anyone looked into who made the input error in the EMR for Resident #111's code status, LPN H stated, I don't know what happened after that, because we got a new DON (Director of Nursing), and she took all the advanced directives off the computer, and told us not to enter the code status in the EMR anymore. LPN H then admitted to making the error in identifying the code status of Resident #111, which delayed needed emergent care. On [DATE] at 2:55 p.m., an interview with LPN M revealed the following: When asked where the code status would be located in the event a resident needed emergency care for a change in condition, LPN M stated, In the front of their physician chart. It's quicker than logging in to the computer. The code status would also be in the care books for each wing, which also contain CNA (Certified Nurse Aide) care guides, Care plans, shower sheets, and fax communications. (Code status) is in the computer in the DPOA papers, and (code status) should be in their face sheet, and on the front flap of the paper chart. I have been here since approximately July (2020), and the process has not changed since I have been there. A review of the facility document for Resident #111, titled Medical Treatment Decisions Of Resident, dated [DATE], revealed the following: Do you wish to prepare an advance directive at this time? Yes I wish to have cardiopulmonary resuscitation (CPR) Yes I wish to be hospitalized if medical staff feels it to be necessary Yes The document was signed by Resident #111, and witnessed by RN N on [DATE]. The document was signed by Physician I on [DATE]. The face sheet for Resident #111, dated [DATE] , provided by the facility, read in part, There are no Advanced Directives selected for this resident. A review of the facility care plans provided via EMR care plan report, revealed no guidance for Resident #111 for advance directives. A review of the facility policy, Advance Directives, dated ,[DATE], read in part: .Full Code: In the event of respiratory and/or [MEDICAL CONDITION], 911 will be called, and the resident will receive all resuscitative measure, including but not limited to CPR (Cardiopulmonary Resuscitation) until EMS (Emergency Medical Services) arrives. In the absence of a DNR (Do Not Resuscitate) order, a resident will be considered a full code .if the person for whom surgical or medical treatment is recommended is not of sound mind, or is not in the condition to make decisions for himself, the written consent of such person's nearest relative, or legally appointed guardian, or person standing in loco parentis (in place of a parent), shall be secured before such medical or surgical treatment is given. This may allow someone who is not a legal healthcare decision maker, to consent to treatment, but NOT to withhold or withdraw life-sustaining treatment .Place copies of all paperwork in chart. A review of www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc- 214, accessed on [DATE], revealed the following: Sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection.[MEDICAL CONDITION] occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically. This may lead to death.[MEDICAL CONDITION] is caused by infection and can happen to anyone.[MEDICAL CONDITION] is most common and most dangerous in: Older adults .People who have chronic conditions, such as diabetes, kidney or lung disease, [MEDICAL CONDITION] .Early treatment of [REDACTED].Most often,[MEDICAL CONDITION] occurs in people who are hospitalized , or who have recently been hospitalized .Risk factors .Have diabetes or [MEDICAL CONDITION] .have wounds or injuries .Early, aggressive treatment boosts your chances of [MEDICAL CONDITION]. People who [MEDICAL CONDITION] require close monitoring and treatment in a hospital intensive care unit .

Based on observation, interview, and record review the facility failed to prevent the development of a facility-acquired Stage II pressure ulcer and failed to prevent the worsening of another Stage II coccyx pressure ulcer for one Resident (#34) which resulted in harm. And, the facility failed to perform appropriate wound care for one Resident (#30) of three residents reviewed for wound care. These deficient practices resulted in wound care not being performed per standard of practice, worsening pressure ulcers, the development of a pressure ulcer, and pain. Findings include: (All times represent Central Time) Resident #30 Review of Resident #30's Minimum Data Set (MDS) assessment, dated 12/9/19, showed an admission date of [DATE] with the following Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) reflected 15/15 indicative of intact cognition. Resident #30 required one staff assistance with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. Review of Observation Detail List Report observation date 1/15/20, read in part, Necrotic area to L (left) great toe and L 2nd toe . Pressure ulcer to L heel . Resident #30 was in contact isolation for [MEDICAL CONDITION]. Review of cdc.gov/cdiff [DIAGNOSES REDACTED] FACTSHEET undated, read in part, Clostridioides difficile (formerly known as [MEDICAL CONDITION]) is a bacterium that causes diarrhea and [MEDICAL CONDITION] (an inflammation of the colon). [DIAGNOSES REDACTED] infections can be deadly . SPREAD C.diff spreads when people touch surfaces that are contaminated with poop from an infected person. Or when people don't wash their hands with soap and water . PREVENT .Wearing gloves and gowns when treating patients with C.diff-and remembering that hand sanitizer doesn't kill [DIAGNOSES REDACTED]. On 1/28/20 at 9:45 a.m., wound care for Resident #30 was observed performed by Registered Nurse (RN) P. RN P was not observed performing hand hygiene prior to applying Personal Protective Equipment (PPE) of a blue gown and clear, vinyl gloves prior to entering the room. After entering, Resident #30's room door was left wide open and the curtain was not pulled to block the direct view into the hallway. Resident #30 was seated in an unlocked, wheelchair with his right wheel resting directly over kinked oxygen tubing. RN P stated, Let me fix that, it can't be doing you much good. RN P attempted to roll the wheelchair but it was blocked by the wall. Spilled clear liquid was noted on the floor in front of and to both sides of the wheelchair. RN P stated, I'll get back to that (addressing the large spill on the floor). RN P then lifted his right wheel off the floor, as Resident #30 remained seated, which freed the oxygen tubing. RN P removed Resident #30's pillow off the overbed table and without cleaning the surface, placed a clean incontinence brief and wound care supplies down. No hand hygiene was performed after handling the oxygen tubing from the floor and wheelchair. RN P then removed Resident #30's left shoe and sock. A dressing was noted to the great toe and left heel. The fourth and fifth toe nails extended past the edge of the toes. RN P removed the two dressings wearing the original gloves applied prior to room entrance. Resident #30 remained seated in his wheelchair directly over the large floor spill without the placement of a barrier. Resident #30 was not offered any limb support. The great toe had an open wound covering the tip and right side of the toe. The 2nd toe tip revealed dark discoloration. The left heel was difficult to observe since Resident #30 was unable to left his foot more than a few inches off the floor. A mirror was not available. After the removal of the dressings, RN P walked through the spilled liquid and entered the bathroom and returned with a wash basin filled with soapy water. The wash basin was not identified with Resident #30's name, had another room number written on the side, and was dated (MONTH) 2020. RN P dipped gauze inside of the basin and then cleansed the great toe, the second toe, and lastly the heel wound. The same pair of gloves were used throughout and came in contact with the soapy water with each wound cleansing; therefore, contaminating the soapy water. Next, RN P removed her gloves and applied a new pair without performing hand hygiene. RN P then retrieved and applied [MEDICATION NAME] to the 2nd toe. RN 'P then removed and applied another pair of gloves without performing hand hygiene. RN P ripped off several pieces of tape and stuck them to the contaminated over bed table. RN P then gathered the incontinence brief and wound care supplies from the over bed table and lowered her self to the floor (touched the floor for support with right hand) and placed the supplies directly on the floor to the left side of Resident #30's wheelchair. Several wound care items bounced off the incontinence brief and landed on the floor. RN P did not change her gloves and perform hand hygiene before proceeding on with the wound care. RN P abducted Resident #30's left leg towards herself in attempt to apply the heel dressing. Resident #30's foot remained unsupported a few inches off the floor. RN P was noted to touch the floor several times in an attempt to support herself when kneeled on the floor. RN P with soiled gloves squeezed a white cream directly on her gloved finger and rubbed the cream on Resident #30's left heel wound. RN 'P applied dressings to the great toe and left heel using the tape from the over bed table. The dressing were left undated and not initialed. The wounds were not measured. With the same gloves, RN P put Resident #30's sock and shoe back on his foot. Next, RN P gathered the remaining wound care supplies and placed them inside her scrub shirt pocket underneath her isolation gown resulting in gross cross-contamination. Resident #30 was instructed to stand up from his unlocked wheelchair, over the wet floor, and RN P partially pulled down Resident #30's pants exposing his buttocks in attempt to view a previously identified pressure ulcer to his coccyx. Resident #30 was in direct view of the hallway. During an interview on 1/28/20 at 1:38 p.m., Resident #30 was asked how he felt about the wound care provided by RN P went from earlier that day. Resident #30 stated, It was completely unprofessional. Why didn't she just put me in bed? She couldn't do the job. She could have adjusted the bed up and seen what she was doing. She had me hold my foot above all that water .she didn't even clean it up .I was uncomfortable and had to keep adjusting myself. Resident #34 Review of Resident #34's Minimum Data Set (MDS) assessment, dated 12/17/2019, showed an admission date of [DATE], with the following Diagnoses: [REDACTED]. The Brief Interview for Mental Status (BIMS) reflected 12/15 indicative of moderately impaired cognition. Resident #34 was non-ambulatory and required extensive two-staff assistance for bed mobility, transfers, and toilet use. Review of Resident #34's Observation Detail Report dated 12/12/19, read in part, Satge II pressure area (admitted with wound) to coccyx 2.2 (length) x 0.7 (width) x 0.2 (depth) .Buttock is red in color and blanchable . Review of Resident #34's Observation Detail Report dated 12/16/19, read in part, Has pressure area to coccyx .Groin and buttocks red .' Review of Resident #34's Observation Detail Report dated 12/18/19, read in part, Stage II (coccyx) 1.0 (length) x 0.9 (width) unable to determine depth .' Review of Resident #34's Observation Detail Report dated 12/25/19, read in part, Stage II (coccyx) 4.0 (length) x 2.0 (width) x 0 (depth) . Review of Resident #34's Observation Detail Report dated 1/6/20, read in part, bilateral open areas to groin, left measures 4.4 (length) x 3.8 (width) x 0.1 (depth), right measures 6.8 x 4.2 x 0.1, surrounding skin is red and edges are macerated , increased odor noted, yellow 'caky' discharge noted to the bilateral groin creases . Review of Resident #34's Progress Notes, dated 1/27/20 at 3:03 p.m., read in part, c/o (complaint of) pain to open area to right buttock and coccyx area .measures 9 cm (centimeter) by 8 cm. The area is a Stage 2 ulcer . On 1/27/20 at 1:37 p.m. (Central Time) wound care was observed performed by RN K and CNA R. After Resident #34 was transferred from her wheelchair to bed, she was turned on her right side. Her incontinence brief was lowered and a strong odor of urine was noted. Resident #34 expressed that she had been sitting in her wheelchair for approximately 2 hours. Resident #34's sacrum, coccyx, inner buttocks were deep red and excoriated with several areas of broken skin. Resident #34 moaned with wound cleansing and guarding was also noted. Resident expressed, it hurts. Review of Resident #34's Physician Note, 12/27/19, read in part, having loose stools and has marked irritation of the buttock and vulvar areas, probably from stool .She needed assistance to roll on her side .She has some loose stool which is cleaned up. There is some redness in the perianal area up onto the sacrum and down around the vulvar area. There are small ulcers, anteriorly, which seems to be fairly superficial . Review of Resident #34's Physician Orders, print date 1/27/20, read in part, 1/26/20-Apply (brand name wound care dressing) to coccyx area every 3 days and as needed .for pressure wound . There was no physician order to address treatment for [REDACTED]. Review of Resident #34's Care Plan for impaired skin integrity, dated 12/23/19, read in part, Establish a 1-2 hour turning and repositioning schedule as appropriate to meet the resident's needs .Cleanse and dry skin with bathing, after incontinence episodes . Review of facility's Pressure Ulcer Prevention/Supportive Approaches dated 4/2018, read in part, Pressure Ulcer Preventative /Supportive approaches will be implemented appropriate to the residents level of risk and the residents care plan updated to reflect the approaches . On 01/29/20 at 7:12 a.m., during an observation of catheter care performed by CNA Q and CNA W, Resident #34 complained of burning (pain) to her buttock/coccyx area. Resident #34 stated, I am called unwilling - that I don't want to be repositioned. Anything I am asked to do, anything, I will do it .I didn't know I had to ask to be repositioned at night . Resident #34 also said night staff would leave her sleeping, if she appeared comfortable, and not reposition her. Resident #34's sacral dressing was observed following catheter care. A transparent, waterproof type film dressing was positioned on Resident #34's reddened sacral area, covering the sacrum, coccyx, and upper/inner right and left buttock areas. The clear film dressing had lifted from the skin, with the lower left edge folded over on itself. The undated dressing was not sealed to the skin. CNA W slid the dressing around on the surface of Resident #34's sacral wound area, until it was positioned in the middle of Resident #34's sacrum. During an interview at this same time, CNA W (night CNA) acknowledged and agreed if Resident #34 was comfortable, and lying on her back, CNA W would leave her in that position, without repositioning, at night.

Based on observation, interview and record review, the facility failed to provide necessary treatment to prevent the development of new pressure ulcers, and failed to provide appropriate care and services to promote healing and prevent infection of pressure ulcers for 1 Resident (#2) of 1 resident reviewed for pressure ulcers from a total sample of 11 residents. This deficient practice resulted in harm for this resident with the development of one Stage III left ischial (buttock) pressure ulcer and development of two new pressure ulcers; one to the bottom, left great toe, and one to the left, second toe tip; with increased pain, increased risk of infection, and the potential for delayed healing. Findings include: All times listed are Central Standard Time. The Minimum Data Set (MDS) assessment for Resident #2, dated 10/5/15, revealed he is [AGE] years old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #2 was totally dependent upon staff for bed mobility, transfers, dressing, eating, personal hygiene and toileting; required 2+ person assistance with all repositioning and transfers; and was always incontinent of bowel and bladder. Resident #2 scored a 14 of 15, on the Brief Interview for Mental Status (BIMS) reflective of being cognitively intact. The 10/05/2015 MDS assessment indicated Resident #2 was at risk for development of pressure ulcers, with no pressure ulcers present. Review of Resident #2's Prevention of Pressure Wound Care Plan, dated 12/21/15 revealed the following interventions, in part: .Deliver prescribed treatment . .Keep heels elevated with pillows . .use devices as ordered . .+ (positive)[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphlococcus aureus), contact precautions . (1/3/16) Review of Progress Note dated 12/21/2015 revealed the Resident #2 was noted to have open areas to left ishial butt cheek .all four measuring 0.5 cm (centimeters) x 0.5 cm in size .red in color . Dietary was notified of the stage II pressure areas per a 12/22/2015 progress note and indicated that the Resident is without suspected nutritional deficiency. The Weekly Pressure Wound Log for Resident #2 revealed the following: 12/21/15 left ishial #1; Stage II; Size: 1 cm circular 12/23/15 left ishial #1; Stage II; Size: 0.5 x 0.6 x less than 0.1 12/21/15 left ishial #2; Stage II; Size 1 cm circular 12/23/13 left ishial #2; Stage II; Size 0.5 x 0.6 x 0.1 12/21/14 left ishial #3; Stage II: Size 1 cm circular 12/23/15 left ishial #3; Stage II: Size 0.4 x 0.7 x less than 0.1 12/28/15 left ishial #1; Unstageable; 6 cm x 2 cm x 1 mm (millimeter)(incorporates the 3 open areas, including ishial #1, #2, and #3, which are now one) 12/30/15 left ishial #1; Unstageable; 7 cm x 3 cm x undetermined depth; 80% of wound bed slough 12/31/15 left ishial #1; Unstageable; 7 cm x 4 cm x approximately 2 mm, center of wound dark brown 1/6/15 left ishial #1; Unstageable; 2.8 x 5.0 x 0.8 with a tunneling depth of 1.9 to medial aspect Progress Notes for Resident #2 revealed the following: 1/3/2016 .Culture result received from [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphlococcus aureus) .N.O. (new order) [MEDICATION NAME] DS BID (twice daily) x 10 days . 1/4/2016 .Resident noted to have hives all over upper torso. Researched chart and found that [MEDICATION NAME] had been dc'd (discontinued) in August due to allergic reaction . 1/7/2016 .Wound appears to continue to deteriorate and get deeper. Area measures 2.8 x 5.1 x 1.1 in depth with a tunneling depth of 1.8 to medial aspect ischial wound .odor noted . The Wound Clinic report, dated 1/8/16 revealed the following: .Post Debridement measurements: 3.3 cm (centimeters) length x 4.1 cm width x 1.3 cm depth .Stage 3. .Culture of the wound has shown a [MEDICAL CONDITION]-resisitant staph aureus (MRSA) . .it is suggested because of the relative depth and undermining that negative pressure wound therapy be instituted . Wound Clinic orders dated 1/8/2016 included: Wound VAC (Vacuum Assisted Closure). Change dressing TIW (three times a week). Large simplace dressing. Continuous pressure, 125mmHg. Bridging to upper thigh or lower abdomen. For Stage 3 Pressure ulcer. Observation for Resident #2 on 1/13/16 at 7:50 a.m. with Certified Nurse Aide (CNA) J and CNA K showed Resident #2 had been incontinent of stool and the Wound VAC dressing on the left buttock of Resident #2 contained feces underneath the drape (clear adhesive dressing). Feces was visible from the edge of the drape up to the wound edge. The feces was unable to be cleansed from below the dressing. CNA J exited the room to request assessment of the drape by Licensed Practical Nurse (LPN) A. LPN A examined the dressing and exited the room to find Registered Nurse B to assist. Resident #2 reported that his pain was a 9/10 (pain scale), when asked by LPN A. LPN A administered IR [MEDICATION NAME] 15 mg (milligram) pill at 8:26 a.m LPN A stated she (would be) .back in half an hour . Observation of the Wound VAC Bridge dressing change for Resident #2 was continued on 1/13/16 at 9:59 a.m. with LPN A and RN B. Feces was visible under the drape, on the resident's left buttocks skin up to the edge of the wound. Following the removal of a feces contaminated dressing, the left buttock adjacent to the wound was cleansed. Cross- contamination with feces between dirty and clean areas was observed multiple times by this surveyor. LPN A failed to wash her hands following removal of contaminated gloves with multiple glove changes. A washcloth soiled with feces, and [MEDICAL CONDITION] from around the wound fell on to the floor in Resident #2's room. LPN A grabbed the bedside cart edges with newly gloved hands, and repositioned the bedside cart closer to the bed. The soiled washcloth was moved on the floor by the bedside cart wheel. The smallest, circular foam insert (part of the dressing) was placed into the wound by LPN A and held in place with her contaminated gloved finger, while she positioned the Bridge Dressing over the top of the foam insert. The drape was incorrectly placed over the top of the Bridge (per manufacturer's instructions), securing it to the left buttock, and holding the circular foam insert in the wound. LPN A failed to place drape over the circular foam inserted into the wound, as the manufacturer's instructions direct. During an interview on 1/13/16 at approximately 10:40 a.m. LPN A, stated, .The wound clinic has not demonstrated how to do (the) dressing . LPN A appeared unsure of how to apply the dressing, and after using all of the dressing kit drape, she requested an additional Bridge Dressing Kit be retrieved by RN B. LPN A stated, .This is the first time changing the wound VAC since the wound clinic was here (1/8/16) . When asked how she knew how to apply the dressing, LPN A stated, .Just (the) instructions in chart or in the (treatment) binder . RN O, during an interview on 1/13/16 at 12:45 p.m. searched the South Hall Treatment binder and stated there were, .no directions in (the) treatment book .that is where it is supposed to be . Resident #2's medical chart was reviewed and no directions for wound VAC treatment were present in the chart. Wound VAC (machine) instruction were received from the Regional Clinical Consultant L on 1/13/16 at 1:10 p.m. She reported the instructions were located in the Director of Nursing (DON) office, and a copy should be accessible for the Wound VAC and the Bridge Dressing in the Treatment binder. The DON was not present within the facility during the survey completed on 1/14/16. When the Regional Clinical Consultant was asked how the nursing staff would know how to properly operate the wound vac (with the instructions in the DON's office) she did not reply. The Bridge Dressing instructions were again requested from Regional Clinical Consultant L. During an interview on 1/14/16 at 6:25 a.m., when asked if there were any other directions for application of the dressing (i.e. from the Wound Clinic, or Physician Orders) RN O stated No. The manufacturers Bridge Dressing Kit instructions (dated 6/2009) included, in part: Place the selected V.A.C. [MEDICATION NAME] Dressing piece into the wound. Align the pre-cut hole of the V.A.C. Drape over the wound .Trim to fit as necessary, allowing for a 3 to 5 cm border .(and) Place the V.A.C. Drape adhesive side down over the wound . .Place the VAC Drape adhesive side down over the wound. TIP: A smooth and wrinklefree drape helps prevent dressing leaks . .Remove the white tab from the bridge end, exposing the adhesive. Align the pre-cut hole on the bridge with the hole on the VAC Drape and press firmly to ensure the bridge interface is smooth and wrinkle-free . During the interview on 1/14/16 at 6:25 a.m., when asked what consequences could result from failing to apply the pre-cut hole of the V.A.C. Drape over the wound, per manufacturer's instructions, RN O stated, .(It's) not proper .a lot of things could go wrong .(they) would have hopefully prevented stool from contaminating (the) wound . During an interview on 1/14/16 at 6:50 a.m., LPN A acknowledged it was her first time .doing and applying this dressing . LPN A stated, she .looked for instructions on the wound dressing packaging . but none were present. LPN A stated there was .no demonstration of wound care .never watched a video .(had) no idea how to use the drape, I had never seen that (manufacturer's written instructions) . When asked if she placed the pre-cut hole of the V.A.C. Drape over the wound as directed in the manufacturer's instructions, LPN A stated, .No, I didn't .That is what I forgot to do . When asked about cross-contamination of stool during the dressing change, LPN A stated, .I knew I wasn't supposed to touch the clean linen bag with my dirty gloves .I would agree there were problems with that .the stool had contaminated everything . When asked what consequences could result from failing to apply the Bridge dressing according to manufacturer's instructions LPN A stated, .Could cause more damage . During an observation on 1/12/16 at 1:45 p.m., Resident #2's toes of both feet were observed to be touching the footboard of his bed, and his heels were not floated (raised with a pillow to prevent contact with the mattress) according to the plan of care. An observation on 1/12/15 at 3:45 found Resident #2's heels in contact with the bed, and both of his feet touching the footboard of the bed. During an interview on 1/12/16 at 4:05 p.m when Resident #2 was asked if there was anything that he would like to share with this Surveyor regarding his care and stay at the facility he stated, The bed is too short - my feet hang over all the time .I hit the top with my head, and the bottom with my feet. Resident #2 stated it was .very uncomfortable , and reported that he had mentioned it to staff a few times and the Nursing Home Administrator (NHA). Observation on 1/13/16 at 4:05 p.m. found his toes to be resting on the footboard, and his head at the very top of the mattress when positioned at an approximate 30 degree incline. Resident #2 stated that he was .six feet ., when asked his height. Observation of Resident #2's feet on 1/13/16 at approximately 8:00 a.m., found the bottom of the left great toe reddened. During an interview on 1/13/16 at approximately 8:00 a.m. Licensed Practical Nurse (LPN) A, when asked about the bottom of the left great toe stated, .(it) barely blanches .resembles pressure (ulcer), but his heels are floated so makes me somewhat confused. CNA J, (also present in the room) stated, .I have seen his feet up against (the) footboard . An observation on 1/13/16 at 9:59 a.m. found that the footboard had been removed from Resident #2's bed. Resident #2's heels were observed to be in contact with the mattress (not floated to prevent pressure areas). During an observation and interview on 1/13/16 at 12:55 p.m. Registered Nurse (RN) O examined Resident #2's left foot and stated, .looks like pressure wounds to me .' Two areas on Resident #2's left foot were assessed including: .left great toe bottom .red, flat, non-blanchable .0.8 x 0.4 x 0 . and .left second toe tip .non-blanchable, red, flat .0.3 x 0.2 x 0 . RN O was responsible for measurement of all wounds within the facility. When asked if she was previously aware of the left toe pressure areas, RN O stated they (pressure areas) were .new today .new now .to me. ( )