Every finding on record at Greensville Health and Rehabilitation Center

Based on observation, staff interviews, clinical record review, and facility documentation review, the facility staff failed to protect the residents' rights to have secure and confidential personal and medical records for four Residents (Residents #2, #19, #10 and #3) in a survey sample of 26 residents. The findings included:1. For Resident #2 (R2) the facility failed to protect the residents' rights to have secure and confidential personal and medical records by displaying a DNR (Do Not Resuscitate) band on the wall over the head of the bed visible to the public and other residents. On [DATE], during initial rounds R2 was observed in bed, a Do Not Resuscitate (DNR) band was posted on a cork board on the wall over the bed. Resident #2 was originally admitted on [DATE] and readmitted recently on [DATE] after hospitalization. The Resident's diagnoses included but were not limited to cognitive communication deficit, history of ischemic attack, cerebral infarct, do not resuscitate, and syncope and collapse. Resident #2's, most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of [DATE], was a Re-Entry Assessment. The MDS coded Resident #2 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15 possible points, the resident was unable to complete the interview. A review of R2's clinical record revealed R19's Advanced Directive was Do No Resuscitate (DNR).On [DATE] at approximately 1:25PM, certified nursing assistant #5 was questioned on the purpose of the purple dots on the name tags outside the room, she stated, they are to remind us that the resident does not want cardiopulmonary resuscitation (CPR) if their heart stops. On [DATE] at 11:45 AM Licensed Practical Nurse (LPN) #4 was interviewed for the DNR bands on the walls over residents' bed and according to LPN #4 the DNR bands are to communicate the resident's code status to staff. When asked if displaying DNR bands visibly to the public and other residents was a violation of the resident's rights to privacy and confidentiality of personal clinical information LPN#4 stated, I believe that could be so. The Administrator, Director of Nursing (DON), Assistant Director of Nursing, Dietary Manager, [NAME] President of Operations, Clinical Director of Reimbursement, Medical Records Coordinator and Regional Director of Clinical Services they were informed of the findings on [DATE] at 4:15 PM, during an end of day meeting. The Director of Nursing stated that she was not aware of DNR bands attached to over the beds. When asked if this was a violation of the resident's right to privacy and confidentiality to clinical information she stated, Absolutely this would be a violation, and we will address it right away. 2. For Resident #19 (R19) the facility failed to protect the residents' rights to have secure and confidential personal and medical records by displaying a DNR (Do Not Resuscitate) band on the wall over the head of the bed, visible to the public and other residents. On [DATE], during initial rounds R19 was observed in bed, a Do Not Resuscitate (DNR) band was posted on a cork board on the wall over the bed. Resident #19 was admitted on [DATE]. The Resident's diagnoses included but were not limited to Chronic diastolic congestive heart disease, schizophrenia, pulmonary disease and do not resuscitate (DNR). Resident #19's, most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of [DATE], was a Quarterly Assessment. The MDS coded Resident #19 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 possible points indicating no cognitive impairment. On [DATE] at approximately 1:25PM, certified nursing assistant #5 was questioned on the purpose of the purple dots on the name tags outside the room, she stated, they are to remind us that the resident does not want cardiopulmonary resuscitation (CPR) if their heart stops. On [DATE] at 11:45 AM Licensed Practical Nurse (LPN) #4 was interviewed for the DNR bands on the walls over residents' bed and according to LPN #4 the DNR bands are to communicate the resident's code status to staff. When asked if displaying DNR bands visibly to the public and other residents was a violation of the resident's rights to privacy and confidentiality of personal clinical information LPN#4 stated, I believe that could be so. A review of R19's clinical record revealed R19's Advanced Directive was Do No Resuscitate (DNR). The Administrator, Director of Nursing (DON), Assistant Director of Nursing, Dietary Manager, [NAME] President of Operations, Clinical Director of Reimbursement, Medical Records Coordinator and Regional Director of Clinical Services they were informed of the findings on [DATE] at 4:15 PM, during an end of day meeting. The Director of Nursing stated that she was not aware of DNR bands attached to over the beds. When asked if this was a violation of the resident's right to privacy and confidentiality to clinical information she stated, Absolutely this would be a violation, and we will address it right away. 3. For R10, the facility staff failed to protect her rights to personal privacy and confidentiality by displaying a sign indicating she was receiving hospice services and a copy of her advance directives on a board over the head of her bed visible to the public and other residents. During initial rounds on [DATE] at 12:40PM, R10 was observed alert and oriented in her bed, a sign was posted on a board over the head of the bed which read in part.STOP! DO NOT CALL 911, Call (name redacted) hospice service provider, phone # .and a list of the hospice care givers names and a completed copy of her advance directives. A very pale grayish-lavender dot was on the name tag outside the room. R10 was admitted to the facility on [DATE] with diagnoses to include but not limited to hypertensive heart disease, chronic pain syndrome, peripheral vascular disease, cardiomyopathy, dementia, and congestive heart failure. R10 was admitted to hospice services on [DATE]. A review of R10's Minimum Data Set (MDS) with an assessment reference date of [DATE] revealed R10 had a Brief Interview Mental Status (BIMS) score of 15/15, which indicated R10 was cognitively intact. 4. For R3 the facility staff failed to protect her right to personal privacy and confidentiality by displaying a DNR (Do Not Resuscitate) band on the wall over the head of the bed visible to the public and other residents. R3 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include but not limited to hypertension, major depressive disorder, dementia with severe psychotic disturbance, legal blindness, and schizoaffective disorder. Review of R3's Minimum Data Set (MDS) with an assessment reference date of [DATE] revealed R3 had a Brief Interview Mental Status (BIMS) which was coded as 00 which indicated R3 was not interview able. During initial rounds on [DATE] at 12:45PM, R3 was observed in bed, a DNR band was posted on wall over her bed. A purple dot was on the name tag outside the room. On [DATE] at approximately 1:25PM, certified nursing assistant #5 was questioned on the purpose of the purple dots on the name tags outside the room, she stated, they are to remind us that the resident does not want CPR if her heart stops (cardiopulmonary resuscitation). On [DATE] at 11:45 AM Licensed Practical Nurse LPN #4 was interviewed for the purple dots and the DNR (Do Not Resuscitate) bands on the walls over residents' bed and according to LPN #4 the DNR bands are to communicate the resident's code status to staff. When asked if displacing DNR bands and copies of Advance Directives visible to the public and other residents was a violation of the resident's rights to privacy and confidentiality of personal clinical informationLPN#4 stated, I believe that could be so. On [DATE] at 4:15 PM, during an end of day meeting with the Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Manager, [NAME] President of Operations, Clinical Director of Reimbursement, Medical Records Coordinator and Regional Director of Clinical Services the Director of Nursing stated that the purpose of the purple dots were to alert staff to the resident's code status and she was not aware of DNR bands attached to over the beds. When asked if this was a violation of the resident's right to privacy and confidentiality to clinical information she stated, Absolutely this would be a violation, and we will address it right away.

Based on observation, resident and staff interviews, clinical record review and facility document review, the facility staff failed to ensure resident receive a physician ordered wound treatment in accordance with professional standards for one of twenty-six residents in the survey sample (Resident R16.Findings include:The facility staff failed to transcribe and apply the wound care treatment ordered on 6/25/26 by the Wound Specialist Nurse Practitioner to R16's right foot wound.R16 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include but not limited to end stage renal disease, dependence on renal dialysis, anemia, atrial fibrillation, major depressive disorder, diabetic mellitus type 2, dementia congestive heart failure and chronic pulmonary edema. R16's most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/27/26 coded R16 in Section C. 0100 Cognitive Patterns Brief Interview for Mental Status (BIMS) 15/15 indicating R16 is cognitively intact. Section G coded R16 as requiring substantial/maximum assistance with bathing and dressing.A review of R16's clinical record wound evaluation summary dated 6/25/26 by the Wound Specialist Nurse Practitioner revealed: wound on the right heel plantar surface measuring 2.3 x 2.2 x 0.2 centimeters with a surface area of 5.06 centimeter, moderate serosanguinous exudate (a watery mix of clear or pale-yellow blood serum, and a small amount of blood, giving it a thin, pinkish, or light red color drainage from a wound) and 100% granulation tissue (the new, bumpy tissue the body creates to fill a wound). The treatment plan includes application of iodosorb gel (a anti-microbial wound gel used to treat chronic exudating wounds like venous, pressure and diabetic foot ulcers) and calcium alginate (a seaweed-based dressing that absorbs excess fluid) and cover with a foam dressing three times per week and as needed if the dressing becomes saturated, soiled or dislodged. Resident with a history of peripheral vascular disease.A review of the nurse progress note dated 6/25/26 by LPN #4 read in part. R16 was examined by wound care nurse practitioner today to assess the wound to his right heel, measuring 2.3 x 2.2 x 0.2 centimeters with a surface area of 5.06 centimeters. Moderate serosanguinous exudate. 100% granulation tissue. Treatment plan is to apply iodosorb and calcium alginate and cover with dressing three times per week and as needed.A review of the nurse progress note dated 7/9/26 by the Assistant Director of Nursing read in part .wound rounds made with Wound Care Nurse Practitioner. Right heel wound measured 1.9x 2.1 x 0.2 centimeters, moderate serosanguinous drainage noted. 100% granulation tissue present upon exam. No signs of infection noted. Site noted to be improving as evidenced by decreased surface area. Dressing treatment plan: calcinate alginate and iodosorb gel with silicone foam border dressing. A review of the Treatment Medication Record (TAR) for June and July 2026 revealed an order to cleanse right heel wound with wound cleanser, pat dry, apply iodosorb gel to wound bed, cover with foam dressing once daily and as needed if dressing becomes soiled. The entry on the TAR failed to include the order for calcium alginate and the entry was scheduled daily instead of the ordered three times a week.On 7/15/26 at approximately 3:15 PM, a treatment observation was conducted. LPN#2 accompanied by LPN#4 completed wound treatment to R16's right heel by cleansing his right heel plantar surface wound with wound cleanser, applying iodosorb gel and covering with foam dressing every day. The Wound Care Nurse Practitioner's 6/25/26 and 7/9/26 assessment summaries were reviewed with LPN#2 and LPN#4 with the order for three times a week and for application of calcium alginate. According to LPN#2 they had been completing the order of the iodosorb only as the calcium alginate had not been transcribed and the wound looked much better but that she would notify the Nurse Practitioner to inform him of the failure to follow the order as written. On 7/15/26 at 4:15 PM during the exit meeting the above findings were shared with the Administrator, Director of Nursing, [NAME] President of Operations, Assistant Director of Nursing, Director of Clinical Reimbursement, Medical Records Coordinator and Regional Director of Clinical Services. The Director of Nursing was asked what her expectation of the nurse when a new order was given by the medical provider, she responded, the nurse is to review the order, transcribe it correctly and carry it out as ordered. On 7/16/26 at 8:45AM, an interview was conducted with the Wound Care Nurse Practitioner on the facility staff's failure to follow his wound care orders since 6/25/26 and according to him R16's wound has shown significant improvement, and order would be adjusted accordingly.On 7/16/26 at approximately 2:55 PM during the exit meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services and Director of Clinical Reimbursement, the failure to follow the wound care nurse practitioner's orders for R16 was shared with the facility team. No further information was provided.

Based on clinical record review, staff interviews and facility documentation, the facility staff failed to provide routine scheduled medications to three residents in a survey sample of twenty-six residents (R8, R3 and R62).Findings include:The facility staff failed to administer scheduled medications due to medications not being available. 1.R8 was admitted to the facility 2/26/26 with diagnoses to include but not limited osteoarthritis, anemia, wedge compression fracture T7-T8 vertebrae and chronic obstructive pulmonary disease. R8's most recent MDS assessment (Minimum Data Set) with an assessment Reference Date 6/2/26 coded R8 in Section C. Cognitive Patterns, Brief Interview Mental Status 00 as not interview able.During clinical record review, progress notes and June 2026 Medication Administration Record revealed the following medications were not available to be administered: Anu sol suppository insert one suppository rectally at bedtime for bedtime for hemorrhoids - 6/11/26 - on order, not availableSystane eye drops instill one drop in both eyes two times a day for dry eyes - on 6/4/26, 6/25/26 and 6/26/26 at bedtime - on order, awaitingA review of progress notes 7/1/26 -7/9/26 revealed the following medications were not available to be administered to R8.Calcium citrate 600 milligrams by mouth every day at dinner time - 7/9/26 not in drawerMagnesium Oxide 400 milligrams by mouth give 1 tablet by mouth one time a day for supplement - on 7/9/26 not available2. R3 was originally admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses to include but not limited to hypertension, Alzheimer's disease, major depressive disorder, and dementia with psychotic disturbance. The facility psychological services provider (name redacted) Licensed Clinical Social Worker assessed R3 with moderate cognitive decline.A review of R3's Medication Administration Record (MAR) for June and July 2026 revealed the following medications lacked evidence that the medication was administered to R3: Atorvastatin 40 milligrams by mouth at bedtime on 6/10/26, 6/11/26 and 6/12/26; 7/4/26, 7/9/26 noted with a blank/hole on the MARClaritin 10 milligrams by mouth at 0600 every day on 6/16/26 and 6/27/26 noted with a blank/hole on the MARHaldol 1 milligram by mouth at bedtime on 6/12/26 noted with a blank/holeLevofloxacin 600 milligrams give one tablet by mouth one time a day for infection for seven administrations (doses documented as being given 6/10 through 6/15/26 for six administrations), 6/16.26 is coded as 9 see nurses notesNystatin give 5 milliliters by mouth three times a day for irritated gums - on 6/19/26 and 6/27/26 at 0600 is blank/hole on the MARGabapentin 100 milligrams give 2 capsules by mouth three times a day for neuropathy - dose scheduled for 1400 on 6/1/26, 6/4/26, 6/6/26 is blank/hole on the MAR; 6/8/26 at 1400 and 2200 is blank/hole in MARTravatan eye drops instill one drop both eyes at bedtime for Glaucoma - on 7/4/26 and 7/9/26 blank/hole on the MAR3. R62 was admitted to the facility 4/2/26 with diagnoses to include but not limited to hypertensive heart disease without failure, convulsions, obstructive sleep apnea, anxiety, major depressive disorder, and bilateral cataracts. Her most recent MDS (Minimum Data Set assessment) with ARD (Assessment Reference Date) of 5/14/26 coded the Brief Interview for Mental Status as 15/15, indicating R62 is cognitively intact. A review of R62's Medication Administration Record and nurse progress notes for June and July 2026 revealed the facility failed to ensure residents receive medications as ordered by the medical provider:Aspercreme Lidocaine External Cream 4 % apply to left foot topically two times a day for left foot pain - 7/15/26, 7/14/26, 7/13/26, 7/12/26, 7/10/26, 7/6/26, 7/5/26, 7/4/26, 7/3/26, 7/2/26, 7/1/26 per progress notes medication was on orderArtificial Tears Ophthalmic Solution 0.5-0.6 % instill 1 drop in both eyes three times a day for dry eyes - does not administered on 7/15/26, 7/14/26, 7/13/26, 7/12/26, 7/10/26, 7/9/26, 7/8/26, 7/7/26, 7/6/26, 7/5/26, 7/4/26, 7/3/26, 7/2/26, 7/1/26 and 6/30/26 as per progress notes medication on order or not available in Omnicell (Automated Dispensing Machine)Cranberry tablet 450 milligram give 1 tablet by mouth one time a day for urinary tract infection prevention - on 7/9/26 and 7/14/26 waiting for pharmacy to deliverSenokot tablet 8.6-50 Milligrams give one tablet by mouth two times a day for constipation - on 7/5/26 per progress note awaiting delivery from pharmacyOn 7/15/26 an interview was conducted with LPN#4 on what a blank/hole meant on the MAR and she stated, a blank or hole on the MAR would indicate the medication wasn't given or maybe the nurse gave it but forgot to sign it. LPN#4 was also asked what actions she would take if a medication was not available in the medication cart or if a new order. According to LPN#4 the process is to check the cart, check the Omnicell (Automated Dispensing Machine), call the pharmacy and get an estimate of when the medication will be delivered and if past the one-hour window notify the doctor. When asked where they obtained over the counter (OTC's) medications she stated she was not sure. The Regional Nurse Consultant stated he could help her with that information and stated they had recently changed ownership as well as pharmacy providers. He stated OTCs were available in bulk bottles and in the medication storage rooms.On 7/16/26 at 9:15AM an interview was conducted with LPN #3 on what actions she would take if a medication was not available in the medication cart or if a new order. According to LPN#3 she would search the cart and the medication room, go check in the Omnicell, call the pharmacy and if not able to get in time for the ordered time, then she would let the resident know and notify the doctor if outside the one-hour window. LPN#3 was questioned on what it meant if the MAR had a blank or hole and according to LPN#3 it would mean that the nurse forgot to sign off or maybe they did not give the medication. On 7/16/26 at approximately 3:10 PM, LPN#1 was questioned on what actions she would take if a medication was not available in the medication cart or if a new order. According to LPN#1, she would document that the medication was not available, call the pharmacy and determine the delivery time, check in the Omnicell and call the Director of Nursing so she can guide me through what else she could do. She stated they had recently changed pharmacy providers and previously they could call the local pharmacy next door and they would bring them whatever medication the doctor ordered.On 7/15/26 at 4:15 PM during the end of day meeting the above findings were shared with the Administrator, Director of Nursing, [NAME] President of Operations, Assistant Director of Nursing, Director of Clinical Reimbursement, Medical Records Coordinator and Regional Director of Clinical Services. The Director of Nursing was asked what her expectation of the nurse when a new order was given by the medical provider or medications were not available in the medication cart, she responded, the nurse is to check the med cart, check the med room, look in in the Omnicell and if not available there to contact the pharmacy to determine delivery status and notify the doctor if the medication will not be available to administer at the scheduled time. We recently changed ownership and now have a new pharmacy provider. We have educated the nurses on the new procedures, and I am developing a list of over-the-counter medications that will be house stock. Nurses are to review the order, transcribe it correctly and carry it out as ordered.A review of the facility's Provider Pharmacy (name redacted) Policy on pharmacy services Policy #1.1, page 5 of 210 reads in part. Procedures. 4.f. Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours a day, seven days a week. New medication orders are available for administration on the next routine delivery, unless otherwise requested by the facility staff. Medications will be delivered by the primary pharmacy or back-up pharmacy or are available from the emergency medication kit/back-up medication supply. Review of the pharmacy provider's policy on Unavailable Medications, Policy #6.10, reads in part. Policy. The facility must make every effort to ensure that the medications are available to meet the needs of each resident. Procedures, the nursing staff shall.1. Notify the attending physician (on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy is available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order.No further information provided.

Based on interview, clinical record review and facility documentation the faciity staff failed to ensure residents were free from significant medication errors for 1 Resident in survey sample of 26 residents.For Resident #76 (R76) the facility staff failed to ensure a resident diagnosed with dementia, did not pull his PICC line out and failed to have the appropriate antibiotics available for administration. R76 was admitted to the facility on [DATE] with diagnoses that included but were not limited to interstitial pulmonary disease, personal history of venous thrombosis and embolism, type 2 diabetes, hypertensive heart disease, atherosclerotic heart disease of coronary artery, old myocardial infarction, UTI with sepsis, obstructive and reflux uropathy. R76 most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/13/26, scored R76 as having a BIMS (Brief Interview of Mental Status) score of eight out of a possible 15 indicating moderate cognitive impairment. R76 required physical assist of one staff member A review of the clinical record revealed that R76 was discharged from the acute care hospital to the facility with a PICC (Peripherally Inserted Central Catheter) and orders that included: Doxycycline100 MG tablet twice per day for 4 doses.Piperacillin-tazobactam infusion -Commonly known as: Zosyn-Infuse 3.375 gm intravenously every 8 hours for 10 days. A review of the clinical record revealed the following progress notes: 7/10/26 7:19 pm - Piperacillin-Tazobactam-NaCl Intravenous Solution Reconstituted 3-0.375 GM/50MLUse 1 dose intravenously three times a day related to urinary tract infection for 30 Administrations Awaiting pharmacy. 7/10/26 7:57 pm - Resident was found to have pulled his PICC lineout, it was sitting on his bedside table. Called provider on call, [NAME], received order to continue Doxycycline as ordered and schedule him to have the PICC line reinserted at the beginning of next week. A review of the MAR (Medication Administration Record) revealed that on 7/10/26, the day of admission, the resident's Doxycycline 100 mg tablet at 6 pm was marked as unavailable. On the afternoon of 7/15/26 an interview was conducted with the Administrator and the DON. The DON explained that the facility had contacted the physician and that they gave the order to get the PICC line reinserted at the beginning of the next week. The DON stated that she felt the facility did all they could to accommodate the needs of the resident. When asked why the resident was receiving the IV antibiotic she stated for a diagnosis of Sepsis. The DON stated that the resident had been on the Piperacillin while in hospital and was still able to get the remaining (2 doses) of doxycycline and should be ok until the PICC line was replaced. A review of the clinical record revealed that the resident missed 12 doses of Piperacillin-tazobactam prior to the PICC line being reinserted. R76 did not receive the antibiotic from 7/10/26 at 6 am until 7/14/26 at 2 pm when the PICC line was reinserted. On 7/15/26 during the end of day meeting the administrator was made aware of the concern and no further information was provided.

Based on observation, interview clinical record review and facility documentation the facility staff failed to ensure the residents right to be free from abuse, for one resident (R46) in a survey sample of 26 residents. For R46 the facility staff failed to ensure the resident's right to be free from abuse. R46 was admitted to the facility on [DATE] with diagnoses that included but not limited to coronary artery disease, hypertension, non-Alzheimer's dementia, renal insufficiency, diabetes, cognitive communication deficit, anxiety and depression. R46 most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/3/26, coded the resident as having a BIMS (Brief Interview of Mental Status) score of nine out of a possible 15, indicating moderate cognitive impairment. R46's most recent MDS also coded R46 as requiring assistance of one staff person for all aspects of ADL care. On 7/15/26 at approximately 9:00 am R46 was observed sitting up in bed watching tv. An interview with R46 was conducted and R46 stated she had no memory of anyone hitting her or throwing something at her. R46 stated that she gets help with bathing and showering. A review of the facility documentation revealed that on 6/11/25 R46 was getting a shower by CNA3 on the evening shift. Per facility documentation, the supervisor, RN1 wrote the following in his witness statement: When interviewing the resident [R46] she stated that CNA3 hit her in the face and shoved her up against the wall while in the shower. On assessment, the resident complained of left humerus pain when palpating the area. Stat X-Ray was ordered. The following statements are from the CNA's that were working on the evening of 6/11/25 CNA 4 wrote I was helping another resident in front room when I noticed CNA 3 [name redacted] and R46 [name redacted] having an altercation over a blanket that [R46] kept throwing in the floor. CNA3 was picking it up and patient had hands in the air when CNA3 threw the blanket in her face. That's when CNA3 realized I was standing in the hallway and asked me, did I see that. CNA5 witness statement read: When I looked up, I noticed CNA3 and R46 in the hall on west wing. The two were in an altercation. I saw CNA3 grab a handful of linen from the floor and throw it in R46's face. A review of the facility documentation revealed the R46 called her daughter after the incident with CNA3. R46's daughter called the facility and spoke to the supervisor on duty and the supervisor reported that he went into the shower room and CNA3 was in the shower room with R46 who was crying at the time. CNA3 was immediately suspended, pending investigation. The facility staff submitted the incident report to OLC, APS, Police Report, and Ombudsman. They submitted a timely five-day follow-up that stated the following: Conclusion: Investigation revealed that there was a verbal exchange between Resident [R46] and CNA {CNA3] in the hallway. There are witnesses to the CNA3 throwing linens in R46's face after a struggle with the linens in the hallway. There are no witnesses to the shower room allegation. Assessments revealed no further discomfort in her arm, negative X-Ray and conversations with the resident seem to indicate that she no longer recalls the events previously described. Corrected Action:CNA [CNA3] employed here since 5/8/25 has been terminated. Interviewable residents have no comments about feeling unsafe in our facility. ABUSE education began the next morning (6/12/25) & has been completed for all staff. On 6/16/26 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to review and revise the nursing care plan during a significant weight loss for one Resident (Resident #1) in a survey sample of 26 residents.The findings included:Resident #1 was admitted on [DATE] after a hospitalization for a fractured left humerus and left hip with surgical repair of both. The Resident's diagnoses included but were not limited to: Diabetes, lupus, dysphagia with peg [per endoscopic gastrostomy feeding] tube insertion, bolus feeding, malnutrition, anemia, and right lung cancer. The Resident was sent back to the hospital for aspiration pneumonia and respiratory failure on 5-23-26, returning to the facility on 6-1-26.The most recent MDS (Minimum Data Set federal assessment) was completed as a five-day readmission assessment with an Assessment Reference Date (ARD) of 6-8-26. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment. The Resident required assistance from staff with eating to include feeding tube continuous infusions. The document recorded no rejections of care, no behaviors, and no problems with swallowing. The Resident was coded as weighing 98 pounds, receiving 51% or greater calories from tube feeding, with 5% or greater weight loss, and 5% or greater weight gain which was an error. All weights were conducted by a mechanical lift. The Resident was wheelchair bound.On 7-14-26 at 1:15 PM Resident #1 was observed in bed with a feeding pump on a pump stand by her bed attached to a peg tube in her abdomen covered from sight. The pump was off.On 7-15-26 the clinical record was reviewed to include physician's orders. The order for the feeding pump was Glucerna 45 milliliters per hour continuous, and water at 150 milliliters every 4 hours ordered on readmission 6-1-26. On 7-15-26 hospital and nursing facility weight documents were reviewed and revealed the following;6-1-26 - Hospital discharge records 109 lbs6-2-26 nursing facility records 103 lbs6-3-26 nursing facility records 101.3 lbs6-8-26 nursing facility records 98.4 lbs6-15-26 nursing facility records 98.1 lbsThese records indicate a significant weight loss of 11 pounds or greater than 10% since readmission 14 days earlier. The Resident was not receiving a diuretic.The Speech Language Pathologist [SLP] Speech Therapist [ST] notes were requested and reviewed. They revealed that the ST did not see the Resident until 7-11-26 and the note documented that the Resident would remain NPO [nothing by mouth] and that the continuous tube feedings would continue. The ST saw the Resident again on 7-14-26, during survey and the note indicated the Resident's abilities had improved and the Resident had been given mildly thick drinks, pureed foods, however, would remain NPO with continuous tube feedings. On 7-16-26 the Resident was observed by surveyors consuming potato soup with the ST seated beside the Resident. Registered Dietician [RD] notes were documented on 6-9-26, 6-21-26, and during survey on 7-14-26. Those documents revealed the following;On 6-9-26 the RD documented the Resident was not tolerating the Diabeta Source feeding formula and refer to MD [doctor]. The Resident was not receiving Diabeta Source. The Resident was receiving Glucerna 1.5 calorie carb steady formula at 45 milliliters an hour with no indication of intolerance.On 6-21-26 the RD documented no changes and to increase the feeding as tolerated. The feeding was never increased.On 7-14-26 during survey the RD documented Boost supplements ordered with meals, and that the max amount that the Resident has been able to tolerate of the tube feeding is 45 milliliters per hour. There is no indication from the RD, ST, nor the physician that any increase in supplements, added calories, or feeding formula was ever tried until 7-11-26 when the Resident was presented a pleasure tray by the ST, which was allegedly a failure, and then again with the ST during survey with surveyor observed success.On 7-16-26 Resident #1 was observed during lunch in the dining room with the ST. The Resident was observed to be eating potato soup and was consuming it independently without difficulty and stated she was enjoying it. The Resident was noted to have a pump with tubing attached to a continuous feeding source flowing through a peg tube in her abdomen covered by clothing. The infusion was noted to be Glucerna 1.5 cal [calorie] carb steady feeding solution infusing at 45 milliliters per hour, and water infusing at 50 milliliters per hour continuously. The care plan was reviewed and revealed two different Focuses both dated 6-15-26 2 weeks after returning from the hospital. Those were as follows;1. Resident requires tube feeding related to dysphagia for nutrition.2. Potential for nutritional problem noted weight loss since readmission and at risk for additional weight loss. The Care plan Goals were; Maintain adequate nutrition and hydration status as evidenced by weight stable and no signs/symptoms of malnutrition or dehydration. Maintain weight and tolerate tube feedings. The interventions for the focuses and goals included weight as ordered/indicated, RD evaluate quarterly and as needed, monitor caloric intake and estimate needs, make recommendations for changes to tube feeding and water flushes, see MD (doctor) orders for current feeding orders.The care plan also contained old interventions from the time when the Resident was receiving bolus feedings, which she did not tolerate and would refuse. This was prior to her hospitalization on 5-23-26 which was caused by aspirating [inhaling] stomach contents resulting in pneumonia. Those interventions included head of bed elevated 45 degrees during and 30 minutes after tube feeding, and Aspirate gastric contents hold feeding if greater than 30 milliliters. The Resident was not weighed as ordered; the RD did not evaluate during a significant weight loss and made no mention of the Resident's caloric needs. The RD made no recommendations for changes during a significant weight loss so that the doctor could change the feeding orders as the new feeding after hospitalization was being tolerated. The old interventions for head of bed elevation could have been confusing for staff as the Resident should have had the head of bed always elevated for the now continuous feeding. The feeding monitoring aspiration of 30 milliliters causing a hold on the feeding did not include a description of when to check and how long to hold the feeding. A new feeding monitoring order was evidently received though it was not reflected in the care plan. That order was documented as having been administered in the Medication and Treatment Administration records, and follows below;The Medication and Treatment Administration records were reviewed for July 2026, and an order was being signed as completed for Enteral feed order for monitoring two times a day check tube placement by aspirating stomach contents every 8 hours, if greater than 100 milliliters hold feeding one hour and recheck residual if greater than 100 milliliters after recheck hold and call MDOn 7-16-26 at 1:30 PM, Resident #1 was reweighed by staff who were interviewed by and with the surveyor present. The Resident's current weight was 102 lbs which indicated she was gaining back [4 lbs] some weight that was lost and tolerating the tube feeding and oral feeding now being supplied. The staff ST stated that an increase in feeding may be due.On 7-15-26 at 4:30 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator, both were informed of the facility staff's failure to implement and review/revise the Resident's nursing care plan. Both stated they would provide all documentation requested.On 7-16-26 at 2:30 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator the above findings including added documents were discussed. The facility staff stated they had nothing further to provide.

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to address and implement interventions for significant weight loss for one Resident (Resident #1) in a survey sample of 26 residents. The findings included:Resident #1 was admitted on [DATE] after a hospitalization for a fractured left humerus and left hip with surgical repair of both. The Resident's diagnoses included but were not limited to: Diabetes, lupus, dysphagia with peg [per endoscopic gastrostomy feeding] tube insertion, bolus feeding, malnutrition, anemia, and right lung cancer. The Resident was sent back to the hospital for aspiration pneumonia and respiratory failure on 5-23-26, returning to the facility on 6-1-26.The most recent MDS (Minimum Data Set federal assessment) was completed as a five-day readmission assessment with an Assessment Reference Date (ARD) of 6-8-26. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment. The Resident required assistance from staff with eating to include feeding tube continuous infusions. The document recorded no rejections of care, no behaviors, and no problems with swallowing. The Resident was coded as weighing 98 pounds, receiving 51% or greater calories from tube feeding, with 5% or greater weight loss, and 5% or greater weight gain which was an error. All weights were conducted by a mechanical lift. The Resident was wheelchair bound.On 7-14-26 at 1:15 PM Resident #1 was observed in bed with a feeding pump on a pump stand by her bed attached to a peg tube in her abdomen covered from sight. The pump was off.On 7-15-26 the clinical record was reviewed to include physician's orders. The order for the feeding pump was Glucerna 45 milliliters per hour continuous, and water at 150 milliliters every 4 hours ordered on readmission 6-1-26. On 7-15-26 hospital and nursing facility weight documents were reviewed and revealed the following;6-1-26 - Hospital discharge records 109 lbs6-2-26 nursing facility records 103 lbs6-3-26 nursing facility records 101.3 lbs6-8-26 nursing facility records 98.4 lbs6-15-26 nursing facility records 98.1 lbsThese records indicate a significant weight loss of 11 pounds or greater than 10% since readmission 14 days earlier. The Resident was not receiving diuretics.Physician notes indicated The Resident was seen on 6-2-26 by the doctor, however, no supplements nor vitamin replacements were ordered, and the note was not placed in the clinical record until faxed to the facility on 6-22-26. Physician's orders were reviewed and revealed no changes for the Resident with no additions to nutrition supplementation up to and through the time of survey.The Speech Language Pathologist [SLP] Speech Therapist [ST] notes were requested and reviewed. They revealed that the ST did not see the Resident until 7-11-26 and the note documented that the Resident would remain NPO [nothing by mouth] and that the continuous tube feedings would continue. The ST saw the Resident again on 7-14-26, during survey and the note indicated the Resident's abilities had improved and the Resident had been given mildly thick drinks, pureed foods, however, would remain NPO with continuous tube feedings. On 7-16-26 the Resident was observed by surveyors consuming potato soup with the ST seated beside the Resident. Registered Dietician [RD] notes were documented on 6-9-26, 6-21-26, and during survey on 7-14-26. Those documents revealed the following;On 6-9-26 the RD documented the Resident was not tolerating the Diabeta Source feeding formula and refer to MD [doctor]. The Resident was not receiving Diabeta Source. The Resident was receiving Glucerna 1.5 calorie carb steady formula at 45 milliliters an hour with no indication of intolerance.On 6-21-26 the RD documented no changes and to increase the feeding as tolerated. The feeding was never increased.On 7-14-26 during survey the RD documented Boost supplements ordered with meals, and that the max amount that the Resident has been able to tolerate of the tube feeding is 45 milliliters per hour. There is no indication from the RD, ST, nor the physician that any increase in supplements, added calories, or feeding formula was ever tried until 7-11-26 when the Resident was presented a pleasure tray by the ST, which was allegedly a failure, and then again with the ST on 7-16-26 during survey with surveyor observed success.On 7-16-26 Resident #1 was observed during lunch in the dining room with the ST. The Resident was observed to be eating potato soup and was consuming it independently without difficulty and stated she was enjoying it. The Resident was noted to have a pump with tubing attached to a continuous feeding source flowing through a peg tube in her abdomen covered by clothing. The infusion was noted to be Glucerna 1.5 cal [calorie] carb steady feeding solution infusing at 45 milliliters per hour, and water infusing at 50 milliliters per hour continuously. The care plan was reviewed and revealed two different Focuses both dated 6-15-26 2 weeks after returning from the hospital. Those were as follows;1. Resident requires tube feeding related to dysphagia for nutrition.2. Potential for nutritional problem noted weight loss since readmission and at risk for additional weight loss. The Care plan Goals were; Maintain adequate nutrition and hydration status as evidenced by weight stable and no signs/symptoms of malnutrition or dehydration. Maintain weight and tolerate tube feedings. The interventions for the focuses and goals included weight as ordered/indicated, RD evaluate quarterly and as needed, monitor caloric intake and estimate needs, make recommendations for changes to tube feeding and water flushes, see MD (doctor) orders for current feeding orders.The care plan also contained old interventions from the time when the Resident was receiving bolus feedings, which she did not tolerate and would refuse. This was prior to her hospitalization on 5-23-26 which was caused by aspirating [inhaling] stomach contents resulting in pneumonia. Those included head of bed elevated 45 degrees during and 30 minutes after tube feeding, and Aspirate gastric contents hold feeding if greater than 30 milliliters. The Resident was not weighed as ordered; the RD did not evaluate during a significant weight loss and made no mention of the Resident's caloric needs. The RD made no recommendations for changes during a significant weight loss so that the doctor could change the feeding orders as the new feeding after hospitalization was being tolerated. The old interventions for head of bed elevation could have been confusing for staff as the Resident should have had the head of bed always elevated for the now continuous feeding. The feeding monitoring aspiration of 30 milliliters causing a hold on the feeding did not include a description of when to check and how long to hold the feeding. A new feeding monitoring order was evidently received though it was not reflected in the care plan. That order was documented as having been administered in the Medication and Treatment Administration records, and follows below;The Medication and Treatment Administration records were reviewed for July 2026, and an order was being signed as completed for Enteral feed order for monitoring two times a day check tube placement by aspirating stomach contents every 8 hours, if greater than 100 milliliters hold feeding one hour and recheck residual if greater than 100 milliliters after recheck hold and call MDOn 7-16-26 at 1:30 PM, Resident #1 was reweighed by staff who were interviewed by and with the surveyor present. The Resident's current weight was 102 lbs which indicated she was gaining back [4 lbs] some weight that was lost and tolerating the tube feeding and oral feeding now being supplied. The ST staff stated that an increase in feeding may be due.On 7-15-26 at 4:30 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator, both were informed of the facility staff's delay in treatment during a significant weight loss for this dependent Resident, and further to implement and review/revise the Resident's nursing care plan. Both stated they would provide all documentation requested.On 7-16-26 at 2:30 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Administrator the above findings including added received documents were discussed. The facility staff stated they had nothing further to provide.

Based on observation, interview, and facility policy review, the facility failed to serve milk from the kitchen's tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below and staff failed to wear hair restraints when they served soup to residents from two crock pots in the facility's main dining room for 25 out of 61 residents who consumed meals prepared at the facility. Findings include: Review of the facility's policy titled, Food Safety, with a revised date of 12/13, revealed, . All cold items need to be held at 40 [degrees] F. or lower. To keep food cold during service surround product with draining ice or keep refrigerated and only pull a few out as needed during service. Review of the facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, with a revised date of 11/22, revealed, All employees who handle food, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents . Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. 1. Observation on 07/26/23 at 4:48 PM of food and beverages being served from the kitchen's evening tray line revealed cartons of milk were being served from a plastic container which did not contain any ice to keep the milk cold. Temperature monitoring of one of these cartons of milk revealed it had an elevated internal temperature of 46.8 degrees F. During an interview on 07/26/23 at 4:50 PM, the Dietary Manager (DM) stated when staff serve cartons of milk from the kitchen tray line, they are expected to keep the milk covered in ice to maintain its internal temperature at 41 degrees F. or below. 2. Observation in the facility's main dining room on 07/25/23 at 11:15 AM revealed there were two opened cock pots of soup on a countertop. Observation on 07/25/23 at 11:18 AM revealed there were 24 residents in the dining room and Employee G, Employee H, Employee K, and Certified Nursing Assistant (CNA) D served soup from the two crock pots to residents in the dining room. Closer observations of Employee G, Employee H, Employee K, and CNA D revealed they were not wearing hair restraints when they removed soup from the crock pots, placed the soup into bowls or cups and served the soup to residents seated in the dining room. Observation in the facility's main dining room on 07/27/23 at 11:18 AM revealed there were two opened cock pots of soup on a countertop. Observation on 07/25/23 from 11:18 AM to 11:27 AM revealed Employee G, Employee N, Employee K, and CNA D served soup from the two crock pots to approximately 24 residents who were in the dining room. Closer observations of Employee G, Employee N, Employee K, and CNA D revealed they were not wearing hair restraints when they removed soup from the crock pots, placed the soup into bowls or cups and served it to residents seated in the dining room. During an interview on 07/27/23 at 12:05 PM Employee G and Employee K stated they had not been instructed to wear hairnets when they served residents soup from the crock pots in the dining room. Employee G also stated that she was aware hairnets were available right inside the kitchen door but had not been instructed to wear a hair restraint when serving soup from the crock pots in the dining room. During an interview on 07/27/23 at 12:15 PM the Dietary Manager (DM) confirmed staff had not been previously instructed to wear hair nets when they served soup to residents from the two opened crock pots in the dining room.

Based on observation, staff interview, and facility documentation review, the facility staff failed to implement infection control practices to prevent the spread of infection on 2 of 2 nursing units, which had the potential to affect multiple Residents. The findings included: 1. The facility staff failed to adhere to standard precautions and perform hand hygiene/cleanse hands between Residents during medication administration. On 7/26/23 at 8:58 AM until 10:05 AM, continuous observations of medication administration were conducted with LPN E. The following was observed: LPN E retrieved from the medication cart, the medications for Resident #33. LPN E then approached Resident #33, who was sitting in the hallway across from the nursing station, administered the medications, then returned to the medication cart to dispose of the medication cup and water cup. LPN E then proceeded to retrieve the medications from the cart for Resident #40. LPN E prepared the medications at the medication cart, then went to the nourishment room on the other nursing unit to retrieve a liquid medication supplement. LPN E then returned to the medication cart and poured the supplement into a cup. LPN E and Surveyor C went to Resident #40's room, and the nurse administered the medications and supplement to the Resident. LPN E then returned to the nursing station, opened the door to the medication room, poured the remaining liquid supplement in the sink and threw the cup away. LPN E then returned to the medication cart and began pulling the medications for Resident #7. LPN E put two bottles of eye drops into her pocket and had a cup of the pills and a cup of water in each hand, entered the room of Resident #7. LPN E then provided the Resident the cup of medications, which the Resident took a few from the cup at a time and then would drink water and repeat this process until all 9 pills had been taken. LPN E then put on a pair of gloves and administered eye drops to both eyes of Resident #7. LPN E told Resident #7 and Surveyor C she would return to administer the other eye drops later because she needed to wait between the two drops. LPN E then returned to the medication cart, parked in the hallway, removed her gloves, and then proceeded to document on the computer the administration of the pills and the eye drops. LPN E then at 9:35 AM, began retrieving the medications for Resident #52 from the cart. Following the preparation of the medications, LPN E entered Resident #52's room, administered the po (my mouth) medications/pills. LPN E then donned (put on) gloves, checked the Resident's blood sugar, removed the insulin vial from her pocket and realized the syringe wasn't large enough. LPN E then returned to the medication cart parked in the hallway, opened the cart, and using her gloved hand started touching items in the cart looking for the correct insulin syringe. LPN E then went to the nursing station, opened another medication cart, went through the drawer, touching many items with her gloved hands and obtained 3 syringes. LPN E then, still with the gloves on, returned to the prior cart parked in the hallway, placed two of the syringes in the top drawer of the medication cart and then opened one syringe. She used an alcohol swab to cleanse the diaphragm/seal on the top of the insulin vial and then laid the used alcohol prep pad directly onto the surface of the medication cart. LPN E then proceeded to draw up the correct amount of insulin into the syringe. LPN E then picked up the used alcohol prep pad from the top of the medication cart, returned to the Resident's room and uses the same previously used alcohol prep pad to cleanse the back of the left arm of Resident #52, where the insulin was to be administered. LPN E then administered the insulin, exited the room, and returned to the medication cart in the hallway. LPN E was still wearing the same pair of gloves initially put on following the checking of Resident #52's blood sugar. LPN E then picked up her ink pen and wrote down Resident #52's blood sugar reading on a sheet of paper. LPN E then collected and discarded the trash from the top of the medication cart. LPN E then doffed (removed) her gloves, put on a clean pair of gloves opened the medication cart to retrieve a Sani cloth wipe. LPN E then proceeded to wipe all sides of glucometer once and placed the glucometer directly onto the medication cart to air dry. LPN E then removed her gloves and proceeded to use the computer to document the administration of the medications to Resident #52. On 07/26/23 at 09:53 AM, Employee P, the maintenance director approached LPN E at the medication cart and asked if she had the paperwork ready for Resident #44, as he was getting ready to take the Resident to dialysis. LPN E said she did not and then walked to the nursing station, completed a form and then went back to the hallway to retrieve a vital sign machine and obtained Resident #44's vital signs. LPN E then recorded the vital signs on the paper and handed it to Employee P. On 07/26/23 at 09:59 AM, LPN E returned to the medication cart and used hand sanitizer for the first time since the observation began at 8:58 AM. On 07/26/23 at 10:00 AM, LPN E returned to the room of Resident #7 and administered drops to the Resident's right eye. No gloves were put on during this task. LPN E then returned to the medication cart and immediately began retrieving medications from the cart for another Resident. Again, no additional hand hygiene was performed. On 7/26/23, in the late morning, LPN E was approached by Surveyor C. When asked about hand hygiene and a discussion held about the observations during the administration of medications. LPN E apologized and said she should have washed her hands between each Resident. Review of the facility's infection prevention and control policy was conducted. An excerpt from this policy read, . 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The Centers for Disease Control and Prevention (CDC) gives guidance in their document titled, Hand Hygiene in Healthcare Settings. The document read, Clean Hands Count for Healthcare Providers: Protect yourself and your patients from potentially deadly germs by cleaning your hands. Be sure you clean your hands the right way at the right times .When to perform hand hygiene? Multiple opportunities for hand hygiene may occur during a single care episode. Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, after caring for a person with known or suspected infectious diarrhea, before moving from work on a soiled body site to a clean body site on the same patient . The above referenced CDC document went on to state, .Glove Use: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient. Carefully remove gloves to prevent hand contamination . Accessed online at: https://www.cdc.gov/handhygiene/providers/index.html The Centers for Disease Control and Prevention (CDC) gives guidance in their document titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. Excerpts from this document read as follows: .5a. Hand Hygiene: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment, After contact with blood, body fluids or contaminated surfaces, Immediately after glove removal. Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered . Accessed online at: https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html On 7/26/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above observations and concerns. No additional information was provided. 2. The facility staff failed to practice infection control practices to prevent the spread of infection, as evidenced by the re-use of an alcohol prep pad, during insulin administration involving Resident #52. On 7/26/23 at 9:37 AM, LPN E was observed during the preparation and administration of medications for Resident #52. LPN E administered the po (my mouth) medications/pills. LPN E then donned (put on) gloves, checked the Resident's blood sugar, removed the insulin vial from her pocket and realized the syringe wasn't large enough. LPN E then returns to the medication cart parked in the hallway, opens the cart, and starts using her hands to observe the syringes in the cart, then goes to the nursing station, opens another medication cart, goes through the drawer, touching many items with her gloved hands and obtains 3 syringes. LPN E then, still with the gloves on, returns to the prior cart parked in the hallway, places two of the syringes in the top drawer, then opens one syringe, uses an alcohol swab to cleanse the diaphragms/seal on the top of the insulin vial and then lays the used alcohol prep pad directly onto the surface of the medication cart. LPN E then proceeded to draw the correct amount of insulin into the syringe. LPN E then picked up the used alcohol prep pad from the top of the medication cart, returned to the Resident's room and uses the same previously used alcohol prep pad to cleanse the back of the left arm of Resident #52, where the insulin was to be administered. LPN E then administered the insulin, exited the room, and returns to the medication cart in the hallway. LPN E was still wearing the same pair of gloves initially put on following the checking of Resident #52's blood sugar. LPN E then proceeded to pick up her ink pen and write down Resident #52's blood sugar reading on a sheet of paper. LPN E then collected and discarded the trash from the top of the medication cart. LPN E then doffed (removed) her gloves, put on a clean pair of gloves, opened the medication cart to retrieve a Sani cloth wipe. LPN E then proceeded to wipe all sides of glucometer once and placed the glucometer directly onto the medication cart to air dry. LPN E then removed her gloves and proceeded to use the computer to document the administration of the medications to Resident #52, all without performing any hand hygiene. The Centers for Disease Control and Prevention (CDC) gives guidance in their document titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. Excerpts from this document read as follows: .5. Standard Precautions: Use Standard Precautions to care for all patients in all settings. Standard Precautions include: 5a. Hand hygiene, 5b. Environmental cleaning and disinfection, 5c. Injection and medication safety . Standard Precautions are the basic practices that apply to all patient care, regardless of the patient's suspected or confirmed infectious state, and apply to all settings where care is delivered. These practices protect healthcare personnel and prevent healthcare personnel or the environment from transmitting infections to other patients . The above referenced document went on to give the following guidance specific to the administration of injections and medications. It read, .5c. Injection and Medication Safety: Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination, including sinks or other water sources. Use aseptic technique when preparing and administering medications. Disinfect the access diaphragms of medication vials before inserting a device into the vial. Use needles and syringes for one patient only (this includes manufactured prefilled syringes and cartridge devices such as insulin pens). Enter medication containers with a new needle and a new syringe, even when obtaining additional doses for the same patient . Accessed online at: https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html On 7/27/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above observations. No further information was provided. 3. The facility staff failed to handle a soiled incontinence brief in a manner to prevent the spread of infection. On 07/27/23 at 09:55 AM, Surveyor C requested that LPN D accompany her to the room of Resident #35 to make observations of his feet. During this observation, a soiled incontinence brief was noted to be open to air/not in a bag sitting in a chair at the bedside. LPN D confirmed that the brief was soiled. LPN D put on gloves and picked up the soiled incontinence brief, exited the room carrying the brief, still open to air/unbagged through the hall passing about 4 Resident rooms to place the brief in a trash receptacle in the hallway. When asked how the brief should have been handled, she indicated it should not have been sitting in a chair due to infection control concerns and stated, I will take care of it and said she would speak to the CNA. On 07/27/23 at 11:58 AM, an interview was conducted with CNA B. When asked to explain how soiled incontinence briefs are to be handled, CNA B said, We are to put it in a bag and put it in the trash. When asked why it is put in a bag, CNA B said, because it's infection control. On 7/27/23 at 2:30 PM, an interview was conducted with CNA C. When asked how soiled incontinence briefs are to be handled, CNA C said, I remove the soiled brief and put it in a bag, but I had left one. When asked why it was sitting in the chair open to air, CNA C said, I had forgot it and got distracted. When asked why the soiled briefs are to be placed in a bag, CNA C said, To keep the germs from other parts. Review of the facility's infection prevention and control policy was conducted. An excerpt from this policy read, . 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The Centers for Disease Control and Prevention (CDC) gives guidance in their document titled, Environmental Infection Control Guidelines: Guidelines for Environmental Infection Control in Health-Care Facilities (2003). The document categorizes practices by categories and identified category IC as: Required by state or federal regulation or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed, where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standard). An excerpt from the above referenced CDC document read, .G.III. Routine Handling of Contaminated Laundry: . G.III.B. Bag or otherwise contain contaminated textiles and fabrics at the point of use. (OSHA: 29 CFR 1910.1030 S d.4.iv), G.III.B.1. Do not sort or prerinse contaminated textiles or fabrics in patient-care areas. (OSHA: 29 CFR 1910.1030 Sd.4.iv), G.III.B.2. Use leak-resistant containment for textiles and fabrics contaminated with blood or body substances. (OSHA: 29 CFR 1910.1030 S d.4.iv) . This information was accessed online at: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#g On 7/27/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above observation. Both confirmed that soiled briefs are to be placed in a bag and not sat on other surfaces to prevent the spread of infection. No further information was provided.

Based on staff interview and facility documentation review, the facility staff charged the Resident and deducted from their patient trust account, funds in excess what was due to the facility for three Residents (Resident #17, #37 and #23), in a survey sample of 6 Residents reviewed with trust accounts. This happened on five occasions. The findings included: 1. For Resident #17, the facility staff withdrew $153 in excess of what was due towards the cost of care on two occasions, March 2023, and May 2023. On 7/27/23, Surveyor C received and reviewed the Resident trust account statement for Resident #17 for the year of 2023. During this review it was noted that on March 3, 2023, $1,129 was deducted/withdrawn from the Resident's trust account for Care Cost Auto WDL [automatic withdrawal]. Review of the patient pay information from the Virginia Medicaid Web portal indicated Resident #17 owed the facility $976 each month. Then on 4/7/23, instead of withdrawing the $976 due for the cost of care, the facility withdrew $823, to offset the overpayment in March. On 5/3/23, another withdrawal for $1129 was made and noted as Care Cost Auto WDL. Again, Resident #17 was indicated by Medicaid to only owe $976. Then on 6/12/23, when the care cost withdrawal was made, only $823 was deducted to offset the prior months over payment. 2. For Resident #37, the facility staff made deductions from the Resident trust fund more than what was due to the facility. On 7/27/23, Surveyor C received and reviewed the Resident trust account statement for Resident #37 for the year of 2023. During this review it was noted that on March 3, 2023, $1,561 was deducted/withdrawn from the Resident's trust account for Care Cost Auto WDL [automatic withdrawal]. Review of the patient pay information from the Virginia Medicaid Web portal indicated Resident #37 owed the facility $1351 each month. Then on 5/3/23, instead of withdrawing the $1,351 due for the cost of care, the facility withdrew $1,141, to offset the overpayment in March. 3. For Resident #23, the facility staff withdrew excess funds from the Resident's trust account/bank account funds in excess of what was due/owed to the facility on 2 occasions. On 7/27/23, Surveyor C received and reviewed the Resident trust account statement for Resident #23 for the year of 2023. During this review it was noted that on March 1, 2023, a deduction in the amount of $90 was deducted/withdrawn from the Resident's trust account for Care Cost Auto WDL [automatic withdrawal]. Then on March 3, 2023, an additional amount of $1,158 was withdrawn and noted as a Care Cost Auto WDL. This totaled $1,248 being withdrawn for the month of March. Review of the patient pay information from the Virginia Medicaid Web portal indicated Resident #23 owed the facility $1,065 each month. Then on 4/7/23, instead of withdrawing the $1,065 due for the cost of care, the facility withdrew $882, to offset the overpayment in March. On 5/1/23, a withdrawal for care cost was made in the amount of $90. On 5/3/23, an additional withdrawal for $1,158 was made, both were noted as Care Cost Auto WDL. Again, Resident #23 was indicated by Medicaid to only owe $1,065. Then on 6/12/23, when the care cost withdrawal was made, only $882 was deducted to offset the prior months over payment. On 7/27/23 at 03:15 PM, an interview was conducted with Employee M, the business office manager (BOM). Employee M confirmed that she determines the amount a Resident owes as a patient pay/liability via the the Medicaid web portal. Employee M confirmed all the above findings. When asked about the above findings, Employee M then stated, It pulled automatically, referring to the wrong amounts being set-up to auto-deduct each month. It was expressed that despite it happening in March 2023, corrections were not made until April. Residents were not credited the over payment within the month that the error occurred. Then in April 2023, the same over payments were made and restitution not made until the following month. The BOM said, I have put a block on it now so it will quit pulling the wrong amount. I must put it in manually. With regards to the corrections not being made until the following month, the business office manager said, For March there would have had a credit, so I applied it [the credit] to the next month. Surveyor C asked if any of the above discrepancies/errors had been discussed with the Resident's identified as being affected. The business office manager said, No. When asked if not refunding overpayments and just waiting until the next month and collect less due to the facility is generally accepted accounting practice, the business office manager said, Well no, it shouldn't be done that way, it was a mistake, and it was fixed. On 7/27/23, during the end of day meeting the facility Administrator was made aware of the above findings. On 7/28/23, the Administrator provided a written statement from Employee M that indicated the Resident trust accounts had been changed on 6/30/23, so that funds will not be automatically withdrawn each month, she will manually enter the amount to be deducted for care costs/patient pay. No further information was provided.

Based on observation, interview, record review, and facility policy review the facility failed to serve the planned menu as approved by the facility's Registered Dietitian (RD) to residents with physician's orders for regular, mechanical soft, or pureed diets. This failure had the potential to affect 61 residents who were served meals from the facility's kitchen. Findings include: Review of the facility's policy titled, Menus, revised on 10/17, revealed, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance. A group interview meeting was conducted on 07/26/23 at 1:00 PM with five residents whom the facility identified as reliable historians. During the meeting, two of the five residents (R53, and R56), voiced concerns about the kitchen not always serving the facility's planned menu. Observation on 07/26/23 at 4:40 PM revealed unidentified dietary staff were preparing resident evening meal trays from the kitchen's tray line and the only menu posted in the kitchen was for regular diets. Review of the menu revealed staff were not serving the Caesar salad and ice cream sundae that was planned on the menu for regular diets. Staff were serving a tossed salad instead of the Cesar salad and a cup of ice cream instead of the ice cream sundae. Review of the RD approved regular diet for the evening meal of 07/26/23 revealed the following foods were on the menu to be served: pizza, Caesar salad, bread stick, and ice cream sundae. Review of the RD approved mechanical soft diet menu for the evening meal of 07/26/23 revealed the following foods were on the menu to be served; four cheese pasta, capri blend vegetables, a bread stick, and an ice cream sundae. Review of the RD approved pureed diet menu for the evening meal of 07/26/23 revealed the following foods were on the menu to be served; pureed four cheese pasta, pureed carpi blend vegetables, pureed bread stick, and pudding parfait. Observation on 07/26/23 at 4:42 PM revealed unidentified dietary staff served residents on mechanical soft diets the following on their meal trays: chopped chicken nuggets, broccoli, a bread stick, and a cup of ice cream. The dietary staff were observed to serve residents on pureed diets the following on their meal trays: pureed pizza, pureed broccoli, pureed bread stick, and a cup of ice cream. During an interview on 07/26/23 at 4:45 PM, Cook (C)1, who prepared and served the evening meal on 7/26/23 confirmed the regular diet menu was not being served as planned. C1 also stated menus for mechanical soft and pureed diet were not available for the kitchen staff to follow; so, for the 07/26/23 evening meal she decided to serve residents on mechanical soft diets chopped chicken nuggets, broccoli, bread stick, and ice cream, and she decided to serve residents on pureed diets pureed pizza, pureed broccoli, pureed bread, and ice cream. C1 stated she documented the menu changes for the regular menu on the Menu Substitution Log, C1 stated changes were made to the facility's regular menu approximately one to two times per week. Review of the kitchen's July 2023, Menu Substitution Log revealed staff documented menu changes were made on 07/05/23, 07/11/23, 07/20/23, 07/25/23, and 07/26/23. During an interview on 07/26/23 at 4:50 PM the Dietary Manager (DM) stated the facility's current resident population had physician's orders to receive diets which included regular, mechanical soft, or pureed. The DM confirmed the regular diet menu was the only menu posted in the kitchen and this menu was not being followed as planned by staff during the evening meal of 07/26/23. The DM explained the menus for mechanical soft and pureed diets were not available in the kitchen for staff to follow, so staff chopped and pureed the foods that were planned on the regular menu to serve to residents on mechanical soft or pureed diets at meals. The DM stated the facility's RD approved the facility's menu which included the menu extensions for mechanical soft and pureed diets, but the RD approved menus for mechanical soft and pureed diets were not available for staff to utilize and it was this way since April 2023 when she started working at the facility as the DM. The DM stated she would locate the consultant RD approved facility menus and left the kitchen area. The DM returned to the kitchen with a copy of the facility's planned menu that was signed and approved by the consultant RD which included menus for mechanical soft and pureed diets. During an interview on 07/26/23 at 4:55 PM the DM also stated staff documented menu changes on the Menu Substitution Log when they made changes to the regular diet menu and the RD reviewed this documentation during her next facility visit. During an interview on 07/26/23 at 5:03 PM the Administrator stated the facility's approved menu for all diet types needed to be available to the kitchen staff, so the menu could be prepared as planned. During an interview on 07/28/23 at 9:15 AM the facility's consultant RD stated she expected the facility's approved menu to be accessible to dietary staff, so the menu could be prepared at each meal as planned for all diet types.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to continue skilled services and bill the Resident as requested on the SNF ABN notice (Skilled Nursing Facility Advance Beneficiary Notice) issued to 2 Residents (Resident #14 and #44) in a survey sample of 3 Residents, reviewed for such notices. The findings included: 1. For Resident #14, the Resident selected on a SNF ABN form that she wanted to continue to receive the services, and the facility staff ended the services, despite the Resident's request. On 7/26/23, during a review of Resident #14's SNF ABN notice, it was noted that the Resident #14's skilled care services were ending on 4/7/23. The facility staff presented the Resident with a SNF ABN notice on 4/4/23, which Resident #14 selected option 2, which read, I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Review of the therapy notes revealed that Resident #14's last day of therapy services was 4/6/23. [NAME] documents were reviewed and confirmed the same. On 07/26/23 at 02:46 PM, Surveyor C met with Employee M, the business office manager. Employee M confirmed that Resident #14's last skilled day was 4/6/23, and no further therapy services were provided after that date. 2. For Resident #44, who selected on a SNF ABN notice that she wanted skilled care to continue and she would pay for it, the facility staff stopped the service anyway. On 7/26/23, during a review of Resident #44's SNF ABN notice, it was noted that the Resident #44's skilled care services were ending on 5/29/23. The facility staff presented the Resident with a SNF ABN notice on 5/25/23, which Resident #44 selected option 2, which read, I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Review of the therapy notes revealed that Resident #44's last day of therapy services was 5/29/23. [NAME] documents were reviewed and confirmed the same. On 07/26/23 at 02:46 PM, Surveyor C met with Employee M, the business office manager. Employee M confirmed that Resident #44's last skilled day was 5/29/23, and no further therapy services were provided after that date. On 07/26/23 at 02:50 PM, Surveyor C met with Employee M, the business office manager. Employee M confirmed she is responsible for issuing ABN notices to Residents. She was asked to explain her understanding of the options on the ABN form. The business office manager gave the following explanation with regards to option 2, if someone is staying here, then option 2 should be the one they should pick, because they are agreeing they are going to pay for the bill and that Medicare will not be billed. Employee M was asked if a Resident selects options 1 or 2 on the SNF ABN form, if this is communicated to anyone and if it changes what services the Resident receives, she said, I don't think so. The facility policy regarding skilled nursing facility advanced beneficiary notice (SNFABN) was requested. The facility staff indicated they did not have a policy for this. On 7/26/23 at 4 PM, the business office manager, Employee M, provided the survey team with documents she had with regards to SNF ABN notices, in lieu of a policy. The documents were reviewed and were blank SNF ABN and NOMNC (notice of Medicare non-coverage) forms, in English and Spanish. In the CMS document, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). This instruction sheet read, .There are 3 options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice . The CMS instructions regarding when a resident selects option 2, read: .When the beneficiary selects Option 2, the care is provided, and the beneficiary pays for it out-of-pocket. The SNF does not submit a claim to Medicare. Since there is no Medicare claim, the beneficiary has no appeal rights. Note: Although Option 2 indicates that Medicare will not be billed, SNFs must still adhere to the Medicare requirements for submitting no pay bills. See Chapter 6 of the Medicare Claims Processing manual for SNF claim submission guidance. Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN- On 7/27/23 at 9:29 AM, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to assess for appropriateness of self-administration of medications for 1 Resident (Resident #23) in a survey sample of 44 Residents. The findings included: For Resident #23, the facility allowed the Resident to have physician ordered ointment, at the bedside, without first assessing the Resident's ability to self-medicate. On 7/25/23 at 3:31 PM, Resident #23 was noted to have a medication cup of a clear ointment at the bedside, unsecured. On 7/25/23 at approximately 3:35 PM, Surveyor C had LPN B accompany her to the room of Resident #23. When asked what the cup of ointment was, LPN B said, she didn't know. When asked if it should be at the bedside, LPN B said, No and discarded it in the trash. LPN B then went to the nursing station and looked at Resident #23's physician orders and noted an order for Neosporin ointment that is to be applied twice daily. LPN B said, it must have been left there from the night shift. On 7/25/23, a clinical record review was conducted of Resident #23's chart. This chart revealed no physician order, no assessment of their ability to safely self-administer medications, nor a care plan to indicate the Resident was able to self-administer medications. Also noted in the clinical record, in the admission documents was a document titled, Self-Administration of Medication Consent Form that indicated No, I do not want to exercise my right to self-administer my medications. A physician order dated 7/4/23, was noted that read, Neosporin Original External Ointment (Neomycin Bacitracin Polymyxin), Apply to groin rash topically two times a day for groin rash. On 7/27/23 at 2:40 PM, an interview was conducted with Employee H, who was a Registered Nurse (RN). Employee H develops the nursing care plans for Residents within the facility and when asked about Residents who self-administer medications, Employee H identified that the facility currently has no Residents who self-administer medications. When asked about the storing of medication and leaving medications at the bedside, Employee H indicated that medications are not to be left at the bedside of a Resident. When asked what the associated risks of doing so are, Employee H said, The resident may not take it, another patient could take it and it is a safety hazard. Review of the facility policy titled; Self-Administration of Medications was conducted. This policy read, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . On 7/27/23, during the end of day meeting, the Administrator and Director of Nursing were made aware of the concern and no further information was provided. On 7/28/23 at approximately 9 AM, Surveyor C met with Resident #23. Resident #23 reported that staff gives him the ointment that I put it on myself. Resident #23 went on to say, I signed a paper last night. On 7/28/23 at 10:16 AM, the facility Administrator provided the survey team with a document titled, Self-Administration of Medication Consent Form that Resident #23 signed 7/27/23. The facility Administrator also provided a copy of a BIMS (brief interview for mental status) Evaluation that had been conducted on Resident #23 on 7/23/23, that indicated Resident #23 was cognitively intact. However, there was still no assessment of the Resident's physical ability to determine if self-administering medications was clinically appropriate for the Resident. No further information was provided.

Based on observation, interview, record review, and facility policy review, the facility failed to have call bells accessible for two of two residents (Resident (R)5, and R19) reviewed for accommodation of needs out of 44 sampled residents. These failures had the potential to cause a delay in the provision of care for these two residents. Findings include: Review of the facility policy titled, Answering the Call light, revised on 11/22, revealed, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 1. Review of R5's Medical Diagnosis, sheet located in the Med Diag [diagnosis] tab of the electronic medical record (EMR) revealed R5 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and lack of coordination. Review of R5's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/09/23, located in the MDS tab of the EMR, revealed R5 required extensive assistance with bed mobility, transfers, personal hygiene and total dependence with toilet use, was sometimes understood, and had impaired functional range of motion on one side of her upper extremities. R5 scored three out of 15 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. Review of R5's comprehensive Care Plan, dated 06/20/23, and located in the Care Plan tab of the EMR, revealed a Focus which specified R5 was at high risk for falls related to cerebral vascular accident with hemiplegia, limited physical mobility, poor safety awareness, use of antidepressant for appetite stimulant. A care plan intervention included, Be sure the call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 07/25/23 at 2:24 PM, 3:50 PM, and 4:45 PM revealed R5 was in bed and her call bell was out of her reach. The resident's call bell was positioned near the top of her bed on the left side. Observation on 07/25/23 at 5:10 PM revealed R5 was eating her evening meal in bed with no staff in the room and her call bell out of her reach. The resident's call bell was positioned near the top of her bed on the left side. Observation on 07/26/23 at 10:08 AM, 12:35 PM, 1:40 PM, and 2:10 PM revealed R5 was seated in a geri-chair in her room and her call bell was out of her reach. R5's call bell was positioned on her bed. During the observation on 07/26/23 at 12:35 PM, R5 was asked if she could reach her call bell that was positioned on her bed. The resident attempted to reach the call bell with her left hand but was unable to reach her call bell. During an interview on 07/26/23 at 2:10 PM, Certified Nursing Assistant (CNA) E confirmed R5's call bell was out of the resident's reach. CNA E stated R5's call bell should be positioned as close to her as possible because the resident used her call bell to request staff assistance. Observation on 07/26/23 at 2:12 PM revealed CNA E handed R5 her call bell and R5 easily activated the call bell upon request. During an interview on 07/27/23 at 4:35 PM the Clinical Service Director (CSD) stated R5 should have her call bell within reach to request staff assistance. 2. Review of R19's Medical Diagnosis, sheet located in the Med Diag tab of the EMR, revealed R19 had diagnoses which included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, and lack of coordination. Review of R19's quarterly MDS assessment, with an ARD of 06/24/23, located in the MDS tab of the EMR, revealed R19 required one-person physical assistance with bed mobility, transfers and walking in room, had unclear speech, and impaired functional range of motion on one side of his upper extremities. R19 scored seven out of 15 on the BIMS which indicated severe cognitive impairment. Review of R19's comprehensive Care Plan, dated 07/04/23 and located in the Care Plan tab of the EMR, revealed a Focus which specified R19 was at a high risk for falls related to gait and balance problems secondary to cerebral vascular accident related to hemiplegia. A care plan intervention included, Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation on 07/25/23 at 4:39 PM, and from 5:09 PM to 6:12 PM, revealed R19 was seated in his wheelchair in his room and his call light was not accessible to him. The resident's call light was observed to be on his bed next to the wall which was out of his reach. Observation on 07/25/23 from 5:23 PM to 6:03 PM revealed R19 was seated in a wheelchair in his room with his evening meal in front of him. The resident's call light was observed to be on his bed next to the wall which was out of R19's reach. During an interview on 07/25/23 at 6:03 PM CNA E confirmed R19's call bell was out of his reach. CNA E stated R19's call bell should be within his reach because he used it to call staff for assistance. Observation on 07/26/23 at 9:00 AM, and 9:15 AM revealed R19 was seated in his wheelchair in his room and his call bell was not within his reach. The resident's call light was observed to be on his bed next to the wall. During an interview on 07/27/23 at 4:35 PM the CSD confirmed R19's call bell should be within his reach.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 2 residents, Resident #15 and Resident #44, in a survey sample of 44 residents. The findings included: 1. The facility staff failed to offer and/or provide Resident #15 or their Responsible Party (RP) with Advance Directive planning. On [DATE] at approximately 11:30 AM, an attempt to interview Resident #15 was made, however she declined. An interview was conducted with her Responsible Party (RP). The RP stated, I take an active part in planning my mother's care here at the facility, I do not recall anyone ever asking her whether or not she would want CPR [cardiopulmonary resuscitation], but I can tell you that she does not, she has wanted DNR [do not resuscitate] for many years now. On [DATE] at approximately 12:15 PM, a clinical record review for Resident #15 was performed and revealed active physician's orders dated [DATE] that read, Active, Full Code and the patient's profile banner read, FULL CODE status which indicated that CPR would be initiated in the event of cardiac and/or respiratory arrest. A Social Service History & Initial Assessment note, dated [DATE], indicated that Resident #15 was oriented to person, place, time, and situation, and had a Brief Interview for Mental Status (BIMS) rating of 15, cognitively intact. There was no documentation in the clinical record that the facility staff offered or provided education about Advance Directive planning, to include the assessment of Code Status, Full Code versus Do Not Resuscitate, with Resident #15 or her Responsible Party (RP). On [DATE] at approximately 3:00 PM, an interview was conducted with the Director of Social Services (DSS) who confirmed the findings and stated that she was responsible for Advance Directive planning with residents and their families. She stated that the lack of documentation for Resident #15 must have been an oversight. The DSS was informed that the RP had reported that her mother should be a DNR. A facility policy was requested and received. Review of the facility policy titled, Advance Directives, read, A resident's choice about advance directives will be respected. On [DATE] at approximately 5:00 PM, the DSS reported that she met with Resident #15 and her RP and confirmed Resident #15's wishes to be DNR. A DNR order was initiated with the physician and documented in the clinical record. On [DATE], at the end of day debriefing, the Facility Administrator and Director of Nursing were updated. No further information was provided. 06401 2. Review of the facility policy titled, Advanced Directives, revised on ,d+[DATE], revealed, The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy . The director of nursing services (DNS) or designee notifies the attending physician of advanced directive (or changes in advanced directives) so that appropriate orders can be documented in the resident's medical record and plan of care . The resident's wishes are communicated to the resident's direct care staff and physician by placing the advanced directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care plan meetings. Review of Resident (R)44's Medical Diagnosis, sheet located in the Med Diag[nosis] tab of the electronic medical record (EMR), revealed R44 was originally admitted with a diagnosis of end stage kidney disease. Review of R44's Durable Do Not Resuscitate (DNR) Order, dated [DATE], provided by the facility, specified R44 was capable of making an informed decision about providing, withholding, or withdrawing a specific treatment of course of medical treatment. The DNR order was signed by R44 and R44's physician. Review of R44's Base Line Care Plan, dated [DATE], located in the MISC[ellaneous] tab of the EMR, revealed R44's advanced directive was noted as a DNR. The care plan's goal specified; Resident's Advanced Directives wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through next review period. Review of R44's Hospital Discharge Summary, dated [DATE], provided by the facility, specified the resident was a Full Code. Review of R44's Physician Orders, located in the Orders tab of the EMR, revealed an order for a Full Code dated [DATE]. Review of R44's comprehensive Care Plan, dated [DATE], located in the Care Plan tab of the EMR, revealed a Focus which specified Advanced Directive [R44's name] has following Advanced Directives on record Do Not Resuscitate. The care plan's goal specified, Advance Directives are in effect, and [R44's name] wishes and directions will be carried out in accordance with her advance directives. A care plan intervention indicated, An Advance Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered. Review of R44's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], located in the MDS tab of the EMR, revealed R44 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated R44 was cognitively intact. During an interview on [DATE] at 10:42 AM the Social Worker (SW) stated R44's medical record contained conflicting information regarding the resident's code status. The SW stated the R44's EMR had a DNR order dated [DATE] and the resident's care plan specified she was a DNR, but R44 had a current physician's order for a Full Code that was initiated on [DATE]. The SW stated that she would check with R44 regarding this code status discrepancy. During an interview on [DATE] at 10:50 AM the SW stated she spoke with R44, and she wanted to remain a DNR as she had previously specified and as noted in her current care plan. The SW stated on [DATE], the facility's Clinical Service Director (CSD) put an order in for R44 to be a Full Code, but she did not know why an order was written to change the resident's code status because that was not what the resident wanted. During an interview on [DATE] at 11:10 AM, the CSD stated she put in an order on [DATE] to change R44's code status from DNR to Full Code because the resident's [DATE] hospital discharge summary specified the resident was a Full Code. The CSD stated she thought the SW was responsible for checking with the resident when there was a change in a resident's code status to ensure this change was what the resident wanted. During an interview on [DATE] at 11:15 AM the SW stated she did not recall talking with R44 about her code status change from a DNR to a Full Code when she was readmitted to the facility from the hospital on [DATE]. The SW stated if she was aware R44's code status changed from DNR to Full Code she would have discussed this change with R44 and updated the resident's care plan to reflect this change. During an interview on [DATE] at 1:20 PM, R44 stated she had not changed her code status from a DNR to Full Code and she wanted to remain a DNR. During an interview on [DATE] at 2:40 PM, the Administrator stated she was aware of the error on R44's code status not specifying the resident was a DNR. The Administrator stated R44 could clearly make her code status known and her desire to remain a DNR would be honored by the facility.

Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the care plan following a significant weight loss affecting one Resident (Resident #4) in a survey sample of 44 Residents. The findings included: For Resident #4, who had a significant weight loss while at the facility, the facility staff failed to review and revise the care plan with interventions to address the weight loss and interventions implemented by the facility. From 7/25/23-7/28/23, various observations were made of Resident #4 during the lunch and supper meals. Resident #4 was interviewed and said she had no appetite. Resident #4 was observed to be unable to feed herself and was totally dependent upon facility staff for assistance. A clinical record review was conducted and revealed that Resident #4 was admitted to the facility on [DATE], and was noted to weigh 108 lbs. Resident #4's weight was taken almost weekly and noted a continuous decline. On 6/19/23, Resident #4 weighed 97.7 lbs. This was a 10% weight loss in a month. On 7/24/23, Resident #4 weighed 91.7 lbs., which is a total of 16-pound weight loss in just two months. Review of the care plan revealed the Resident's care plan for weight loss risk was not developed until 7/11/23. On 7/27/23, the facility Administrator and Clinical Director were presented with concerns regarding Resident #4's weight by the survey team. On 7/28/23, the facility's Clinical Director presented information that explained they had implemented nutritional supplements, to include but not limited to multivitamin, pro-stat [a protein supplement], high calorie cereal, med pass and even a medication to stimulate the appetite. The clinical director also indicated that a family conference was being scheduled to discuss the option of a gastroenterology consult for the consideration of a feeding tube. None of these interventions nor the weight loss were identified in the Resident's care plan. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 3 residents, Resident #55, Resident #34, and Resident #52, in a sample size of 44 residents. The findings included: 1. For Resident #55, facility staff failed to administer medications as ordered by the physician. On 7/25/23 at approximately 11:30 AM, an interview was conducted with Resident #55. Resident #55 stated, The doctor prescribed my some cream the other day for a rash on my left thigh and I still haven't received it, the rash is still there. On 7/25/23 at approximately 12:15 PM, a clinical record review was performed and revealed a nursing note dated 7/23/23 at 18:54 which documented a telephone order received from the physician for Diprolene .5% cream, apply to rash once daily . and an orders administration note dated 7/24/23 at 08:37 which documented Diprolene External Ointment 0.05% .On order awaiting arrival. There was no documentation of the ointment being administered on Resident #55's medication administration record (MAR) for 7/24/23 and 7/25/23. On 7/25/23 at approximately 12:45 PM, an interview was conducted with the Facility Administrator who was updated on the findings and stated, I will look into this right away. At approximately 3:00 PM, the Facility Administrator stated that the Pharmacy had just delivered Resident #55's ointment and she had instructed LPN C to administer it to Resident #55 right away. On 7/25/23 at approximately 5:30 PM, a follow-up interview was conducted with Resident #55 who stated, No one has given me any cream yet, I don't know what is going on, I really want to have it. The Facility Administrator was updated and brought the tube of ointment to the Conference Room stating, I was reassured that this had been given to Resident #55 a couple of hours ago, I gave it to the nurse as soon as I received it. The tube of ointment was inspected, the cap was removed, and the protective foil under the cap remained intact which indicated that it had not been punctured, which is necessary in order to access the ointment. The Facility Administrator confirmed it did not appear that the ointment had been administered as she was led to believe. A review of Resident #55's MAR revealed that LPN C actually had documented she had administered a dose to Resident #55 at 3:32 PM, 2 hours previously. The Facility Administrator verified that the administration of medication must be documented immediately following the actual administration and stated, The nurse did not follow my expectation, the facility policy, or professional nursing standards, I will be re-educating her immediately, this is unacceptable. A facility policy was requested and received. Review of the facility policy titled, Documentation of Medication Administration, revised April 2007, item 2, read, Administration of medication must be documented immediately after (never before) it is given. According to [NAME] Manual of Nursing Practice, 11th edition, 2019, page 15, Standards of Practice-General Principles, item 1, read, The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable and Box 2-1, Common Legal Claims for Departure from the Standards of Care, item 8, read, Failure to implement a physician's, advanced practice nurse's, or physician assistant's order properly or in a timely fashion, item 9, Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately, item 19, Failure to make prompt, accurate entries in a patient's medical record and item 21, Failure to adhere to facility policy or procedural guidelines. On 7/25/23 at the end of day de-briefing, the Facility Administrator and Director of Nursing (DON) were updated on the findings. No further information was provided. 41449 2. For Resident #52, the nurse failed to follow the standard of nursing practice as evidenced by the nurse documented the administration of a physician ordered cream, when it had not been administered. On 07/26/23 at 09:35 AM, LPN E was observed during the medication administration. LPN E pulled and prepared the medication for Resident #52. During the preparation of the medications, LPN E noted that there was an order for Zinc Paste, LPN E said, That is the in the room. LPN E was observed to administer the medications to Resident #52, zinc paste was not applied. Upon completion of the Resident taking her pills, LPN E returned to the medication cart. On 7/26/23, during a clinical record review, Surveyor C was reconciling the medication orders to the medications administered. It was noted that LPN E had signed off that zinc paste had been applied when other medications were administered. On 7/26/23, at 12:17 AM, Surveyor C questioned LPN E about signing off the zinc paste. LPN E said, The CNA administered the zinc paste when they bathed [Resident #52's name redacted] and washed her up. On 07/26/23 at 12:24 PM, an interview was conducted with CNA E. CNA E confirmed she was assigned to provide care for Resident #52. When asked about her care provided thus far, CNA E said, I had help this morning and we washed her up. The Resident refused to take her gown off, so I am going back after lunch and try again. When asked if she put any kind of cream on her bottom, CNA E said yes, we put the protective cream on her. CNA E accompanied surveyor C to the Resident's room and showed the surveyor the tube of cream used. It was protective ointment, CNA E said, We used to use a white cream that was thicker we used but the rash cleared up so now we use this [protective cream]. CNA E confirmed the white cream previously used was a barrier cream and at no point has she applied a zinc paste to Resident #52. Review of the facility policy titled, Documentation of Medication Administration, was conducted. This policy read, 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the Resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given . On 7/26/23, during an end of day meeting, the facility administrator and Clinical Director were made aware of the above observations during medication administration observations conducted with LPN E. 3. For Resident #34, the nurse failed to follow the nursing standard of practice as evidenced by signing off the wrong medication that was administered. On 7/27/23 at 9:40 AM, LPN D was observed during the administration of medications. LPN D prepared the medications for Resident #34, which included but was not limited to artificial tears, two drops were to be applied to each eye. LPN D administered the medications including the artificial tears to Resident #34 and notified the Resident she would return later to administer additional eye drops but needed to wait a few minutes between the different drops. LPN D then returned to the medication cart and signed off the medications administered. LPN D signed off that Combigan Solution 0.2-0.5% drop was administered to the left eye, which was not yet administered. On 7/27/23 at approximately 11 AM, LPN D returned to Resident #34 to administer Combigan Solution 0.2-0.5% eye drops. LPN D then returned to the medication cart and realized she had signed off the administration of this drop when she had administered the artificial tears at 9:40 AM. LPN D said, I marked the wrong one earlier, it was a mistake. Review of the facility policy titled, Documentation of Medication Administration, was conducted. This policy read, 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the Resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given . The facility Administrator identified [NAME] as their nursing standard of practice. According to the [NAME] Manual of Nursing Practice eighth edition, on page 18, box 2-3 identified Common legal claims for departure from Standards of Care. An excerpt from this read, . Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . Failure to make prompt, accurate entries in a patient's medical record . On 7/27/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above observation. No further information was provided/received.

Based on observation, staff interviews and clinical record review, the facility staff failed to ensure quality of care based on professional standards and the person-centered care plan was provided for one Resident (Resident #38) in a survey sample of 44 Residents. The findings included: For Resident #38 the facility staff failed to ensure that the Resident had appropriate seating to maintain her comfort, relieve pressure, prevent her legs from dangling, which would promote swelling/edema in her legs and feet; and be safe in the facility provided wheelchair. On 7/25/23, Resident #38 was observed sitting in a wheelchair at the nursing station. Resident #38 was observed to be sitting on two cushions, which elevated her to the point that her legs were dangling and not touching the floor. Footrests were not on the chair. Observations of Resident #38's room revealed leg rests and foot pedals for the wheelchair in the floor next to the bed. Also noted was a 1/2 tray that would go on the wheelchair but was not in use. On 7/26/23, a clinical record review was conducted. This review revealed that Resident #38 had an active physician order that was written 10/21/21, that read, 1/2 lap tray while up in wheelchair to aid with positioning. Resident #38's therapy notes revealed a history of a left rotator cuff tear. The therapy notes further revealed that Resident #38 had some limitations on her left upper extremity. On the morning of 7/27/23, Resident #38 was observed to be up in her wheelchair and attending a group activity. Resident #38 was observed again sitting on 2 cushions, which elevated her where only the toes of her right foot would touch the floor. Resident #38 was sitting leaning to the right and her right side/hip was pressing against the side of the wheelchair. The half-tray was not in place, nor were the leg pedals and footrests. On 07/27/23 at 10:05 AM, an interview was conducted with CNA C. CNA C was asked why Resident #38 was sitting on 2 cushions. CNA C said, We couldn't find her wheelchair cushion, so I went and got another one, then her family sent her one so now she has two. She sat so low at the table, now this gets her up higher to the table. CNA C was asked about her legs just dangling and feet not touching the floor. CNA C said, I have to check with therapy about them [leg rests and foot pedals]. During the interview CNA C confirmed that Resident #38 has swelling and edema in her legs and feet So I only get her up every other day so she can lay down and rest the other days. CNA C was asked about the tray for the wheelchair. CNA C then accompanied Surveyor C to the room of Resident #38 and was shown the 1/2 tray, CNA C said, Therapy did that to keep her left arm raised to help with the swelling. CNA C then took the 1/2 tray and applied it to the wheelchair. CNA C made no mention of the wheelchair leg rests and foot pedals that were in the room underneath the 1/2 tray. On 07/27/23 at 10:42 AM, an interview was conducted with Employee N, the Occupational Therapist (OT). The OT was asked to generally explain how Residents should be sitting in a wheelchair. The OT said, 90/90/90 [meaning the hips, knees and ankles should all be bent at 90 degrees], the OT then demonstrated this with her feet touching flat on the floor. The OT went on to say, There should be no sacral sitting and feet shouldn't just be dangling. When asked to elaborate on why feet should not be dangling, Employee N said, It is bad for blood flow and increased contractures. Surveyor C asked the therapist, what about wheelchair seat cushions? The occupational therapist stated that, Everyone should have one, to decrease sacral wounds and for stability. The OT was asked if two cushions was appropriate and the OT said, No, I have not ever done that. Employee N was then asked specifically about Resident #38's 1/2 tray table for the wheelchair. The OT said, It is for her sublexed arm, feels uncomfortable with gravity pulling it down, but she doesn't always like to have it. The OT was then asked to accompany Surveyor C to the activity room to observe Resident #38's seating. The OT said, I saw her recently 2-3 weeks ago and didn't see two cushions under her then. I don't have anything good to say to you right now about how she is sitting, I agree with you. I don't know why she is on 2 cushions. The OT confirmed that Resident #38 was leaning to the right side with her side against the side of the wheelchair. The OT stated she would make adjustments and correct her seating. On 07/27/23 at 11 AM, Surveyor C observed Resident #38 sitting in the dining room, she was noted to be sitting straight, one foot resting on a footrest and her legs were crossed. The 1/2 tray was removed. On 7/27/23 at 11:08 AM, a follow-up interview was conducted with Employee N, the Occupational Therapist and Employee O, the assistant therapy director/physical therapy assistant was present. They both explained that one of the wheelchair cushions was removed, positioned her center of her chair, applied footrests, and removed the tray. Employee O, the assistant therapy director said she found out the Resident had a different cushion that allowed her feet to rest on the floor which was more appropriate, and we will be working to get her that type of cushion again. We removed the tray because it wasn't appropriate for that chair. When asked what their concerns were with how Resident #38 was seated, the indicated, It was a concern for pressure, the arm, edema and safety. It wasn't safe. On 7/27/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above findings. No further information was provided.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide/arrange for one Resident (Resident #13) in a survey sample of 44 Residents to obtain new prescription lenses in her glasses, as ordered. The findings included: On 7/25/23 at 2:40 PM, during initial tour, Resident #13 was visited in her room. Resident #13 was asked about her vision and the Resident said, I need to get my vision checked and reported she is having difficulty seeing. The Resident did not recall last time she saw eye doctor. On 7/26/23, a clinical record review was conducted of Resident #13's chart. This review revealed the following: Resident #13 had a physician order dated 9/15/22, that read, May have consultation for ophthalmology, podiatry, dental and optometry as needed. Resident #13's care plan was reviewed, and her vision or use of glasses was not identified on the care plan. Documentation regarding the offering of an eye exam with regards to the Resident's report of difficulty seeing was not found in the clinical chart. On 7/26/23, the facility Administrator was asked to provide any evidence she had with regards to Resident #13 seeing an eye doctor. The facility Administrator indicated that Employee E, the social worker handles this and was out of the office for the day. On 7/27/23, Surveyor C met with Employee E and was provided documentation which included a progress note dated 9/21/22, which read, SW [social worker] asked [Resident #13's name redacted] . She does say she is blind in 1 eye and vision is blurry in the other and she is willing to go to an eye doctor to see if new glasses will help her vision. SW to try to get her an appointment with [name of provider redacted] as she will have to go by stretcher. Employee E also provided evidence of where Resident #13 was seen by the eye doctor on 1/31/23. The note from the eye doctor read, Vision 20/400 Right eye .New glasses Rx [prescription] given. Optic neuropathy both eyes. Employee E said she had spoken with Resident #13 on this day, 7/27/23, and the Resident reported to her she didn't need new glasses. On 07/27/23 at 02:06 PM, Resident #13 was visited in her room again. Resident #13's family member and responsible party was also at the bedside. When asked about the new prescription given for glasses, the Resident's family member stated, They were going to cost $700 and they didn't proceed because they couldn't afford them. When asked if any alternatives or options to assist with the costs were given, the Resident's family member said no. On 7/27/23, during the end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of pressure ulcers for one Resident (Resident #35) in a survey sample of 44 Residents. The findings included: For Resident #35, who was at risk for the development of a pressure ulcer, the facility staff failed to apply heel protective boots as ordered by the physician. A clinical record review was conducted and revealed that Resident #35 had a physician order dated 5/23/23, that read, place heel protector on right heel every shift for wound. An excerpt from Resident #35's care plan read, The resident has potential for pressure ulcer development r/t [related to] immobility, incontinent of B&B [bowel and bladder]. Interventions for this care plan focus area was, Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown . Resident #35's most recent Braden Scale for Predicting Pressure Sore Risk was conducted 5/23/23, and the Resident scored 14, which indicated the Resident was at moderate risk for development of pressure sores. On 7/25/23, 7/26/23, and 7/27/23, numerous observations were made of Resident #35. Each observation revealed, Resident #35 was lying in bed, his heels had no protective boots, and his heels were noted to be resting directly on the mattress. On 07/27/23 at 09:55 AM, Surveyor C requested that LPN D accompany her to the room of Resident #35 to make observations of his feet. LPN D confirmed that Resident #35's heels were resting directly on the bed with nothing in place to relive pressure. LPN D and Surveyor C observed Resident #35's feet and LPN D stated that Resident #35's right heel was boggy and there was a discolored area on the Resident's left heel that LPN D stated, appeared as a scab. Following the above observations, LPN D looked in Resident #35's room and was unable to find any heel protective boots. LPN D then went to the supply closet and again was not able to find any heel protective boots. LPN D then called another staff member, who handles supplies and then about 15 minutes later, approached Surveyor C and showed the surveyor that she had obtained a pair of heel protective boots and was going to apply them to Resident #35's feet. Resident #35's most recent skin observation completed 7/24/23, identified no skin impairments. The facility policy titled; Prevention of Pressure Injuries was reviewed. This policy read, . Prevention: skin care. 1. Keep the skin clean and hydrated . 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. Use facility-approved protective dressings for at risk individuals . In the facility provided Wound Protocols, it read, Pressure Ulcer Prevention Protocol: . 8. Position the resident to minimize pressure over bony prominences and shearing forces over the hells and elbows, base of head, and ears, 9. Use appropriate offloading or pressure-redistribution devices . On 7/27/23, during the end of day meeting, the facility Administrator and Clinical Director were made aware of the above findings. On 7/28/23 at 10:55 AM, the facility Administrator provided Surveyor C with a copy of physician orders that were implemented for Resident #35 in response to the above findings. The orders read, Place heel protector on bilateral heels every shift for wound, skin prep to bilateral heels every shift. No further information was provided.

Based on observation, staff interview and clinical record review the facility staff failed to prevent and treat pressure wounds for 2 residents (Resident #1 and #35) of 26 residents in the survey sample resulting in harm for Resident #1. 1. For Resident #1, the facility did not provide an air mattress for four months, did not administer a physician order [REDACTED]. This resulted in harm. 2. For Resident #35, the facility failed to provide interventions to prevent pressure injuries. Resident #35 had three deep fingernail indentations in the right palm of the Resident's hand that had contractures. The findings included: 1. For Resident #1, the facility did not provide an air mattress for four months, did not administer a physician order [REDACTED]. This resulted in harm. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7/9/18. The resident had a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. She required extensive assistance with activities of daily living. On 10/10/18, Resident #1 was observed lying in bed. When asked if she had a wound, Resident #1 stated no. When asked if she had any pain, Resident #1 stated no. On 10/12/18 at 10:05 a.m. Resident #1's right hip wound was observed by Surveyor #1. The wound was clean and red around the edges, no drainage and measured approximately 2 cm x 5 cm. The right hip wound was originally identified on 4/6/18 as a stage 2 wound to the right hip that was present when she was readmitted from the hospital to the facility. The wound was documented in the clinical record as follows: 4/6/18: Wound Assessment Record read, Stage 2 right hip wound, 100% excoriation, small amount of serous drainage measuring 14.0 x 7.0 x 0.1 centimeters (cm). The assessment included treatment orders that read, Orders per hospice Nurse to Clean with normal saline, pat dry and apply foam dressing. This order was included on the (MONTH) (YEAR) Medication Administration Record (MAR) as Right hip, ankle apply foam drsg daily, excoriation to buttock apply zinc barrier cream PRN (as needed) diaper change. This entry on the MAR does not include the part of the order that read, clean with normal saline. While this entry on the MAR was signed off on daily, it is unclear which of the treatments were performed as it includes multiple treatments for multiple areas on the body. 4/9/18: Hospice nursing note read, Drsgs dated 4/8/18. Reapply RT (right) ankle dressings as it not secure. Discuss care with staff nurse (name). 4/11/18: Facility nursing note read, resident wounds evaluated and treated per hospice nurse week of 4-11-> 4-18-18 prior to staff nurse for evaluation. Hospice nurse (name) discussed P[NAME] (plan of care) + reports overall improved, right trochanter (hip) unstageable. 4/12/18: Hospice nursing note read, Wound care performed. The largest wound on the right hip appears to be improving. Appears dry and smaller in size. Other wounds appear to be improving as well. 4/15/18: physician progress notes [REDACTED]. large eschar- boggy- malodorous. DX (diagnosis) Large decubitus R hip. P (plan)- wound care consult- [MEDICATION NAME] topical. According to the (MONTH) (YEAR) MAR, the [MEDICATION NAME] was not started until 4/24/18, nine days after it was ordered by the physician. The wound consult was not completed until 4/25/18, 10 days after it was ordered. 4/15/18: Facility nursing note read, 1420- (doctor name) in N.O. (new order). The new orders address changes to current medications. The note did not include the orders for the [MEDICATION NAME] or the wound consult. 4/16/18: Hospice nursing note read, Wound care performed, 3 sites closed. RT (right) hip has 75% eschar. 4/23/18: Hospice nursing note read, Right hip wound has drainage and odor order obtained for [MEDICATION NAME] 250 mg (milligram) crush to win (sic) site daily. 4/24/18: Hospice nursing note read, Rt hip wound has eschar and drainage with odor, began [MEDICATION NAME] crushed to wound. Other wounds have closed. 4/25/18: Wound Care physician progress notes [REDACTED]. She presents with an unstageable (due to necrosis) of the right hip of at least 1 days duration. There is heavy serous exudate. There is no indication of pain associated with this condition. The wound measured 9 x 5 x not measurable. The wound was described with heavy serous exudate and 100% eschar. [MEDICATION NAME] powder once daily for 30 days was ordered for the treatment. 4/25/18: Wound Assessment Record read, Unstageable due to slough/eschar. Wound bed= 100% eschar. Measurements 9 cm x 5 cm. Drainage= Sanguineous, large. Infection= yes. Symptoms of infection= increased drainage, malodorous or purulent drainage. Pain with wound/ treatment= Yes. Pain Intensity= grimacing. Pain management= effective. According to the (MONTH) (YEAR) MAR, Resident #1 had an order for [REDACTED]. She was administered this medication on two occasions, 4/14/18 and 4/17/18. She did not receive any pain medication on 4/25/18. On 10/12/18 at 10:40 a.m., the Assistant Director of Nursing (ADON) was asked which days of the week the wound care doctor came to the facility. She stated he came every Wednesday. The ADON was asked to verify the dates that the wound care doctor came to the facility in (MONTH) (YEAR). She showed the survey team progress notes documenting that the wound care doctor had been at the facility every Wednesday in April, to include Wednesday, 4/18/18. The wound care doctor did not assess Resident #1 on 4/18/18. On 10/12/18 at 12:25 p.m. Resident #1's hip wound was reviewed with the Director of Nursing (DON). It was reviewed that the physician ordered [MEDICATION NAME] and a wound care consult on 4/15/18 and neither intervention was implemented timely. The DON was asked how an order in a physician progress notes [REDACTED]. It was the responsibility of the unit nurse to transcribe the order from the physician's progress note. She stated that there was a delay in treatment for [REDACTED]. It was also reviewed with the DON that the wound care doctor had been in the facility on 4/18/18 and did not assess Resident #1. The DON was asked to provide all information related to Resident #1's hip wound to include treatments, assessments and interventions in place to manage skin care. The DON stated that the previous ADON was the facility's wound care nurse. The previous ADON left her position on 4/7/18. The current DON started working at the facility on 4/9/18 in the ADON position. On 5/7/18, the previous DON left her position and the current DON (who had been hired for the ADON position) moved into the DON role. A new ADON was hired on 8/1/18. This change in nurse staffing and loss of the wound care nurse occurred around the same time that Resident #1 was identified with the right hip wound. Resident #1's care plan was reviewed. The skin care plan was dated 3/13/18 and was in place before Resident #1 had gone out to the hospital. It read, (resident) is @ risk for skin breakdown r/t (related to) incontinence & pressure ulcer r/t (related to) decreased mobility. Handwritten on the document was an entry for 4/5/18 that read, (resident) has 5 PU (pressure ulcers) upon admission from hospital- see assessment. The approaches/ interventions read, use moisture for dry skin, report new areas, weekly skin assessment, assist resident to turn, treatment as ordered- see MAR and perineal care. A new approach dated 4/6 was handwritten on the document. This approach read, Follow skin care orders from ____ Hospice- see orders air loss mattress to bed- check function + placement every shift. 4/6/18 physician order [REDACTED]. The order was discontinued on 8/23/18. 8/23/18 physician order [REDACTED]. Check placement and setting each shift. The Hospice Certification and Plan of Care document was reviewed. The hospice nurse signed that verbal plan of care instructions were provided on 4/6/18 and the provider (facility) received the document on 4/10/18. Section 14 DME (durable medical equipment) and Supplies read, Supplies: dietary supplies, feeding bags, feeding machine, gloves. The air mattress is not listed as an item supplied by the hospice company. The air mattress is not discussed in the hospice plan of care. The air mattress was not included on the (MONTH) (YEAR) MAR or TAR. As the air mattress was re-ordered on [DATE], it appears that this is the first date the air mattress was implemented for Resident #1. The air mattress was included on the (MONTH) (YEAR) MAR. The entry read, Hospice provided air mattress overlay settings at 120 for pressure relief at all times Check placement and settings each shift. In summary, Resident #1 was readmitted to the facility from the hospital with a stage 2 wound to the right hip. The facility did not implement the air mattress ordered on [DATE]. On 4/11/18, the wound was documented as unstageable. On 4/15/18, the wound was documented by the physician to have an odor indicating that an infection was present. The physician ordered the antibiotic [MEDICATION NAME] and it was not implemented for nine days. The doctor also ordered a wound consult. On 4/16/18, the hospice nurse documented that the wound had 75% eschar. On 4/23/18, the hospice nurse documented that the wound had drainage and odor (indicating infection was present). The antibiotic [MEDICATION NAME] was started on 4/24/18. The wound doctor was at the facility on 4/18/18 and did not assess Resident #1. The wound doctor assessed the resident the following week on 4/25/18, ten days after the consult was ordered. The wound care doctor described the wound as 100% eschar with heavy serous exudate. On 4/25/18, the facility staff described the wound as having an infection with symptoms described as increased drainage and malodorous or purulent drainage. As facility staff did not implement physician ordered interventions, Resident #1's wound progressed from a stage 2 wound to an infected, unstageable wound with 100% eschar. 2. For Resident #35, the facility failed to provide interventions to prevent pressure injuries. Resident #35 had three deep fingernail indentations in the right palm of the Resident's hand that had contractures. Resident #35, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #35 has bilateral above-the-knee amputations and receives tube feedings via gastrostomy tube. Resident # 35's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 09/10/2018. Resident #35 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as severely impaired. Functional status for mobility was coded as total dependence on staff for performance and support. On 10/10/2018 at 1:40 PM, Resident #35 was observed awake in bed in supine position and the head of the bed was elevated approximately 45 degrees. It was noted Resident had closed fists and arms were flexed consistent with contractures. Hand padding was not visualized. On 10/10/2018 at 4:00 PM, Resident #35 was observed in bed. On 10/11/2018 at 8:35 AM, Resident #35 was observed awake in bed in the supine position and the head of the bed was elevated approximately 45 degrees. No hand padding was visualized. On 10/11/2018 at 11:15 AM, Resident #35 was observed in bed. On 10/12/2018 at 8:30 AM, Resident #35 was observed awake in bed in supine position and the head of the bed elevated approximately 45 degrees. On 10/12/2018 10:00 AM, Registered Nurse (RN) B and two surveyors entered the Resident's room. RN B performed a skin assessment. No open areas or rashes were visualized. Both of Resident's arm and hands had contractures with flexed elbows and closed fists. RN stated it was difficult to extend Resident's fingers. Two surveyors observed three deep fingernail imprints on Resident's right palm when RN extended right fingers. No breaks in skin were observed but noted an odor when Resident's fists were opened. On 10/12/2018 at approximately 10:25 AM, an interview with certified nursing assistant (CNA) A was conducted. When asked about hand padding, the CNA stated they tried washcloths but 'they don't stay' stated the washcloths 'come out and get all over the bed.' On 10/12/2018, physician's orders [REDACTED]. The care plan was reviewed. Risk for skin breakdown is on the care plan, but measures to prevent pressure injury from contractures was not addressed in the care plan. The nursing weekly summaries were reviewed. Copies of nurse's notes for the months of August, September, and (MONTH) (YEAR) were requested of facility staff. The facility provided nine nursing weekly summary documents dated from 08/02/2018 to 09/29/2018. All of the summaries document skin as dry and intact but none of the summaries document skin assessment associated with contractures of arms and hands. On 10/12/2018, the findings were shared with Administrator and the DON. No further documentation was offered.

Based on observation, staff interview, facility documentation and clinical record review, the facility failed to, for one resident, Resident #43, in a survey sample of 26 residents, to ensure the resident's mechanical soft diet was followed, resulting in harm. Resident #43 was served cantaloupe chunks instead of a fruit crisp that was on the Registered Dietician's approved menu. As a result of eating a cantaloupe chunk, the resident choked and required the [MEDICATION NAME] maneuver and suctioning. The findings included: Resident # 43 was admitted to the facility 3-4-17. Her [DIAGNOSES REDACTED]. Resident #43's most recent MDS (minimum data set) with an ARD (assessment reference date) of 9-24-18 was coded as a quarterly assessment. Resident #43 was coded as having a BIMS (Brief Interview for Memory Status) Score of 9 out of 15 indicating moderate cognitive impairment. She was coded as needing extensive to total assistance of one staff member to perform her activities of daily living. Resident #43 was coded as requiring extensive assistance for eating. The resident was coded as having a mechanically altered diet. On 10/10/18 at 1:33 PM a review of the clinical record revealed the resident's diet was changed from puree to soft/chopped meats in August, (YEAR). On 10/10/18 at 1:46 PM a review of the clinical record revealed the IDT (interdisciplinary team) notes dated 10-3-18 at 12:30 PM revealed CNA (certified nursing assistant) reported resident having difficulty swallowing and talking. I asked her could she speak and she could not. [MEDICATION NAME] maneuver given x two. Resident removed from dining room to MDS office and PT (physical therapist) Director assisted with [MEDICATION NAME] - Resident moving air and taken to her room and suctioned by nurse and coughed up chunk of cantaloupe. Review of the nurse's note dated 10-3-18 at 1:40 PM documented: The resident rushed back from dining room- choking- lips blue- suction x 3-4 minutes with [MEDICATION NAME] catheter- large piece of cantaloupe was coughed up by resident- Resident speaking after episode- some coughing, VS 98-104-16 150/80, and a chest X-Ray was done. Review of the incident report for the incident dated 10-3-18 revealed: MDS nurse suctioned and resident spit out a piece of cantaloupe about the size of a quarter. Review of the dietary note for 10-3-18 at 12:30 PM revealed: [MEDICATION NAME] maneuver given x 2 coughed up chunks of cantaloupe. Review of the lunch menu for 10-3-18 revealed the following items were served for a soft diet: ground apple ginger pork, dressing with gravy, baby carrots (cooked), roll, fruit crisp. Review of the Speech Therapy (ST) discharge summary notes revealed: Patient exhibits moderate oropharyngeal dysphagia (dysphagia) . may need to avoid specific food items or require additional time. Review of the care plan dated 7-19-18 revealed the resident requires a mechanical soft diet with the following interventions: * Allow ample time to ingest meal * Encourage to finish at least one item on plate. * Feed as she allows if she refuses to feed herself * Routine and as needed review by RD * Use of divided plate for easier retrieval of food * Encourage fluid intake * Weight monthly and as needed The care plan was revised on 10-3-18 to include the resident was at risk for aspiration with the goal of no further episodes of aspiration/choking. Interventions included: * Restorative (nursing) for dining * Continue mechanical soft diet * Out of bed for all meals * Sit upright 30 minutes after meals On 10/10/18 at 2:18 PM, an interview with RN (registered nurse) A (unit manager) was conducted. She stated that she was at the nurses desk, she (the resident) was in the large dining room and was being rolled to the room and that she got the suction machine, suctioned her, and the catheter pulled out a chunk of cantaloupe about the size of a quarter, Just one piece. On 10/10/18 at 2:30 PM, an interview was conducted with the ST (speech therapist). She stated the resident was doing fine on mechanical chopped meats, had increased her intake, no choking or coughing. She is now in restorative dining. She also stated she can clear with liquids, can spit out if she can't swallow, As long as it is soft cooked gravy with meat. The ST was asked if cantaloupe was appropriate for the soft diet, she stated No, it is huge pieces, should not have been given to her. She approximated the size of the chunks of cantaloupe 1 x 1 inch or so, and that she would do better with canned fruits/vegetables. The ST stated, The cantaloupe is hard. She did state: I have not seen any cantaloupe or hard fruits/vegetables since the episode. On 10/10/18 at 2:46 PM, the dietary manager was interviewed. She stated the resident's diet was regular with ground meat/mechanical which means ground meat. She stated the 10-3-18 lunch for the soft diet was pork/gravy, dressing and gravy, carrots, supposed to be fruit crisp. She stated that the fruit crisp was not served as it was not available and gave fresh fruit as a substitute, stating, It was cantaloupe. She stated that the dietary manger makes the decision for the alternate. She described the fruit crisp would have been baked peaches with an oatmeal crust. When asked about the size of the chunks of the cantaloupe as Cantaloupe like a square, like chunks. She held her fingers apart to approximately one inch by one inch. When asked what measures had taken place to prevent further incidents of choking, the dietary manager stated: We are not serving fresh fruit anymore and unless it is small, as instructed by the DON (director of nursing) . She stated the RD (registered dietician) comes in twice weekly. The dietary manager produced from their diet manual a description of the mechanical soft diet. This included: A mechanical soft is used for individuals who have difficulty chewing regular textured foods . Foods that are difficult to chew are chopped, ground, shredded and/or cooked to facilitate chewing and ease of swallowing. It included for fruits: include a variety with more fruit than juice as appropriate: Canned, cooked, tender, , chopped or shredded, or juice at appropriate thickness. On 10/11/18 at 10:04 AM, the RD came in to talk about the choking incident. The RD was questioned as to how does the dietary manager know what substitutes to employ when food on the menu is not available. The RD stated, Staff has been taught for appropriate substitutes. The RD stated that on the mechanically altered diet the fruit should be fine cut. She went on to state, I will be meeting with dietary staff today, I will review what is in place to avoid this, I don't want this to happen again. She later presented an inservice dated 8-16-18 to include: * Right texture of diets- choking issues * Drain steam table nightly * Be careful wearing gloves while serving * When pureeing items from packages, put in bowl before processor * Residents cup on tray if sent out be responsible for getting back * Keep kitchen open until 8:00 PM In summary, Resident #43 did not receive the ordered diet that had been approved by the RD and instead received cantaloupe of at least the size of a quarter which caused choking- blue lips, inability to speak, requiring emergency treatment of [REDACTED]. On 10-11-18 at 2:53 PM, the facility Administrator and DON were notified of a harm level deficiency. On 10-12-18, Resident #43 was observed up in her wheelchair at the dining room table. A CNA was in close proximity. There was only soft food on the tray, there were no large chunks of any food served. On 10-12-18 at 11:15 AM, the Administrator was questioning harm level deficiency as she believed it was a potential for harm and that melon is allowed on a mechanical diet. We wish they had cut it more.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed for 2 residents (Resident #3 and #11) of 16 residents in the survey sample to prevent, identify and treat pressure wounds resulting in harm for Resident #3. 1. For Resident #3, a pressure wound on the right heel was first identified on 5/4/16. On 5/6/16 the wound was noted to have a black scab. The wound care nurse did not assess the wound until 5/13/16. According to the care plan, no preventative measures were in place to prevent the development of the right heel wound. A treatment to the right heel wound was not started until 5/20/16. As of 9/9/16, Resident #3's right heel wound measured 5.8 x 9.7 x 0.2 (centimeters). 1a. For Resident #3, wound care and the actual wound was observed by another surveyor to show the description and measurements of the wound. 2. For Resident #2, the facility staff failed to perform pressure ulcer wound care in a manner to prevent the spread of infection. treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, documents, in part: The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer. Accurate staging and description of pressure sores is a perquisite to the development and implementation of appropriate, effective treatment protocols and to effective, ongoing monitoring of tissue healing. Also: 7. Assessment of pressure sore healing. Progress toward healing should be evaluated weekly. If signs of ulcer deterioration are observed sooner (e.g. during daily dressing changes), steps to reverse them should be taken immediately. 9. Reassessment of Treatment Plan and evaluation of Adherence. If the ulcer is not healing, the clinician must reassess the treatment plan and determine whether it is being followed. In particular the clinician should assess whether tissue load management is adequate and should evaluate the extent of adherence to cleansing and dressing . Necrotic tissue and or underlying abscess should be suspected if the ulcer is not healing. And: Use devices that totally relieve pressure on the heels, most commonly by raising the heels off of the bed And also, individuals in bed should have a care plan that includes the use of devices that totally relieve pressure on the heels . The findings included: 1. For Resident #3, a pressure wound on the right heel was first identified on 5/4/16. On 5/6/16 the wound was noted to have a black scab. The wound care nurse did not assess the wound until 5/13/16. According to the care plan, no preventative measures were in place to prevent the development of the right heel wound. A treatment to the right heel wound was not started until 5/20/16. As of 9/9/16, Resident #3's right heel wound measured 5.8 x 9.7 x 0.2 (centimeters). Resident #3, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 7/22/16. She was coded with a Brief Interview of Mental status score of 5 indicating severe cognitive impairment. Bed mobility was coded as 4/2 (total dependence/ one person assist) and transfer was coded as 4/3 (total dependence/ two person assist). She was coded to be at risk for developing a pressure ulcer. She was coded to have two pressure ulcers, a stage II and a stage III. She was coded to have range of motion limitations to both lower extremities. The MDS assessment completed prior to the development of the right heel wound was a 60 day assessment with an ARD of 4/28/16. Resident #3 was coded with a Brief Interview of Mental status score of 3 indicating severe cognitive impairment. Bed mobility was coded as 3/2 (extensive assistance/ one person assist) and transfer was coded as 4/3 (total dependence/ two person assist). She was coded to be at risk for developing a pressure ulcer. She did not have any pressure ulcers at the time of assessment. She was coded to have no range of motion limitations. Resident #3 was observed on 9/8/16 at 10 a.m. during the group interview. She was reclined in the geri chair with her heels elevated. She was wearing gripper socks. She was not wearing heel protectors. Resident #3 was observed in bed on 9/9/16 at 8:25 a.m. Her heels were floated. She was not wearing heel protectors. The following timeline shows the progression of Resident #3 ' s right heel wound: -3/3/16, an admission nursing assessment was completed. In section J. Musculoskeletal it was documented that Resident #3 had an Ankle Foot Orthotic (AFO). In section O. Skin, the skin condition was described as warm, dry, and bruises/ecchymosis. The skin treatments documented were turning/repositioning and none. Section P. Foot Problems and Care was documented as none. In section V. Risk for Pressure Ulcers a score of 16 was calculated. The form read Total score of 0-17 High Risk (must implement care plan). Higher number indicates higher risk. While it was documented that the resident did not have any foot problems, she wore the AFO to correct a dropped right foot. -5/3/16, the daily skilled nurses note documented Resident #3's skin as warm and dry to touch. There was no documentation of a skin issue. There was no documentation that the heels were floated or heel protectors were applied. -5/4/16, a physical therapy note documented Some increased pressure noted on left heel area which was reported to nursing. -5/4/16, Resident #3's right heel wound was first documented in the clinical record in the daily skilled nurses note. The note read Continues to c/o (complain of) pain to R (right) heel. The note also read Resident's R (right) heel noted with larger sore area brown in color + tender to touch. Cleaned and foam dressing applied. This assessment was completed by Licensed Practical Nurse B (LPN B). -5/4/16, the 24 Hour Report completed by LPN B read R (right) heel noted with stage I ulcer now. -5/5/16, the daily skilled nurses note documented Resident #3's skin was warm and dry to touch. In the skin section Rt (right) heel was written in under the decubitus wound check box. The decubitus wound boxes were checked, indicating the area was observed by the day, evening and night shift nurses. The evening shift nurse documented heel protectors on + floated. -5/6/16, the right heel wound was documented on the Nursing Weekly Summary form. This form was used to complete the weekly skin checks. The form read Rt (right) heel area soft with redness with one small area with black scab- protective ointment applied- float heels and have bunny boots on. The body diagram included on the form was marked at the right heel and read reddened with small area discolored. This assessment was completed by Licensed Practical Nurse A (LPN A). -5/13/16 at 12:55 a.m., a Nursing Weekly Summary form was completed. The form read Nurses weekly assessment + body audit. The form also read No new open areas noted to skin. The form included the instruction Mark the location of skin conditions/ wounds etc. on illustration below, address areas in narrative below. No skin issues were marked on the diagram. -5/13/16, the wound care nurse, Registered Nurse A (RN A), first assessed the right heel wound. RN A's initial assessment was completed 10 days after the right heel wound was first documented in the nurse ' s notes on 5/4/16. - 5/13/16, RN A completed a Wound Assessment Report for the right heel wound. The wound type was documented as pressure ulcer at stage I. The Assessment Occasion read new wound. The wound measured 1 x 1.3 x 0 (centimeters). The resident was noted to have pain with grimacing. The wound bed was not described. The wound bed section was blank. - 5/13/16 at 9:00 a.m., RN A wrote a wound care order. The order read Rt. (right) heel DTI (deep tissue injury): daily clean with saline, pat dry, apply protective ointment cover with foam dsg (dressing). This is the first wound treatment ordered for the right heel wound found on 5/4/16. When this order was added to the May 2016 Medication Administration Record (MAR), it was written to treat the left heel instead of the right heel. -5/13/16, RN A also documented the right heel wound in the Interdisciplinary Progress Notes. The note read MASD (moisture associated skin damage) + DTI (deep tissue injury) Rt (right) heel. Treatment initiated per Dr. (doctor) order + RP (responsible party) _____ present @ bedside. It is important to note that while RN A staged the right heel wound as stage I in her 5/13/16 wound assessment, she documented the area as a deep tissue injury in the 5/13/16 order and the 5/13/16 interdisciplinary note. - 5/18/16: (wound nurse) wound type: deep tissue injury, measurements: 1 x 1.3 x 0 (centimeters) No pain. No drainage. No wound bed description. 5/20/16: treatment order on May 2016 MAR was changed to indicate treatment to the right heel (correct heel). - 5/24/16 (new order): Discontinue current treatment to right heel. Clean right heel with normal saline apply santyl ointment apply foam dressing daily. This order was implemented on the MAR. - 5/26/16: (wound nurse) wound type: deep tissue injury, measurements: 1.5 x 2.8 x 0 (centimeters), Pain with grimacing. No drainage. No description of wound bed. - 6/2/16: (wound nurse) wound type: deep tissue injury, measurements: 2.5 x 4.4 x 0 (centimeters), No pain. Drainage: serous, scant. No description of wound bed. - 6/9/16: (wound nurse) wound type: deep tissue injury, measurements: 2.0 x 3.0 x 0.1 (centimeters), No pain. Drainage: serosanguineous, scant. No description of wound bed. -6/16/16: (wound nurse) Wound Assessments Report completed by wound care nurse. Treatments read Rt (right) heel ulcer; unstageable ulcer, daily clean with saline; pat dry, topically apply santyl ointment, cover with dry gauze with kling and tape - 6/16/16 (physician note) R (right) heel ulcer stage II-III- will C+S (culture). Cont (continue) local (?) care with wet-dry dressing cont follow. It is important to note that the wound care nurse and doctor both assessed the heel wound on 6/16/16. The wound nurse staged the wound as unstageable and the doctor staged the wound as II-III. - 6/16/16 (new order): Wet Dry dressing right heel two times per day. This order was implemented on the June 2016 MAR. - 6/23/16: (wound nurse) wound type: necrotic tissue, measurements: 3.0 x 4.5 x 0.0 (centimeters), Pain with grimacing. Drainage: serous, scant. No description of wound bed. - 6/27/16 (new order): Santyl to right heel wound daily. This order was added to the TAR a second time, as the order from 5/24/16 had never been discontinued - 6/29/16 (new order): Refer to wound clinic - 6/30/16: (wound nurse) wound type: necrotic tissue, measurements: 5.0 x 5.3 x 0.0 (centimeters), Pain with grimacing. Drainage: serous, small. No description of wound bed. - 7/5/16 (new order): Wound care Rt. (right) heel: non stageable ulcer Daily clean with Dakins 1/4 st (solution) Apply Santyl. Cover with lightly moist Dakins gauze, Kling tape Apply air mattress, check function Q (every) shift - 7/7/16: (wound nurse) wound type: necrotic tissue, measurements: 6.0 x 6.0 x 0.0 (centimeters), Pain with grimacing. Drainage: serosanguineous, small. No description of wound bed. - 7/8/16: Wound consult report read large boggy R (right) heel ulcer with odor. Recommendations 1) Needs debridement R (right) heel-> will schedule 2) D/C (discontinue) Santyl- start Dakins wet->dry. 3) continue air mattress, booties, dangling. 7/26/16: Wound consult report read Post op #1(post operative visit #1) S/P (status [REDACTED]. X-ray shows acute osteo[DIAGNOSES REDACTED] R (right) heel. [DIAGNOSES REDACTED] is an infection of the bone. Treatment Orders: The treatment orders were reviewed on the MARs and Treatment Administration Records (TAR). The May 2016 MAR included the order dated 5/13/16 which read Left heel; Daily clean with saline, pat dry, apply protective ointment, cover with foam dressing. This order was signed as completed from 5/13/16- 5/20/16. It is important to note that the right heel was supposed to receive the treatment, not the left heel as indicated on the May 2016 MAR. According to the May 2016 MAR documentation, the wrong heel was treated. The order for treatment to the left heel was discontinued on 5/20/16. -5/20/16- A new order was added to the May 2015 MAR for treatment to the right heel. It read Right heel; Daily clean with saline, pat dry, apply protective ointment, cover with foam dressing. This treatment was for the correct heel (right heel). 5/20/16 is the first date for which documentation on the MAR or TAR indicated that Resident #3 received treatment to the right heel. Her wound was first identified on 5/4/16, 16 days prior. -5/24/16- Clean right heel with normal saline apply santyl ointment apply foam dressing daily. This order was added to the May 2016 TAR. This order was signed as completed on the May 2016 and June 2016 TAR from 5/25/16 until 6/30/16. -6/16/16: Wet Dry dressing right heel two times per day. This order was added to the June 2016 MAR and signed as completed. According to the June 2016 TAR, Santyl (ordered 5/24/16) was not discontinued when the wet dry dressing order was implemented. Staff were signing off that both dressings were completed daily. According to the June 2016 MAR and TAR, the resident received both wound care treatments from 6/16/16 through at least 6/30/16. The July 2016 MAR and TAR was not reviewed. - 6/27/16: Santyl to right heel wound daily. This order was added to the June 2016 TAR a second time, as the Santyl order from 5/24/16 had never been discontinued. When this order was added, the wet dry dressing was not discontinued from the June 2016 MAR. Staff documented that both treatments were administered on the June 2016 MAR and TAR. Care Plans: Resident #3's care plans were reviewed. The care plan signed on 3/23/16 by facility staff was the care plan in place prior to the development of the right heel wound. The 3/23/16 care plan included seven care planned areas. None of the seven areas address skin care or pressure wound prevention. It is important to note that Resident #3 had been coded as at risk for the development of pressure wounds on her MDS and she triggered as high risk on the facility Risk for Pressure Ulcers assessment, the assessment completed upon admission that indicated Resident #3 needed to be care planned for wound prevention. The care plan was revised on 5/13/16 to include the problem Pressure ulcer rt (right) heel and included the interventions: -Use moisturizing lotion for dry skin as needed -Report any new reddened or open areas to charge nurse -Routine skin assessments by licensed nurse. Update doctor if pressure area is not responding to treatment -Assist resident to turn and reposition routinely -Place resident on low-air-loss bed -Assess for pain related to pressure ulcer or its treatment -Treatment as prescribed by doctor It is important to note that heel protectors and float heels are not interventions included on the 5/13/16 care plan. A care plan created on 7/7/16 with the problem Pressure ulcer to lt (left) heel included float heels while in bed as an intervention. This care plan dated 7/7/16 was the first time float heels was included in the care plan. The 7/7/16 care plan did not include heel protectors as an intervention. According to the Wound Assessment Report dated 7/7/16, the left heel wound was found at stage I. While the care plan indicated Resident #3 had a low air loss mattress on 5/13/16, the mattress was not actually ordered or implemented until 7/5/16. The facility provided a copy of Resident #3's Resident Status Sheet, a care plan used by the Certified Nursing Assistants. This form was kept in a binder on the unit. The survey team did not see the form prior to receiving the copy. The section titled Supportive read 7/5/16 air mattress 1 draw sheet 1 flat sheet. The section titled Skin read use protective cream with each brief change and heel protectors as resident will allow. These interventions were not dated. The DON was asked to provide a copy of Resident #3's shower/ bathing record. The DON stated that the facility did not document when showers and baths were completed. Interviews On 9/8/16, at the end of day meeting, the facility administrative staff were interviewed. The Facility administrative staff were notified that Resident #3's care plan (in place prior to the development of the right heel wound) did not address skin care or wound prevention. The care plan included four pages. The survey team made a copy of this care plan on 9/8/16. During the meeting, the facility staff were notified that the survey team was considering Resident #3's right heel wound situation a harm level deficiency. On 9/9/16 at 9:45 a.m., a meeting was held with the Administrator, DON, MDS nurse, wound nurse, and Therapy Director to discuss Resident #3 ' s right heel wound. The facility staff provided a copy of page 1 of the 3/23/16 care plan. One of the seven problems read (resident name) requires mod (moderate) to extensive asst (assistance) w/ (with) ADLs (activities of daily living) d/t (due to) surgical spinal procedure- spinal fusion. Hand written in beneath the typed out approaches read Heel protectors bilaterally as resident will tolerate, lotion or protective oint (ointment) to skin as needed, turn + position often. This hand written information was not on the care plan the survey team had copied on 9/8/16. The 3/23/16 care plan had been altered by the facility staff. The facility staff were asked to provide the original 3/23/16 care plan document, including all four pages. They provided a 3/23/16 care plan with the approaches hand written in. They could not provide the original care plan that did not include the hand written approaches. The facility staff in the meeting stated they did not know how the care plan document was altered overnight. The DON stated that heel protectors were in place for Resident #3 prior to the development of the wound. The DON stated that Resident #3 would kick the heel protectors off. It was not documented in the clinical record or on the care plan that Resident #3 was non-compliant with wearing the heel protectors. The resident was not observed to wear heel protectors at any time during the survey. The DON was asked why Resident #3's 5/13/16 care plan indicated that she was to have a low air loss mattress, but the mattress was not ordered until 7/5/16. The DON stated she did not know why the low air loss mattress was an intervention on the 5/13/16 care plan. The DON stated that until 7/5/16, Resident #3 had the same mattress that all residents received upon admittance to the facility. She stated that a low air loss mattress is different. (Low air loss mattress is used to prevent or help cure pressure sores). The Therapy Director was interviewed. When asked if therapy assessed assistive devices for residents who were admitted to the facility with a device, he stated yes. When asked if the assessment was documented, the Therapy Director stated it would be documented if there was an issue identified with the device. When asked if therapy assessed Resident #3's AFO worn on the right foot, he stated the therapy staff applied the AFO for the resident and would have noted if they observed an issue. At this time, the Director of Nursing (DON) stated that the nursing staff would also assess the use of assistive devices. The wound care nurse was interviewed. When asked how she became aware of the right heel wound, she stated that the second shift nurse left a note in her box on 5/12/16. It was reviewed that the right heel wound was first identified on 5/4/16 and then identified to have a black scab on 5/6/16. When asked if the floor nurses were supposed to notify the wound care nurse if a wound was identified, the wound care nurse stated yes, as soon as possible. When asked about the Certified Nursing Assistant role in skin assessment, the DON stated that the Certified Nursing Assistant was to observe the skin when doing care and to report any skin area immediately to the charge nurse. The wound care nurse was asked why she used Santyl to treat a deep tissue injury. From Santyl.com Santyl is a FDA (Food and Drug Administration) approved prescription medicine that removes dead tissue from wounds so they can start to heal. The wound care nurse did not answer the question about the use of Santyl, but she did state that once she entered a wound as a Deep Tissue Injury in her electronic tracking system, she could not change it to a stage. She stated she would have to start a new wound tracking form. When asked if the wound tracking documentation allowed a flow sheet from one week to the next, the wound care nurse stated no. It was reviewed with the wound care nurse that none of the weekly assessments included a wound bed description or staging. It is unclear from the tracking what stage the wound was from week to week. On 9/9/16 at 1:35 p.m., another interview was conducted with the wound care nurse. The wound care nurse stated that she had worked at the facility about a year. At this time, the wound care nurse stated that she had just realized that there were several different skin forms available in the electronic system to track skin issues. Although pressure ulcer was a form choice, the wound care nurse stated that she usually used the form called other to document wounds. She stated that she just realized that each of the forms had a different set of prompts to describe the different types of skin issues. When asked how recently she had learned about the forms, she stated it had been during the time of the survey. It was reviewed with the wound nurse that treatment orders were not discontinued on the MAR or TAR when a new order was added. It was reviewed that the documentation showed Resident #3 received multiple wound care treatments at the same time. The wound care nurse stated she was not aware until recently that she needed to discontinue the old treatment order when a new treatment order was added. When asked if there should be a physician's order for foam dressing to be applied, the wound care nurse stated yes. The wound care nurse was also notified that there was concern that the floor nurses did not notify her of the heel wound until eight days after the wound had been identified. The wound care nurse stated that she did not see a scabbed area when she first assessed the right heel. The wound care nurse stated that she identified there was a communication issue regarding the floor nurses notifying her of new wounds and skin issues. She stated that the communication needed to improve. She stated that there was a staff meeting in August 2016 that addressed the need for a change in the way wounds were assessed. She stated that she is trying to assess new admissions with the nurses. She stated that the nurses completing the weekly skin checks are to measure a wound, but they were not supposed to stage the wound. During the staff meeting, the 24 hour report documentation was reviewed with the nurses. They were instructed to include wounds on the 24 hour report. The wound care nurse was asked if Resident #3 currently used heel protector boots. She stated that she did not know. She was informed that Resident #3 had not been observed wearing the boots at any time during the survey. The wound care nurse stated that maybe the boots were in the room somewhere. The wound care nurse stated that the heel cushion Resident #3 used was a memory foam pillow brought in by the family. She stated she was in the process of finding a better cushion to float Resident #3 ' s heels. She pulled a cushion out of the drawer in her office that she intended to try. Resident #3's wound treatment orders were reviewed with the wound care nurse. It was reviewed with the wound nurse that the order written on 5/13/16 was implemented on the wrong heel per the order on the MAR. The wound care nurse stated that she printed out treatment orders on a weekly basis and provided them to the floor nurses to keep on the treatment cart. She stated that this was her practice in May 2016, so the floor nurse would have known to treat the right heel instead of the left heel. It was reviewed with the wound care nurse that the floor nurses signed off that they completed a treatment to the left heel for seven days. The wound care nurse stated that she did not have access to the MARs and TARs until recently, about a month ago. She stated that if she performed a wound treatment, she had no ability to document that she had completed the treatment. She stated that one of the other nurses would sign their initials so the MAR or TAR was documented that the treatment had been completed. When asked if someone else was signing for work that she had completed, the wound care nurse stated yes. On 9/9/16 at 2:15 p.m., Registered Nurse E (RN E) was interviewed. RN E was the nurse who performed Resident #3 ' s wound care earlier in the morning. When asked how she knew what treatment order to use when performing wound care, RN E pointed to the computer screen and stated she would use the order in the computer. When asked if there was any other reference she used, RN E thought for a moment and then referenced the treatment order print out from the wound care nurse. On 9/9/16 at 12:25 p.m., the Administrator notified the survey team that one of her staff who had been in attendance at the meeting earlier in the morning with the survey team had added the information to the altered care plan. On 9/9/16 at 2:45 p.m., LPN A (the nurse who had identified the right heel black scab on 5/6/16) was interviewed. LPN A was asked how she found the black scab on the right heel. She stated she found the area during the weekly skin assessment. She stated that she had physically looked at the wound. When asked if she could remember what the wound looked like, LPN A stated that the right heel was soft around the blackened area. She stated the area was not raised but she could feel the edges. When asked how she would communicate a skin concern to the wound care nurse, LPN A stated that she would document the issue on the 24 Hour Report and leave the wound care nurse a note. When asked if Resident #3 wore heel protectors prior to the development of the area, LPN A stated that she was unsure. When asked if a physician order was required for the use of heel protectors, LPN A stated that the use of heel protectors and protective ointment did not require a physician's order. On 9/9/16 at 5:00 p.m., the 24 hour reports were reviewed with the DON. The DON stated that LPN A worked the night shift and was responsible for starting the daily 24 Hour Report for the following day. Upon review of the 5/7/16 24 Hour Report started by LPN A, the right heel wound observed on 5/6/16 was not documented. On 9/9/16 at the end of day meeting, the MDS nurse stated that care plans were developed from the care area assessment (CAA) worksheets generated from the MDS assessment. The MDS nurse also stated that a care plan would be revised when something new happened with the resident. At the end of day meeting on 9/8/16 and multiple occasions on 9/9/16, the facility staff were asked to provide the order for the dressing applied as documented in the 5/4/16 nurses note. The order was not provided to the survey team. There was no physician orders for the dressing applied to the wound. Facility Skin Policy and Stage Definitions The facility policy titled Prevention of Pressure Ulcers was reviewed. The General Guidelines section read 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. The section Interventions and Preventative Measures: General read 2. For a person in bed: b. Determine if resident needs a special mattress; c. If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated. The policy did not include descriptions of wound staging. Wound staging information was accessed at the The National Pressure Ulcer Advisory Panel website: www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/>: Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.¿Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.¿Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are vis

Based on observation and staff interview, the facility staff failed to safely store an oxygen cylinder for one Resident (#7) of 17 Residents in the survey sample resulting in immediate jeopardy and substandard quality of care. After removal of the immediate jeopardy, the scope and severity was lowered to a level 2, isolated (D). 1. An oxygen cylinder was stored unsecured on the floor of Resident #7's room, approximately 4 feet from the head of her bed. The survey team agreed that this situation consisted of IJ, since the cylinder could become an out of control projectile should it be toppled and the regulator become displaced. The findings included: 1. An oxygen cylinder was stored unsecured on the floor of Resident #7's room, approximately 4 feet from the head of her bed. Resident #7, an [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. Her medical history included right femur fracture, right knee replacement, chronic [MEDICAL CONDITION], hypertension, high cholesterol, diabetes, and [MEDICAL CONDITION]. Resident #7's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/14/2015 was coded as a 14 day assessment. The Resident was coded a BIMS (Brief Interview of Mental Status) score of 15, indicating no cognitive impairment. Resident #7 was coded as being totally dependent on one person for activities of daily living, and as being always continent of bowel and bladder. On 10/14/2015 at 2:00 PM, a Resident Interview was conducted with Resident #7. Resident #7 was in a private room and was sitting in a wheelchair on the left side of the bed (looking at the bed) with her right leg elevated in a horizontal position. During the discussion with Resident #7, an unsecured oxygen cylinder was noted to be on her right side against the wall behind her, and approximately 4 feet from the head of her bed. The survey team agreed that this situation consisted The cylinder was approximately 2 feet tall, heavy metal composition, with an oxygen regulator on the top. The gauge on top indicated that the bottle was full. At 2:10 PM, two other surveyors on the team were summoned to witness the cylinder in place. At this time Resident #7 stated that the oxygen cylinder had been here for some time. The survey team agreed that this situation consisted of IJ, since the cylinder could become an out of control projectile should it be toppled and the regulator become displaced. At 2:45 PM, Supervisors at the Virginia Department of Health, Office of Licensure and Certification (OLC) were contacted regarding the Immediate Jeopardy for Resident #7. After a discussion, OLC Supervisors agreed with the IJ assessment concerning Resident #7. At 2:50 PM surveyors conducted an examination of all other rooms in the facility to be certain no other resident was in danger of a free standing oxygen tank. No others were found. At 3:02 PM the facility Administrator and Director of Nursing were notified of the IJ findings. They immediately removed the oxygen cylinder from the room, and stated that it was left behind by the transporters who brought Resident #7 to the facility from the acute care hospital. At 3:35 PM a Plan of Correction (POC) was presented and it was not accepted. At 3:40 PM the POC was accepted and the Immediate Jeopardy was lifted. The Plan of Correction consisted of the following points: 1. The oxygen cylinder was removed from the Resident 's room and properly secured. 2. An immediate sweep of the facility was conducted to identify whether or not any other oxygen cylinders were unsecured within the facility by ________(RM), LPN (Licensed Practical Nurse) and __________ (TM), LPN. An additional sweep was conducted by the Corporate Nurse who arrived when notified. None were located. 3. An in-service was held by the Director of Nursing for all staff on duty to review the violation and importance of safe securement of oxygen cylinders within the facility at all times. Staff was instructed to immediately secure all oxygen cylinders on arrival regardless of source. A listing of all employees will be utilized to assure that all staff members have been in serviced prior to assignment. 4. The Director of Nursing will audit the room of all new admissions to assure safe securement of oxygen cylinders at all times. 5. The facility alleges compliance with the regulation related to safe storage of oxygen on 10/14/2015 at 3:42 PM. On 10/15/15 at 1:15 p.m., a tour of the facility was conducted with the Maintenance Manager, Other A. On the hallway behind the West nurse's station, and in front of the Dirty Utility room there was an Oxygen Storage room. Other A used a combination code to unlock the door. Portable green tanks, 'E' cylinders, were observed in single cylinder carts and some of the tanks were in a stationary compartmentalized holding case. There was one small portable cylinder, 'A' tank, that was secured in a single cylinder cart and there were approximately 5-6 empty single cylinder carts. All of the oxygen cylinders were securely stored. Guidance for safe handling of oxygen cylinders was provided by the Joint Commission at www.jointcommission.org <http://www.jointcommission.org> as follows: It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile. On 10/15/2015 at 3:50 PM, the administration was again advised of the failure of the staff to ensure that an oxygen cylinder was stored in a safe and secure manner for Resident #7 resulting in Immediate Jeopardy.