Every finding on record at Ivy at Deer Lodge

Based on observation, interview, and record review, the facility staff failed to correctly position a mechanical lift sling to prevent an accident, which caused injury to a resident when she fell from the lift, for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to experience pain, she had an injury to the head, and a fear of the lift, which has not subsided. Findings include:Review of a Facility Reported Event, for 2/18/25, showed resident #5 had fallen from a mechanical lift during a transfer from the bed to the wheelchair. The report showed a staff member had failed to hook the lift sling properly to the lift, causing resident #5 to fall to the floor. During an interview on 12/2/25 at 1:32 p.m., resident #5 stated, I remember that incident. Staff were getting me up, but they didn't hook the sling right. When they went to move me with the lift, I fell out of the sling and hit the bed, and then the floor. I had hit my head on the metal part of the bed. It hurt really bad. I had a giant goose egg on my head. It could have been worse.Review of resident #5's medical record progress notes showed:- 2/18/25 at 10:00 a.m. - Res was found on the floor lying flat on her back with her head up next to her bed. Res was positioned underneath the hoyer lift. Cna's voice res was not properly positioned safely to hoyer pad when she fell from it. Res voices this was an accurate account of events . No bruising or injuries noted at time of assessment. [sic]-2/18/25 at 1:00 p.m. - Res noted to have a small nodule on her right middle head r/t s/p fall. Res voices her pain is at a 5.-2/19/25 at 2:00 p.m. - Res c/o upper to mid back pain r/t S/P fall on 2/18/25. VSS. She voices her pain is greater than 5. MD and family notified via voicemail and fax. She is transported to [Facility Name] via facility transportation. [sic]Review of a physician's note, for resident #5, dated 2/25/25, showed, PT reports last week at the [Facility Name] while transferring she was dropped. Pt reports nightly headaches and back pain since event. [sic]During an observation on 12/3/25 at 9:17 a.m., staff members F and Q were observed assisting resident #5 to get up for the day. Staff positioned resident #5 in the mechanical lift sling and began raising her from the bed. Resident #5 was holding on to the bars of the lift, and her hands were white from a tight grip. Resident #5 winced when staff started moving the lift. Once the staff moved her over her wheelchair, resident #5 grabbed the lift bar with both hands and became quiet. When staff pulled the sling out from under resident #5, she winced and stopped talking.During an interview on 12/3/25 at 9:42 a.m., resident #5 stated, I am most afraid when I don't know the staff or when I don't trust them. I double-check the straps every time I get transferred now. Social services never talked to me about the incident, and no one from the facility did. I am terrified, and it sucks. Review of a facility document titled Accidents and Supervision with a revision date of 5/16/25, showed: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s).Policy Explanation and Compliance Guidelines:The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. [sic]

Based on observation, interview, and record review, the facility failed to identify psychosocial harm after a resident's traumatic experience and fall from a mechanical lift, and failed to provide medically necessary social services for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to continue to be fearful of transfers with the lift and falling, which increased her anxiety. Findings include:During an interview on 12/1/25 at 1:03 p.m., resident #5 stated, I have a hard time with some of the staff. It is like they don't listen to me when I tell them how to do things. There are some staff here I don't trust.During an interview on 12/2/25 at 1:32 p.m., resident #5 stated, I remember the incident with the lift. Staff were getting me up, but they didn't hook the sling right. When they went to lift me, I fell out of the sling and hit the bed and then the floor. It hurt really bad. I didn't want to go to the clinic because I hurt so badly . I had a goose egg on my head. I am scared of falling from the lift again. I am even scared when they [staff] pull the sling out from under me. It really makes me nervous when the CNA who dropped me is getting me up. I spoke to [staff member B], and she said the situation was handled. I don't know what they [staff] consider handled.Resident #5 was able to recall the names of the two staff members performing the mechanical lift transfer and all details of the incident from 2/18/25.During an observation on 12/3/25 at 9:17 a.m., staff members F and Q were observed getting resident #5 up for the day. Staff positioned resident #5 in the mechanical lift sling and began raising her from the bed. Resident #5 was holding on to the bars of the lift, and her hands were white from a tight grip. Resident #5 winced when staff started moving the lift. Once the staff moved her over her wheelchair, resident #5 grabbed the lift bar with both hands and was quiet. When staff pulled the sling out from under resident #5, she winced and stopped talking. During an interview on 12/3/25 at 9:30 a.m., staff member F stated that resident #5 had shown signs of fear during transfers right after the incident happened. She [resident #5] has expressed fear of some staff members, . especially the one who dropped her. During an interview on 12/3/25 at 9:42 a.m., resident #5 stated, I am most afraid when I don't know the staff or when I don't trust them. I double-check the straps every time I get transferred now. Social services never talked to me about the incident, and no one from the facility did. I am terrified of falling, and it sucks. During an interview on 12/3/25 at 10:08 a.m., staff member P stated she did follow up with resident #5 after the incident with the lift. Staff member P stated she would document conversations with resident #5 in progress notes in resident #5's chart. Staff member P stated, She [resident #5] did request that the staff member responsible for the fall not work with her anymore, and to the best of my knowledge, she doesn't work with resident #5. I did not do a formal assessment for psychosocial harm or PTSD. I didn't realize she was afraid during transfers or scared of falling.During an interview on 12/3/25 at 11:46 a.m., staff member B stated staff member R . works on the 100 hall now. Staff member R knows she is not to care for resident #5. Staff member R was assisting resident #5 when she fell from the mechanical lift. Review of resident #5's medical record failed to show that any psychosocial assessments were completed after the fall from the lift on 2/18/25. Review of resident #5's medical record failed to show that any social service notes were documented after the fall from the lift on 2/18/25.A request was made on 12/3/25 for all social service progress notes for February and March 2025. There were no notes provided by the end of the survey period. Review of a facility document titled, Social Services, with an implementation date of 1/2/25, showed: Policy: The facility, regardless of size, will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:. 4. The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include:. k. Identifying and seeking ways to support residents' individual needs through the assessment and care planning process.n. Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.o. Meeting the needs of residents who are grieving from losses and coping with stressful events.7. The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning. [sic]

Based on observations, interviews, and record reviews, the facility failed to ensure staff performed appropriate hand hygiene during meal service; failed to ensure laundry staff removed personal protective equipment appropriately after working with dirty laundry and linens; and failed to ensure staff performed all resident cares wearing personal protective equipment for Enhanced Barrier Precautions per CDC guidelines. These failures placed residents at increased risk for transmission of infectious organisms. Findings include:1. During an observation on 12/2/25 at 7:51 a.m., staff member I entered the kitchen without performing hand hygiene and came out with a drink which was delivered to a resident.During an observation on 12/2/25 at 7:59 a.m., staff member J exited the kitchen wearing gloves, served a drink to a resident, went back into the kitchen touching the door, did not change gloves or perform hand hygiene, and then continued with the meal service preparing drinks for multiple residents.During an observation and interview on 12/2/25 at 8:02 a.m., staff member K was observed entering the dining area and going through the kitchen door without performing hand hygiene. Staff member K then proceeded to assist four residents with meal setup without performing hand hygiene in between. Staff member K stated he should have used hand sanitizer between each resident.During an interview on 12/2/25 at 8:11 a.m., staff member M stated, You're supposed to use hand sanitizer every time between delivering trays.During an interview on 12/2/25 at 8:12 a.m., staff member I stated, I'm confused, I don't think you have to do hand sanitizer every time you go in the kitchen if you're just going to grab a tray, but yes, I guess you should.During an interview on 12/2/25 at 8:14 am, staff member K approached this surveyor and asked, Am I supposed to wash my hands every time I serve a meal? Staff member K stated, I should have been doing it, and walked away.During an interview on 12/2/25 at 8:23 a.m., staff member H stated his kitchen staff should be washing their hands in the sink when they first come through the kitchen door, but they don't have to perform hand hygiene in between serving trays. Staff member H stated he was not sure what the CNAs were supposed to do in between serving trays and asked this surveyor, What should we be doing? Staff member H stated he was going to talk to staff member A regarding what the policy was.During an interview on 12/2/25 at 8:59 a.m., staff member B stated hand sanitizer should be used every time before grabbing a new tray in between residents.Review of a facility policy, titled, Hand Hygiene, dated 1/2/25, showed the following: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Review of a facility document, titled, Hand Hygiene Table, copyright 2025, showed the following: .Between resident contacts.Either Soap and Water or Alcohol Based Hand Rub. [sic] 2. During an observation and interview on 12/03/25 at 8:28 a.m., staff member N demonstrated the procedural process she would normally use when handling and cleaning dirty laundry. Staff member N removed her dirty gown, prior to removing her dirty gloves, after she had finished putting dirty laundry into the washing machine, thus contaminating her clothing. Staff member N stated the process of removing dirty PPE didn't seem right to her, then stated, But it was how I was shown when I started working here. During an interview on 12/3/25 at 8:45 a.m., staff member O stated she was aware of the process staff member N was using to remove PPE after performing laundry services for dirty clothing and bed linens, although the failed practice was not addressed by staff member O. During an interview on 12/3/25 at 8:54 a.m., staff member B stated she was not aware of laundry staff removing dirty PPE incorrectly. Staff member B stated she had not personally observed the infection control practices in the laundry room, but is aware she needs to in order to identify concerns.Review of a facility policy, titled, Personal Protective Equipment, dated 1/2/25, showed the following: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff.5.Sequence of donning/removing PPE when using multiple types.b. Remove PPE in this order: gloves, goggles or face shield, gown.Perform hand hygiene after removing gown.7. Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed.3. During an observation on 12/3/25 at 9:17 a.m., staff members F and Q were assisting resident #5 with getting up for the day. Resident #5 had a wound and an indwelling catheter. Staff member F disinfected the lift and sling while staff member Q got resident #5 dressed and brief changed. Staff member Q was not wearing a protective gown. Staff member F assisted staff member Q with transferring resident #5 to her wheelchair. Staff member F was not wearing a protective gown. Neither staff member F nor Q wore protective gowns while performing personal care on resident #5, although the resident had a wound and an indwelling catheter.During an interview on 12/3/25 at 9:30 a.m., staff member F stated, I would use PPE for someone on EBP while doing direct catheter care or wound care, although this did not occur for resident #5. During an interview on 12/3/25 at 11:46 a.m., staff member B stated that staff should wear a protective gown and gloves for anyone on Enhanced Barrier Precautions. Staff member B said anyone with a wound or a catheter would be on Enhanced Barrier Precautions, and any staff completing wound care or doing anything with catheters should be wearing appropriate PPE.During an interview on 12/3/25 at 1:08 p.m., staff member B stated she followed CDC guidelines and the facility's policy for the use of EBP signs on residents' doors. Staff member B stated that staff must wear PPE when they are providing care to residents with wounds and catheters, but it was not always required for resident care. Staff member B stated, At the bottom of our PPE policy, it says the CDC guidelines, but it's confusing because they are different than our policy.Review of a facility document titled Enhanced Barrier Precautions with an implementation date of 1/2/25, showed: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Policy Explanation and Compliance Guidelines:1. Prompt recognition of need:.c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.4. High-contact resident care activities include:a. Dressingb. Bathingc. Transferring d. Providing hygienee. Changing linensf. Changing briefs or assisting with toileting. [sic]

Based on observation, interview, and record review, the facility failed to ensure staff member C primed an insulin pen prior to administration of insulin for 1 (#43) of 4 observed medication administration residents. Findings include:During an observation and interview on 12/2/25 at 7:56 a.m., staff member C prepared resident #43's medication and insulin for administration. Staff member C stated they (nurses) did not prime insulin pens prior to dialing the insulin dosage for residents at this facility. She stated some facilities did prime insulin pens and other facilities did not prime insulin pens. Staff member C stated she was unsure what the facility's policy and procedure showed for insulin administration related to priming an insulin pen.During an interview on 12/2/25 at 8:51 a.m., staff member B stated per the facility policy and procedure, insulin pens were to be primed before dialing the dosage of insulin.During an interview on 12/2/25 at 9:05 a.m., staff member D stated the nursing staff were required to prime an insulin pen prior to dialing the insulin dosage into the pen. Staff member D stated she primes the insulin pen with 5 units of insulin.Review of the facility policy titled, Insulin Pen, date implemented 1/2/25, showed after attaching the pen needle:- .h. Prime the insulin pen:- i. Dial 2 units by turning the dose selector clockwise.- ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears.

Based on interview and record review, the facility failed to revise a resident's comprehensive care plan with interventions after an incident with a mechanical lift and failed to include psychosocial interventions for 1 (#5) of 14 sampled residents. Findings include: During an interview on 12/3/25 at 9:42 a.m., resident #5 stated, I am most afraid when I don't know the staff or when I don't trust them. I double-check the straps on the lift every time I get transferred now. Social services never talked to me about the incident, and no one from the facility did. I am terrified, and it sucks. During an interview on 12/3/25 at 10:08 a.m., staff member P stated, After an incident like hers [resident #5], I would usually go talk to her and enter a progress note. Staff member P said she was unaware that resident #5 was afraid of the lift or falling again and had not completed an assessment for psychosocial well-being.During an interview on 12/3/25 at 11:46 a.m., staff member B said each department was in charge of its section for care planning. Staff member B stated she was unsure if the care plan had been updated to reflect the interventions shown in the facility's investigation of resident #5's fall from the lift. Review of resident #5's comprehensive care plan, with a revision date of 2/28/25, showed: -Focus: [resident name] has had an actual fall with no injury r/t mechanical lift dysfunction.-Goal: [resident name] will resume usual activities without further incident through the review date.-Interventions: Educate staff on policy and procedure of using a mechanical lift (Hoyer lift). For no apparent acute injury, determine and address causative factors of the fall. Encourage diagnostic testing to rule out potential injury. Neuro-checks and vitals per protocol. Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. [sic]The comprehensive care plan failed to show interventions for her fear of falling from the lift again and her psychosocial needs. Review of a facility document titled Comprehensive Care Plans, with an implementation date of 1/2/25, showed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs.Review of a facility document titled Social Services with an implementation date of 1/2/25, showed: Policy: The facility, regardless of size, will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.k. Identifying and seeking ways to support residents' individual needs through the assessment and care planning process.n. Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.

Based on observation, interview, and record review, the facility failed to ensure an assessment was completed to evaluate the safety of residents who desired to self-administer medications for 2 (#8 and #43) of 4 observed medication administration residents. Findings include: 1. During an observation on 12/2/25 at 7:45 a.m., staff member C prepared the following medications to administer to resident #43 orally: - finasteride 5 mg, - lisinopril 2.5 mg, - meloxicam 15 mg, - omeprazole 20 mg, - oxybutynin chloride 5 mg, - torsemide 20 mg, - tamsulosin 0.4 mg, - gabapentin 300 mg, - glipizide 10 mg, - vitamin B12 1,000 mcg, and - vitamin D3 2,000 units. During an observation on 12/2/25 at 7:55 a.m., staff member C left all of resident #43's oral medications on his bedside table and reminded him to take his medications. Staff member C then left resident #43's room and closed the door. During an interview on 12/2/25 at 7:59 a.m., staff member C stated resident #43 was cognitively intact and took his medications independently. She stated resident #43 had an assessment for self-administration of medications completed. During an interview on 12/2/25 at 1:33 p.m., staff member B stated she was looking for an assessment for self-administration of medications for resident #43 but had not found a completed assessment. Staff member B stated she would need to perform an assessment to ensure resident #43 was safe to self-administer his medications. 2. During an observation on 12/3/25 at 11:18 a.m., resident #8 was sleeping in her bed with a medicine cup approximately half full of multiple pills and capsules sitting on her bedside table. During an interview on 12/3/25 at 11:21 a.m., staff member D stated resident #8 did not have a self-medication administration assessment or provider order. Staff member D stated she would usually check on resident #8 three or four times to make sure she takes her medications because she falls asleep a lot. Staff member D then immediately went into resident #8's room and woke her up to take her medications. Review of the facility policy titled, Resident Self-Administration of Medications, date implemented 1/2/25, showed: - . 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. - . 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: - a. The medications appropriate and safe for self-administration; - . c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for; and - .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.

Based on observation, interview, and record review, facility failed to identify, assess, document, measure, obtain, and follow physician orders for wound care for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to identify changes in the resident's skin status, which occurred over a short period of time, and failed to address wound changes timely for the provision of medical assistance or needed interventions. The facility failed to have a wound management system in place that provided the necessary oversight for care and treatment of wounds, based on professional standards of practice. Resident #4 was admitted to the facility with multiple wounds in various stages of breakdown, and the wounds were documented to be getting worse, in part due to his uncontrolled pain. On 11/20/24 at 2:02 p.m. an Immediate Jeopardy was announced to the Administrator and Director of Nursing for F686- Pressure Ulcers Care and Prevention. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon verification for the removal of the immediacy, may be lowered to an H. An acceptable plan for the Removal of Immediacy was approved on 11/25/24 at 5:16 p.m. Findings include: 1. During an interview on 11/18/24 at 3:56 p.m., NF1 said she was contacted on 11/10/24 that resident #4 had passed away within 24 hours of being admitted to the hospital. She then contacted a 3rd party to perform an autopsy due the physician report. NF1 said the physician reported, It was the worst case of neglect they have ever seen. NF1 said, His (#4's) wounds were horrific, and he basically had no backside; his arms and feet were involved. His official Cause of Death was severe sepsis. During an interview on 11/20/24 at 9:49 a.m., staff member F said she was working the day resident #4 was admitted to the facility. When resident #4 arrived at the facility, he refused to move himself from the stretcher to the bed. Staff member F said he was in extreme pain. Staff member F said the facility was aware resident #4 had severe wounds when the facility agreed to admit him. Staff member F said, He basically had no skin on the back of his legs, his pannus, and his back. Staff member F said resident #4 had so many wounds over his body she asked for help to do his admission skin evaluation. During an interview on 11/20/24 at 2:35 p.m., staff member D said resident #4's wounds were primarily sheering wounds on his buttocks, on his legs and one under his pannus. The wounds were not pressure wounds, and there was never any discharge from the wounds. Resident #4's wounds would bleed, but were not infected. Staff member D said resident #4 refused all treatments and medications over a weekend. Staff member D said the facility could not get resident #4 to participate in therapies or get out of bed. Staff member D said resident #4's wounds were not infected when he was sent to the emergency department for further evaluation. During an interview on 11/20/24 at 3:28 p.m., staff member B said resident #4 would refuse cares and pain medications. His wounds were all superficial and would bleed. Staff member B said one weekend he refused all cares and medications; he began to decline. Staff member B said the resident was in pain, and the facility sent him to the emergency department for an evaluation. He was admitted to the hospital. Review of resident #4's facility Order Summary Report, dated 10/1/24 through 11/9/24 showed an order for resident #4 for turning and repositioning as appropriate, and dressing changes were ordered as needed for wound care, for 14 days. The physician order did not give a specific timeframe for turning and repositioning, and the nursing staff neglected to consistently document resident #4's response or refusals for the repositioning or participation in care. Nursing staff neglected to ensure the wound care orders were in place for the routine changing of the dressings and treatment of resident #4's wounds. Review of resident #4's Admission Assessment, dated 10/3/24, showed the following wounds: - The resident had a Stage II pressure injury to his left hip measuring 14 cm x 5.5 cm. - Three Stage II pressure injuries to his right buttock, one measuring 2.5 cm x 1.5 cm, one 2.5 cm x 2.8 cm, and another that was 2.5 cm x 3.0 cm. - One Stage II pressure injury to the resident's left buttock measuring 2.5 cm x 3.0 cm. - Multiple skin tears to the resident's left forearm, to both lower extremities, to the resident's left thigh, and to the resident's abdomen. No measurements, description or number of skin tears was documented. - There was no documentation at that time of admission for resident #4's left scapular wound and no documentation of wound assessment for drainage or odor present. Review of resident #4's skin/wound notes, from 10/17/24 through 11/1/24, showed the following measurements: 10/17/24; - Stage II right buttock, 5.0 cm x 4.0 cm x depth of 0.1 cm - Right thigh, 3.0 cm x 3.0 cm - Right thigh, 2.5 cm x 2.5 cm - Posterior shin/calf, 9.5 cm x 3.5 cm - Left buttock, 2.5 cm x 3.0 cm x 0.1 cm 10/25/24; - Right buttock, 5 cm x 4 cm x 0.1 cm - Left buttock, 2.5 cm x 3 cm x 0.1 cm - Right thigh, 2.5 cm x 2.5 cm - Right thigh, 2.5 cm x 2.5 cm - Posterior shin/calf, 7.5 cm x 3.5 cm 11/1/24; - Stage II right buttock, 3.5 cm x 4.5 cm x 0.1 cm - Stage II left buttock 5.3 cm x 3.0 cm x 0.1 cm - Stage II right buttock, 2.0 cm x 3.2 cm x 0.1 cm - Stage II right buttock, 5.0 cm x 3.0 cm x 0.1 cm - Right thigh, 3.0 cm x 3.4 cm, skin tear - Left lower leg, 8.0 cm x 4.1 cm Resident #4's skin/wound notes showed a progression of an increase in size over the duration of his stay within the facility. The inconsistent documentation and care provided for the wounds contributed to resident #4's worsening wounds and severe pain he experienced. Review of resident #4's Weekly Skin Observations, dated 10/9/24 through 10/30/24 showed the following: 10/9/24; - Pannus skin tear. There were no measurements documented. - Buttock skin tear. There were no measurements documented. - Documentation buttock wounds, scapular wounds, leg wounds and hip wounds were not documented. No measurements, wound types and status were documented. 10/16/24; All wounds listed as skin tears. There were no measurements documented 10/23/24; - All wounds were listed as abrasions The sizes were documented as: - Right iliac front, 5 cm x 3.1 cm x 0.1 cm - Left iliac front, 4.0 cm x 2.5 cm x 0.1 cm - Left hip, 5.0 cm x 3.0 cm x 0.1 cm - Left lower leg rear, 8.1 cm x 4 cm x 0.1 cm - Stage II right buttock, 12.7 cm x 5.5 cm x 0.1 cm - Stage II left buttock, 5.0 cm x 3.0 cm x 0.1 cm - No documentation of any wound conditions were noted, and the documentation was signed off on 10/30/24. 10/30/24; - Pressure right buttock, 12.7 cm x 5.5 cm x 0.1 cm, no staging - Pressure left buttock, 5.0 cm x 3.0 cm x 0.1 cm, no staging - Left Lower leg rear, 8.0 cm x 4.1 cm, abrasion - Other left lower abdomen, abrasion, no measurements - Other, right upper thigh skin tear, 3.0 cm x 3.5 cm Skin observation documentation showed the inconsistency of the identification of each wound area and the inconsistency of documentation with assessments of wounds for type of wound, measurements, and if odor was present. Review of resident #4's care plan, provided by the facility, showed a problem of Stage II biateral buttock and left hip pressure ulcer with an intervention initiation date of 10/3/24, and weekly skin assessments and staff were to monitor for signs and symptoms of infection. On 10/21/24 interventions of nutritional supplements, and staff to encourage turning and repositioning were added. No interventions for repositioning or nutritional supplements were in place until 18 days into his stay. Record review of an emergency department (ED) physician note for resident #4, dated 11/9/24, showed a chief complaint of decreased responsiveness, not eating or taking his medications. The ED physician noted resident #4 arrived on 4L of oxygen via nasal cannula and had an oxygen saturation of 87 to 88%. Resident #4 would respond to painful stimuli. When moved from the EMS gurney to the hospital bed, the patient yelled Jesus Christ. The nursing home had reported to the ED that resident #4 had two large decubitus ulcers only, one on his sacrum buttocks, and the other on his left shoulder. Resident #4's physical exam showed: .Constitutional: General: He is in acute distress; Appearance: He is obese. He is ill-appearing and toxic-appearing; Comments: Patient [NAME] of yeast his hygiene is poor and the patient is bedridden. HENT: Head: Normocephalic and atraumatic; Comments: there was a large scab matted with hair on the crown of the scalp that was removed and there is a shallow ulcer that peers to be a basal cell carcinoma. .Assessment/Plan: AMS, decreased level of responsiveness, likely severe sepsis . The patient's pressure sores and decubitus sores on his buttocks sacral region and thighs were seen cultured and photos were taken; the pressure sore on the left scapular region also cultured and pictures taken and there is a pressure sore blister with blood on the right heel, and there is a sore on the left posterior leg. Also in the differential diagnosis besides severe sepsis have to asked to be the consideration of wound botulism. .Final Impression 1. Severe sepsis with organ failure 2. Decubitus ulcers and pressure sores the buttocks sacrum and left scapular region, Appear to be stage III. 3. Dehydration 4. Overall this is very concerning for neglect. [sic] Record review of resident #4's death summary, dated 11/10/24, showed: .Admission Diagnosis: sepsis Discharge Diagnosis: Severe sepsis with septic shock. Acute kidney injury. Acute encephalopathy Hospital Course: Patient was transferred to our institution form [sic] an outside hospital less than 24 hours ago with septic shock. Source was soft tissue and skin infections secondary to multiple decubiti ulcers, some of which were gangrenous. Despite aggressive medical therapy with volume resuscitation, antibiotics and vasopressor support the patient's hemodynamics continued to worsen. He was encephalopathic the entire time . his illness caused his death at 4:41 a.m . 2. During an observation and interview on 11/20/24 at 9:49 a.m., resident #2 was observed to be in her room and reclined on her bed. Resident #2 had both heels resting on the surface of the bed, with no padding or offloading of her heels noted. The room had a strong foul odor upon entering from the hallway. Staff member F donned gloves and removed the dressings from both of the resident's feet. The right heel wound was cleaned, and a small amount of tissue was debrided from around the wound. The right heel wound was dry, measured 9.5 cm x 4.5 cm, and had a foul odor. The left heel wound was dry, measured 12 cm x 4.5 cm, and had a foul odor. Staff member F cleaned the wounds with saline, applied betadine with a swab, and wrapped both feet with kerlix gauze. Staff member F said she does not measure the wounds with each dressing change but will measure them weekly when she does a big evaluation. She does not stage (assess severity) the wounds because it is beyond her scope of practice. Staff member F said the physician order was for a dressing change daily, and she will document the dressing change was performed in the nursing note. Resident #2 stated she acquired the wound from the bed, while in the facility. She stated she walked into the facility for rehab and, now she is in a wheelchair. She was no longer able to walk or stand on her feet. Staff member F then corrected resident #2 stating; she acquired the wounds while in the hospital. Resident #2 was noted to be shaking her head from side to side in disagreement. Staff member F said resident #2 had just finished antibiotics for her heel wounds. During an interview on 11/20/24 at 2:35 p.m., staff member D said resident #2 has heel wounds because she refuses to offload her heels. Staff member D said resident #2 has had an odor from her wounds for quite a few weeks, and the wound clinic did not recommend any antibiotics. The wound clinic will not debride #2's wounds until she saw a vascular surgeon for an evaluation. Staff member D said the antibiotics she was given were for a urinary tract infection, not for her wounds. During an interview on 11/21/24 at 12:21 p.m., resident #2 said she was admitted to the facility for rehabilitation and strengthening. She was receiving physical therapy services and was getting stronger. Resident #2 said the facility then fired the physical therapist, and she did not receive therapy services for several weeks, until a new physical therapist was hired. She spent that time sitting in a chair or lying in bed, causing her to develop pressure wounds on her heels. Resident #2 said when she was admitted to the hospital for her kidney failure, her wounds would be debrided. Resident #2 said she is no longer able to walk because of the wounds on her heels. During an interview on 11/25/24 at 3:49 p.m., staff member B stated resident #2 found to have a non-trauma related fracture to her foot, due to deterioration of her bones. There was a concern with the aeration of the tissue in her foot. Resident #2 requested to be transported to the facility so she could be near the physician treating the wounds. Review of resident #2's Skin/Wound Notes showed the following: 9/2/24; - Right foot 3rd digit measuring 1.0 cm x 1.0 cm - Left foot 2nd digit measuring 0.3 cm x 0.3 cm - No documentation of the wound type or description of the wound was present. 9/8/24; - Right 3rd digit measuring 0.5 cm x 0.5 cm - Left 2nd digit measuring 0.2 cm x 0.2 cm - Blister to right heel measuring 4 cm x 2.4 cm -- No documentation of wound type or description of the wound was present. 9/14/24; - Right foot 3rd digit measuring 1.5 cm x 0.3 cm x 0.4 cm depth - Left foot 2nd digit measuring 0.5 cm x 1 cm - No documentation of wound type or description of the wound was present. No documentation for the right heel was present. 9/28/24; - Hospital acquired pressure wounds to bilateral feet. - Right heel 0.8 cm x 0.5 cm eschar present, Unstageable - Left heel 2.7 cm x 1.5 cm eschar present, Unstageable - No documentation of right 3rd digit and left 2nd digit, no documentation of wound description was present. 10/6/24; - Hospital acquired pressure wounds to bilateral feet. - Right heel measuring 0.7 cm x 0.6 cm eschar present - Left heel measuring 2.5 cm x 1.3 cm eschar present - No documentation of right 3rd digit and left 2nd digit was noted in any of the further skin/wound notes. 10/17/24; - Hospital acquired pressure wounds to bilateral feet. - Right heel measuring 0.7 cm x 0.6 cm - Left heel measuring 2.8 cm x 1.8 cm 10/25/24; - Hospital acquired pressure wounds to bilateral feet. - Right heel measuring 0.7 cm x 0.6 cm - Left heel measuring 3 cm x 3 cm - Left heel wound was increasing in size. 10/28/24; - Hospital acquired pressure wounds to bilateral feet - Wound to left heel measuring 8.5 cm x 4 cm. Continues to have foul odor with moderate drainage, wound bed eschar. Continues on antibiotic treatment. - Left heel wound increased in size significantly and now has drainage with a foul odor. 11/1/24; - Right heel measuring 5.8 cm x 5.5 cm eschar present. - Left heel measuring 9 cm x 4.5 cm. eschar present. No odor - Both heel wounds were increasing in size. 11/6/24; - Right heel measuring 11.4 cm x 6.3 cm - Left heel measuring 11.5 cm x 5 cm - Both heel wounds were increasing in size. 11/14/24; - Hospital acquired pressure wounds to bilateral feet. - Right heel measuring 11.1 cm x 5.6 cm - Left heel measuring 11.8 cm x 4.9 cm Skin/wound notes show a progressively increasing size and worsening condition of the wounds. Review of resident #2's Weekly Skin Observation showed the following: 8/16/24. - Left toe injury no measurements 8/23/24 - Right 2nd toe no measurements 8/30/24 - Right knee measuring 2 cm x 1.5 cm - Right toe measuring 2 cm x 1 cm 9/7/24 - Right toe pressure wound measuring 0.2 cm x 0.2 cm x 0.1 cm 9/27/24 - Right heel measuring 2.7 cm x 1.5 cm eschar present, no odor - Left heel measuring 0.8 cm x 0.5 cm eschar present, no odor 10/7/24 - Left and Right heels, pressure, suspect for deep tissue injury 10/11/24 - Left and Right heels, pressure, suspect for deep tissue injury 10/19/24 - Left heel pressure. NA for stage 10/26/24 - Right heel pressure measured 5 cm x 4 cm x .5 cm. Stage III - Left heel pressure measured 5 cm x 3 cm x .5 cm. Stage III 11/2/24 - Left and Right heels pressure, Stage III. No measurements 11/9/24 and 11/16/24 - Right and Left heels pressure. No measurements or staging 45448 3. During an interview on 11/20/24 at 9:49 a.m., staff member F said resident #3 was able to walk prior to his hip fracture. Staff member F said resident #3 was noted to have a small area on his heel that looked like a sheer injury. The following week, the area had increased in size, and eventually the injury required surgical debridement. During an interview on 11/20/24 at 2:35 p.m., staff member D said resident #3 started having skin issues following his hip fracture. He was having another resident with a scooter, pull him back to the facility, in his wheelchair. He fell out of his wheelchair. Staff member D said when he returned to the facility, following the repair of his hip, she ordered an air bed (pressure relieving) and to offload his heels. He quit eating and was referred to the wound clinic. Staff member D said he gave up (wanting to live his life) and made the decision to enter hospice. During an interview on 11/21/24 at 9:35 a.m., staff member E said she cared for resident #3 often, as she was usually assigned the hallway where his room was located. Staff member E said resident #3 had facility acquired pressure ulcers. Staff member E said resident #3 would motor around in a wheelchair after his hip fracture and was quite social. Staff member E said resident #3 declined very quickly after the pressure ulcers were identified, and she felt he did not want to go on, and just gave up. Review of resident #3's EMR documentation, showed: 8/4/24 - The CNA found serosanguineous fluid dried to the left sock, in the heel area. The sock was removed, and a large popped blister, was noted on the left heel. Nursing noted the wound would be assessed by IDT on Monday. No IDT notes with assessment were provided. 8/7/24 - Weekly skin assessment showed a left heel popped blister measuring 3.2 cm x 7.2 cm. No description of a wound assessment or drainage was noted. 8/14/24 - The weekly skin assessment showed a right buttock pressure wound measuring 3 cm x 2.2 cm x 0.1 cm, Stage II, and a left heel deep tissue wound, measuring 4 cm x 5.2 cm x 0.1 cm. No wound assessment or drainage was noted. 8/16/24 - The skin/wound note showed, deep tissue injury to left heel and pressure ulcer to right buttock. Left heel measuring 2.7 cm x 5 cm. Skin around the wound is intact and healthy. Pressure ulcer to right buttock 1.5 cm x 1.8 cm x .01 cm. Wound bed slough, light serous drainage, no odor. Skin around wound was reddened. 8/18/24 - The skin/wound note showed, pressure ulcer on right buttock was cleansed, and a border dressing was applied. The wound had slough, light serous drainage, and an odor was present. No documentation was provided for physician notification. Change in size, depth, or surrounding tissue was not documented. No documentation for the left heel wound was found. 8/19/24 - The skin/wound note showed, pressure ulcer on right buttock was cleansed and a border dressing was applied. The wound had slough, light serous drainage, and an odor was present. No documentation was provided for a physician notification. Change in size, depth, or surrounding tissue was not documented. No documentation for a left heel wound was found. 8/21/24 - The weekly skin assessment showed a right buttock pressure wound 3.5 cm x 5 cm x 0.2 cm, Stage II, and a left heel deep tissue injury measured 5.25 cm x 6.25 cm x 0.1 cm. No wound assessment or drainage was noted. 8/28/24 - A general progress note showed, a dressing change was made to the right buttock per physician orders. Eschar was covering the wound bed, no scant drainage, no odor, and no signs or symptoms of infection were noted. No documentation for the left heel wound was found. The weekly skin assessment showed a right buttock pressure wound with no measurements, and a left deep tissue would with no measurements. No documentation of a wound assessment or drainage was noted. 8/31/24 - The skin/wound note showed, a certified wound clinician assessed the resident's wound. New orders were received for a deep tissue injury to the left heel and unstageable pressure ulcer to the right buttock. Deep tissue injury to the left heel measuring 4 cm x 4 cm, eschar was on the wound bed, no drainage was noted, foul odor, and wound edges were clean and intact. Dakins solution applied wet to dry as a dressing to encourage debridement. Pressure ulcer to the right buttock measuring 5 cm x 3 cm x 5 cm, eschar was on the wound bed, light serous drainage, edges were undefined, no odor was present. The skin around the wound was healthy. Cleanse the area with normal saline or wound cleaner, apply betadine to wound bed, skin prep to wound edges, and leave wound open to air. A referral to wound clinic for consult was made. 9/5/24- Resident #3 was transferred to the emergency department for evaluation of an altered mental status. He was admitted to the facility with a diagnosis of acute osteomyelitis of the left ankle and foot, related to his left heel wound. 9/24/24 - The resident returned to the facility, from the hospitalization . The weekly skin assessment showed a coccyx wound measuring 1 cm x 0.4 cm, a right buttock pressure wound that measured 6 cm x 8.5 cm x 1.8 cm, and a left heel pressure wound that measured 4.2 cm x 2.6 cm x 0.5 cm. No documentation of a wound assessment or drainage was noted. The resident had a pressure sore to the sacrum and left heel, and a wound vac treatment was in place. 9/28/24 - The skin/wound note showed, the Right buttock wound measured 6 cm x 8.5 cm x 1.8 cm, had 100% granulation, the wound edges were defined, and there was sanguinous drainage with no odor. The surrounding tissue was healthy and pink. The left heel wound measured 4.2 cm x 2.6 cm x 0.5 cm, 100% granulation, the wound edges were defined, and there was sanguinous drainage with no odor. The surrounding tissue was healthy and pink. The resident was followed by the wound clinic for evaluation and treatment. The note showed, resident #3's . wounds are related to a hospital acquired stage IV pressure ulcer to the right buttock and left heel with surgical debridement. [sic] 10/1/24 - The weekly skin assessment showed a right buttock pressure wound and a left heel wound. No documentation was present for a coccyx wound, and there was no documentation of wound assessments or drainage noted. 10/6/24 - A general progress note showed, while changing the wound vac on the buttock, nursing noted a red and open area on resident #3's coccyx. The area was cleaned with normal saline, and a Tegaderm was applied until the area could be assessed for treatment by the IDT team. A small dark area to the right heel, believed to be remnants from when the heel was compromised previously, was noted. The ADON and provider were notified. No measurements of either the coccyx or the right heel were documented. No IDT notes were provided that addressed treatment or assessment of the coccyx wound. 10/8/24 - A general progress note showed, the newest wound on resident #3's coccyx appeared unchanged. There was no description or measurements documented. 10/11/24 - The weekly skin check showed a right buttock pressure wound, a left heel pressure wound, both Stage IV, and a sacrum pressure wound, Stage II. No wound measurements, no wound assessments, and no wound drainage were noted. 10/12/24 - An alert note showed, related to resident #3's new wound to his coccyx, nursing staff continued to perform wound orders as directed and will continue to monitor. There was no notation of a left heel wound or buttock wounds, and no measurements were noted. The weekly skin assessment showed a right buttock pressure wound, and a left heel wound, both Stage IV and no measurements were documented. There was no documented coccyx wound, no documentation of wound assessments, or documentation of drainage, noted. 10/13/24 - A general progress note showed, nursing noted no change in wound status this shift. No documentation of individual wounds and assessments. 10/17/24 - The skin/wound note showed, resident #3's right buttock ischium wound measured 6 cm x 8.3 cm x 2.9 cm with 50% slough, and less than 50% bone is superficial, wound edges defined. The wound had sanguinous drainage with no odor, and surrounding tissue discoloration. The coccyx had a non blanchable reddened area, with measurements of 2.1 cm x 2.5 cm x 0.1 cm, Stage III wound. There was a small amount of serosanguineous drainage, no odor was present, 75% slough, 25% granulation, no odor, and discoloration of surrounding tissue. The left heel wound measured 4 cm x 5.9 cm x 0.3 cm with 0.2 cm undermining, 50% yellow slough and 50% exposed bone. The wound edges were defined, there was serosanguinous drainage with no odor, and the tissue surround the wound was healthy and pink. 10/18/24 - The weekly skin assessment showed a left buttock surgical incision, and a left heel surgical incision. No measurements or assessments were documented. 10/25/24 - The skin/wound note showed, resident #3's right buttock ischium wound measured 6.7 cm x 6.2 cm x 3.5 cm, with undermining of 2.7 cm, 50% slough, less than 50% bone is superficial, wound edges were defined, sanguinous drainage with no odor, and there was surrounding tissue discoloration. The coccyx had a non-blanchable reddened area with measurements of 3.1 cm x 2.5 cm x 0.1 cm, Stage III wound with a small amount of serosanguineous drainage, no odor and slough 75%, 25% granulation, and discoloration of the surrounding tissue. 10/29/24- Resident #3 was admitted to hospice services. 11/4/24 - Resident #3 became nonresponsive and passed away at the facility. Record review of facility provided documents showed, Provider Visit Note, dated 8/4/24, an evaluation of lab values only. The provider visit notes did not include any notes on #3's skin or wounds, the evaluation of the skin/wounds, or more detail related to them. Record review of facility provided, Provider Visit Note, dated 9/30/24, showed a full readmission evaluation. The section for extremities/integumentary evaluation showed bilateral lower extremity weakness with resident #3 using a wheelchair for mobility and a wound vac was in place on the sacrum and left heel. The physician referred to the registered nurse note for details. No further wound documentation was noted. Record review of facility provided, Provider Visit Note, for #3, dated 10/22/24, showed a 30 - day medical compliance visit. The section for extremities/integumentary evaluation showed 2+ bilateral lower extremity edema, and left upper extremity edema, and a wound vac in place on the sacrum and left heel. The notes referred to the registered nurse note for details. The note showed resident #3 was followed by wound clinic. No further wound documentation was noted. During an interview on 11/20/24 at 2:35 p.m., staff member D said she would usually see and assess a new admission to the facility within 72 hours. She would place the orders for wound care at that time, or they would come from the hospital. Staff member D said residents should come with physician treatment orders from the hospital, on admission, and then they are reviewed by her. She will look at resident skin ulcers and assess them, then place physician orders. Staff member D said she documents her wound assessments in the patient history of the EHR. During an interview on 11/25/24 at 3:40 p.m., staff member B said she was responsible for providing wound oversight. If the wound occurred in the facility, she would initially stage (determine severity) the wound, and the resident would be sent out to the wound clinic. Staff member B said staff member D would assess the wounds if a concern was identified. Through the immediate jeopardy process, surveyors discovered the wound notes and documentation for the physician was limited, related to the amount of information entered into the provided space (of the EHR). Staff member B said she provided education for staff member D on how to write her notes, in a progress note.

Based on interview and record review, the facility failed to assess, document, treat, and monitor pain for 1 (#4) of 6 sampled residents. Resident #4 had severe pain during pressure ulcer dressing changes and turning and repositioning, which caused the resident to refuse care and dressing changes. Resident #4 expressed to the staff the pain regimen he had in place had not worked in relieving his pain during dressing changes and cares, resulting in increased skin breakdown. Resident #4 was transferred to the hospital on 11/9/24, and he passed away on 11/10/24. The facility failed to provide adequate pain management in a timely and effective manner to meet the resident's pain needs. The facility failed to identify and treat the resident's changes in condition as needed, and failed to utilize a root cause analysis process to determine the root causes of the resident's pain, for the identification and implementation of pain interventions. On 11/20/24 at 4:52 p.m., an Immediate Jeopardy was announced to the Administrator and Director of Nursing for Pain Management. The Severity and Scope of the Immediate Jeopardy was at the level of J, lowered to a G upon the removal of immediacy. An acceptable plan for the Removal of Immediacy was approved on 11/25/24 at 5:16 p.m. Findings include: During an interview on 11/20/24 at 9:29 a.m., staff member F stated when resident #4 was admitted he had no skin on his buttock, back and arms. Staff member F stated resident #4 refused to get off the gurney when he first arrived at the facility due to the pain. Staff member F stated the resident was in so much pain he would refuse cares and dressing changes. During an interview on 11/20/24 at 2:35 p.m., staff member D stated resident #4 had multiple wounds, which were caused by shearing (pressure and friction injuring the skin at the same time). Staff member D stated the resident had declined in the two days prior to being transferred to the hospital. Staff member D stated the wounds were infected toward the weekend and it was difficult to get him out of bed and to turn and reposition. Staff member D stated changes were made to the resident's pain regimen. During an interview on 11/21/24 at 9:35 a.m., staff member E said she was concerned about resident #4's pain and pain control. Resident #4 complained of pain a lot, and he did not want to participate in therapy or other activities. He would not participate a lot in his care. Staff member E said she contacted staff member D, and she came in to talk with resident #4. Staff member E said after #4 was a resident for a week, the facility started working to adjust his pain medications. Staff member E said resident #4 had a pain patch, which was related to chronic pain, not the wounds, but he was only wanting Tylenol for his pain. She asked him why he only wanted Tylenol, and he said it was because the Norco was not effective for his pain. Staff member E said he had as needed pain medication ordered but it was not on a routine pain medication regimen for pain related to woundcare. Review of resident #4's MAR/TAR, dated 10/1/24 through 11/9/24 showed: - From 10/4/24 through 10/31/24, resident #4 was on scheduled pain medication. Prior to 10/4/24 resident #4 was on as needed pain medication. The resident consistently reported the pain regimen was ineffective. There were multiple changes in the medication for pain management with no documentation of the effectiveness. The resident's pain ratings ranged from 1 to 10, with the higher number of 5-10 being consistently documented. From 11/1/24 through 11/9/24, resident #4 was on scheduled pain medication, which showed pain ratings from three to six. On 11/5/24, the resident's pain medication was changed from hydrocodone to oxycodone. The resident's pain ratings ranged from two to nine during this time. The resident was not premedicated consistently prior to wound care, which caused the resident to refuse the wound care, and the wounds worsened and more wounds documented. Review of resident #4's pain assessments were related to the time frames of every shift and scheduled times, and failed to consistently include documentation of complaints of pain at other times during the day, including time frames for wound care. The resident was not consistently medicated prior to wound care, and there were days, 11/6/24 and 11/7/24, when the pain medication was not administrated. There nursing staff were inconsistent in the documentation for the follow up for pain medication effectiveness. On 11/4/24, the pharmacist completed a medication evaluation for pain. The pharmacist recommended adding an as needed dose of pain medication every four hours. After a couple weeks, the pharmacist recommended assessing the resident's total morphine equivalents per day and perhaps increase the dosage of the pain medication. There was no documentation of any pharmacy evaluations for the resident's pain concerns prior to 11/4/24. Review of resident #4's non-pharmacological interventions for pain lacked consistent documentation for the effectiveness of the pain interventions offered or utilized. Review of resident #4's Nursing Admission Assessment, dated 10/3/24, showed the resident had severe pain during dressing changes and turning and repositioning related to pressure ulcers. The resident reported constant pain rated at 5/10. Review of resident #4's physician Order Summary Report, dated 10/3/24 - 11/9/24, showed the following medications for pain: - 10/3/24 buprenorphine transdermal patch weekly 10 mcg/hr, order date of 10/3/24 with a start date of 10/7/24 - 10/3/24 buprenorphine transdermal patch weekly 10 mcg/hr, order date of 10/3/24 with a start date of 10/10/24 - 10/3/24 hydrocodone 5-325 mg (hydrocodone 5 mg-acetaminophen 325 mg) every 12 hours as needed for moderate pain. Discontinued on 10/4/24 - 10/4/24 hydrocodone 5-325 mg every eight hours for moderate pain. Discontinued on 10/4/24 - 10/4/24 hydrocodone 5-325 mg three times a day for pain-moderate pain control. Discontinued on 11/4/24 - 10/4/24 oxycodone 5 mg every six hours as needed for pain-severe pain control. Discontinued on 10/4/24 - 10/24/24 Norco 5-325 mg ever four hours as needed for pain. Administer between scheduled doses. Discontinued on 11/4/24 - 11/4/24 oxycodone 5 mg every four hours as needed for pain. Discontinued on 11/4/24 - 11/5/24 oxycodone 5 mg every four hours as needed for pain rated at 5-10. Discontinued on 11/5/24 - 11/6/24 oxycodone 5 mg every four hours. Discontinued on 11/7/24. Resident #4's pain regimen was consistently documented as ineffective based on the resident's complaints and refusals of wound care and turning and repositioning. Review of resident #4's care plan, for pain, showed the following: - Administer analgesic medications as ordered. Monitor/document side effects and effectiveness every shift (initiated 10/4/24) - Ask physician to review medication if side effects persist (initiated 10/4/24) - Review for pain medication efficacy. Assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required . therapeutic regimen followed, but pain control not adequate, changes required (initiated 10/4/24) - Encourage repositioning every 1-2 hours (initiated 10/21/25) - Monitor for increased pain or decline in status related to pain. (initiated 10/3/24) Resident #4 did not have physician orders for pain medications after 11/7/24. The resident was transferred to the hospital on 11/9/24 where he passed away. Review of the facility Policy, titled Pain Management, implemented on 1/2/24, showed: - .1 a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. 1 b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. 1 c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences . 8 a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences . 8 b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated .

Based on observation, interview, and record review, the facility failed to ensure residents were free of neglect for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to have systems in place for wound care, which resulted in three Immediate Jeopardy deficiencies being identified. Resident outcomes included: a. Resident #2 showed progressive worsening of pressure ulcers from a Stage II (blisters) worsening to Unstageable in ten days, and the resident was admitted to the hospital for the worsening wounds with foul odor, increased assistance with ADLs, and edema. b. Resident #3 showed progressive worsening of pressure ulcers and was placed on hospice, following a hospital stay with sepsis, and passed away at the facility, upon returning. c. Resident #4 was admitted to the facility with skin tears, with varying stages of healing, and pressure injuries. Resident #4's wounds showed worsening over time, progressing from skin tears to wound injuries. Resident #4 was transferred to the hospital on 11/9/24, and passed away on 11/10/24 at the hospital, due to sepsis (infection). On 11/20/24, three Immediate Jeopardy's were announced to the Administrator and Director of Nursing, one specifically identified as neglect of care, stemming from the following deficiencies identified: a. Pressure Ulcers, and the failure to identify, assess, document, measure, to obtain and follow physician orders for wound care, and the facility failed to develop a wound management system that was sufficient to meet the resident needs for wound care. The Severity and Scope of the Immediate Jeopardy for the Neglect of Care was identified to be at the level of K, and lowered to an H when the immediacy was removed for the residents. b. Pain Management and Neglect was cited at the Immediate Jeopardy level for the failure to assess, document, treat, and provide necessary pain management in a timely manner, and prior to wound care, and this failure resulted in moderate to severe pain during wound care, and refusals of wound care, for 1 (#4). The facility failed to identify changes in a resident's condition, and treat the change(s) as needed, and failed to do a root cause analysis to determine the causes of resident pain related to wounds in an attempt to alleviate or decrease the pain. The Severity and Scope of the Pain Management and Neglect Immediate Jeopardy's were cited at the level of J, and lowered to a G, upon the removal of the immediacy for the residents involved. Acceptable Plans for the removal of immediacy were received, and approved by the State Survey Agency, as of 11/25/24 at 5:16 p.m. Findings include: 1. During an interview on 11/18/24 at 3:56 p.m., NF1 said she was contacted on 11/10/24, and told resident #4 had passed away, within 24 hours of being admitted to the hospital. She then contacted a 3rd party to perform an autopsy due to the physician report. NF1 said the physician reported, It was the worst case of neglect they have ever seen. NF1 said, His wounds were horrific, and he basically had no backside, his arms and feet were involved. The resident's official Cause of Death was severe sepsis. During an interview on 11/20/24 at 9:49 a.m., staff member F said she was working the day resident #4 was admitted to the facility. When resident #4 arrived at the facility, he refused to move himself from the stretcher to the bed. Staff member F said he was in extreme pain. Resident #4 was transferred by staff from the stretcher to the bed. Staff member F said the facility was aware resident #4 had severe wounds when the facility agreed to admit him. Staff member F said, He basically had no skin on the back of his legs, his pannus, and his back. Staff member F said resident #4 had so many wounds over his body, she had to ask for help to do his admission skin evaluation. Staff member F said resident #4 was in a lot of pain while being admitted to the facility and staff member F felt he refused care due to his pain. During an interview on 11/20/24 at 3:28 p.m., staff member B said resident #4 would refuse cares and pain medications. His wounds were all superficial, and they would bleed. Staff member B said, one weekend he refused all cares and medications; than he began to decline. Staff member B said the resident was in pain, and the facility sent him to the emergency department for an evaluation, and he was admitted to the hospital. During an interview on 11/21/24 at 9:35 a.m., staff member E said she was concerned about resident #4's pain and pain control. Resident #4 complained of pain a lot, and he did not want to participate in therapy or other activities, and he would not participate in a lot in his care. Staff member E said she contacted staff member D, and she came in to talk with resident #4. Staff member E said after the resident was there for a week, the facility started working to adjust the resident's pain medications. Staff member E said resident #4 had a pain patch, which was not given for the treatment of wounds, and only wanted Tylenol for his pain. She asked him why he only wanted Tylenol, and he said it was because the Norco was not effective for his pain. Staff member E said he had as needed pain medication ordered, but he was not on a routine pain medication regimen (specifically for wounds or care of them). During an interview on 11/20/24 at 9:29 a.m., staff member F stated resident #4 was admitted , and he had no skin on his buttock, back, and arms. Staff member F stated resident #4 refused to get off the gurney when he first arrived, due to the pain. Staff member F stated the resident was in so much pain he would refuse cares and dressing changes for his wounds. During an interview on 11/20/24 at 2:35 p.m., staff member D stated resident #4 had multiple wounds, which were caused by shearing (pressure and friction injuring the skin at the same time). Staff member D stated the resident had declined in the two days prior to being transferred to the hospital, and the wounds were infected toward the weekend, and it was difficult to get him out of bed, and to turn and reposition the resident. Staff member D stated changes were made to the resident's pain regimen. Staff member D said resident #4's wounds were primarily sheering wounds on his buttocks, on his legs, and one under his pannus. The wounds were not a pressure wound, and there was never any discharge (drainage). Resident #4's wounds would bleed, but were not infected. Staff member D said resident #4 was on a patch (pain patch for his chronic back pain), and he received hydrocodone for pain control when he arrived. The resident only wanted to take Tylenol for his pain. The facility kept resident #4 on that pain regimen. Staff member D said resident #4 refused all treatments and medications over a weekend, and when she evaluated him on the following Monday, she discontinued the hydrocodone and started him on oxycodone. He remained on the Tylenol and pain patch. Staff member D said the facility could not get resident #4 to participate in therapies or get out of bed. Staff member D said resident #4's wounds were not infected when he was sent to the emergency department for an evaluation. Record review of resident #4's order summary report, dated 10/1/24 through 11/9/24, showed an order for resident #4 for turning and repositioning as appropriate. Dressing changes were ordered as needed for wound care for 14 days. The physician order did not show a specific time frame for turning and repositioning of the resident for wound prevention, and the nursing staff neglected to consistently document resident #4's response or refusals for repositioning. The licensed staff neglected to ensure the wound care orders were in place, comprehensive, and that staff had necessary knowledge to ensure the resident was repositioned in a manner that would help prevent further decline or deterioration of the wounds, nor did they include necessary details for the changing of dressings and treatment of resident #4's wounds. Review of resident #4's electronic medical record showed: -10/3/24 Resident #4 admission assessment showed a left hip Stage II pressure ulcer 14.0 cm x 5.5 cm; right buttock Stage II pressure ulcer 2.5 cm x 1.5 cm; right buttock Stage II pressure ulcer 2.5 cm x 2.8 cm; right buttock pressure ulcer Stage II 2.5 cm x 3 cm: left buttock Stage II pressure ulcer 2.5 cm x 3 cm; left forearm skin tear 5.8 cm x 3.2 cm; multiple left thigh and multiple abdominal wounds. The facility neglected to document resident #4's left scapula pressure ulcer, present on admission from the transferring facility. Resident #4 was unable to turn and reposition himself independently and was documented to have a pain rating of 5 out of 10, with 10 being the worst level of pain. -10/4/24 Resident #4's progress note, documented at 00:27 a.m., showed the resident was experiencing pain due to several wounds on his back. No pain level or interventions for pain were documented. -10/8/24 Resident #4's progress note at 4:26 a.m., showed attempts to reposition the resident were refused due to his severe pain. No pain level or interventions for pain were documented. His next pain medication was given at 6:00 a.m. -10/16/24 Resident #4 was unable to turn and reposition himself independently. All of his skin wounds, including pressure wounds, were identified as skin tears. Nursing staff neglected to document the correct wound classifications, measurements and assessment for resident #4's pressure wounds, which directs the type of wound treatments provided. -10/17/24 Resident #4's progress note at 12:27 a.m., showed the resident refused to be repositioned. No documentation was provided for why he had refused. Previous pain medication was given at 6:00 a.m. -10/23/24 Resident #4's progress note at 8:09 p.m., showed resident #4 refused incontinent care, his previous medication for pain was given at 2:00 p.m. No documentation was provided for why he had refused. Resident #4's skin observation showed he had limited mobility, bowel and bladder incontinence with dry skin and itching. Documentation showed he had a potential for skin infection and was a nutritional risk. Two of resident #4's wounds were listed as Stage II pressure injuries and four wounds were listed as abrasions. The nursing staff neglected to document wound measurements or the status of all his wounds. There was no documentation on resident #4's ability to turn and reposition independently. -10/25/24 Resident #4's skin/wound assessment showed resident #4 refused to be repositioned off of his back. However, documentation showed the following for resident #4's bilateral right buttock Stage II pressure ulcer 5.0 cm x 4.4 cm x 0.1 cm; left buttock Stage II pressure ulcer 2.5 cm x 3.0 cm x .01 cm; there were multiple small wounds at various stages of healing on/around the anus; the left forearm healed; left knee healed; medial shin healed; right thigh x 2 - 2.5 cm x 2.5 cm; posterior shin/calf 7.5 cm x 3.5 cm, partial thickness with loss of dermis, wound bed shallow, with large amount of serosanguineous drainage on buttocks, no odor. Nursing staff neglected to document on his left scapula wound. -10/27/24 Resident #4's progress note at 1:13 p.m. showed resident #4 refused to be repositioned, his previous pain medication was given at 6:00 am. No documentation was provided for why he refused repositioning. -10/30/24 Resident #4 had limited mobility, bowel and bladder incontinence with dry skin and itching. Documentation showed he had a potential for skin infection, was at nutritional risk, and at risk for fluid and hydration concern. Two of resident #4's wounds were listed as pressure injuries, and six of his wounds were listed as abrasions or skin tears. The nursing staff neglected to document wound staging (severity/type), wound measurements or the status of all wounds. -10/31/24 Resident #4's progress note showed the CNA notified the nurse that resident #4 had redness to his heel. Nursing assessed his heel, and the resident had been resting against the footboard of the bed. A new blister was identified on his heel. Nursing staff neglected to document which heel was involved and include measurements or necessary details of the wound. -11/2/24 Resident #4's progress note at 4:07 p.m. showed the resident declined any turning, repositioning, or skin checks, stating, I am not having a good day. No documentation was found on his pain level or why he was not having a good day. -11/3/24 Resident #4's progress note at 1:13 p.m., showed resident #4 continued to refuse all cares and dressing changes. The last dose of pain medication was given at 6:00 a.m. -11/4/24 Resident #4's progress note at 2:47 a.m. showed resident #4 allowed staff to perform peri care. The resident began to refuse further care because it hurt too much (due to wounds). The resident refused all care and asked to be left alone and let the pain pill work. -11/9/24 Resident #4's progress note showed he had developed a new sheer area to the back of his left shoulder. Pressure ulcers were not healing, and the resident was sent to the ER for further evaluation. Record review of resident #4's electronic medical record showed there were five days without wound care orders, from 10/17/24 to 10/22/24, and two days without wound orders, from 10/23/24 to 10/25/24. All wounds were left open to air, and there were no orders for the different types of wounds, allowing for bacteria to enter the wounds if not treated appropriately. Resident #4's medical record showed nursing staff neglected to comprehensively and consistently assess, document, and treat the resident with necessary interventions based on the type and severity of the wounds resident #4 had. The resident's pain was not treated prior to the dressing changes, which caused refusals of care, leading to the worsening of wounds. Resident #4 was not on routine pain medications to account for the pain he was experiencing due to his wounds. 2. During an observation and interview on 11/20/24 at 9:49 a.m., resident #2 was observed to be in her room and reclined on her bed. Resident #2 had both heels resting on the bed surface, no padding or offloading of her heels were observed. The room had a strong foul odor upon entering from the hallway. Staff member F donned gloves and removed the dressings from both of the resident's feet. The right heel wound was cleaned, and a small amount of tissue was debrided from around the wound. The right heel wound was dry, measured 9.5 cm x 4.5 cm, and had a foul odor. The left heel wound was dry, measured 12 cm x 4.5 cm, and had a foul odor. Staff member F cleaned the wounds with saline, applied betadine with a swab, and wrapped both feet with kerlix gauze. Staff member F said she does not measure the wounds with each dressing change but will measure them weekly when she does a big evaluation. She does not stage (assess severity) the wounds because it is beyond her scope of practice. Staff member F said the treatment order was for a dressing change daily, and she will document the dressing change was performed in the nursing note. Resident #2 stated she acquired the wound in the facility, from the bed. She stated she walked into the facility for rehab and now she is in a wheelchair. The resident was no longer able to walk or stand on her feet. Staff member F then corrected resident #2 stating; she acquired the wounds while in the hospital. Resident #2 was observed shaking her head from side to side in disagreement. Staff member F said resident #2 had just finished antibiotics for her heel wounds. During an interview on 11/20/24 at 2:35 p.m., staff member D said resident #2 had heel wounds because she refuses to offload her heels. Staff member D said resident #2 has had an odor from her wounds for quite a few weeks, and the wound clinic did not recommend any antibiotics, and the wound clinic will not debride her wounds until she sees a vascular surgeon for evaluation. Staff member D said the antibiotics the resident was given was for a urinary tract infection, not for her wounds. During an interview on 11/21/24 at 12:21 p.m., resident #2 said she was admitted to the facility for rehabilitation and strengthening. She was receiving physical therapy services and was getting stronger. Resident #2 said the facility then fired the physical therapist, and she did not receive therapy services for several weeks, until a new physical therapist was hired. She spent that time sitting in a chair or lying in bed, causing her to develop pressure wounds on her heels. Resident #2 said when she was admitted to the hospital for her kidney failure, her wounds would be debrided. Resident #2 said she is no longer able to walk because of the wounds on her heels. During an interview on 11/25/24 at 3:49 p.m., staff member B stated resident #2 was found to have a non-trauma related fracture to her foot, due to deterioration of her bones. There was a concern with the aeration of the tissue in her foot. Resident #2 requested to be transported to the facility near her, for wound care. Review of resident #2's electronic medical record showed: -8/2/24- Resident #2's admission assessment showed a vascular wound on her 3rd toe, right foot. No measurements were documented. -8/16/24 Resident #2's skin observation showed a left toe wound marked as other. Nursing neglected to document the type of wound or measurements of the wound. -8/23/24 Resident #2's skin observation showed a vascular wound on her 2nd toe, right foot. Nursing neglected to document the type of wound or measurements of the wound. -8/30/24 Resident #2's skin observation showed an abrasion to the right knee, 2 cm x 1 cm; right toe 2 cm x 1 cm. Nursing neglected to document the location or a description of the toe wounds. -9/2/24 Resident #2's skin/wound note showed a right foot 3rd digit measuring 1 cm x 1 cm; left foot 2nd digit measuring 0.3 cm x 0.3 cm. -9/8/24 Resident #2's skin/wound note showed a right 3rd digit wound measuring 0.5 cm x 0.5 cm; left 2nd digit measuring 0.2 cm x 0.2 cm; blister to the right heel 4.0 cm x 2.4 cm. -9/14/24 Resident #2's skin/wound note showed a right 3rd digit wound measuring 1.5 cm x 0.3 cm x 0.4 cm; left 2nd digit measuring 0.5 cm x 1.0 cm; nursing neglected to document the heel wound. -9/28/24 Resident #2's skin/wound note showed a right heel 0.8 cm x 0.5 cm eschar present, Unstageable; left heel 2.7 cm x 1.5 cm eschar present, Unstageable. The wounds were now documented as hospital acquired pressure wounds to bilateral feet and there was no further documentation within the medical record for the right 3rd digit or left 2nd digit wounds. -10/6/24 Resident #2's skin/wound notes showed a right heel measuring 0.7 cm x 0.6 cm eschar present; Left heel measuring 2.5 cm x 1.3 cm eschar present. -10/17/24 Resident #2's skin/wound notes showed a right heel measuring 0.7 cm x 0.6 cm; left heel measuring 2.8 cm x 1.8 cm. -10/25/24 Resident #2's skin/wound notes showed a right heel measuring 0.7 cm x 0.6 cm; left heel measuring 3.0 cm x 3.0 cm. -10/28/24 Resident #2's skin/wound notes showed the left heel wound was now measuring 8.5 cm x 4 cm with a continued foul odor and moderate drainage. Resident #2 was on antibiotics for treatment. The left heel wound had grown (deteriorated) significantly in three days. -11/1/24 Resident #2's skin/wound notes showed the right heel measuring 5.8 cm x 5.5 cm, eschar present; left heel measuring 9 cm x 4.5 cm, eschar present with no odor. -11/6/24 Resident #2's skin/wound notes showed the right heel measuring 11.4 cm x 6.3 cm; left heel measuring 11.8 cm x 4.9 cm. Both heel wounds had increased in size significantly in five days. A review of the wound documentation showed the facility neglected to consistently document the wound measurements and type of wound with staging, and the condition of the wounds. Resident #2's skin assessments were not consistently accurate for the number of wounds, location of the wounds, or the types of the wounds. These failures contributed to the worsening of the wounds over time. Review of resident #2's Care Plan showed bilateral pressure injuries to the left heel and right posterior foot, with a wound infection. Interventions were antibiotic therapy, monitor for new or worsening symptoms, enhanced barrier precautions due to wounds, and a referral to the wound clinic. 45448 3. During an interview on 11/20/24 at 9:49 a.m., staff member F said resident #3 was able to walk prior to his hip fracture. Staff member F said resident #3 was noted to have a small area on his heel that looked like a sheer injury. The following week, the area had increased in size and eventually required surgical debridement. During an interview on 11/21/24 at 9:35 a.m., staff member E said she cared for resident #3 often, as she was usually assigned the hallway, where his room was located. Staff member E said resident #3 had facility acquired pressure ulcers. Staff member E said resident #3 would motor around in a wheelchair after his hip fracture and was quite social. Staff member E said resident #3 declined very quickly after the pressure ulcers were acquired and identified, and she felt he did not want to go on and just gave up. Review of resident #3's EMR documentation, showed: 8/7/24 - Weekly skin assessment showed a popped blister, on the left heel, measuring 3.2 cm x 7.2 cm. There was no description of the wound or drainage noted. 8/14/24 - Weekly skin assessment showed a right buttock pressure wound measuring 3 cm x 2.2 cm x 0.1 cm, Stage II, and a left heel deep tissue wound measuring 4 cm x 5.2 cm x 0.1 cm. No wound assessment or drainage was noted. 8/16/24 - Skin/wound note showed, a deep tissue injury to the resident's left heel, and a pressure ulcer to the right buttock. Left heel measuring 2.7 cm x 5 cm. Skin around the wound is intact and healthy. Pressure ulcer to right buttock 1.5 cm x 1.8 cm x .01 cm. Wound bed slough, light serous drainage, no odor. Skin around wound was reddened. 8/18/24 - Skin/wound note showed, pressure ulcer on right buttock was cleansed, and a border dressing was applied. The wound had slough, light serous drainage, and an odor was present. No documentation was provided for the physician notification. A change in size, depth, or surrounding tissue was not documented. No documentation for the left heel wound was found. 8/19/24 - Skin/wound note showed, pressure ulcer on right buttock was cleansed, and a border dressing was applied. The wound had slough, light serous drainage, and an odor was present. No documentation was provided for the physician notification. A change in the size, depth, or surrounding tissue was not documented for the wound, and there was no documentation for left heel wound found. 8/21/24 - Weekly skin assessment showed a right buttock pressure wound 3.5 cm x 5 cm x 0.2 cm, Stage II, and a left heel deep tissue injury measured 5.25 cm x 6.25 cm x 0.1 cm. No wound assessment or drainage was noted. 8/28/24 - A general progress note for the resident showed a dressing change was made to the right buttock per the physician orders. Eschar was covering the wound bed, no scant drainage, no odor, and no signs or symptoms of infection were noted. No documentation for the left heel wound was found. The weekly skin assessment showed a right buttock pressure wound and a left deep tissue wound with no measurements for either wound. 8/31/24 - The resident's Skin/wound note showed, a certified wound clinician assessed the resident's wound. New treatment orders were received for a deep tissue injury to the resident's left heel measuring 4 cm x 4 cm, eschar was on the wound bed, foul odor, no drainage was noted, and wound edges were clean and intact. A pressure ulcer to the right buttock measuring 5 cm x 3 cm x 5 cm, with eschar was on the wound bed, light serous drainage, edges were undefined, no odor was present. The skin around the wound was healthy. A referral to the wound clinic for a consult was made. 9/5/24 - Resident #3 was transferred to the emergency department for an evaluation due to an altered mental status. He was admitted to the facility with a diagnosis of acute osteomyelitis of the left ankle and foot, related to his left heel wound. 9/24/24- The resident returned to the facility, from hospitalization . The Weekly skin assessment showed a coccyx wound measuring 1 cm x 0.4 cm, a right buttock pressure wound that measured 6 cm x 8.5 cm x 1.8 cm, and a left heel pressure wound that measured 4.2 cm x 2.6 cm x 0.5 cm. No documentation of a wound assessment or drainage was noted. 9/28/24 - the Skin/wound note showed, the right buttock wound measured 6 cm x 8.5 cm x 1.8 cm, had 100% granulation, the wound edges were defined, and there was sanguineous drainage with no odor. The left heel wound measured 4.2 cm x 2.6 cm x 0.5 cm, 100% granulation, the wound edges were defined, and there was sanguineous drainage with no odor. The resident was followed by the wound clinic for evaluation and treatment. The note showed, . resident #3's wounds are related to a hospital acquired Stage IV pressure ulcer to the right buttock and left heel with surgical debridement. 10/1/24 - The weekly skin assessment showed a right buttock pressure wound, and a left heel wound. There was no documentation of a coccyx wound, no documentation of wound assessments, and no documentation to show if drainage was noted. 10/6/24 - A general progress note showed, while changing the wound vac on the resident's buttock, nursing noted a red and open area on resident #3's coccyx. The area was cleaned with normal saline, and a Tegaderm was applied until the area could be assessed for treatment by the IDT team. The ADON and provider were notified. No measurements of either the coccyx or right heel were documented. No IDT notes were provided that addressed any treatment or assessment of the coccyx wound. 10/8/24- A general progress note showed, the newest wound on resident #3's coccyx appeared unchanged. No description of the wound or wound measurements were documented. 10/11/24 - The weekly skin check showed a right buttock pressure wound, a left heel pressure wound, both Stage IV, and a sacrum pressure wound, Stage II. No wound measurements were documented, and there were no wound assessments or drainage noted. 10/12/24 - The weekly skin assessment showed a right buttock pressure wound and a left heel wound, both [NAME] IV, with no measurements documented. No documentation was present on the coccyx wound, no documentation was present of the wound assessments or drainage. 10/17/24 - The Skin/wound note showed, resident #3's right buttock ischium wound measured 6 cm x 8.3 cm x 2.9 cm with 50% slough and less than 50% bone, is superficial, wound edges defined. The wound had sanguineous drainage with no odor, and surrounding tissue discoloration. The coccyx had non blanchable reddened area with measurements of 2 cm x 2.5 cm x 0.1 cm, Stage III wound. There was a small amount of serosanguineous drainage, no odor was present, 75% slough, 25% granulation, no odor, and discoloration of surrounding tissue. The left heel wound measured 4 cm x 5.9 cm x 0.3 cm with 0.2 cm undermining, 50% yellow slough and 50% exposed bone. The wound edges were defined, there was serosanguineous drainage with no odor, and the tissue surrounding the wound was healthy and pink. 10/18/24 - The weekly skin assessment showed a left buttock surgical incision, and a left heel surgical incision. No measurements or assessments were documented and the coccyx wound was not documented. 10/25/24 - The Skin/wound note showed, resident #3's right buttock ischium wound measured 6.7 cm x 6.2 cm x 3.5 cm, with undermining of 2.7 cm, 50% slough, less than 50% bone is superficial, wound edges were defined, sanguineous drainage with no odor, and surrounding tissue discoloration. The coccyx had a non-blanchable reddened area with measurements of 3.1 cm x 2.5 cm x 0.1 cm, Stage III wound with a small amount of serosanguineous drainage, no odor and slough 75%, 25% granulation, and discoloration of surrounding tissue. No documentation of the left heel wound was found. 10/29/24 - Resident #3 was admitted to hospice services. 11/4/24- Resident #3 became nonresponsive and passed away at the facility. Record review of a facility provided, Provider Visit Note, dated 9/30/24 by staff member D, showed a full readmission evaluation. The section for the resident's extremities/integumentary evaluation showed bilateral lower extremity weakness, with resident #3 using a wheelchair for mobility, and a wound vac in place on the sacrum and left heel. The note referred to the registered nurses's note for details on the resident's wounds. No further wound documentation was noted. Record review of facility provided, Provider Visit Note, dated 10/22/24 by staff member D, showed a 30-day medical compliance visit. The section for extremities/integumentary evaluation, showed 2+ bilateral lower extremity edema and left upper extremity edema and the wound vac was in place on the sacrum and left heel. The note referred to the registered nurse's note for details. Resident #3 was to be followed by the wound clinic. No further wound documentation was noted. During an interview on 11/20/24 at 2:35 p.m., staff member D said she would usually see and assess a new admission to the facility within 72 hours. She would place the orders at that time, or they would come from the hospital. Staff member D said residents should come with orders from the hospital on admission and then they are reviewed by her. She will look at resident skin ulcers and assess them, then place orders. Staff member D said she documents her wound assessments in the patient history. During an interview on 11/25/24 at 3:40 p.m., staff member B said she was responsible for providing wound oversight. If the wound occurred in the facility, she would initially stage the wound, and the resident would be sent out to the wound clinic. Staff member B said staff member D would assess the wounds if a concern was identified. Wound orders were ordered and in place for a duration of 14 days as a flag to reassess and check to see if treatment was beneficial and appropriate for the wound. Staff member B said through the immediate jeopardy process, it was discovered the wound notes from the physician were limited for the amount of information provided, which was due to the provided space. Staff member B said she provided education for staff member D on how to write her progress notes for wounds.

Based on observation, interview, and record review, the facility failed to ensure food items in the refrigerator and freezer were labeled and dated, failed to maintain a clean and sanitary environment in the kitchen, and the facility failed to ensure kitchen staff wore beard coverings while serving food. This deficient practice had the potential to affect all residents receiving food from the facility's kitchen. Findings include: 1. During the initial tour of the kitchen on 10/7/24 at 12:20 p.m., the following was observed: Refrigerator: - An undated and unlabeled clear container with a green lid containing sliced cheese - Two undated and unlabeled gray plastic cups containing an unknown liquid - An undated and unlabeled container with mixed vegetables in the refrigerator. Freezer: - Four undated and unlabeled plastic storage bags of diced rhubarb - An undated and unlabeled plastic storage bag containing pepperoni - An open and undated bag containing blueberries During an interview on 10/8/24 at 3:17 p.m., staff member J stated all food stored in the refrigerator and freezer, to include if it was opened, was to be labeled and dated. Review of the facility's policy, Food Safety Requirements, dated 9/1/24, showed: . 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. . c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: . iv. Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded . [sic] 2. During an observation on 10/8/24 at 3:03 p.m., there was dirt, grease, grime, trash and food particles on the floor in the corners and along the wall throughout the kitchen. During an interview on 10/8/24 at 3:18 p.m., staff member I stated there were no cleaning logs in place for cleaning and sanitizing in the kitchen. During an interview on 10/9/24 at 11:29 a.m., staff member I stated housekeeping is too busy to clean in the kitchen, and cleaning in the kitchen is the dietary department's responsibility. During an observation on 10/9/24 at 11:35 a.m., dirt, grease, grime, dirty dishes and food particles remained on the floor in the corners and along the walls throughout the kitchen. Review of the facility's policy, Sanitation Inspection, dated 1/1/24, showed: . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 3. During an observation on 10/9/24 at 12:01 p.m., staff member I was not wearing a beard net over his facial hair while serving food. During an interview on 10/9/24 at 1:24 p.m., staff member I stated, I don't know if we are supposed to wear beard nets. I haven't seen anything that we are supposed to. Staff member I further stated the facility did not have beard nets for use. A review of the facility's policy, Food Safety Requirements, dated 9/1/24, showed: . 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. . d. Dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food .

Based on observation and interview, the facility failed to remove and dispose of expired medical supplies in the medication room. These failures increased the risk of expired medical supplies being used for any resident at the facility. Findings include: During an observation on 10/10/24 at 9:55 a.m., the following items were observed in the medication room: - 2 needles, 25-gauge x 1 labeled with an expiration date of 9/30/24 - 38 dark blue topped vacutainers labeled with an expiration date of 8/31/24 - 4 light blue vacutainers labeled with an expiration date of 8/31/24 - 7 light blue vacutainers labeled with an expiration date of 9/30/24 - 54 orange topped vacutainers labeled with an expiration date of 11/30/23 - 1 Luer Loc 30ml syringe labeled with an expiration date of 9/20/24 - 1 ml syringe labeled with an expiration date of 8/16/24 - 1 collection swab labeled with an expiration date of 4/7/24 During an interview on 10/10/24 at 10:55 a.m., staff member F stated she is the one responsible for checking for expired medications and supplies. Staff member F stated she had just gone through the room that week and couldn't believe she missed the expired supplies. On 10/10/24 at 9:15 a.m. the Medication and Medical Supply Storage policy, and the Medication and Medical Supply Destruction policy, were requested from the facility. These policies were not provided before the end of the survey.

Based on interview and record review, the facility failed to provide written notice of the reason for a facility-initiated transfer to a resident or the resident's representative, for 3 (#s 36, 54, and 149) of 3 sampled residents for transfers, and staff were not aware of the process of the transfer notices, who completed them, and a policy and procedure was not provided to show it was operationalized; and the facility failed to notify the Office of the State Long-Term Care Ombudsman, for 1 (#36) of 3 residents sampled for hospitalization s. Findings include: 1. Review of resident #36's medical record showed the resident was transported to the hospital for an acute change in condition on 9/27/24. The medical record failed to show the required written notice of the reason for the transfer was provided to the resident or representative. During an interview on 10/9/24 at 9:12 a.m., staff member G stated social services sends notifications to the Ombudsman for transfers and discharges. Staff member G stated there is no physical form that residents sign or receive before being transferred. During an interview on 10/9/24 at 10:54 a.m., staff member E stated the list of transfers and discharges is sent to the Ombudsman monthly. During an interview on 10/9/24 at 3:42 p.m., NF3 stated there was no transfer discharge information received from facility staff at [Facility Name] for the month of September 2024. 48268 2. a. Review of resident #54's medical record showed the resident was transported to the hospital for acute changes in condition on 7/3/24, 7/5/24, and 7/24/24. The medical record failed to show the required written notice of the reason for the transfers was provided to the resident or representative. b. Review of resident #149's medical record showed the resident was transported to the hospital for acute changes in condition on 7/5/24, 7/14/24, 9/3/24, and 10/9/24. The medical record failed to show the required written notice of the reason for the transfers was provided to the resident or representative. During an interview on 10/8/24 at 1:27 p.m., staff member C stated she only completed the 30-day transfer notification forms, and did not know who was responsible for completing immediate transfer notifications for transfers to the hospital. Staff member C stated, I don't know if nursing does that, but I do not. During an interview on 10/8/24 at 1:48 p.m., staff member G stated she was not aware of any specific form which notified a resident or a resident's representative of the reason for a transfer. A request for resident #54 and #149's written notification of transfer were requested on 10/9/24. None were received prior to the end of the survey. A request for transfer notification policy was requested on 10/9/24. No transfer notification policy was received prior to the end of the survey.

Based on interview and record review, the facility failed to provide the required bed hold notice to the resident or the resident's representatives prior to, or timely after, a transfer, for 2 (#s 54 and 149) of 3 residents sampled for hospitalization s. Findings include: a. Review of resident #54's medical record showed the resident was transported to the hospital for acute changes in condition on 7/3/24, 7/5/24, and 7/24/24. The medical record showed bed hold notifications signed by staff member H, but not signed by a resident or resident representative. There was no documentation in the medical record to show the resident or his representative was provided or notified of the required written bed hold notice. b. Review of resident #149's medical record showed the resident was transported to the hospital for acute changes in condition on 7/5/24, 7/14/24, 9/3/24, and 10/9/24. The medical record showed bed hold notifications signed by staff member H, but not signed by a resident or resident representative. There was no documentation in the medical record to show the resident or his representative was provided or notified of the bed hold notice. During an interview on 10/8/24 at 1:27 p.m., staff member C stated her office was not responsible for completing bed hold notifications. Staff member C stated bed hold notifications were the responsibility of the medical records staff. During an interview on 10/8/24 at 1:55 p.m., staff member H stated she was responsible for completing the bed hold notifications. Staff member H reported that she . usually completes them whenever someone has been sent to the hospital. They are completed on the next business day, or whenever I become aware that a resident went to the hospital. Staff member H stated she was never told that the notification should be provided to the resident or their representative, and was taught that the form was for billing or medical record use only. During an interview on 10/8/24 at 1:48 p.m., staff member G stated she was not aware of any specific form associated with the bed hold when a resident was being transferred and had never completed one prior to transferring a resident. Review of a facility document titled, Bed Hold Notice upon Transfer, dated 1/1/24, showed the following: - Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the durations of the bed-hold policy and addresses information explaining the return of the resident to the next available bed . - . 2. In the event of an emergency transfers of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. [sic]

Based on interview and record review, the facility failed to provide evidence to show the facility took action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. The failure had the potential to affect all residents who attended the resident council or who had interest in the council's activities, and specifically 3 (#s 4, 7, and 21) of 3 sampled residents who attended resident council. Findings include: During an interview on 10/8/24 at 2:24 p.m., resident #4 stated, We have had the same exact menu for over a year and a half. It keeps coming up at resident council, but nothing ever changes. During an interview on 10/9/24 at 12:10 p.m., resident #7 stated going to resident council was like talking to the wind. They don't follow up on anything. During an interview on 10/9/24 at 12:20 p.m., resident #21 stated, hardly anyone goes to resident council anymore because our input doesn't seem to matter. For example, we have had problems with the menus and lost laundry and we tell them (administration) and are told, 'Give me a couple days to look into it.' Nothing ever comes of anything we bring up at the council meetings. Our concerns just don't seem to matter. During an interview on 10/9/24 at 1:45 p.m., staff member A stated the concerns (from Resident Council) were discussed during daily standup meeting, and then forwarded to the appropriate department for resolution. During an interview on 10/9/24 at 2:02 p.m., staff member B stated the former dietary manager had called the person in charge of the menus for the corporation a couple of months ago, but never heard back. Staff member B did not know if there was any follow-up from the initial call. During an interview on 10/9/24 at 2:10 p.m , staff member I stated he had not been in the position long but had been trying to locate alternate menus in the corporate system. Staff member I presented a copy of the current menu for review, and stated the menu had not changed for almost two years. During an interview on 10/9/24 at 2:40 p.m., staff member E stated there was a follow-up form in use for concerns brought up by residents during resident council. The form would be given to the applicable department head, after the resident council meeting, for follow-up and resolution. Staff member E stated she had copies of the forms but was unable to locate any in her resident council files at the time of the interview. Review of the facility's resident council minutes for calendar year 2024 showed lost laundry and menu concerns beginning on the February 2024 meeting, and both concerns remained on the agenda as old business through September 2024, noted as not handled. Review of resident council minutes also showed several resident suggestions for lost laundry, missing items, and menu variations. There was no documentation to show any of the suggestions had been implemented or discussed, and the concerns remained unresolved as of the end of the survey period, as noted by resident and staff interviews. A request for tracking documentation for grievances addressed at resident council was made on 10/9/24 and 10/10/24. No documentation was received by the end of the survey period. Review of facility policy titled, Resident Council Meetings, dated 1/1/24, showed, . 7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council.

Based on interviews and record reviews the facility failed to allow the residents a choice for their attending physician for 3 (#s 2, 3, and 4) of 3 sampled residents for physician services. Findings include: During an interview on 9/17/24 at 3:22 p.m., resident #2 said he did not want to see staff member C as his physician. Resident #2 stated he told staff member C he did not want her to be his physician on multiple occasions. Resident #2 said staff member C told him he did not have a choice because he was a VA (Veterans Administration) resident. Resident #2 said he had a right to be able to choose his physician, and the facility would not honor that right. During an interview on 9/18/24 at 10:25 a.m., resident #2 said NF1 was his physician and staff member C kept changing the orders NF1 wrote for him. NF3 was in the room, and she said she would see resident #2 weekly. She stated she did not understand why the facility would not let NF1 be the primary care provider for resident #2. NF3 said she knew residents had a right to choose their own physician. During an interview on 9/18/24 at 3:51 p.m., staff member C said she was resident #2's physician. She said resident #2 did not have a choice of primary care physician because he was a VA resident, and it was a requirement of his contract with the VA to be seen by staff member C. Staff member C stated he was allowed to switch to a different physician, but he would either be required to move to a different facility, or he would lose his VA benefit if he was not seeing a VA affiliated physician. She said if that happened, he would have no way to pay for his stay, and then he would be kicked out of the facility. Staff member C said she was the primary care provider for all residents in the facility. She said it just made things easier for the residents to switch them all to her care when they were admitted to the facility. During an interview on 9/18/24 at 12:15 p.m., staff member D said resident #2 told her he did not want staff member C to be his physician. She said all the residents at the facility had to have staff member C as their primary care physician because she was also the medical director. Staff member D said resident #2 wanted NF1 to be his primary care provider. During an interview on 9/18/24 at 4:30 p.m., resident #3 said he was not given a choice of physician when he was admitted . He said he would have really liked having a choice. Resident #3 said staff member C was assigned to him when he was admitted . During an interview on 9/18/24 at 4:53 p.m., resident #4 said he was not given a choice of physician when he was admitted . He said he did not know he had the right to choose his primary care provider. Resident #4 stated, I would have loved to keep my regular doctor, but they told me when I came here that I had to see the doctor here. During an interview on 9/19/24 at 8:38 a.m., staff member A said all residents, including short term local residents, were always switched from their primary care physician to staff member C. During an interview on 9/19/24 at 8:42 a.m., staff member B said all residents, on admission, sign the residents rights which show they have a right to choose their physician. Staff member B stated when she would do an admission, she would explain to the resident how convenient it was to have staff member C as their physician. Staff member B said the residents would always agree to have staff member C as their primary care physician in the facility. She said VA residents do not have a choice. During an interview on 9/19/24 at 9:08 a.m., staff member F said she knew residents have the right to choose their own physician, and she knew the facility was required to help find options if the resident did not want staff member C as their primary care provider. Staff member F said she had worked for the facility for about [AGE] years, and she could not remember a time when any resident had chosen a primary care physician other than a provider employed by the facility. During an interview on 9/19/24 at 9:17 a.m., staff member G said she had not been with the facility very long, but she had conducted four admissions. Staff member G said she was taught to read the resident rights, verbatim, to the residents or resident representatives upon admission. She said she was aware residents should have the right to choose their physician, but she said all of the residents were switched to staff member C when they were admitted . During an interview and record review on 9/18/24 at 3:50 p.m., staff member C provided a document she identified as the VA contract for resident #2 and stated, .(she wanted to) straighten a few things out . Staff member C stated the VA contract was proof she was required to be resident #2's primary care physician. Review of the provided VA document, dated 8/10/23, showed: a fax from Montana VA Healthcare Services to the facility. The contract showed resident #2's assigned primary care provider was NF4. The document did not show resident #2 was required to choose staff member C for his primary care provider. Review of a facility provided document titled, Exhibit B Resident Rights, not dated, showed, Each resident shall have the right: .To have free choice of providers of medical services, such as physician and pharmacy .

Based on observation and interview the facility failed to provide a clean homelike environment for 3 (#s 2, 3, and 4) of 3 sampled residents and had the potential to affect all residents who go to the dining room. Findings include: During an observation and interview on [DATE] at 3:22 p.m., resident #2 was observed in his room on his bed wearing an incontinence brief. The brief was torn off on one side exposing the residents left hip and half of his left glute. Resident #2 was not covered with a sheet or a blanket and was not wearing any clothing. There were two urinals in his garbage can. One of the urinals was full to the handle with dark amber urine. The other was full above the handle with clear yellow urine. The room smelled of stale urine. There was a sticky material on the floor. Resident #2 said the staff would come to empty the urinals if he used his call light to ask. He said occasionally the staff would empty the urinals without being told but usually not. Resident #2 said he would wear clothing if he had any that fit properly but he had not had any clothing that was comfortable since he was admitted to the facility. He stated the floor was dirty often but said the staff were busy, so he did not complain about it. There were two flies in the resident's room landing on his bedside table and crawling on his cup. During a telephone interview on [DATE] at 8:46 a.m., NF2 said the room was usually dirty when she came in to see resident #2. She said his urinals were usually full sitting in his garbage can. She described coming in to see resident #2 and finding him completely naked on his bed uncovered. She said resident #2 had taken his brief off and put it in his wash basin because it was soiled with urine. NF2 stated resident #2 had told her his skin was getting itchy, so he took the brief off. During an observation and interview on [DATE] at 10:25 a.m., the two urinals were full again in resident #2's garbage can. The linens on the bed were the same as observed prior (on [DATE] at 3:22 p.m.). There were several flies in resident #2's room. NF3 said resident #2's room was typically filthy when she arrived to care for resident #2. Resident #2 was wearing sweatpants. Resident #2 said this was the first time he had pants in a year. He said one of the staff members got them from the laundry and resident #2 said, I think they took them from some guy that died in here. Resident #2 said the sweatpants did not fit him properly. He pulled the waistband out away from his abdomen, and the waistband allowed a gap of approximately 3 inches. During an interview on [DATE] at 12:15 p.m., staff member D said she was assigned to resident #2. When she was asked about the urinals in resident #2's garbage can, she said she had not noticed the urinals, but she said it had been a busy day. She said she would have the CNA empty them. She said the CNAs were supposed to do regular rounds and check on the resident's needs. During an observation and interview on [DATE] at 4:30 p.m., residents #3 and #4 were in the hallway. Resident #4 had a fly swatter and was hitting a fly in the hallway. Resident #4 stated he had the fly swatter because there were so many flies in the dining room it was disgusting. Resident #3 agreed, he said the flies in the building were terrible. As resident #3 was talking, a fly landed on the wall. Resident #4 hit it with his fly swatter and then rolled over the fly with his wheelchair. Resident #4 said the flies in the dining area were landing on his food and they were on the tables and walls. Another fly landed on the wall next to resident #3 and resident #4 hit that fly with his fly swatter, killing it, then it landed on the floor in the hallway.

Based on observation, interview, and record review the facility failed to provide hospice services in coordination with the management and staff of the nursing home per the hospice agreement for 1 (#2) of 2 sampled residents. Findings include: During a telephone interview on 9/18/24 at 8:46 a.m., NF2 said she and another nurse saw resident #2 once a week for hospice services. She said the facility had not had a group care meeting in months. She said staff member C had been going against NF1's orders and not providing medications ordered by NF1. NF2 said resident #2's room was usually dirty and his urinals were usually full sitting in his garbage can when she came in to see resident #2. She said resident #2 had been requesting to have a different physician from staff member C, but the facility was not allowing him to change physicians. NF2 said the facility was not allowing her or any of the other hospice staff to visit resident #2 without being escorted by one of the facility staff members. NF2 said she did not know why staff member C was going around NF1's orders. NF2 said she was concerned because of the discord between staff member C and NF1 was affecting resident #2's care. NF2 stated resident #2 was not receiving the medications that had been ordered by NF1. During an interview and observation on 9/18/24 at 10:25 a.m., resident #2 was sitting on his bed. NF3 was in the room with resident #2 providing cares. Resident #2's garbage can contained two full urinals. NF3 said she comes to see resident #2 weekly along with another nurse from hospice. She said his room was usually dirty and the urinals were usually full in the garbage can. She said the facility had not been allowing the hospice staff to visit resident #2 without having a facility staff member accompany them. When she arrived for this visit no facility staff noticed her, so she went quickly down the hall, so they wouldn't send anyone with her. Resident #2 said he did not like it when he wasn't allowed to visit with the hospice nurses alone. He said he did not like it when the facility staff listened to his conversations with the hospice staff. Resident #2 said he did not want to see staff member C at all, but she had told him he did not have a choice because he couldn't fight with the VA. He said he liked NF1 and the other provider from hospice, and he didn't know why he also had to see staff member C. NF3 said staff member C would not give resident #2 the medication ordered by NF1. NF3 said the facility was saying resident #2 was sleeping all the time and showing signs of being over sedated so they were trying to go against NF1's orders. NF3 said resident #2 had not been over sedated any time she came to see him and that resident #2 had been complaining of not being able to sleep and his anxiety had been out of control. Resident #2 said he had been having a hard time sleeping, and he had been having anxiety. NF3 said staff members C and E had been undermining what the hospice providers had been trying to do for resident #2. During an interview on 9/18/24 at 1:50 p.m. staff member C said typically the hospice physician would take care of medication orders for residents who were on hospice care. She stated she might write orders for residents who had been on hospice for a long time and who required medication for diagnoses such as diabetes or congestive heart failure. She said she did not like having a resident on opioids and benzodiazepines at the same time and she talked to NF1 about resident #2. She said NF1 told her he wanted to continue those medications for resident #2's hospice care so she sent resident #2's list of medications to a pharmacist to see if the pharmacist would recommend decreasing the medications and she also had resident #2 see a psychologist. She said the psychologist agreed with her and discontinued the medications (Lorazepam and Clonazepam). During an interview on 9/19/24 at 12:56 p.m., NF1 said he did not know why staff member C was trying to change his orders for resident #2's hospice care. He said typically the hospice provider would write the medication orders for hospice residents and the primary physician would only manage the regular medications for a resident. He said he spoke to staff member C a few times trying to coordinate care for resident #2. NF1 stated, I feel like they need to have more compassion for this guy. I have no idea why she (staff member C) is so adamant about these things (decreasing resident #2's hospice medications). We really should be able to make this work together. The best solution would be to get him (resident #2) back in the VA in Butte where he can have his regular physicians and VA care. Review of a facility provided document titled, Hospice-Skilled Nursing Facility Agreement, dated 5/13/22, showed, an agreement between the facility and the hospice agency taking care of resident #2. The agreement showed, .All services provided by Nursing Home hereunder shall be (i) authorized by Hospice, (ii) furnished in a safe and effective manner by qualified personnel and (iii) delivered in accordance with the Hospice Patient's Hospice Plan of Care. Hospice shall be responsible for determining the appropriate course of hospice care . Nursing Home shall provide Nursing Home Room and Board Services . including personal care services, including assistance in activities, administration of medications, maintaining cleanliness of a resident's room .

Based on interview and record review, the facility failed to meet professional standards for medications being administered, per the physician's order, and the resident had insomnia, for 1(#2) of 1 sampled resident. Findings include: During an interview on 9/18/24 at 8:46 a.m., NF2 said she faxed an order for Clonazepam (8/29/24) written by NF1 for resident #2. Resident #2 told NF2 he was not sleeping well and would like to have his Clonazepam started again. NF2 said she spoke with NF1, and he ordered the Clonazepam as resident #2 requested. NF2 said when the facility received the physician order, staff member E faxed it back with a handwritten note, requesting clarification. NF2 said she spoke to staff member E and explained NF1 wanted resident #2 to begin taking the Clonazepam. NF2 said she explained to staff member E they were aware the psychologist discontinued it (the medication), and they wanted to put him back on it (on 8/30/24). During an interview on 9/17/24 at 3:22 p.m., resident #2 stated he never wanted staff member C to be his physician and had told her on several occasions he did not want to see her. He said NF1 was his primary care physician, and staff member C kept taking away the medications NF1 ordered for him. He said he had been having a hard time sleeping and had been having severe anxiety, but staff member C would not allow the nurses to give him the medication NF1 ordered for him to help with his sleep and anxiety. Review of resident #2's EMR showed an order from NF1, dated 8/29/24 at 9:14 a.m. for Clonazepam 0.5 mg 1 tablet a day for anxiety/agitation and insomnia. A nurse note, dated 8/30/24 at 4:51 p.m., authored by staff member E, showed, received call from [NF2 Name] for order clarification from [NF1 Name]. [NF2 name] stated order is part of comfort (care) package. Resident has no s/s of actively dying including but not limited to: no death rattle, no skin discoloration, no SOB, resident alert and orientated, comfortable at this time. Sent to MD to review. [sic] Resident #2's MAR lacked an order entered for Clonazepam 0.5 mg 1 tablet daily for anxiety/agitation and insomnia. During a telephone interview on 9/19/24 at 11:51 a.m., NF2 stated she spoke to staff member E and told her NF1 intended for resident #2 to receive the Clonazepam per the physician order. She said she told staff member E it was ordered as part of his regular comfort care package, but she did not tell staff member E it was only to be used when the resident was actively dying. She said resident #2 was on hospice services, NF1 ordered the medication for resident #2, and NF1 intended for resident #2 to receive the medication. During a telephone interview on 9/19/24 at 12:56 p.m., NF1 said he was not aware the facility was not giving resident #2 the Clonazepam he ordered. He said his nurse clarified with the facility and he was aware the psychologist discontinued it, but he ordered it again because the resident was having a hard time sleeping and had been suffering from insomnia. NF1 said he could not understand why staff member C kept trying to decrease the medications he ordered for resident #2. He said he spoke to her a few times trying to coordinate care for resident #2. NF1 stated, I feel like they need to have more compassion for this guy. I have no idea why she (staff member C) is so adamant about these things (decreasing resident #2's hospice medications). We really should be able to make this work together. The best solution would be to get him (resident #2) back in the VA in Butte where he can have his regular physicians and VA care. During an interview on 9/18/24 at 1:50 p.m., staff member C said she typically would not change medications ordered by a hospice physician. She stated in a typical situation she would only manage medications related to a resident's other medical diagnoses like diabetes or congestive heart failure. She said the hospice physician should take care of all the other end of life care medications. She said she does not like residents to be prescribed opioid medication and benzodiazepines but that there were times when those orders were necessary. She asked NF1 about the medications, and NF1 said he did not want to change the medications and felt resident #2 needed them. After speaking with NF1, staff member C stated she was concerned about resident #2 taking benzodiazepines and opioids at the same time and decided to send the medication list to the pharmacist for medication review. Staff member C said she decided to send the medication list for resident #2 to a pharmacist to see if the pharmacist agreed with her. She also referred resident #2 to see a psychologist. The psychologist discontinued Clonazepam and Lorazepam for resident #2. Staff member C was aware NF1 had reordered the Clonazepam for resident #2 on 8/29/24, but she had the facility send it back to him for clarification and staff member C said the resident was not receiving the Clonazepam. She stated, We are just going to sit on that order for now. She stated the facility was awaiting clarification from NF1. She said she had not contacted NF1 to ask about the order and she was aware the order had been written on 8/29/24 (19 days prior). She was not aware of the note written by staff member E indicating NF1 clarified the order. Staff member C said she could not remember if she had spoken to staff member E after the order was clarified on 8/30/24. Two requests (on 9/18/24 at 12:30 p.m. and on 9/19/24 at 11:45 a.m.) were made to staff member A to interview staff member E. Staff member E was not made available for an interview by the end of the survey. Review of General Notes, in the resident's EHR, for resident #2, written from 4/22/24 through 9/18/24, lacked documentation of resident #2 having signs or symptoms of oversedation. General Notes written on 4/22/24 showed resident #2 complained of insomnia, on 9/7/24 the notes showed resident slept poorly, 9/16/24 resident slept poorly, and on 9/17/24 resident #2 was awake all night.

Based on interview and record review the facility failed to allow free access to visitors for 1 (#2) of 2 sampled residents. Findings include: During a telephone interview on 9/18/24 at 8:46 a.m., NF2 said she came to visit resident #2 on 9/4/24 for his weekly hospice visit, and a staff nurse accompanied her to resident #2's room. The staff member told NF2 she was no longer allowed to visit resident #2 without a facility staff member present at all times. During an interview on 9/18/24 t 10:25 a.m., NF3 said she came to visit resident #2 and was told she had to have a facility staff member with her while she was visiting resident #2. She said the hospice CNA came to see resident #2, and she was told she could not go in resident #2's room alone. The CNA told her resident #2 had to tell the staff member to leave when the CNA was going to give him a bed bath. The staff member would not leave and required the hospice CNA give the bed bath with the staff member in the room. Review of resident #2's EMR showed a General Note, dated 9/4/24 at 5:25 p.m., Accompanied Hospice Aide while she visited with resident. Resident was pleasant, brief was dry, no complaints of pain or discomfort. Resident refused bath but did agree to let hospice aide give him a bed bath. Review of resident #2's EMR showed a General Note on 9/4/24 at 9:30 a.m., Accompanied Hospice nurse while she visited with resident. Resident was pleasant, brief was dry, no complaints of pain or discomfort. Resident did complain about difficulty sleeping at night. During an interview on 9/18/24 at 12:15 p.m., staff member D said she was instructed by staff member E to accompany any of the hospice personnel to resident #2's room. She was told by staff member E the hospice personnel were putting ideas in resident #2's head, and that they should not be left alone in the room with resident #2. Staff D said that way facility staff could hear what was being said and report back to staff member E. Staff member D said staff member E told her to document resident #2's room was clean, and his brief was dry, and he did not have any complaints because the hospice personnel were making false claims. Staff member D said staff member E told her what to document. Staff member D said documentation was not the same for other residents on hospice. She said she would not typically even document when hospice came to see a resident because they do their own documentation in the hospice records. She said the only reason she documented like that for resident #2 was because staff member E instructed her exactly what to chart. Staff member D said staff member E told her to stay with the hospice personnel while they were with resident #2. Two requests (on 9/18/24 at 12:30 p.m. and on 9/19/24 at 11:45 a.m.) were made to staff member A to interview staff member E. Staff member E was not made available for an interview by the end of the survey. Review of a facility document titled, Exhibit B Resident Rights, not dated, showed: Each resident shall have the right: . a) to privacy in treatment and personal care: . e) to privately talk and/or meet with and see anyone; .

Based on interviews and record review, the facility failed to refund the resident or resident representative refunds within 30 days from the resident's date of discharge from the facility for 2 (#s 1 and 2) of 2 sampled residents for refunds. This practice had the potential to affect any residents discharging with a refund due. Findings include: Review of resident #1's facility provided financial record showed resident #1's date of discharge was 1/25/24. A refund of $2,000.00 was requested to be refunded to resident #1's representative. The issue date of the refund check sent to resident #1's representative was 3/18/24. This refund was issued 53 days after the date of discharge. Review of resident #2's facility provided financial record showed resident # 2's date of discharge was 3/21/24. A refund of $2,655.00 was requested to be refunded to resident #2's representative. The issue date of the refund check sent to resident # 2's representative was 5/1/24. This refund was issued 41 days after the date of discharge. During an interview on 7/15/24 at 10:30 a.m., staff member A stated the facility was changing finance companies during the processing of resident #2's refund. Staff member A stated the refund was late. During an interview on 7/16/24 at 3:27 p.m., staff member A stated resident # 1's refund was late. Staff member A stated there were no other residents with refunds in the last six months. A review of the facility's policy, Conveyance of Resident Funds Upon Death, reflected, Upon the death of a resident with personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate

Based on interview and record review, the facility staff failed to intervene when noticing 1 (#1) of 1 sampled resident vaping in another resident room. This resulted in staff finding the resident at a later time, and staff were unable to get a response from the resident due to intoxication. The Resident required emergency transport to the hospital. Findings include: A review of resident #1's Facility Reported Incident investigation, from 3/17/23 showed: - Staff member D stated she observed what she thought to be smoke as she walked past the resident room. Staff member D stated she could smell marijuana five to ten minutes later. Staff member D stated after she checked on another resident, she walked back past the room she had seen what she believed to be smoke, and she saw resident #1, .slumped in her chair, gray in color, not responding to commands. At that time, she called for staff member G to come evaluate resident #1. - Staff member G stated she came in to find resident #1 in her power chair, .eyes closed head back and non-responsive . [sic] - Staff member I came to assist and performed a sternal rub on the resident resulting in resident #1 fluttering her eyes and stating, I feel electrocuted all over my body. During an interview on 8/2/23 at 4:20 p.m., staff member D stated she wondered if she had seen smoke as she walked past the room resident #1 was in, but continued to the other room she was headed to. Staff member D stated she probably should have stopped to check. Review of the hospital discharge summary, dated 3/13/23, showed resident #1 was given two ampules of Narcan by emergency medical staff. Review of hospital documents for resident #1, showed on 3/13/23 at 6:22 p.m., resident #1 tested positive for cannabinoids and an overdose level of benzodiazepines. The diagnosis showed accidental or unintentional, initial encounter for the substances. Review of resident #1's Facility Reported Incident investigation from 3/17/23, showed during an interview with resident #1, staff member C documented resident #1 said, Thought I was taking a puff of regular pot (cannibus) not concentrated . Review of the facility Resident Smoking policy, implemented in August 2022 and revised September 2022, showed, .smoking is prohibited in all areas except the designated smoking area.

Based on interview and record review, the facility failed to provide a therapeutic diet to 1 (#21) of 2 sampled residents, and had incorrectly ordered food preparation cards for 2 (#s 21 and 24) of 2 sampled residents. This failure had the likelihood to cause physical harm from aspiration. Findings include: During an observation and interview, on 9/13/22 at 9:50 a.m., resident #21 was lying in his bed with a bedside table over his lap. He had several regular consistency drinks on the table with straws. Resident #21 had just tried to take a drink of milk and it was dripping down his chin. He grabbed the black waste basket and began to cough and spit the milk back out. Resident #21 stated, I thought I could get the milk down today, but I guess that's not happening. Resident #21 did not know if he had a specialized diet, but it was difficult for him to drink thin liquids and he needed assistance eating. During an interview on 9/14/22 at 9:21 a.m., staff member K stated staff member J put the dietary orders from the dietician, located in a binder in the kitchen office area, into the computer program that the cafeteria staff used to print out each individual resident's food preparation cards. Staff member K stated neither resident #21 nor resident #24 had received nectar thick liquids at breakfast, and staff member J was supposed to have changed their orders in the system. During an interview on 9/14/22 at 2:48 p.m., staff member B stated the facility did not have any training or inservice documented for facility dietary staff related to specialized diets or thickening. During an interview on 9/14/22 at 4:20 p.m., staff member C stated for existing residents, if a new diet was needed, the physician would be notified and an order entered by the nurse, and given to the kitchen to put in their white binder for diet orders. During an interview on 9/15/22 at 8:08 a.m., staff member J stated he entered the orders from the dieticians and nurses into the computer system and the dietary staff used the information to print the food cards to prepare the correct meals for each resident. He was unsure why the dietician's orders in the electronic chart and the binder were incorrect in the food card system. Review of resident food cards used for the breakfast meal on 9/14/22 showed: - resident #21's food card as regular, with no therapeutic alterations listed and, - resident #24's food card was listed to have nectar thick. Review of the facility document, Dietary order listing report, printed 9/13/22 at 12:45 p.m., showed: - [Resident #21] .regular diet, regular texture, nectar thickened liquids consistency. Revision date 8/15/2022. - [Resident #24] .Regular diet, regular/thin consistency. Revision date 4/30/2021. Review of resident #21's Diet Requisition Form, dated 7/28/22, showed, a checkmark by Nectar for thickened liquids with a handwritten note showing, shakes did not need to be additionally thickened. Under the Comments section, *Crush pills* Patient requires 1:1 feeding assist. The form was located in the white kitchen binder and scanned into the electronic health record. Review of resident #24's Diet Requisition Form, dated 4/30/21, located in the white kitchen binder, showed, resident #24 did not have any of the thickened liquids diet alterations marked. Review of the facility policy, Therapeutic Diet Orders, last revised September 2022, showed, .dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form .as prescribed, and, Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietician .all diet orders are to be communicated to the dietary department in accordance with facility procedures. The facility did not have a procedure to ensure that all residents were receiving the correctly ordered diets and/or alterations to their diets on the food cards the dietary staff used to prepare meals. 47003

Based on observations, interviews, and record reviews, the facility staff failed to uphold and follow policies and procedures related to the prevention of the spread of Covid-19, which included the failure to effectively train and monitor all staff on donning/doffing PPE and hand hygiene during the provision of resident care and services, for 10 (#s 3, 4, 5, 8, 13, 14, 15, 16, 17, 18); failed to implement infection control signage for a resident on isolation precautions, for staff/visitor awareness, for 1 (#8), of 10 resident's rooms observed on 200 hall; staff failed to sanitize and wash their hands during passing and setting up meal trays for 4 (#s 5, 8, 13, 14); residents were not encouraged to wear masks while out of their rooms, in open areas of the facility, to include the dining room, for 5 (#s 1, 2, 3, 4, and 5); failed to use proper hand washing/sanitizing procedures when testing 3 (#s 1, 3, and 4) for Covid-19, and, failed to ensure a designated RN provided oversight for the prevention of Covid-19, by ensuring current staff were trained and educated on Covid-19, enviromental cleaning and disinfecting, preventing transmission of infectious agents, use of PPE, refreshers with current staff on basic infection control including universal precautions, and updates from CMS and CDC. During the survey, three residents tested positive for Covid-19, (#s 10, 12, and 13) out of 42 sampled residents. These infection control deficient practices affected the majority of the 42 residents at the facility, eight residents had recently passed away due to Covid-19, and 14 staff were positive for Covid-19. IMMEDIATE JEOPARDY On [DATE]at 2:34 p.m., the facility Administrator, DON, Infection Preventionist, VP of Clinical Services and Clinical Director were notified that an Immediate Jeopardy existed in the area of F880 Infection Prevention and Control. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of L, and upon removal of immediacy lowered to an H. The facility did not submit an acceptable plan to remove the immediacy prior to the end of the survey. The facility submitted a plan which was accepted by the State Survey Agency on [DATE] at 6:48 p.m., alleging the immediacy was removed on [DATE] at 4:50 p.m On [DATE] at 1:49 p.m., the surveyors were onsite and verified the plan was implemented and carried out as stated on the plan, and the immediacy removed as of [DATE] at 4:50 p.m. Findings include: Review of the facility list, Current Covid Positive Resident for the date of [DATE], showed 29 out of 41 residents had Covid-19, on the survey entrance date. On the afternoon of [DATE], three more residents (#s 10, 12, and 13) tested positive for the Covid-19 virus. Review of the facility policy and procedure, Infection Surveillance, with no date, showed outbreaks of all infections would be investigated. Those symptomatic persons were to be removed from the main population and placed with suspected or confirmed Covid-19 residents in private rooms, with the door kept closed, and private bathrooms, as possible. Review of the Emergency Plan for Pandemic Policy, with a date of 2019, showed the pandemic response coordinator would be the facility administrator. The policy outlined the overall response to a pandemic outbreak and emergency protocol. The protocol would be revised, based on local, state, and state/federal guidance as deemed necessary by the governing body of the organization. 1. During an observation on [DATE] at 9:36 a.m., staff member H exited room [ROOM NUMBER], removed her face shield and gloves, and sanitized her hands. Staff member H took a sanitizing cloth from a container, wiped down the shield, and then placed the shield on a hook on the outside of the door of room [ROOM NUMBER]. The shield had no name on it to identify whose shield it was, and the shield was not protected from infectious agents in the air or that which may be spread in the hall. Other shields were on miscellaneous doors throughout the hall. The other shields had no markings to identify the owner of the shields, and they were not covered or protected from infectious agents when hanging in the hall on the doors. During an interview on [DATE] at 9:12 a.m., staff member H stated the facility policy was to put on a gown, shield, and gloves prior to entering a resident room on the Covid-19 unit. When exiting the resident's room, she was to discard the gloves, remove the shield, remove the gown if soiled, or if she encountered bodily fluids. She then washed the shield and hung the shield outside, on a resident's door. During an interview on [DATE] at 9:41 a.m., staff member H stated having two shields somewhere around, in the 200 hall, at different distances. When asked if other staff wore her shield, staff member H stated another staff member could use her shield by mistake, but probably would not wear it unless there was an emergency and it had to be quick. During an interview on [DATE] at 9:21 a.m., staff member M stated she changed her gown whenever she came in contact with a resident. She would change her gown before working with another resident. During an interview on [DATE] at 9:28 a.m. staff member L stated she was to remove her gown each time after exiting a resident's room, and before going into another resident's room. During an observation on the Covid-19 contained hall, on [DATE] at 9:56 a.m., staff member H exited resident #15 and #16's room, carrying a plastic bag of soiled items and placed them in a red covered container. The staff member then removed the gloves, shield, sanitized her hands, washed the shield with a sanitizing cloth, and then sanitized her hands. The staff member did not remove the contaminated, disposable gown. Staff member H then entered resident #17 and #18's room. When exiting the room, staff member H still did not remove the contaminated disposable gown. Not all residents on the unit were positive for Covid-19 at the time. During observations on [DATE], in the 200 hall, from 9:12 a.m. until exiting the sealed off covid unit at 10:05 a.m., staff member M and H entered multiple resident rooms and wore the same contaminated, disposable gowns, throughout that time period. 2. During an observation on [DATE] at 8:47 a.m., neither resident #8's door, nor the surrounding area, had posted information on what type of PPE should be used when entering the residents room. A plastic storage container was located to the left of resident #8's door. The container held disposable gowns, gloves, and masks. During an observation and interview on [DATE] at 8:51 a.m., staff members D was observed going into resident #8's room. The staff member was not wearing any PPE. When exiting the room, staff member D stated if resident #8 did not have signage posted at the door, staff no longer were required to wear PPE when entering resident #8's room. Staff member D stated she was told by staff that she did not have to wear PPE for resident #8. Staff member D stated she had been on vacation for 21 days and just got back to work and did not know there was an outbreak of Covid-19 in the facility. During an interview on [DATE] at 2:14 p.m., staff member C stated resident #8 was still on isolation precautions as resident #8 was not vaccinated for Covid-19. The resident was to be quarantined. The staff member thought the precautions were posted at resident #8's door, went and looked, returned, and said no there were no precautions posted at resident #8's door, and just the PPE supply container was at the door. 3. During an observation on [DATE] at 8:25 a.m., staff member D grabbed a meal tray out of the enclosed food cart, without washing or sanitizing her hands. The staff member delivered the food tray to resident #8 and exited the resident's room. Staff member D did not sanitize/wash her hands, and then she reached into the food cart, partially pulling out two trays, grabbing one tray, and pushing the other back into the food cart. Staff member D delivered the tray to resident #13's room and set up the resident's meal on the bedside table without washing/santizing her hands prior to assisting with the tray. During an observation on [DATE] at 10:28 a.m., staff member D went into resident #14's room, exited, did not wash/sanitize her hands and entered resident #4 and #5's room. The staff member exited resident #4 and #5's room at 10:31 a.m. The staff member did not wash/sanitize her hands. Staff member D then entered resident #13's room at 10:34 a.m. The staff member exited resident #13's room with a bag, sealed with garbage, which she placed in a garbage bin. Staff member D did not wash/sanitize her hands, and then she returned to resident #13's room. 4. During an observation on [DATE] at 10:55 a.m., staff member C was on hall 100, exiting a resident's room. The staff member had gloved hands at the time. Staff member C stated she was rapid testing residents #1, 3, and 4 (for Covid-19) because they were not feeling well. 5. During an observation and interview in the dining room, on [DATE] at 11:25 a.m., resident #5 was seated in a wheelchair, close to the exit door, leading to the back porch. Resident #5 was not wearing a mask. When questioned if he was asked to wear a mask, he said no. Resident #5 said he had Covid-19; and, resident #4 was seated in a chair, in front of the dining room windows, six feet away from resident #5. Resident #4 was not wearing a mask. At 11:35 a.m., resident #4 stated no one had asked him to wear a mask. Staff were observed walking in and out of the dining room, requesting items from the kitchen. No staff member asked either resident #4 or 5 if they would like to wear a mask from 11:25 a.m. until 11:54 a.m. 6. During an observation on [DATE] at 8:25 a.m., staff member Q, without sanitizing/washing hands after exiting from a room on the 100 hall, and pulled resident #14's tray from the food cart. Staff member Q delivered and set up resident #14's tray on the bedside table in the resident's room. Staff member Q exited the room without washing/sanitizing hands, then went into the dining room, into the door of the kitchen, received resident #1's breakfast meal, took the meal to resident #1, who was seated in the dining room at a table across from the kitchen door. Staff member Q set resident #1's food in front of him. Staff member Q did not propery sanitize or wash hands during the resident interactions with the meal trays. During an observation from outside the dining room, on [DATE] at 8:30 a.m., resident #4 (was unmasked) walked into and around the dining room, near resident #1, who was eating at a dining table. Resident #1 was not wearing a mask. Resident #4 received coffee and sat at a table by the dining room windows, on the outside wall. Neither resident used protective masks when in the open dining room. During an observation on [DATE] at 8:47 a.m., resident #5 entered the dining room in a wheelchair, not wearing a mask. Resident #5 placed his wheelchair close to the outside door and stated he was waiting to smoke. Resident #5 was within 4 feet of resident #1, and neither had a mask on. Staff did not attempt to provide any interventions for safety related to Covid-19 prevention efforts. During an observation on [DATE] at 8:50 a.m., staff member Q wheeled resident #2 into the dining room, in his wheelchair. Resident #2 was not wearing a mask. He was seated at a table next to resident #5, five feet from resident #5. Without offering any of the three residents (#s 2, 4, or 5) in the dining room a mask, staff member Q went to the kitchen door, and received a cup of coffee. Resident #2 wheeled his wheelchair over to resident #5 and pulled out a can of chew from his jacket pocket, opened the lid, and offered some chew to resident #5. Resident #5 reached into the can of chew and took a pinch of chew with his fingers. The two residents were no more than four feet away from each other, neither wearing a mask, and sharing a tobacco product. Staff member Q brought back the coffee and poured the coffee into resident #2's coffee mug, while resident #2 was offering the chew to resident #5. Staff member Q left the table, washed her hands at the sink, and left the dining room. Staff member Q did not offer, remind, or provide education on the risks/benefits for the residents on mask use for the prevention of Covid-19, or address the sharing of the tobacco product. During an observation and interview on [DATE] at 1:03 p.m., the following was observed: - Resident #4 was seated in a chair, in the television area off the dining room. The resident was not wearing a mask, but when asked, showed he had one crumpled up in his pocket. Resident #4 said he didn't feel well, and a shower would feel good. He was coughing off and on during the observation period. - A couch was next to resident #4, and resident #3 was observed at the other end of the couch, and resident #3 was being assisted with his meal by staff member Q. Resident #3 appeared frail, back rigid, head slightly leaning back, and arms positioned on the wheelchair arms. Resident #3 had an oxygen tank on the back of his chair, and a nasal cannula was positioned in his nostrils. Resident #3's mouth was partially open and would close when food was placed in his mouth by staff member Q. -Resident #4 was heard continuing to cough off and on during the observation of resident #3's meal intake. 7. Review of the facility inservice training information for the staff showed: a. Staff had a presentation on donning and doffing PPE, proper handwashing, and disinfecting face shields and goggles. The training date was [DATE]. -No current training was provided by the facility during the Covid-19 outbreak. b. An Inservice Education form, titled, GUIDELINES FOR INFECTION CONTROL, conducted by staff member N, for the housekeeping department, showed no content or summary of the in-service containing information on infection control. No signatures of staff who attended, or the date and the time that the in-service was presented, was include for the education. c. Review of the facility's Covid-19 Education Plan (Policy for what to do with Covid-19), with no print date, showed: -Staff would be required to change PPE between residents on the quarantine unit, Covid unit could use same PPE during entire shift, -Staff would be tested using required guidelines, -Management would work together to educate staff on wearing PPE, and monitoring floor staff for compliance to PPE use, resident placement, and the use of cleaners/sanitizers, -Management staff would ensure that testing was taking place as direct by county prevalence requirements. -All staff would be tested for Covid-19 based on the county prevalence percentage numbers. During an interview on [DATE] at, 10:40 a.m., staff member R stated she had not signed a form of the facility's policy on Covid-19 or information on the infection control practices at the facility. During an interview on [DATE] at 1:35 p.m. staff member F stated she had no training on the facility's policy on Covid-19 or infection control used at the facility. Staff member F stated she was a [MEDICATION(S)] (contractraced employee), and travelers did not work in/on the Covid-19 unit. Review of the signed documents, showing staff confirmed they were given education on the Covid-19 Education Plan, did not show staff member R and staff member F had reviewed and signed a form, although they were working at the facility. Review of a housekeeping Inservice Education form, with no date of the inservice, showed no names of staff who attended the inservice. The inservice agenda was to be given by the housekeeping supervisor. The agenda was on Covid-19, PPE, wearing masks indoors, Covid-19 testing (when and how often), exposure to Covid-19, protection from the Covid -19 virus, and protecting self and others. No updated, or other in-services/trainings, were provided by the facility on infection control specific to housekeeping requirements related to the prevention of Covid-19 or the spread of the infection. 8. Review of the facility's, Emergency Plan for Pandemic Policy, with a date of 2019, showed: -The policy outlined overall response to a pandemic outbreak and emergency protocol. The protocol would be revised, based on local, state, and state/federal guidance as deemed necessary by the governing body of the organization. -Training and education would be the responsibility of a specific RN (currently not on staff roster) for ensuring current staff were trained and educated on Covid-19, environmental cleaning and disinfecting, preventing transmission of infectious agents, use of PPE, refreshers with current staff on basic infection control including universal precautions, and updates from CMS and CDC. During the extended survey, a review of the facilities document COVID-19 tracking rerport showed there were 39 (#s 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42) of 42 residents who tested positive for COVID-19, and 8 residents died between [DATE] to [DATE]. During an interview on [DATE] at 10:37 a.m., staff member A stated the QAPI committee meets a minimum of quartely. Staff member A stated the committee had a meeting on [DATE] after the first positive case of COVID-19, but did not document it. Staff member A stated the outcome for the meeting was working with county and local health departments. Staff member A stated the QAPI committee initiated guidance for an outbreak. Staff member A stated the staff were educated regarding PPE and the set up of the COVID-19 unit. Staff member A stated the facility had to activate their emergency staffing plan by using contracted staff and the managers also worked the floor. During an interview on [DATE], staff member C and Y stated the facility was not experiencing a shortage in PPE and did not have to reuse any PPE.

Based on interview and record review, the facility failed to ensure the staff initiated CPR and failed to alert EMS for 2 (#s 9 and 19) of 8 sampled residents who were a full code at the time of death. IMMEDIATE JEOPARDY On [DATE] at 2:34 p.m., the facility Administrator, DON, Infection Preventionist, VP of Clinical Services and Clinical Director were notified that an Immediate Jeopardy existed in the area of F678 Cardiopulmonary Resuscitation. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy lowered to a G. The facility did not submit an acceptable plan to remove the immediacy prior to the end of the survey. The facility submitted a plan which was accepted by the State Survey Agency on [DATE] at 6:48 p.m., alleging the immediacy was removed on [DATE] at 4:50 p.m., which was verified by the State Survey Agency on [DATE] at 1:49 p.m The facility had implemented the plan as stated, and the immediacy removed. Findings include: During an interview on [DATE] at 10:56 a.m., staff member Y and C stated it was the expectation of staff to initiate CPR and call EMS when a resident with a full code status stopped breathing. Staff member Y stated the process for changing a resident's code status was to go back to the process. Nurses were to make sure they were putting the order in. Staff member Y stated the progress notes were reviewed daily in a clinical meeting. Staff member Y stated the facility was going to hire a nurse to input orders so the other nurses on shift did not have to worry and would not be distracted from other tasks they have to do. Staff member Y stated they were going through every resident's chart to ensure their code status was up to date and accurate according to the resident's and family/representative wishes. 1. Review of resident #9's POLST showed the resident was a full code. The resident did not have advanced directives that showed any status in code except full code. Review of resident #9's nurse's note, dated [DATE] showed the resident was a full code. The notes showed that staff member C was in the building and notified the family/POA of the resident's code status and showed the POA was asked about the resident's code status and the POA agreed on a DNR status. This change in status did not have a provider order or any change in code status in the resident's clinical record for the staff to use when an emergency occurred. Review of resident #9's nurse's notes showed the resident was transferred to the facility's COVID-19 unit on [DATE]. Nurse's notes showed the resident expired on [DATE] at 9:45 p.m. The facility did not initiate CPR and did not alert EMS when resident #9 was found unresponsive. The EHR did not show documentation which showed signs of clinical death. 2. Review of resident #19's POLST, dated [DATE], showed the resident was a full code via phone consent by the resident's guardian. The form did not have a signature under the patient/legal decision maker section. Review of a nurse's note, dated [DATE] at 12:00 a.m., showed the resident was medicated for pain, with 0.5 ml of [MEDICATION(S)] solution, at 3:00 p.m., 4:00 p.m., 5:10 p.m., and 6:10 p.m The nurse's note showed the resident had shallow respirations at 7:00 p.m., relaxed and [NAME]-stoke breathing at 9:45 p.m., went into respiratory arrest at 10:00 p.m., and had no cardiac activity at 10:15 p.m. Time of death was documented as 10:15 p.m. Review of a typed written note for resident #19, documented by the provider, showed a signature and was dated [DATE]. There was no time documented on the note. It was typed and on a white piece of paper with no title. The note showed the following. On [DATE] Resident's [name] called the facility concerning starting Hospice services d/t recent dx of metastasized cancer. Resident's [designation] stated his wishes for his mother to be comfortable and not want to pursue any farther treatments. After discussing with the family concerning their wishes for the resident, the nurse contacted me, and we discussed the families wishes. I gave a verbal order for the resident to be evaluated for hospice and put on comfort care. When I was notified by the nurse hospice would not be able to provide services to our resident d/t lack of staffing and the current COVID outbreak. In regards of the resident's condition and family wishes, I gave a verbal order for the resident to continue to be comfort care. Due to staff following my verbal order and communicating resident's condition with me, it was assumed the Nurse had properly followed my order and written the order as it was dictated to her. Review of resident #19's EHR did not show an order was written for comfort care only. Review of the facility policy, titled Cardiopulmonary Resuscitation (CPR), showed: 2. If a resident experiences a cardiac arrest, staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition).

During interviews and record review, the facility failed to ensure an X-ray was ordered and obtained in a timely manner for a resident who had a fall with major injury; and failed to timely inform the ordering provider and family of the significant findings of the X-ray, resulting in a delay of care for 1 (#10) of 10 sampled residents. Findings include: 1. Delay of Care with Obtaining an X-ray During an interview on 2/11/21 at 12:21 p.m., NF6 stated resident #10 had been a hospice resident at the facility. She stated the resident was non-verbal but could make her needs known. NF6 stated resident #10 would cry out in anxiety during cares because resident #10 was frightened of falling, but did not routinely call out in pain during cares. NF6 said there was a difference between the resident's non-verbal cues of anxiety and of pain. NF6 continued to state she was finishing her shift on 8/13/20, at the facility, when she was called to resident #10's room. NF6 stated she found resident #10 on the floor of her bathroom and staff member B was next to the resident. NF6 stated staff member B said the patient had an unwitnessed fall. NF6 stated the resident's right hip looked misshapen and felt an obvious deformity of the right hip. NF6 stated resident #10 was crying and yelling out in pain and kept reaching for her right hip. NF6 stated when staff member C came into the resident's room to complete an assessment, she told staff member C she thought resident #10's hip was broken because it was out of place, and the resident was calling out in pain. NF6 stated when the resident was rolled onto her side, she started to yell, no, no, ouch, stop that! NF6 said she wanted to call an ambulance but staff member C and G both said they needed to talk to the hospice agency before they could send her to the emergency room . They told NF6 the resident could lose her hospice coverage if they sent her to the emergency room . NF6 stated staff member C did give her permission to call an ambulance, which she did. NF6 stated by the time she returned to the resident's room, staff members C and G had resident #10 in her wheelchair. The resident was calling out in pain, staff members C and G then moved the resident to her bed. NF6 said the resident was then given oral [MEDICATION(S)] from her hospice medications because she was in such pain. Shortly after the call to 911, NF6 said EMS arrived and assessed the patient, stating the EMTs noticed an obvious deformity of the resident's right hip during their assessment. The EMTs then placed the resident on the stretcher and were prepared to transport the patient from the facility, when staff member G informed the EMT's that the resident was on hospice, and the family did not want the patient sent to the ER. The EMTs then placed a hip binder on the resident and transferred the patient back into her bed. NF6 said she was not allowed to document her findings from resident #10's fall, she was told by staff member C, that resident #10 was not her patient, and was told to clock out and go home. NF6 stated she remained concerned about resident #10, and when she returned to work the next day, she was surprised to find out that resident #10 had not yet had an X-ray of her right hip, and was not expected to have an X-ray until late morning. Review of NF6's electronic time clock record, showed NF6 clocked in at 6:19 a.m., and out at 3:43 p.m., on 8/13/20. And on 8/14/20, NF6 clocked in at 6:23 a.m., and out at 3:44 p.m. During an interview on 2/18/21 at 2:34 p.m., NF7 stated a 911 call came into dispatch from the facility for a fall with injury on 8/13/20 at 3:21 p.m. Review of resident #10's Ambulance Notes from the Hospital, dated 8/13/20, showed a dispatched time of 3:23 p.m., with the ambulance arriving at the facility at 3:38 p.m., and arrived at the patient's room at 3:40 p.m. The note showed EMS left the scene at 4:09 p.m. The EMS Narrative Note, showed, Medic 1 requested to respond the [facility] for an elderly lady who had fallen and possibly broken her hip. Response was slightly delayed due to staff responding from home base. Upon arrival to facility, we were met at the door by staff who stated that we would had to wait to transport due to the fact that the pt is in hospice care and they would be canceling her care if we took her to the ER. We were directed to the Pt room to evaluate any injuries while we waited for transportation confirmation. Once contact to the patient was made, she was laying in the fetal position, in obvious pain. Caretaker on scene stated she was walking by the room when she heard 2 loud thuds, presumably when she fell and hit the door in the bathroom. They were able to lift her off the floor and dress a small wound that was lightly bleeding on the right forearm. Were able to rotate the Pt onto her back in visually inspect her right hip and leg. There was no obvious shortening or rotating of the leg, although there did appear to be an obvious deformity. We decided then to apply a pelvic binder as pressure from the wrapped sheet seemed to provide the patient with some pain relief. After the binder was on, a nurse appeared to tell us that the family was okay with us transporting her. We carefully lifted her (while holding stabilization on the pelvis) over to the cot and began to secure her. At this time, the nurse came back to tell us that the family had changed their mind and that they we were not to transport her to [hospital] but that they would wait for hospice to use a mobile X-ray. We then transported the Pt back to her bed. We made the decision to leave the binder in place as it was relieving pain and we did not want to cause any more pain or harm to the Pt. We radioed dispatch and told them we were being canceled per family/hospice and we left the scene and were back in service. [sic] During an interview and record review on 2/16/21 at 11:20 a.m., staff member C stated she did not specifically recall the events or her findings of the resident's fall on 8/13/20, and would rely on the documentation. She said she relied on staff member G to document the findings of the assessment since staff member G was the charge nurse at the time. A review of resident #10's EHR did not show a documented assessment of the resident's hip was completed by staff member C or G. There was an incident report completed by staff member C, but that report was used internally by the facility and was not part of the resident's medical record. A review of the facility's internal incident report for resident #10, dated 8/14/20 at 3:30 p.m., showed, [Resident #10] found laying in bathroom doorway, head in doorway, feet facing sink, wall to right side, resident was with 2 LPNS upon my entrance into room, assessed for injury legs even, bruises to right knee, skin tear to right elbow noted. Resident grimacing with mobility of BLE assisted resident to WC then into bed. Reassessed by EMTs, [staff member G] called hospice, family, and MD for orders on care. [sic] During an interview on 2/16/21 at 1:00 p.m., staff member B stated she had just started her shift on 8/13/20, at approximately 2:00/2:30 p.m., when she heard a loud noise from resident #10's room. She said when she entered the resident's room, she found the resident on the floor in obvious pain. Staff member B stated she thought resident #10 had broken her hip because she was screaming out in pain and trying to reach for her right hip. Staff member B said when she felt resident #10's right hip it, did not feel right, and you could feel a bump. Staff member B stated she was concerned about a hip fracture because the resident had very brittle bones, and had just recovered from a spontaneous fracture of her right lower leg. Staff member B said she did not document her findings since staff member C and G were there, and she felt there were too many people in the room, so she left. Staff member B stated there seemed to be some disagreement between staff members B, G and NF6 whether they could send the resident to the emergency room , since she was on hospice. Review of staff member B's electronic time clock for work showed staff member B clocked in for her shift at 1:58 p.m., on 8/13/20. During an interview on 2/16/21 at 2:34 p.m., staff member G stated she remembered resident #10's fall. She said she did not recall specific events from that fall, and would rely on her documentation for any specific questions. Staff member G stated she completed the nursing note, and SBAR note from 8/13/20, regarding resident #10's fall. Staff member G said if a resident was on hospice, the facility should check with hospice before sending the resident to the emergency room . She said the resident could lose hospice services if they were sent to the emergency room . During record review and an interview on 2/17/21 at 11:28 p.m., staff member I stated she had just finished giving her end of shift report to staff member B on 8/13/20, at approximately 2:00/2:30 p.m., when she was informed resident #10 had fallen. Staff member I stated, when she entered the resident's room, staff members C and B and other staff, which she could not recall, were assisting the resident. Staff member I said she was concerned the resident (#10) might have fractured her hip since she had bad [CONDITION(S)] and had just healed from a previous fracture. Staff member I stated she did make an internal incident report for the facility but did not document her findings in the resident's chart regarding the resident's fall. Staff member I stated the facility was not able to send the resident to the emergency room since she was on hospice, and if she went to the emergency room without notifying hospice, the resident would be removed from hospice benefits. A review of the incident report completed by staff member I, dated 8/14/20 at 3:30 p.m., showed, 1535 informed by CNA that res was on the floor. This writer to room and resident lying on her back, several staff were already there and assessing her. She had skin tear to right elbow and bruising starting to outer right knee calling out in pain. Assisted up into WC and then bed. EMTs arrived and assessed res and nurse was calling family and hospice for decisions on care/orders. [sic] Review of staff member I's electronic time clock record, showed staff member I clocked in at 5:55 a.m., and out at 4:05 p.m., on 8/13/20. During an interview on 2/17/21 at 8:00 a.m., NF5 stated resident #10 was on hospice with their agency, related to malnutrition. NF5 said resident #10 started hospice services on 5/30/20. She said the resident had brittle bones and was healing after a recent spontaneous fracture of her right lower extremity. NF5 said the facility staff notified her of resident #10's fall and informed her they believed the hip was broken. She said the staff reported the resident was not using her right leg, and the resident appeared to be in a lot of pain, and they were not able to get in touch with the resident's physician. NF5 said she did not speak with the family at the time of the fall, but later that day she spoke with the family about the resident's fall. She said they wanted to have her hip surgically repaired, if possible, if the hip was broken. NF5 said since the facility was not able to get in touch with staff member J to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the verbal order was from NF8. NF5 said she gave the verbal order earlier in the afternoon and documented the occurrence in the medical record at a later date. NF5 stated she told staff member G that NF9 would not be coming to complete an assessment of resident #10, and they should get the X-ray as soon as possible. NF5 stated they preferred the facility contact the hospice agency before having a patient transferred to the hospital, in the event the reason for calling emergency services related to the patient's hospice services. Otherwise, instances when medical care is emergent, such as with resident #10, it was not necessary to call hospice before transferring the resident to the emergency room . She stated a resident who was on hospice services would not lose their hospice benefits if they were evaluated and treated in the emergency room for an emergent situation that did not pertain to their hospice care. Review of resident #10's Hospice Note, dated 8/17/20 at 12:16 p.m., showed, 8/13/20 at 5:20 PM [Facility] called to report that [resident #10] was found in the bathroom and she had fallen and it was apparent that [resident #10] had injured her right leg and they were not able to get in touch of [staff member J] for an xray, so verbal order given from [NF8] for the xray and results was a hip fracture. [NF9] talked to the family and they did want the hip repaired if possible, [resident #10] was discharged from hospice care due to hospitalization for FX hip. [sic] Review of resident #10's Hospice Order Form, from the hospice, dated 8/13/20, showed, Obtain Xray R leg, femur, Tib Fib and R Foot. VO per [NF8], signed [NF5]. [sic] Review of resident #10's Nursing Progress Note, dated 8/13/20 at 6:59 p.m., showed, Nurse called into resident room. Resident found on floor lying on right side, head in bathroom doorway and feet on the floor in the middle of the sink and the toilet. Lights on in room, gripper socks on, resident incontinent, no bed alarm on, no wheelchair close to resident, and room clean and free of clutter. resident alert and oriented to self, pleasant and cooperative. VS: B/P 120/68 lying right arm, P 81, R 18, T 98.4, Sp02 93% on room air. Painscale rated 7/10 with PRN [MEDICATION(S)] liquid administered. Transferred with assist x 2 to bed. skin tear .Called Hospice about 1535 [3:35 p.m.] and talked to [NF5]. [NF5] informed nurse that [NF9] will come see resident to evaluate. [NF2] called and updated about 1550 [3:50 p.m.]. [NF2] would like Hospice to evaluate and not send resident to ER. Called [NF9] about 1613 [4:13 p.m.] and got ok to contact [staff member J] for order for xay. [Staff member J] contacted with no response at this time. [Staff member C] updated at 1530 [3:30 p.m.] . Hospice had provided a verbal order from NF9 for xray of the resident's right hip. The Progress Note was written by staff member G on 8/13/20 at 6:59 p.m., showing the facility had attempted to contact staff member J, but had not heard back from staff member J at that time (6:59 p.m.) Review of resident #10's SBAR Communication Form and Progress Note, dated 8/13/20 at 7:30 p.m., showed, . 2. Fall. Request: monitor vital signs and xray. [NF2] notified on 8/13/20 at 15:50 (3:50 p.m.) and Hospice and [staff member J] notified on 8/13/20 at 1540 [3:40]. This note indicated staff member G had contacted staff member J on 8/13/20 at 3:40 p.m., but the earlier progress note written on 8/13/20 at 6:59 p.m., stated she had contacted staff member J, but had not notified staff member J of the fall. Review of resident #10's Nursing Progress Notes, dated 8/13/20 at 7:37 p.m., showed, Verbal order from [NF5] from Hospice: Xray femur 2V, Tibia and Fibula, AP & LAT, and Foot AP & LAT. Order faxed to [Mobile Imaging Company], called and left message with on call and at office. Order in eMAR. [NF2] updated. Review of the mobile imaging company's orders received from the facility showed an electronic time stamp when the order was faxed of 8:31 p.m., on 8/13/20. The order was created by staff member G for a verbal order from staff member J. The order showed, Xray for Femur 2V, Tibia and Fibula AP/LAT, Foot AP & Lat one time only for right leg pain for 1 day. [sic] A second hard copy order was also faxed to the Mobile Imaging Company with an electronic time stamp with the date and time the order was faxed, which showed, 8/13/20 at 8:30 p.m. The order showed, Femur 2V, Tibia & Fibula, AP & Lat, Foot, AP & Lat. The order was written by staff member G per a verbal order by staff member J. A review resident #10's EHR showed, The hospice agency provided a telephone order to the facility at 4:13 p.m., for the hip X-ray. The facility did not send the order for the X-ray to the mobile imaging company until 8:30 p.m., on 8/13/20. Staff member G had been given a phone order by NF5 at 4:13 p.m., to obtain a right leg and hip X-ray per NF8. The note also showed staff member G had called and left a message for the on-call physician, but the resident's medical record did not indicate staff member J had called back to give the order. There was no documentation of the on-calls recommendation. During an interview on 2/11/21 at 2:40 p.m., NF3 stated the mobile X-ray was not a 24-hour mobile X-ray service, and had operating hours between 9:00 a.m., and 5:00 p.m., Monday through Friday. NF3 stated she was responsible to dispatch the X-ray technicians when they received an order. If an order came in after 5:00 p.m., the X-ray technicians would not be dispatched until the next day. She said since Deerlodge did not have an X-ray technician there, the technician would have to come from Missoula, or [NAME]. She stated if an order came in late in the afternoon or close to 5:00 p.m., there would be no way to send a technician to the facility before the end of the day. NF3 stated she reviewed the company's phone logs from 8/13/20, and they did not receive a phone call from the facility on 8/13/20. If the facility called after hours, it would have gone to the on-call, and a phone log would have been created. NF3 stated they did not receive the orders from the facility for resident #10 until 8/14/20. She said she dispatched the X-ray technician from Missoula to Deerlodge. Review of resident #10's Nursing Progress Note, dated 8/13/20 at 8:20 p.m., showed, Resident POA called several times throughout shift for updates. Informed that X-ray update will most likely be Friday late morning. POA greatfull [sic] resident does not have to be moved several times for xray and [mobile imaging company] will be coming to facility. During record review and interview on 2/17/21 at 10:00 p.m., staff member H stated staff member G notified staff member J of the fall on 8/13/20 at 3:40 p.m., as the documentation in the SBAR showed. Staff member H stated the provider's recommendation was to monitor vital signs and obtain an X-ray as noted in the SBAR. Staff member H stated the documentation speaks for itself. Review of resident #10's EHR showed the X-ray order was not sent to mobile imaging until 8/13/20 at 8:30 p.m. This was five hours from when the facility stated the physician ordered the X-ray. During an interview on 2/17/21 at 12:35 p.m., staff member G stated she contacted staff member J on 8/13/20 at 3:40 p.m., as noted in the SBAR. She stated staff member J recommended an X-ray. Staff member G stated when they talked to the family of the resident, the family did not want the resident sent to the ER for X-rays, so she recommended the mobile X-ray, and the family agreed. Staff member G stated she could not go against the family's wishes for a mobile X-ray. Staff member G said by the time she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not hear back from the mobile imaging office and notified the family that the X-ray would not be there until the next day. Staff member G stated she was aware the mobile X-ray company was not a 24-hour X-ray service but was not sure of their hours. She stated if she had questions of the hours for the mobile X-ray company, it was in the logbook at the nurse's station. Review of the logbook at the nurse's station for the mobile X-ray company, showed the name and directions for ordering a mobile X-Ray, and contained order requisition forms, but the office hours were not noted in the logbook. During record review and an interview on 2/16/21 at 5:45 p.m., staff member J stated she did not recall if she was aware resident #10 had a fall on 8/13/20 and would need to look at the documentation. She stated if she provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She could not recall giving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff member J stated if she did not document the conversation with the facility, then she may not necessarily remember. She stated she did rely on staff to document her recommendations in the resident's chart when she provided a phone order. A review of resident #10's EHR showed there was no documentation from staff member J regarding the fall on 8/13/20 or 8/14/20. Review of resident #10's chart did not show documentation of staff member J's recommendation for the resident after her fall on 8/13/20. During an interview on 2/16/21 at 11:22 a.m., NF1 and NF2 stated that based on phone records, she missed a phone call from the facility on 8/13/20 at 3:47 p.m. She stated they called the facility back at 3:49 p.m., and she spoke with staff member G. NF1 and NF2 said staff member G informed them resident #10 had fallen, and made it sound like the resident was not in any pain, and staff member G was not concerned of any fractures, but wanted to get an X-ray to be sure. NF1 and NF2 said they were not aware the ambulance was there to pick up resident #10, and had they been notified that the patient was in pain, and the facility thought the hip was broken, they would have had the patient sent to the hospital for an X-ray. NF1 said, based on staff member G's information, they decided to check with hospice. NF1 and NF2 stated they thought it would be best if resident #2 had an X-ray by the mobile imaging since they were told the resident was not in pain, and there was not a concern for fracture, and they did not want the resident shuffled around too much because she became very anxious when in a new place. NF1 and NF2 stated they thought the mobile X-ray was from the hospital in town and were never informed that the mobile X-ray only performed X-rays during certain times of the day. Had they known the mobile X-ray had to come from out of town, they would have just had the resident sent to the ER for evaluation. NF1 and NF2 stated they called the nursing home on 8/13/20 at 6:46 p.m., per their phone records, to check on resident #10. They were surprised to find out the resident had not yet been X-rayed, since they gave the approval for the X-ray at 4:07 p.m. NF1 said they then called hospice at 6:46 p.m., per their phone logs, and explained that the resident had not had an X-ray yet. NF1 and NF2 stated they were told by hospice that they had ordered the X-ray immediately after the fall, and facility should be getting that done. NF1 stated she then called the facility again at 8:35 p.m., per her phone logs, and was told the patient was resting comfortably and was not in any pain. They were told by staff member G that they were working on ordering the X-ray. NF1 and NF2 said had they had been informed that the mobile X-ray was coming from out of town, and that the facility had not been in contact with the mobile imaging company, they would never had made resident #10 wait until the next day. NF1 and NF2 said they felt they were not adequately informed of the situation in order to make an informed decision for resident #10. 2. Delay in Reporting of Significant Findings During an interview on 2/11/21 at 12:21 p.m., NF6 stated she was upset that the facility had not notified the provider of resident #10's hip fracture until the evening of 8/14/20, especially since the fall occurred on 8/13/20 around 3:00 p.m., and the patient had an obvious deformity of her right hip. Review of resident #10's Nursing Progress Notes, dated 8/14/20 at 7:35 a.m., showed, Res continues on neuro checks as ordered post fall. Neuros baseline without any changes. Res whimpered and cried during cares. Settled down and went back to sleep on right side. No other pain behaviors noted. Review of resident #10's Nursing Progress Note, dated 8/14/20 at 11:43 p.m., showed, X-ray results received via fax from [Mobile Imaging Company] at 1126 [11:26 a.m.]. Results faxed to Hospice at 1156 [11:56 a.m.]. [NF2] called facility for update on resident at about 1410 [2:40 p.m.]. [NF2] would like [Staff member J] to call at listed phone number to discuss options on where to go from here. [NF2] would like an ortho consult. [Staff member J] updated and will call facility when can. [Staff member J] called facility at 1800 [6:00 p.m.]. [Staff member J] updated on what [NF2] would like. [Staff member J] given [NF2] phone number to discuss options. [NF2] called the facility at 1920 [7:20] with the decision to send resident out to hospital d/t hospital can get ortho consult faster. [NF2] would like resident to finish eating before ambulance called. 1925 [7:25 p.m.] [staff member J] updated with decision of [NF2]. New orders: Send resident via ambulance to ER for evaluation and treat per family request. New orders put in eMAR. 1950 [7:50 p.m.] ambulance called, resident done eating per POA request. 2000 [8:00 p.m.] [hospital] called to update on resident. About 2015 [8:15 p.m.] ambulance arrived at facility with assist x 2. Ambulance staff given resident paperwork to give to hospital face sheet, POLST, Hospice paper, MAR/TAR. Ambulance left facility with resident at 2030 [8:30 p.m.] . During an interview on 2/17/21 at 10:00 p.m., staff member H stated it was the expectation of the facility that staff notify the ordering provider within an hour of receiving results with significant findings. He stated if the nurse was not able to get in touch with the provider staff were expected to try the on-call, notify administration, and/or call the emergency department. During an interview on 2/17/21 at 12:35 p.m., staff member G stated she contacted staff member J regarding the significant findings of resident #10's hip X-ray. Staff member G said significant findings, such as a fracture, should be reported immediately to the provider. If she were not able to contact the provider, she would notify the on-call provider. During an interview 2/16/21 at 7:45 p.m., staff member J stated she had a chance to review about the incident regarding resident #10 on 8/13/20. She stated she did remember the resident had a fall and fractured her hip. She said she had discussed the results of the X-ray with the family on 8/14/20. She said she recalled recommending surgical repair of the hip fracture for pain control, since the resident had dementia and would not be able to follow directions about not moving around. During an interview on 2/17/21 at 9:22 a.m., NF1 and NF2 stated by 8/14/20 at 2:19 p.m., they had not heard anything from the facility regarding the status of the patient and called the facility. They said they were surprised to find out the resident had not had an X-ray until around 10:00 a.m., on 8/14/20. NF1 and NF2 stated they asked that the provider call them with the test results as soon as possible. NF1 and NF2 stated they did not get any calls from hospice, the provider, or the facility again until the provider called them with the test results at 6:33 p.m., on 8/14/20, per their phone log. NF1 and NF2 said they waited so long to hear back from the provider on the results of the X-ray, that they started calling other providers in town to find out what they should do for the resident, since they had not heard back from the provider at the facility. They stated they did not know how bad the patient's hip was until they talked to staff member J at 6:33 p.m. They stated, had the facility made it clear, the facility thought the resident had fractured her hip, they would have had the resident sent immediately to the emergency roiagnom on [DATE], instead of making her wait until the next day. NF1 and NF2 said they did not feel they were provided adequate and complete information by staff member G in order for them to make the best decision for resident #10. NF1 stated she continues to have nightmares, and endless guilt thinking they could have done something for resident #10 earlier, instead they feel that the resident was in terrible pain and suffered greatly for those two days. Review of resident #10's Nursing Progress Note, dated 8/15/20 at 11:04 a.m., showed, Late entry: Resident's POA called to notify facility that resident had hip surgery with 3 rods placed. Made it through surgery fine and has a tentative discharge date from [hospital] of Monday, August 17, 2020. They will notify us if anything changes. A review of the facility's policy and procedure titled, Hospice Program, showed: - .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions . - 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual's needs. These include: c. Notifying the hospice about the following: 1. A significant change in resident's physical, mental, social, or emotional status . 3. A need to transfer the resident from the facility for any condition . d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day . A review of the facility's policy and procedure titled, Hospice Services and Facility Agreement, showed: - Policy: It is the policy of this facility to provide and/or arrange for services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility - 3. If hospice care is furnished in the facility through an agreement, the facility will: a. ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to timeliness of services . - 4. The written agreement(s) will set out at least the following: . e. A provision that the facility will immediately notify the hospice about the following: i. A significant change in the resident's physical, mental, social, or emotional status .

Based on interview and record review, the facility failed to protect 1 (#2) of 21 sampled residents from verbal abuse by a CN[NAME] Findings include: Review of the facility's incident report, dated 9/26/19, showed resident #2 had reported to CNAs that NF1 had abused him by having the gait belt too tight and swearing at him. Event occurred 9/24/19 sometime after dinner, not reported until this morning (9/25/19). (NF1) suspended pending investigation. Review of the facility's five-day investigation notes showed resident #2 was interviewed again and he stuck to his statement that (NF1) had swore at him. Roommate confirmed staff cursed at (resident #2). NF1 admitted she swore at him in her statement. No injuries. Verbal abuse substantiated . During an interview on 10/17/19 at 7:55 a.m. with staff members A and B, staff member B stated resident #2 had reported NF1 had cursed at him during the previous evening. Staff member A stated he started an investigation immediately, and the allegation was confirmed by both resident #2's roommate and NF1. Staff member A stated he notified the facility's regional nurse, district manager, and their Human Resources Department. Staff member B stated the facility provided in-service training's on abuse with all staff the day of the investigation. Staff member B said the facility attached the seven different types of abuse to staff's identification cards as an additional intervention. Staff member A stated in addition to the in-service abuse training which occurred 9/30/19 for all staff, the facility also required staff to complete an abuse training annually. During an interview on 10/17/19 at 9:26 a.m., resident #2 stated, (NF1) was mean. Resident #2 stated he had not had any conflicts with staff since. Review of resident #2's medical record showed an active [DIAGNOSES REDACTED]. Review of the facility's in-service abuse training sign-in was dated 9/30/19 and signed by all staff attendees. Review of NF1's file showed her last day of employment was 9/27/19. Upon hire, NF1 had completed all nursing aide competency training by 10/5/18, which included appropriate resident communication/rights and an abuse prohibition assessment. NF1's background check, which included an abuse registry, was completed 9/11/18. Review of the facility's policy, Abuse Prohibition, revised 11/28/17, showed: (Facility) will prohibit abuse .for all residents .Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability

Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary care and services to avoid constipation resulting in the resident experiencing pain, an inability to eat, and the resident stated she wanted to die, for 1 (#44) of 22 sampled residents. Findings include: Resident #44 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 9/17/18 at 2:49 p.m., resident #44 stated she was sick to her stomach and stated she had not had a bowel movement for five days. Resident #44 stated the staff gave her [MEDICATION NAME] but it was not working. She stated she had asked earlier for an enema and no one gave her one yet. Resident #44 was observed to have a distended abdomen. She pushed on her abdomen and stated it was hard and painful. She stated she could not eat anything, and her abdomen was hard and swollen. She said she was having abdominal pain and felt nauseated. She was seated in a recliner in a reclined position. Staff member M came in during the resident observation and interview and asked the resident if she wanted her Boost drink. The resident stated she was still sick to her stomach and had not eaten anything all day. The resident stated she had not had a bowel movement for five days. Staff member M told the resident she was going to check her record and would come back. Staff member M came back to the resident and asked her if she wanted to take some MOM. The resident told staff member M she wanted a suppository. Staff member M administered a suppository to resident #44. Resident #44 was tearful and cried when staff member M brought in the suppository and stated I just want to die honey. Staff member M reassured the resident she would help her. Staff member M stated resident #44 had a history of [REDACTED]. Review of resident #44's ADL record, under the section Bowel, showed she had not had a recorded bowel movement from 9/12/18 - 9/17/18. Review of the facility tracking form titled, Daily BM Tool, showed resident #44 did not have a documented BM from 9/12/18 - 9/17/18. Review of resident #44's MAR, for (MONTH) (YEAR), showed she was prescribed Senna Plus Tablet 8.6-50 mg one tablet by mouth two times a day for constipation, and [MEDICATION NAME] Powder 17 grams two times a day for constipation. Review of resident #44's MAR, for the month of (MONTH) (YEAR), showed resident #44 did not receive MOM or a Fleets enema for the entire month to include 9/17/18. The MAR indicated [REDACTED] Review of resident #44's Nurse's Notes from 9/12/18 - 9/17/18, showed her appetite was poor, with a complaint of her stomach hurting on 9/15/18 at 7:17 p.m. No entries showed nursing staff had assessed for bowel concerns or that resident #44 had not had a bowel movement. Review of resident #44's Nurse's Note dated 9/17/18 at 1:03 p.m., by staff member K, showed, Resident in poor mood this morning, was allowed to vent to CNE (sic) her concerns and she brightened up. Educated resident on importance of elevating leg, participating in PT and medication compliance. After lunch she was spitting small amounts of phlegm into basin. She denied any nausea at the time stating 'I am full.' Small amounts of phlegm spit into emesis basin. Skin pale pink and dry to the touch. Right leg elevated. Educated resident of the purpose of extra saliva and its actions. Received information well. Review of resident #44's Care Plan, with an initiation date of 4/30/18, showed a focus area that she was at risk for gastrointestinal symptoms or complications related to constipation with a [DIAGNOSES REDACTED].#44 would not develop GI complications, throughout the next review period listed as 9/9/18. Interventions included staff were to administer medications as ordered by the provider and to utilize bowel protocol as needed. There were no interventions included to monitor when resident #44 had a bowel movement or to monitor for constipation. Review of resident #44's medical record showed she had been sent to the emergency roiagnom on [DATE] for complaints of abdominal distention and pain. The emergency medical record showed resident #44 had a CT scan which showed findings of 1. Above average amount of stool throughout the entire colon which is diffusely mild to moderately dilated. No small bowel obstruction . The final impression was listed as, 1. Constipation, unspecified constipation type. During an interview on 9/17/18 at 3:13 p.m., staff member M stated she was not sure about resident #44's bowel movements over the weekend. Staff member M stated the process was to look at the ADL charting for documented bowel movements, and the BM Tool sheet that the nursing staff reviewed. Staff member M stated the night shift was supposed to review the documents, start the bowel protocol on their shift, and report to the day nurse. She stated, We may need to do a review of her (resident #44's) history and perhaps change her daily bowel program. We should have done a better job of monitoring on our part. During an interview on 9/18/18 at 9:10 a.m., staff member F stated the staff were to follow the protocol for residents who had not had a bowel movement for three days. She stated staff was to start with MOM, then a suppository, and then an enema. She stated if there were no results then the nurse was to call the resident's physician. Staff member F stated the CNAs followed the process for charting resident BMs. She stated the nurses were to review the documentation that the CNAs completed each shift, and monitor residents to ensure they have had a BM every three days. Staff member F stated they have a system for tracking resident BMs and the nurses failed to review and treat the resident on the third day in resident #44's case. During an interview on 9/19/18 at 5:39 a.m., staff member N stated the night shift staff was to review all resident records to see if they have had a bowel movement within three days. She stated she reviewed the ADL charting done by the CNAs for bowel movements that were recorded, and if the resident did not have a BM for three days, she would start the bowel protocol and administer MOM and would notify the next shift in report. During an interview on 9/19/18 at 8:51 a.m., staff member K stated she focused on the resident's issue with her throat and did not consider other issues at the time she assessed resident #44 on 9/17/18 at 1:03 p.m. Staff member K stated, The CNA's did their job and the nursing staff dropped the ball. Staff member K stated since resident #44 had an ongoing concern for constipation the documentation of her bowel movements should have been flagged in some way such as placing the need to check each shift on the MAR. She stated education of staff would be helpful to ensure staff were aware of the resident's history and need for close monitoring. Review of the facility form titled Standing Orders Template, under the area Constipation, showed: - If no bowel movement in three days, give milk of magnesia 30 ml PO x one dose at bedtime, - If no bowel movement within next shift, give [MEDICATION NAME] suppository PR x one, - If no bowel movement within two hours, give Fleet enema, - If no results from Fleet enema, call physician/advanced practice provider for further orders.

Based on observation, interview, and record review, the facility failed to ensure residents received supervision during a transfer, with the use of a gait belt, resulting in a resident's fall in which the resident sustained [REDACTED].#3); and, failed to implement and follow interventions to prevent a fall, which resulted in a resident having a head injury and dental injury, which required emergency treatment, for 1 (#7) out of 12 sampled residents. This has the potential to affect all residents who are at risk for falls and require supervision during transfers. Findings include: IMMEDIATE JEOPARDY On 9/13/17 at 11:25 a.m., staff members A and B were notified that an Immediate Jeopardy situation was identified for the area of Accidents and Hazards - F323, relating to falls. It was determined that the severity and scope was at the level of J. Upon removal of the deficient practice immediacy, the severity and scope would then be lowered to a G. The plan to remove the immediacy for Accident's and Hazards is located in F000 of the CMS 2567 document. Resident's identified with a (*) were included in the Immediate Jeopardy. *1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #3's Quarterly MDS, with an ARD of 5/1/17, showed the resident required the extensive assistance of one person who provided physical assistance for transfers, bed mobility, dressing, toilet use and personal hygiene. Resident #3's cognitive skills for daily decision making showed the resident was coded as being severely impaired. Review of resident #3's care plan, with a review date of 3/30/17, showed the resident was at risk for falls due to impaired mobility, cognitive loss, and lack of safety awareness with an initiation date of 11/7/14. One of the interventions listed included that staff would monitor the resident for an assist with toileting needs. The care plan did not reflect a focus area that addressed the resident's need for the required extensive assistance of one person to provide physical assistance for transfers, dressing, toileting, and personal hygiene. Review of resident #3's medical record reflected the resident experienced a fall in her room on 5/11/17 at 6:05 a.m. The event summary report reflected the resident had just gotten out of bed, and the CNA was going to take her to the bathroom. The summary of the investigation showed, Resident did not have gait belt on her and staff unable to intervene in fall. The resident was sent to the hospital for a higher level of care and treatment. Review of resident #3's hospital, final report, assessment, and plan, dated 5/11/17, reflected the resident had a pelvic fracture and a right femoral neck fracture. Surgical intervention was required, and the resident underwent [REDACTED]. During an interview on 9/11/17 at 10:12 a.m., staff member H stated she was the CNA assisting the resident at the time of the fall on 5/11/17 at 6:05 a.m. Staff member H stated it was the end of her shift and she had woken the resident to assist her with getting up for breakfast. Staff member H stated she assisted the resident to sit up in bed and then stand up from the bed. Staff member H stated that while the resident was standing next to her bed she went to the resident's closet to get her clothes. Staff member H stated that while she was at the resident's closet, the resident lost her balance, fell , and hit her head. Staff member H stated she went and got the nurse. Staff member H stated she should have taken more time with the resident and let her get her bearings. Staff member H stated she did not remember ever knowing if the resident required a gait belt. Staff member H stated, I'm still learning. I'm a new CNA. Staff member H stated a gait belt was used for residents who used a walker or for transfers. During an interview on 9/12/17 at 2:00 p.m., staff member J stated gait belts were used for people receiving therapies, or any time a resident needed assistance. During an observation on 9/13/17 at 6:40 a.m., staff member L, with physical contact, assisted resident #3 to sit up on the side of her bed. She placed the resident's slippers on, and then offered the resident her arm to help the resident stand up. The resident walked with a walker to the bathroom, with staff member L beside her, and staff member L's right hand and arm were behind resident #3's back. Resident #3 was assisted to sit and stand up from the toilet. She was assisted with removing her night clothes and changing into clean clothes. Resident #3 had gait belts hanging from the bathroom door, but these were not used during any of the transfers. Staff member L was also not wearing a gait belt. During an interview at that same time, staff member L stated that a gait belt was used when residents were difficult to walk. During an interview on 9/13/17 at 8:30 a.m., NF1 stated that anytime she worked with a resident who had specific needs, she told the CNAs that a gait belt was a must (needed) with any level of assistance. If a resident was independent, then the resident did not need one (gait belt). *2. Resident #7 was admitted to the facility on [DATE]. She was admitted with the [DIAGNOSES REDACTED]. Observation and Contributing Factors of the resident's fall, leading to the Immediate Jeopardy. During an observation on 9/11/17 at 12:20 p.m., resident #7 was sitting, at a centrally located table in the multi-purpose room, with worn slipper socks on the resident's feet. She was sitting with her walker to the right of her. During an observation on 9/11/17 at 12:44 p.m., resident #7 was ambulating herself, without her walker, from her designated seating placement in the kitchen, towards the exit of the dining room. She was going towards the nurses station. She was observed without staff assistance, and there was neither a gait belt on her, or used during the transfer and ambulation, as the resident was unattended, and not being supervised by staff. The resident had a fall. The staff were attentive to the resident after she fell , in which the resident's head made contact with the floor. The resident was bleeding from the mouth, and was laying on her right side. The staff called the ambulance, and the ambulance arrived at the facility at 1:05 p.m., to transfer the resident to the hospital. The resident's walker was observed sitting beside a piano, which was about five feet away from the resident. Interviews During an interview on 9/12/17 at 12:15 p.m., staff member B stated they wished they had more to say about preventing the fall that had occurred. Staff member B was unable to make any additional comments, in relation to the implementation of interventions, to prevent the resident's fall. During an interview on 9/12/17 at 1:45 p.m., staff member J stated that resident #7 did not have a gait belt on when the fall occurred. She stated when new fall interventions were implemented for falls, the interventions were put in a communication book for the staff, but management did not notify direct care staff when new resident information was added to the book. Staff member J stated there was a breakdown in communication between management and the direct care staff, and stated management was not out on the floor interacting with the residents, which made it difficult to know which fall interventions were implemented for the residents. Staff member J stated they were unsure if a gait belt had to be used for resident #7, but stated that the resident did not have a gait belt on at the time of her fall. Staff member J stated the resident usually got assistance with walking, and when the resident was sitting at the dining table, prior to the fall, she did have her walker to her right, but did not see if the resident was using her walker at the time of the fall. Staff member J stated they were unsure of what steps they should have taken to prevent the fall. During an interview on 9/13/17 at 7:15 a.m., staff member G stated resident #7 was unable to sit to stand very well. Staff member G stated that she had worked with resident #7, and they worked on transitions from sitting to standing. Staff member G stated that the resident's walking was ok, but the resident struggled with motor planning. The staff member stated she was surprised about the fall, because the resident usually had one hand on her walker because she was fearful of falling. Staff member G stated the resident was very predictable, and was not difficult to supervise. Staff member G stated she was surprised the resident took off walking in the dining room without her walker. Staff member G stated the resident may have been impatient waiting for staff. She stated the table situation was not good in the dining room, which was probably a contributing factor to the fall. Staff member G stated she believed the the fall in the dining room was probably avoidable, as staff had been available to assist the resident, but did not provide the supervision necessary for the resident. Review of resident #7's hospital discharge summary, dated 9/11/17, showed the resident had a swollen mid nose, large hematoma above the right eye and above the orbit, the left upper incisor was missing, and blood was in her mouth. The report stated she had a small laceration on the bridge of her nose and some bruising to her right hand; dorsally. The findings were listed as a closed fracture of the nasal bone, closed fracture of the tooth, and a facial contusion. The report showed: patient suffered a ground-level fall striking her face on the ground. NO reported loss of consciousness or altered mental state from baseline. She has a right forehead hematoma and right hand brushing. CT brain and C-spine unremarkable except for nasal bone fractures. The facility requested additional mobile imaging services on 9/12/17. Review of the contract company's Significant Findings, dated 9/12/17, showed resident #7 had a fracture to the third digit on the right hand, due to the fall the resident had on 9/11/17. Review of resident #7's care plan, with a print date of 9/14/17, showed the following interventions, related to falls and potential accidents or hazards for the resident: 1. Arrange resident environment as much as possible to facilitate ADL performance 2. Provide cueing for safety and sequencing to maximize current level of functioning 3. Monitor resident for weakness and unsteadiness and report as needed 4. Monitor and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, impulsivity 5. Nonskid footwear when resident is out of bed 6. Staff to assist resident to and from dining room as allows 7. Use gait belt and stand by assist when resident is ambulating with four-wheel walker (created on 9/6/17) 8. Check gripper socks prior to placing on resident on resident and if appear worn, replace with new ones (created on 9/12/17) The facility failed to utilize any of the fall interventions during the 9/11/17, during the observation in the dining room at 12:44 p.m., when the resident had the fall with the major injury. A review of resident #7's MDS assessment information showed: The Admission Assessment, dated 6/30/17, section C0500, showed a BIMS score of 5 out of 15 (severely impaired). - Showed the following ADL Self Performance and ADL Support Scores were coded as the resident needed extensive assist of two or more people for Bed Mobility, Transfer, and Toilet Use. - Showed the following ADL Self Performance and ADL Support Scores were extensive assist of one for the following sections: locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene. - No falls were identified in sections J1700 - J1900 The resident's 60 Day Assessment, with an ARD date of 8/18/17, showed section C0500 was coded with a BIMS score of 7 out of 15 (severely impaired). - Showed the following ADL Self Performance and ADL Support Scores were Extensive assist of two or more people on the following sections: bed mobility, transfer, toilet use. - Showed the following ADL Self Performance and ADL Support Scores were Extensive assist of one on the following sections: walk in the corridor, walk in room, locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene, and bathing. - No falls were identified in sections J1700 - J1900 Resident #7's Additional Falls included: Review of the facility falls report and nursing notes for resident #7 showed the following information: Fall #1 - 7/31/17: Resident #7 was found by the speech therapist on the floor next to her bed and wheel chair. The resident stated she tried to get up, and she had fallen out of bed. There were no injuries noted. The facility failed to identify a root cause for the resident's fall. Fall #2 - 8/8/17: Resident #7 was found on the floor next to her bed. The resident was in her wheel chair having dinner and attempted to self-transfer, resulting in her sliding to the floor. No injuries were noted. The facility failed to identify a root cause for the resident's fall. Fall #3 - 8/15/17: Resident was ambulating with her walker without assistance and went into the dining room. She went to the table she normally sat at. Activities witnessed her reach for her walker, and she fell . She hit her head on the book shelf, which caused a lump, noted on the left side. The facility failed to identify a root cause for the fall. Fall #4 - 9/1/17: Resident was ambulating in the dining room with a four-wheel walker. The resident lost her balance and fell on to her left side. The resident had no apparent injuries noted. On 9/6/17, the resident's care plan was revised to include: Use gait belt and stand by assist when resident is ambulating with the four-wheeled walker. The facility failed to identify a root cause for the fall. Fall #5 - 9/11/17: Listed above, as observed by the surveyor during the recertification survey. Review of resident #7's Fall Nursing Assessment, dated 7/2/17, showed a score of 15.0, which showed the resident had a Mild Fall Risk. Although requested, no additional Fall Nursing Assessments were provided by the facility showing resident #7 had been reassessed by nursing, after or between, the five falls.

Based on record review and interview, the facility Performance Improvement Program, comprised of management interdisciplinary team members, failed to adequately identify quality deficient practices, relating to falls, with and without injury, and failed to develop and implement plans to correct the deficient practices in a timely manner. This failure affected 2 resident's (#s 3 and 7), who were both included in the Immediate Jeopardy situation for F323-Accidents and Hazards, of 12 sampled residents. This failure also had the potential to affect other residents at risk for falls, or who had falls. Findings include: 1. Review of resident #3's care plan, with a review date of 3/30/17, showed the resident was at risk for falls. One of the interventions listed on the care plan included that staff would monitor the resident for assistance with toileting needs. The care plan did not reflect a focus area that addressed the resident's level of need for transfers, dressing, toileting, and personal hygiene. Review of resident #3's medical record reflected the resident experienced a fall in her room on 5/11/17 at 6:05 a.m. The event summary report reflected the resident had just gotten out of bed, and the CNA was going to take her to the bathroom. The summary of the investigation showed, Resident did not have gait belt on her and staff unable to intervene in fall. The resident was sent to the hospital for a higher level of care and treatment, due to the injuries sustained in the fall. During an interview on 9/13/17 at 3:20 p.m., staff members A, B, and C stated they held the Performance Improvement meetings every month, and the medical director was available in person and on the phone. They stated falls were discussed, to include in July 2017, where rounds, safety, communication, huddles, alarms, and notifications, were discussed. No QA plans were brought forth to show the facility had taken action on any concerns related to falls. During an observation on 9/13/17 at 6:40 a.m., staff member L, with physical contact, assisted resident #3 to walk with a walker to the bathroom, with staff member L beside her, and staff member L's right hand and arm were behind resident #3's back. Resident #3 was assisted to sit and stand up from the toilet. Resident #3 had gait belts hanging from the bathroom door, but these were not used during any of the transfers. Staff member L was also not wearing a gait belt. This observation showed the facility continued to transfer the resident without a gait belt, although she had fallen previously, and it was identified that the lack of a gait belt was a concern. This deficient practice, which was four months later, continued to put the resident at risk, although not identified, addressed, and corrected by the facility. Staff had received training on fall after the January 2017 IJ survey, but staff did not always anticipate the resident's needs for safety with transfers or fall safety. 2. During an observation on 9/11/17 at 12:44 p.m., resident #7 was ambulating by herself and was observed without staff assistance. The resident was not supervised, per the care plan, and had a fall. The resident sustained [REDACTED]. The medical record review showed the resident had multiple falls prior to this date, and the facility failed to identify the root causes of the falls, and adequately implement interventions in an attempt to prevent the falls (Refer to F323 - Accidents and Hazards relating to more information on resident #3 and #7). Review of resident #7's care plan, with a print date of 9/14/17, showed interventions related to falls and potential accidents or hazards for the resident. During the observed event on 9/11/17, the facility had not been utilizing the fall interventions identified for the resident. During an interview on 9/12/17 at 1:45 p.m., staff member J stated there was a breakdown in communication between management and the direct care staff, which made it difficult to know which fall interventions were implemented for the residents. Staff member J was unsure if a gait belt had to be used for resident #7. Review of a PI meeting outline and agenda, provided by the facility, for May, June, July, and August, 2017, showed the facility had included the incidence of falls in the meetings, to some capacity, but the facility was unable to provide evidence of any plans developed, actions taken, or monitoring completed, in an attempt to reduce falls with or without injury. The documentation failed to show the facility had attempted to identify trends or concerns relating to quality deficient practices for falls, for any identified concerns the facility may have had. A review of the facility's Fall Log with Injury, dated 9/13/17, showed the facility had 13 residents who had a total of 21 total falls with injury, from April 12, 2017 to September 13, 2017. A request was made for staff training documentation relating to fall management, which may have occurred after the initial training the staff received after the IJ in January 2017. The facility provided an In-Service Sign in Sheet and an agenda itinerary. The Meeting Agenda was dated 6/19/17, and included one statement relating to falls, which was, Falls when management are here. The information, was not inclusive of how the facility continued to educate staff, monitor staff on an ongoing basis, or what plans or interventions were implemented to reduce falls with and without injury. During an interview on 9/13/17 at 3:00 p.m., staff member B stated the facility met monthly, and safety had been discussed, along with other areas of care. The facility would have a goal to look at the root cause of an issue, and during the meeting, the prior plan of correction (from the January Immediate Jeopardy survey), was reviewed. During an interview on 9/17/17 at 11:40 a.m., staff member B stated he had discussed falls in the QAPI meetings, but he really had been focusing on skin issues at the facility, and stated he should have spent more time on the falls.

Based on record review, observation, and interview, the facility failed to have effective systems to utilize and manage resources to maintain the residents' highest practicable well being, and failed to adequately assess, monitor, prevent, and implement systems and interventions for the overall infection control program, the prevention and spread of a gastroenteritis outbreak which occurred twice, a lice outbreak, an increase in [MEDICAL CONDITION] skin infections, abuse and neglect concerns relating to the identification, reporting, investigation, and protection of the resident, and accident's and hazards, specifically falls. These failures had the potential to affect all residents at the facility, and were found to have affected specifically 21 (#s 3, 4, 6, 7, 8, 10, 12, 13, 15, 17, 19, 20, 21, 22, 23, 25, 29, 31, 32, 36, 37) of 38 sampled residents. IMMEDIATE JEOPARDY On 1/31/17 at 4:20 p.m., staff members A and B were notified that an Immediate Jeopardy situation was identified in the areas of Infection Control, Accidents and Hazards, Abuse and Neglect, and Administration. The Severity and Scope of the Immediate Jeopardy for Administration was determined to be at the level of a L. Upon the removal of immediacy for the concerns, the severity and scope would be I. A summary of the plan to remove the immediacy for the areas identified as Immediate Jeopardy is located in F000 of the CMS 2567 document. All resident's identified with the (*) in the deficiencies for Infection Control, Accidents and Hazards, Abuse and Neglect, and Maintaining the Highest Practicable Well Being, directly were affected, and included, in the resident sample for F490 - Administration. Findings included: Review of the facility daily meeting, which is when concerns were discussed for the facility events, and resident issues, showed on the Attendees List for December 2016, and January 2017, that staff member A attended the meetings two times in two months. Staff member A provided direct oversight to all facility employees, oversight of the use of policies and procedures, and oversight of the systems utilized at the facility, to include the provision of resident care. Staff member A was a licensed RN, and on occasion provided clinical services to the residents at the facility. During an interview on 2/2/17 at 8:40 a.m., staff member T stated the interdisciplinary team did not take notes during the daily meeting. This failure did not allow the facility to provide documentation on areas of concern relating to the Immediate Jeopardy areas of concern, or show that areas of concern had follow up completed when they were discussed. During an interview on 1/26/17 at 10:40 a.m., staff member B stated she did not know the specifics of staff member A's job. She stated he usually stayed in the business office most days. She stated he did support her decisions. Staff member B's position provided direct oversight and supervision to all nursing staff, and oversight of resident care and services, under the supervision of staff member A, and her duties included the management of the care systems at the facility. During an interview on 1/26/17 at 1:00 p.m., staff member A stated he did not know why he didn't attended the morning meeting at the facility. He stated staff member B kept him informed regarding facility issues. The following concerns were identified relating to the oversight provided by staff member A and B, which were relayed by the staff member's during the interview. - Staff member A stated he was well aware of the lice outbreak, and had provided assistance with treatment the lice. Although staff member A had this knowledge, further action was not taken on the outbreaks by staff members A or B. -Staff member A stated he assumed lice was treated over and over. Staff member A asked to review the lice policy provided to the surveyors, and stated, If it was not documented, it was not done when discussing steps to prevent the spread of the lice. - Staff member A was not aware of the extent of the gastroenteritis outbreaks at the facility, and not aware there were two outbreaks. Staff member B had not identified the extent of the outbreaks, or ensured adequate clinical systems were in place for the prevention of the spread of the infections. -Staff member A did not know if the nurses followed or used [MEDICAL CONDITION] algorithm for infections, provided by the corporation. Staff member A stated he worked as a nurse on the floor on occasion, mostly at night, and staff member B stated the algorithm documents were located in the front of the nursing documentation book (MAR/TAR), for each nurse to use. F224 Abuse and Neglect: The concern relating to the failure of facility administration to operationalize, and provide oversight and direction for the prevention of abuse, neglect, and psychological harm for the resident's at the facility, and by the facility staff, included: restricting, and threatening to eliminate smoking, which was used to assist with controlling a resident's behaviors, and the resident had a history of [REDACTED]. to smoke, and try to hurry and get through the care, which was found to not be in her best interest. The resident had a compromised resipiratory status, which was neglected by staff, and resulted in the resident being sent out the hospital, for 1 (#8); failed to provide necessary care for the resident's skin, and nursing staff provided treatment's which were not authorized by the physician, and resulted in pain for the resident, for 1 (#4); failed to prevent, report, and investigate an allegation of abuse for 1 (#13); failed to prevent, and intervene in an abusive event that was witnessed, where a resident was being forced to take medications, for 1 (#10). Due to facility administration directly being involved with the oversight of the abuse and neglect prevention program at the facility, the failure of administration, had the potential to affect all residents at the facility. During an interview on 2/1/17 at 2:50 p.m., staff member B stated the Ombudsman did an abuse and neglect in-service in April 2016. During an interview on 2/2/17 at 10:56 a.m., the Ombudsman stated she had not been to the facility to in-service staff on abuse and neglect. The facility had not been able to provide educational information relating to the education of abuse and neglect for the staff for 2016. Record review of two personal files for volunteers at the facility, failed to show evidence of abuse and neglect training. During an interview on 2/1/16 at 10:30 a.m., staff member BB stated he did not recall the last abuse and neglect training, and had direct resident contact regularly. F309 - Maintaining Highest Practicable Well Being: It was found that timely interventions were not implemented for pain and distress for 2 (#s 3 and 7); and the facility failed to provide appropriate and timely skin treatments, causing skin conditions to decline, and become infected, for 4 (#s 4, 17, 22, and 36); failed to assess signs and symptoms [MEDICAL CONDITION] and pneumonia that led to a hospitalization and death for 1 (#6), and failed to effectively manage pain for 1 (#18). Due to facility administration directly being involved with the oversight for maintaining the highest practicable well being for the residents at the facility, the failure of administration had the potential to affect all residents at the facility. F323 - Accidents and Hazards, relating to falls: A review of the facility's Fall Log, dated 1/1/16 to 1/30/17, showed the facility had 240 total falls, 50 from sampled residents. During an interview on 1/25/17 at 2:40 p.m., staff member A stated residents were assessed for falls on admission, and quarterly. He stated reducing falls was a tough one, and We can't restrain residents, and they have the right to fall. Review of the Facility Fall Log showed the facility had 50 falls from the 38 sampled residents, from November 2016 to January 2017, at the time of the complaint survey. It was found many of the falls lacked evidence of new, modified or appropriate interventions, and adequate root cause analysis reviews were not completed on the numerous falls, to include repeat falls for many of the residents, and many of the falls included injuries such as skin tears, and one resident with a clavicle fracture. (Refer to F323). Review of the PI (Quality Assurance) meeting Outline notes, provided by the facility, showed the facility had discussed historical data about falls, but the facility had not been able to provide any plans or measures taken for the prevention of falls, or documentation to show the facility had identified patterns or trends relating to falls in order to prepare to develop a plan for the prevention of falls. F441 - Infection Control: Facility administration was found to be directly involved with the oversight and maintenance of the infection control program for the prevention of infections. It was found that the facility wide program, was not adequately meeting the needs of the residents or regulatory requirements, in the areas of: preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and other services. The facility failed to address and act on the prevention of the spread of a [MEDICAL CONDITION] in a timely manner. [MEDICAL CONDITION] spread to multiple residents and staff members. The facility failed to utilize isolation precautions in a timely manner, and provide education to the residents and staff. This failure affected 15 (#s 7, 8, 10, 12, 15, 17, 19, 20, 22, 25, 29, 32, 36, and 37) residents with nausea, vomiting, and diarrhea, out of 38 sampled residents. A second outbreak of the [MEDICAL CONDITION] occurred, and the facility continued to fail to identify, track, and implement interventions for the residents and staff affected with the nausea, vomiting and diarrhea, which affected at least 8 (#s 7, 10, 12, 19, 22, 25, 29, and 32) residents of 38 sampled. [MEDICAL CONDITION] had the potential to increase the risk of dehydration, and one resident (#19) had an outcome of dehydration, and falls, relating to the [MEDICAL CONDITION]. The facility also failed to identify the type of lice, appropriately treat, prevent, and provide education to the resident's and staff on the prevention, risk factors, and spread of head lice. This affected to 4 (#s 4, 15, 29, & 31) out of 38 sampled residents, and one staff member. And, the facility failed to educate and prevent a staff member from working with an identified infected wound, during the provision of resident care. The staff member was identified to have provided wound care to the residents while the infected wound was present. This failure had the potential to affect all residents at the facility receiving care from the staff. Due to facility administration directly being involved with the oversight for the prevention of infections, and provided daily monitoring through means of communication, report reviews, and direct hands provision of care, the failure of administration had the potential to affect all residents at the facility. A review of the infection control documentation, and individual resident records, for November 2016, showed at least 6 residents with a [DIAGNOSES REDACTED]. For the concerns relating to the gastroenteritis outbreaks, record review showed 30 of the 38 residents at the facility were affected. Both staff member A and B had not attempted to identify patterns or trends, or the severity of the outbreaks at the facility for prevention efforts, or had education been provided to the staff, using the facility policies and procedures, or CDC guidelines, for the outbreak preventions. A review of the facility's Gastroenteritis Intervention Tiers showed the following was not completed: -Determine if an outbreak actually is beginning; check charts and look for other cases on unit or in the rest of the building. Initiate the Outbreak Investigation Summary tool. -Post signs for visitors alerting them of the gastrointestinal outbreak and discourage visiting until outbreak is resolved. -Notify local/state Department of Health per state regulation. Utilize the Structured Talking Points in conjunction with the VPMA to relay needed information. -Notify Department of Health field office and Area on Aging/Ombudsman per state regulation of disruption of services. -Close all group activities, e.g., dining room, Rehab gym, beauty shop, etc. -Attempt to dedicate the use of personal care equipment whenever possible. At a minimum, clean and disinfect equipment between each patient use. -Per CDC, instruct ill employees to stay home for 48 hours after last symptoms. -Environmental services director should observe staff clean a room to ensure proper cleaning/disinfecting procedures are being followed. -Refer to Environmental Guidelines with an emphasis on the use of sodium hypochlorite product specified on the (corporate name) formulary (i.e., Clorox Dispatch). -For Centers not using a microfiber cleaning system, clean affected patient rooms last. Affected patient rooms should be cleaned twice a day. -Environmental services should complete the Discharge/Turnover checklist when a patient is taken off precautions -Center can resume normal routines (e.g., open dining room, rehab gym) in 72-96 hours after last patient/staff symptoms. -Dietary: Since a noro-[MEDICAL CONDITION] can be food borne, it is essential that Dietary staff are maintaining optimal cleaning standards and hand hygiene practices. Review the following and educate and observe. During an interview on 1/31/17 at 12:55 p.m., staff member A stated that it was becoming clear that the facility did not document the actions that were taken to take care of the lice, and that no education occurred. He relied on staff to let him know about the spread of infection, and staff member B would notice a trend. He also stated the facility did not review their policies and procedures on a regular basis, but assumed that somebody at the corporation did that regularly. Review of the PI (Quality Assurance) meeting Outline notes, provided by the facility, showed: 3. a. Infection control Active PI plans - 1 UTI, 2 skin and 2 eye infections to be claimed 5. Quality care a. Active PI plan - skin issues and [MEDICAL CONDITION] e. Risk management trends - falls (Reviewed RMS long, reviewed residents with multiple falls, reviewed for injuries.)

Based on interviews, observations and record reviews, the facility failed to maintain an infection control program for the prevention of infections, which included: preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and other services. The facility failed to address and act on the prevention of the spread of a gastrointestinal virus in a timely manner. The virus spread to multiple residents and staff members. The facility failed to utilize isolation precautions in a timely manner, and provide education to the residents and staff. This failure affected 15 (#s 7, 8, 10, 12, 15, 17, 19, 20, 22, 25, 29, 32, 36, and 37) residents with nausea, vomiting, and diarrhea, out of 38 sampled residents. A second outbreak of the gastrointestinal virus occurred, and the facility continued to fail to identify, track, and implement interventions for the residents and staff affected with the nausea, vomiting and diarrhea, which affected at least 8 (#s 7, 10, 12, 19, 22, 25, 29, and 32) residents of 38 sampled. The virus had the potential to increase the risk of dehydration, and one resident (#19) had an outcome of dehydration, and falls, relating to the gastrointestinal virus. The facility also failed to identify the type of lice, appropriately treat, prevent, and provide education to the resident's and staff on the prevention, risk factors, and spread of head lice. This affected to 4 (#s 4, 15, 29, & 31) out of 38 sampled residents, and one staff member. And, the facility failed to educate and prevent a staff member from working with an identified infected wound, during the provision of resident care. The staff member was identified to have provided wound care to the residents while the infected wound was present. This failure had the potential to affect all residents at the facility receiving care from the staff member. Findings included: IMMEDIATE JEOPARDY On [DATE] at 4:20 p.m., staff members A and B were notified that an Immediate Jeopardy situation was identified in the area of Infection Control. The severity and scope was found to be at the level of L. Upon determination of the removal of immediacy, the severity and scope would be at the level of I. A summary of the plan to remove the immediacy related to infection control has been included in F000 - Initial Comments, of the CMS 2567. All resident's affected by the deficient practices relating to Infection Control, and the prevention of the spread of infections, were identified as involved in the Immediate Jeoparty situation. 1. Lice (Pediculosis Capitus) During an interview on [DATE] at 10:00 a.m., staff member B stated resident #4 was the only resident with lice. The staff member stated the resident got the lice from a stuffed animal, which had been brought into the facility. During an interview on [DATE] at 8:45 a.m., staff member Z stated an employee came into the facility, and worked, and the staff member had head lice, which spread to 2 or 3 residents. She stated there were standing orders in place for the residents at the facility for the treatment of [REDACTED]. A record review of the facility's Standing Orders, provided on [DATE], showed Lice treatment upon discovery check resident in 7 days, repeat as instructed per direction of box, check again in 7 days. The orders did not include documentation for the use of coconut oil for the treatment of [REDACTED]. On [DATE], staff member A provided a copy of the standing orders, signed by the physician on [DATE]. During an interview on [DATE] at 8:50 a.m., staff member L stated resident #4 came to the facility around Thanksgiving, and the resident had lice. The staff member thought the resident got the lice from her stuffed animal. The resident was treated for [REDACTED].#15 and #29) got head lice. Staff member L stated a couple moved into the facility over the summary, and their home had lice in it. The residents were treated for [REDACTED]. She stated that the facility checked every resident after the lice was found on resident #15, but the checks were not documented in the clinical records of the residents. During an interview on [DATE] at 5:25 p.m., staff member Q stated she had not received infection control education in a long time. She stated she was aware three residents had lice but did not know which residents had the head lice. Staff member Q stated the management team was not communicating which residents had the head lice. She stated she was not checked for head lice. During an interview on [DATE] at 6:07 p.m., staff member R stated she was aware of three residents with lice (#s 4, 15, and 31). She stated she attended an infection control class in [DATE]. She stated she was treated for [REDACTED]. When treated the first time for head lice on [DATE], she was in the residents' shower. The staff member then worked the remaining portion of her shift. Staff member R stated she arrived to work on [DATE], and was sent home. She was then called back to work. During a follow-up interview on [DATE] at 6:13 p.m., staff member B stated the facility had three residents with head lice but she could not recall who the residents were. She stated one staff member was devastated that she had brought lice into the building. During an interview on [DATE] at 2:45 p.m., staff member H stated that she was aware of three residents with head lice. She stated the floor nurse had started weekly head checks on residents for lice. The staff member stated the facility had also started to treat those residents with coconut oil. During an interview on [DATE] at 10:00 a.m. staff member C and D stated the following times were when the residents, and the staff member, had lice: - Resident #4: [DATE] - Resident #15: [DATE] - Resident #29: [DATE] - Staff member R: [DATE] and [DATE] (did not correlate with date provided by staff member treated) Staff member C and D did not mention resident #31 as having the head lice. Staff member C and D stated the facility initiated lice checks every Friday when the residents had their skin checked. Staff member C stated the facility administration decided to keep the lice concern quiet from other staff and family members because they didn't want anyone to panic. She stated that she did not provide education to the staff related to head lice. Staff member C stated she had not reviewed the CDC guidelines for treating and preventing the spread of head lice. Staff member D stated she sent staff member R home on [DATE], and then had taken the lice treatment to the staff member's house for completion of the treatment. During an interview on [DATE] at 6:20 p.m., staff member H stated the resident's MAR/TAR did not include documentation of any lice treatments provided. The nursing staff only found out about the lice treatments if it had been discussed during the verbal report for shift change. During an interview on [DATE] at 12:55 p.m., staff member A stated it was clear the facility did not document the things that were done to take care of the lice, and the facility did not educate the staff. He stated if the facility felt the situation was an epidemic then they would report the lice to the appropriate departments. He stated he relied on the staff to let him know about the spread of infections. During an interview on [DATE] at 1:25 p.m., staff members A and B stated they decided to trial coconut oil on the residents with head lice because a staff member had success with treating the staff member's children with the coconut oil at home. The facility had not reviewed the CDC guidelines for head lice. Staff member A stated he assumed lice was treated over and over. Staff member A asked to review the lice policy provided to the surveyors, and stated, If it was not documented, it was not done when discussing steps to prevent the spread of the lice. Staff member B stated she felt the facility did the best they could under the circumstances. During an interview on [DATE] at 10:00 a.m., staff member V stated she was made aware of the lice in [DATE], and she did not know about them earlier. During an interview on [DATE] at 8:00 a.m., resident #15's family member stated she was not notified of the resident having lice. A review of the clinical records for resident #15 and #29 lacked evidence for documentation relating to the head lice. A review of the clinical records for resident #4, 15, 29, and 31, lacked evidence for any documentation relating to the treatment for [REDACTED]. A review of the facility's Infection Control Reporting Form - Skin, showed the following documents were not completed thoroughly, accurately, or consistently for the monitoring of the spread of the lice: a. Resident #4 - admitting [DIAGNOSES REDACTED]. - Skin infection: Lice - Contact precautions started: ,[DATE] stopped: ,[DATE] - Complete 215 strip & spray - Recheck: ,[DATE] - The lice were healthcare acquired - Signed by staff member C, and dated [DATE] Resident #4 was verified to have lice in [DATE], which was not included on the infection control reporting form. Contact precautions had not been documented as in place at that time for the prevention of the spread of the lice. b. Resident #15 - The admitting [DIAGNOSES REDACTED].>- Skin infection: Lice - Contact precautions started: ,[DATE] stopped: ,[DATE] - Complete 215 strip & spray - Recheck: ,[DATE] - The lice were healthcare acquired - Signed by staff member C, and dated [DATE] Resident #15 had admitted to the facility with the lice, which was not documented on the infection control logs during that time period. Contact precautions had not been documented as in place at that time for the prevention of the spread of the lice. c. Resident #29 - admitting [DIAGNOSES REDACTED]. - Skin infection: Lice - Antibiotic treatment: Lice 1x - Contact precautions started: ,[DATE] stopped: ,[DATE] - Complete strip room, spray ,[DATE] - Recheck: ,[DATE] - The lice were community acquired and healthcare acquired - Vector found ,[DATE] - Signed by staff member C, and dated [DATE] - [DATE] d. Resident #31 - admitting [DIAGNOSES REDACTED]. - Skin infection: not filled out - Contact precautions: no dates filled out for starting or stopping precautions - Recheck: ,[DATE] - Community or healthcare acquired was not filled out. - Signed by staff member C, and dated [DATE] A review of the facility's Infection Control Monthly Line Listing, showed the following: a. Resident #4 - admitted : [DATE] - Date onset: [DATE] - Type of symptoms/Diagnosis: [REDACTED].>- Possible stuffed animal [DATE] - MD notified: ,[DATE] b. Resident #31 - MD notified: ,[DATE] - Recheck: ,[DATE] - Infection resolved: ,[DATE] c. Resident #15 - MD notified: ,[DATE] - Recheck: ,[DATE] - Infection resolved: ,[DATE] d. Resident #29 - MD notified: ,[DATE] - Recheck: ,[DATE] - Infection resolved: ,[DATE] The form also showed: [MEDICATION NAME], complete 215 strip and spray, all residents and staff checked, no more, recheck on ,[DATE]. The form did not have accurate dates, product names, the treatments completed with coconut oil, or tracking of the lice. The form lacked evidence relating to resident #31. A review the facility's Pediculosis (Body, Head, Pubic Lice) Policy showed the following: - The purpose of this policy is to adequately treat cases of pediculosis and prevent transmission to others. - Explain all treatments and precautions to residents and family. - Obtain order and implement treatment for [REDACTED]. - Apply treatment per manufacturer's instruction. - Use contact precautions until 24 hours after treatment is administered. - Disinfect hair brushes, combs, or other items that have been in contact with infested areas with Environmental Protection Agency approved, hospital grade, germicidal solution, and hot water, then soak in [MEDICATION NAME] (rubbing) alcohol for 15 minutes. - Clean bed and mattress with germicidal solution. - Treatments on medication administration record. - Document resident's response to treatment. - Document completion of all activities to eliminate infestation - Plan for post treatment monitoring on resident's service plan 2. Gastroenteritis A review of the facility's Gastroenteritis: Data Collection Line Listing, showed 10 sampled residents (#s 7, 8, 12, 15, 17, 19, 20, 32, 36, & 37) out of a total of 22, were documented as having diarrhea, vomiting, and/or nausea dating from [DATE] - [DATE]. Record reviews and interviews, showed the facility also had a gastroenteritis outbreak from [DATE] - [DATE]. The second outbreak was not identified by the facility, therefore, no tracking, interventions, or evaluations were completed for those residents affected. At least 8 (#s 7, 10, 12, 19, 22, 25, 29, 32) of 38 sampled residents had diarrhea, nausea, vomiting, or a temperature during this time period. In addition, 4 resident's (#s 7, 12, 19, and 32) had the gastroenteritis during both outbreaks. During an interview on [DATE] at 1:00 p.m., staff member A stated that he was not aware the facility had any concerns with diarrhea, nausea, or vomiting in November or December of 2016. During an interview on [DATE] at 3:00 p.m., staff member H and staff member Y stated the facility staff did not utilize protective gowns during the gastroenteritis outbreak. They stated the staff did not always wear gloves when providing resident care. Neither staff member had a resident who was in isolation during the outbreaks. Both staff members stated they did have diarrhea during the periods of the outbreaks at the facility, and had worked through their illness. They did not go or stay home for 72 hours after their last symptom of the diarrhea had been exhibited. During an interview on [DATE] at 8:45 a.m., staff member B stated she was unsure how many residents had gastroenteritis but the resident's stayed in their rooms and received clear liquids. She stated that staff member C tracked the number of these resident's. During an interview on [DATE] at 10:20 a.m., staff member B stated they did have a 24-hour bug but it only lasted 24 hours. She stated she talked to corporate employees about the gastroenteritis, and they requested she follow the corporate Gastroenteritis Intervention Tiers. However, by the time she talked to the corporate employees about the gastroenteritis, the concern had already ended. She stated that residents were not in isolation when ill, and they were free to eat at the dining room. The resident's and staff did not wear protective gloves or gowns, and the facility did not contact the county health department to report the outbreak. Staff member B stated she did not notify visitors to the facility, or families of the residents, about the gastroenteritis. She did not provide any education on the prevention of the virus. She did not review the CDC guidelines to ensure appropriate prevention efforts were taken. Staff member B stated that one staff member was allergic to bleach, so the facility did not use bleach to clean the public areas (handrails, door knobs, hallways, etc.) of the facility, but they did try to use bleach in the resident rooms. The residents were not isolated when they had the virus, and roommates were not given an option to move to another room to prevent further spread of the infection. A review of the facility's Gastroenteritis Intervention Tiers showed the following had not been completed, regarding the operationalization of the facility policies: - Determine if an outbreak actually is beginning; check charts and look for other cases on unit or in the rest of the building. Initiate the Outbreak Investigation Summary tool. - Post signs for visitors alerting them of the gastrointestinal outbreak and discourage visiting until outbreak is resolved. - Notify local/state Department of Health per state regulation. - Notify Department of Health field office and Area on Aging/Ombudsman per state regulation of disruption of services. - Close all group activities, e.g., dining room, rehab gym, beauty shop, etc. - Attempt to dedicate the use of personal care equipment whenever possible. At a minimum, clean and disinfect equipment between each patient use. - Per CDC, instruct ill employees to stay home for 48 hours after last symptoms. - Environmental services director should observe staff clean a room to ensure proper cleaning/disinfecting procedures are being followed. - Refer to Environmental Guidelines with an emphasis on the use of sodium hypochlorite product specified on the (corporation name) Health Care formulary (i.e., Clorox Dispatch). - For Centers not using a microfiber cleaning system, clean affected patient rooms last. Affected patient rooms should be cleaned twice a day. - Environmental services should complete the Discharge/Turnover checklist when a patient is taken off precautions - Center can resume normal routines (e.g., open dining room, rehab gym) in ,[DATE] hours after last patient/staff symptoms. - Dietary: Since noro-like virus can be foodborne, it is essential that Dietary staff are maintaining optimal cleaning standards and hand hygiene practices. During an interview on [DATE] at 11:45 a.m., resident #15 stated she had diarrhea recently. She continued to come to the dining room and used hand sanitizer, which was in her pocket. During an interview on [DATE] at 12:20 p.m., staff member C stated she did not keep any data for the outbreak on gastroenteritis at the end of [DATE]. She stated the staff used wipes on the residents' hands, before and after meals. She did not provide education on when to use soap and water versus hand sanitizer. During an interview on [DATE] at 12:25 p.m., staff member G stated she got diarrhea right after Christmas in 2016. She stated the CNAs use the wipes to wash off the residents' hands, and it did not seem to get all the stuff off. Staff member G stated the CNAs should be using soap and water. During an observation on [DATE] at 2:25 p.m., staff member AA walked out of room [ROOM NUMBER], into the shower room, and did not use hand sanitizer. She then walked out of the shower room, into room [ROOM NUMBER], and did not use hand sanitizer. She then walked out of room [ROOM NUMBER], and entered room [ROOM NUMBER], and did not use hand sanitizer. The staff member then walked out of room [ROOM NUMBER], and used the hand sanitizer. During an interview on [DATE] at 2:30 p.m., staff member AA and staff member O stated they used the hand sanitizer every time they exited a room, and after being in three resident rooms they needed to wash their hands with soap and water. The staff members stated they did not know when they should use soap and water instead of hand sanitizer. During and interview on [DATE] at 11:10 a.m. staff member C stated she did not provide one to one education to the staff, document education provided, or other interventions relating to infection control practices. She stated staff currently put notes (form of communication) in a box if a resident had diarrhea. She did not contact the county health department for assistance. During an interview on [DATE] at 12:20 p.m., staff member I stated resident #22 threw up in his room about 3 weeks ago, close to Christmas time. This was not documented in the resident's clinical record, or on any of the facility documentation reviewed. During an observation on [DATE] at 9:50 a.m., staff member W was cleaning the hand rails in the hallway. When asked what cleaning supply she was using she stated window cleaner, because I just cleaned a window. The window cleaner was not a recommended cleaner relating to the disinfection of the facility. 3. Skin Infection - Employee Related During an interview on [DATE] at 9:10 a.m., staff member B stated if someone had an open, infected wound, and the staff member did not keep the wound covered, then this increased the risk for spreading the infection. During an interview on [DATE] at 2:00 p.m., staff member C stated she did not provide any education to staff member G, who had worked with the infected wound that was opened. She stated that the staff member should know what to do with an open, infected wound. She did not document when the staff member had the wound, and stated staff member B would know that time frame. During an interview on [DATE] at 2:01 p.m., staff member B stated staff member G did not work during the time her wound was open and infected. She stated she had a doctors note to stay home. During an interview on [DATE] at 2:05 p.m., staff member G stated she had an infected wound two times on her hand, which was open. This was at the beginning of [DATE]. She took antibiotics two separate times for the infection. Staff member G stated she did work during the time that her wound was open. She stated she started working with the wound covered but this caused the wound to be too wet, and the infection was not healing well, so she took off the covering. She stated that she just wore gloves when she handled the residents' pills. 4. Resident Infections - Cellulitis A record review of the Progress Notes for the following resident's, showed the resident's were identified to have a cellulitis infection. The resident's were housed in close proximity, showing a pattern related to the concern with the failure to prevent infections: - Resident #6: [DATE], room [ROOM NUMBER] - Resident #28: [DATE], room [ROOM NUMBER] - Resident #22: [DATE], room [ROOM NUMBER] - Resident #23: [DATE], room [ROOM NUMBER] - Resident #27: [DATE], [DATE], [DATE], room [ROOM NUMBER] - Resident #3: [DATE] - [DATE] (expired [DATE] related to sepsis), room [ROOM NUMBER] - Staff member G: Beginning of December During an interview on [DATE] at 8:45 a.m., staff member Z stated she did not order cultures for the cellulitis infections, or residents wounds. She stated the cultures would always come back positive. The facility did not attempt to obtain adequate information for the treatment of [REDACTED]. During an interview on [DATE] at 4:10 a.m., staff member NF1 and staff member NF2 stated providing the correct antibiotic for wounds and cellulitis infections would be difficult to do without culturing the wound.

Based on record review, interview and observations, the facility failed to implement individualized interventions to reduce the risk and number of falls, based on the resident's history with falls, and individualized risk factors. The facility failed to assess the residents intervention of a bed alarm for effectiveness as the resident had been ambulating in the hallway for resident 1 (#11); facility failed to assess a resident for a gastrointestinal illness, that led to dehydration, that led to weakness that had resulted in a fractured clavicle for resident (#19); facility failed to provide adequate supervision for a resident with a history of repeated falls, that resulted in skin abrasions, and later a skin infection for 1 (#22); facility failed to provide root cause analysis to provide resident specific interventions, to prevent further falls, and the resident continued to have future falls, and had been hospitalized for [REDACTED].#31), and failed to follow the care plan for falls by having a foot pedal on the wheelchair, the residents foot got caught under the wheelchair, which resulted in a fall causing a skin tear that had become infected for 1 (#7) out of 38 sampled residents. Findings include: IMMEDIATE JEOPARDY On 1/31/17 at 4:20 p.m., staff members A and B were notified that an Immediate Jeopardy situation was identified for the area of Accidents and Hazards, relating to falls. It was determined that the severity and scope was a level of K. Upon removal of the immediacy for the concerns identified, the severity and scope would be a H. The plan to remove the immediacy for Accident's and Hazards is located in F000 of the CMS 2567 document. Resident's identified with a (*) were included in the Immediate Jeopardy. *1. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a BIMS score of 6, severely impaired, documented on his most recent MDS assessment. Review of the facility's Fall Log, dated 1/1/16 to 1/30/17, showed resident #19 had fallen on the following dates: -3/9/16 at 2:30 p.m., in the resident's room, no injuries sustained -3/9/16 at 8:30 p.m., in the resident's room, no injuries sustained -11/30/16 at 4:30 a.m., in the resident's room, sustained a skin tear -12/30/16 at 7:30 a.m., in the resident's room, which resulted in a fractured clavicle Review of the facility's RMS - Event Summary Reports for resident #19, for November and December 2016, showed the following: -11/30/16 at 4:30 a.m.; The resident had fallen in his room and sustained a skin tear to his right forearm. There were no preventive measures put in place prior to the fall. The facility staff were to ensure the resident used his call light before he would get up out of bed. Documentation showed the resident had poor safety awareness prior to the fall. The report had been completed on 12/6/16, 7 days after the fall. -12/30/16 at 7:30 a.m.; The resident had fallen in his room and sustained a fractured left clavicle. The nurse documented that resident #19 had been treated at the emergency department on 12/31/16, for the fractured clavicle. The fall investigation had noted nonskid socks had been an intervention that had been in place. The resident had not felt well, and had weak legs. The root cause of the fall was related to the resident not feeling well, loss of balance, and an unsteady gait. The corrective action had shown the resident had been educated to use his call light. The report had been completed on 1/5/17, 6 days after the fall. Due to the resident's severe cognitive impairments, the education provided would potentially not be recalled, or understood by the resident. Review of resident #19's Care Plan, printed on 1/24/17, had not shown the interventions identified on the RMS - Event Summary Reports, or the corrective actions for the nonskid socks. Review of the facility's Falls Management Policy with a revision date of 3/15/16, showed the following: - Develop individualized plan of care - Review and revise care plan regularly - Update care plan to reflect new interventions Review of resident #19's Emergency Department Provider Notes, dated 12/31/16, showed the following: - Resident had pain in left clavicle with fracture - Elevated white blood cell count of 13.4 (normal range 4.5-11.0) - Cellulitis of the left foot and had been given intravenous antibiotics - Elevated labs that showed dehydration Review of resident #19's Progress Notes for November 2016, and December 2016, showed the following: November 2016 - Resident had change in condition on 11/2/16, that had lasted until 11/5/16, gastrointestinal upset, nausea, vomiting and diarrhea - Resident had change in condition on 11/30/16, showed an unwitnessed fall in the resident's room with a sustained skin tear December 2016 -Resident had a change in condition on 12/30/16, showed resident had a fall after he had tried to get to the bathroom and had a gastric upset in route to the bathroom. -Resident febrile 100.1, had stated I don't feel good, I'm not getting up -Noted weakness -12/31/16 - resident had complained of left foot and shoulder pain and had remained febrile. Resident sent to emergency department where he had been diagnosed with [REDACTED]. The facility had not comprehensively assessed and reviewed the resident's medical status, and risk factors, which increased his risk for falls, and had not updated the resident's care plan with individualized interventions to meet his needs and abilities to prevent falls with and without injury. During an observation on 1/31/17 at 3:00 p.m., resident #19 had been in his room. It had been noted that the resident had been sitting in his chair, and his call light had not been within his reach. During an interview on 1/31/17 at 6:50 p.m., resident #19's family member stated the resident had been very ill with a stomach virus. She had also stated he had fallen after he had been ill, and had been taken to the emergency department where they had found he had a broken clavicle. *2. Resident #31 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's Fall Log, dated 1/1/16 to 1/30/17, showed resident #31 had the following falls: - 1/28/16 at 7:15 p.m., in the resident's room, sustained a skin tear - 1/29/16 at 2:00 a.m., in the resident's room, sustained a skin tear - 2/23/16 at 9:55 p.m., in the resident's room, sustained a skin tear - 5/17/16 at 4:40 a.m., and 3:45 p.m., in the dining room, sustained a skin tear - 8/18/16 at 11:45 a.m., in the dining room, sustained a bruise and skin tear - 8/25/16 at 1:55 p.m., in the hallway, sustained a skin tear - 9/22/16 at 3:00 p.m., in the hallway, sustained a skin tear - 12/4/16 at 1:00 p.m., in the hallway, sustained a skin tear - 12/9/16 at 5:45 p.m., in the hallway, sustained a bruise - 12/23/16 at 11:10 a.m., in the dining room, sustained an abrasion and skin tear - 1/16/17 at 7:30 p.m., in the dining room, sustained a skin tear - 1/27/17 at 5:00 p.m., in the hallway, sustained a laceration Review of the facility's RMS - Event Summary Reports for resident #31 showed the following: November 2016 -11/16/16 - The resident had a fall in the dining room, and had bumped the head. The preventative measures put in place showed an alarm in place on the bed, and a floor mat was in place. Nonskid socks were on, and the resident's care plan reviewed. The documentation showed the resident had a history of [REDACTED]. The root cause of the fall showed the nurse was unsure if the resident had been sleep walking at that time. The report was completed 11/18/16, 2 days after the resident's fall. -12/1/16 - The resident had a fall in the dining room. Preventative measures put in place showed an alarm on the resident's bed, and the care plan updated and reviewed. The root cause of the fall showed how the resident fell , but the facility staff had not developed a plan to prevent future falls for the resident. -12/3/16 - The resident had the fall in the dining room again. Preventative measures put in place showed the resident had an alarm on the bed. The root cause showed resident had been known to sit on the floor, and this was care planned. The dining room was not addressed. -12/4/16 - The resident had the fall in the hallway. Preventative measures put in place showed the resident being monitored by staff. The root cause showed the resident's blood pressure had been low, and neurological checks initiated. There was a lack of evidence for any additional individualized care plan interventions. -12/9/16 - The resident had a fall in the hallway again. Preventative measures put in place showed the resident bed alarm was in place, items were within reach, slipper socks on feet, and care plan reviewed. The documentation failed to address what was occurring at the time of the fall, the current risk factors, or the resident's status that may have contributed to the fall. -12/11/16 - The resident had the fall in the hallway. Preventative measures were put in place and showed slipper socks were on, bed alarm on, bed against wall, and the resident's haldol levels checked. The care plan was reviewed. The facility did not address why the resident fell in the hall, or what specific risk factors were reviewed or identified for the fall. For the falls on 12/12/16 (in hall), 12/26/16 (in diningroom), 1/16/17 (in dining room), 1/17/17 (in dining room), 1/27/17 (in hall), the facility failed to identify, implement, utilize adequate root cause analysis to identify and implement interventions related to the individualized factors relating to the repeated falls. Review of resident #31's Care Plan, printed 1/24/17, had not been updated to reflect new or modified interventions relating to the falls the resident had, or how the facility attempted to prevent future injuries from the falls. Review of resident #31's Progress Notes for December 2016, and January 2017, showed the resident had Change of Condition documentation relating to falls on: 12/1/16, 12/2, 12/3, 12/4, 12/9, 12/23/16, and then also on 1/16, 1/17, and 1/27/17. Review of the facility's Falls Management Policy, with a revision date of 3/15/16, showed the facility should develop an individualized care plan, review and review the care plan regularly, and update the care plan to reflect new interventions identified. During an interview on 1/26/17 at 10:05 a.m., staff member B stated resident #31 had been reminded to slow down when walking. She stated the resident had tripped over her own feet. She stated the resident had fallen, related to a decrease in her haldol medication. The resident had continued to have falls unrelated to the haldol medication change. During an interview on 1/26/17 at 11:30 a.m., staff member P stated the facility had a Stop Light fall prevention, and a Falling Star fall program in place, at one time, for residents that had been a fall risk. She stated that no fall program was being used currently. During an interview on 1/26/17 at 11:35 a.m., staff member J stated resident #31 had fallen because she had shoes that had been too big for her feet. She stated the resident had just been using gripper socks recently. She also stated she had been unsure where to look to find out if a resident had been a fall risk. During an observation on 1/27/17 at 2:50 p.m., resident #31 had been shuffling in the hallway. The resident had on pants that had covered her heels while she had taken several steps. The resident had slipped in the hallway, and a staff member had assisted her to the dining room. During an observation on 1/27/17 at 3:40 p.m., resident #31 had ambulated in the hallway. She had pants on that had covered her heels as she walked. Staff had not identified this as a concern. During an observation on 1/30/17 at 5:00 p.m., resident #31 had been noted to have a laceration and bruise on her left eye brow. The resident's pants had fallen down when she was being observed. During an interview on 1/30/17 at 5:30 p.m., staff member N stated resident #31 had fallen 1/27/17, before dinner. She stated the resident had been walking too fast, and her pants were too long. *3. Review of the facility fall log showed resident #7 had 11 falls from 2/2016 to 12/2016. Review of the resident's care plan showed 2 interventions for falls, for 2016. These include a fall mat in place while in bed, dated 11/9/16; and, staff were to ensure the resident's feet were on the foot pedals before pushing the resident in the wheelchair, dated 9/12/16. Review of resident #7's Progress Notes, dated 12/28/16, showed resident #7 fell out of his wheelchair. The right foot was on the foot pedal, and the left foot caught under the right foot pedal. The resident was experiencing pain, and was sent to the ER for a laceration to his right eye. The staff had failed to follow the resident's care plan for the intervention identified on the care plan. Review of the resident's Event Summary Report for the fall showed the root cause of the fall showed, Staff needs to make resident aware before wheeling him and remind him to pick up left foot. The documentation failed to show what steps would be taken to address the root cause. During an interview on 1/25/17 at 2:40 p.m., staff member A stated the residents were assessed for falls on admission, and quarterly. He stated reducing falls was a tough one, and then stated, We can't restrain residents, and they have the right to fall. During an observation on 1/24/17 at 12:50 p.m., resident #18 was being pushed in a wheelchair without foot pedals. Staff member BB did not provide cues to lift her feet, or provide foot pedals. During an observation on 1/26/17 at 9:25 a.m., resident #23 was pushing another resident in a wheelchair, who had no foot pedals on the chair, and the resident kept putting his feet on the ground while being pushed. *4. Review of resident #23's Progress Notes, dated 11/17/16, showed the resident had a BIMS score of 0 (severely impaired cognition, and a fall risk of 17. A review of the facility's Fall Log from 1/1/16 to 1/30/17, showed resident #23 had 11 falls in the past year. Review of resident #23's Care Plan showed the following interventions that were added since 4/15/16: -1/2/17: Provide verbal cues for safety and sequencing when needed. -1/2/17: Provide resident/caregiver education for safe techniques. Review of resident #23's RMS - Event Summary Reports, which was not a part of the resident's medical record, showed the following root cause/conclusions: a. 11/11/16 at 8:15 p.m. -Resident was assisted to floor by staff after finding in another peer's room and was trying to assist her to her own room when she lost her balance and staff lowered her to the floor. (sic) -Corrective actions: staff to observe resident and try to redirect her to her own room, care plan reviewed and updated as needed, MD & family aware. -The care plan was not updated for 11/11/16. b. 11/15/16 at 2:30 p.m. -Resident was walking up and down hallways, when staff noticed her on the floor at the doorway of male peer, when male peer questioned he stated that she was trying to come into the room and then motioned his arm to push her away, at this time is unclear if male peer pushed female peer to get out of his room. (sic) -Corrective actions: Staff to observe resident and continue to redirect her to her own room, care plans were reviewed and updated as needed, encourage male peer to use call light for assistance, if other resident goes in his room. -The care plan was not updated for 11/15/16. -An abuse report was not filed with the state agency. c. 12/21/16 at 5:15 a.m. -Unsure what happened to resident, was found lying in bed with laceration to head, first aid was given, call placed to MD, was sent to ER for evaluation, resident is check on rounds throughout night. (sic) -Corrective actions: continue to do checks on nocturnal with rounds, observe resident when up walking for steady gait. (sic) -The care plan was not updated for 12/21/16. -The fall log did not accurately reflect the residents fall for 12/21/16, as she did go to the hospital related to her fall. d. 12/31/16 at 10:50 a.m. -Poor safety awareness, non-compliance. (sic) -Corrective actions: redirected. -The care plan was not updated for 12/31/16 The RMS-Event Summary Reports for the resident failed to show the facility identified a root cause for the falls, that the care plan was updated with individualized interventions for the prevention of falls, or that appropriate interventions were identified due to the resident's cognitive barriers, and risk factors. Review of Resident #23's Progress Notes from 11/1/16 to 1/20/17 did not showed a lack of evidence for the following areas relating to falls and fall prevention: - Root-cause analysis of falls. - Incomplete documentation for a change in condition, and then follow-up notes. - Incomplete assessment documentation after the resident returned from the hospital on [DATE]. -Several progress notes showed the resident was unsteady walking. The facility did not follow-up with interventions or address the unsteadiness with walking on residents care plan. During an interview on 1/30/17 at 5:55 p.m., staff member N stated resident #23 did not have history of falls, unless the resident was sick. She was not aware of any individualized interventions for the prevention of falls. During observations on 1/30/17 at 5:40 p.m., in room 201, and 1/31/17 at 9:25 a.m. in room 106, the resident was observed to be in another resident's room. She was sitting in the other resident's chair. During the following observations, resident #23 was walking in the halls, and the resident was unsteady: -2/1/17 at 4:20 p.m. -2/2/17 at 1:30 p.m. -2/2/17 at 3:10 p.m. *5. Review of resident #22's medical record, showed the resident had a BIMS score of 0 (severely impaired cognition), and a fall risk of 19 (dated 11/10/16 in his progress note). A review of the facility's Fall Log, from 1/1/16 to 1/30/17, showed resident #22 had 17 falls in the past year. The resident was never transferred to the hospital for any of the falls. He had two more falls in the month of January. Review of resident #22's Care Plan showed the following interventions for falls were added to the plan since 3/22/16: - 11/3/16: Resident is to be toileted and laid down after lunch - 1/2/17: Monitor vital signs including orthostatic blood pressure as needed, and report to MD as indicated - 1/2/17: Offer/assist resident with urinal as requested/needed - 1/3/17: Place call light within reach at all times - 1/5/17: Resident has been witnessed by staff scooting to edge of bed and/or chair, and sliding self to floor - 1/25/17: Place glasses within reach and encourage use Review of resident #22's RMS - Event Summary Reports, which were not a part of the resident's medical record, showed the following root causes/conclusions: a. 11/2/16 at 7:00 p.m. -Resident was watching World Series in large solarium, and slid out of his wheelchair onto the floor causing an abrasion to forehead and knees. -Corrective actions: Staff to encourage resident to be seating (sic) on the couch while watching TV in large solarium, care plan reviewed and updated. -Care plan updated on 11/3/16 with an intervention to toilet resident and lay him down after lunch. Care plan was not updated with the intervention to encourage resident to sit on couch. He is also a two person assist. (sic) b. 11/4/16 at 9:00 p.m. -Root cause not completed. -Corrective actions: staff to assess thoroughly after being lowered to floor for injury, family and MD aware of the fall care plan reviewed and updated as needed. -The care plan was not updated for 11/4/16. c. 11/5/16 at 2:45 p.m. -Resident has had low blood sugars lately, MD aware, has been sleeping more than usual, unsure the cause, MD was notified. -Corrective actions: Order for labs and UA, was obtained, staff encouraged to have resident drink more fluids, waiting on results of UA, care plan reviewed and updated as needed. -The care plan was not updated for 11/5/16. -There was no further assessment of the low blood sugars. d. 11/11/16 at 7:45 p.m. -Resident likes to standup and sit down in his chair, poor safety awareness. -Corrective actions: resident was assessed for injury non noted, has been recently evaluated by PT, care plan was reviewed. (sic) -The care plan was not updated for 11/11/16 e. 11/21/16 at 4:00 p.m. -Poor safety awareness. -Corrective actions: alarm reapplied. -The care plan was not updated for 11/21/16 f. 11/25/16 at 3:00 p.m. -Resident has poor safety awareness, he continues to sit on edge of chair, and moves the wheelchair with his feet. -Corrective actions: staff to observe resident and encourage to have him sit back in wheelchair and move chair with his feet. Care plan reviewed and updated as needed. -The care plan was not updated for 11/25/16 g. 12/30/16 at 9:30 a.m. -Resident confusion, has been witnessed by staff that he is scooting self to edge of chair and sliding to floor. -Corrective actions: continue current precautions, care plan reviewed and updated as needed. -The care plan was not updated for 12/30/16 h. 11/21/16 at 4:00 p.m. -Poor safety awareness. -Corrective actions: alarm reapplied. -The care plan was not updated for 11/21/16 Review of Resident #22's Progress Notes from 11/1/16 to 1/25/17, did not show the following: -Fall assessments and root-cause analysis of falls. -Incomplete change in conditions and follow-up notes. -Follow-up to the MD after irregular neurological checks. -Reviewed or updated interventions on the care plan. During an interview on 1/31/17 at 9:15 a.m., staff member P stated she use to provide input to the management team on falls but does not do that anymore. She was unsure what to do about resident #22 and #23's falls. She stated the facility used to have a fall program in place and unsure why they do not have one anymore. She was unaware of any specific interventions to use for the residents. During an interview on 1/31/17 at 9:25 a.m., staff member S stated she does not give feedback to management about falls. She stated that resident #22 likes to laugh and will not get aggressive if you make him laugh or smile before doing his cares. Staff member S stated she felt resident #23 needed to be watched and she likes to feel independent. She was not taught any specific interventions for the residents. The staff member goes by her gut feeling when taking care of them. 6. Review of the facility fall log showed resident #11 had 11 falls from 2/2016 through 2/1/17. Review of the Quarterly MDS, with the ARD of 12/28/16, showed resident #11 had severe cognitive deficits. The documented root causes and conclusions for the resident's falls, based on the RMS - Event Reports for the residents, showed: - 11/10/16 - Resident was in chair where she was sleeping, stood up and fell to the floor. The nurse was unsure if the resident was fully awake when she stood up. Staff to encourage resident to sit before standing, after waking. - 12/3/16 - Resident was ambulating in room unassisted. - 12/10/16 - Resident was sitting in her recliner as aide walked into room. The resident slid out of the recliner onto the floor on her buttocks. No injury was noted. It was possible the resident was sleeping and slid out of the chair, as she chooses at times to sleep in her chair. - 1/2/17 - Resident lost her balance while turning around. - 1/16/17 - Resident was leaving dining area and went down the wrong hall, and went into the wrong room. The staff heard a female scream, and staff went into room and witnessed the resident who was laying on her right side. Review of the RMS - Event Summary Reports for the resident, showed preventative measures in place prior to the falls were: - 11/10/16 - Resident aware of how to use call light for assistance. - 12/3/16 - Bed alarm in place, however resident had just been seen ambulating in hallway prior to fall. - 12/10/16 - Items within reach, call light in place, and the care plan reviewed and updated. - 1/2/17 - Nothing was documented. - 1/16/17 - The care plan was reviewed, and the staff were to observe resident when leaving dining area to assist her down the right hall. Review of resident #11's care plan showed one new intervention for falls since 2/3/16. The new intervention, dated 1/3/17, showed Provide verbal cues for proper pacing and energy conservation techniques. The facility had not updated the resident's plan based on the history of the resident's individualized fall factors as they changed through the year. Review of the Progress Notes dated 12/14/16, showed resident #11 was ambulating from room down 200 hallway without walker - floor being waxed by housekeeping staff - resident slipped on wet wax and slid against wall by room 201, scraping elbow against wall as she fell to a sitting position on floor. During an interview and observation on 2/2/17 at 1:20 p.m., staff members W and X were mopping the dining room floor. Twelve residents were sitting at tables in the dining room. Staff member X stated they did try to wait for the residents to leave, but there was always someone in the room. Staff member X proceeded to mop under tables with residents sitting at those tables. Staff members X and W were asked if they knew the residents who fell frequently, and they stated resident #31 was the only one who fell . Resident #31 was observed walking on the wet floor. Staff member W stated they had asked residents to wait for the floor to dry before leaving the dining room.

Based on interview, record review and observation, the facility failed to provide timely interventions for pain and distress for 2 (#s 3 and 7); failed to provide appropriate and timely skin treatments, causing skin conditions to decline, and become infected, for 4 (#s 4, 17, 22, and 36); failed to assess signs and symptoms [MEDICAL CONDITION] and pneumonia that led to a hospitalization and death for 1 (#6), and failed to effectively manage pain for 1 (#18) of 38 sampled residents. Findings include: IMMEDIATE JEOPARDY On [DATE] at 4:20 p.m., staff members A and B were notified that an Immediate Jeopardy situation was identified in the area of Maintaining the Residents Highest Practicable Well Being. The substandard care concerns were determined to be at the severity and scope of a K. Upon removal of the immediacy for the concerns identified, the severity and scope would be at the level of H. The summary for the plan to remove the immediacy is located in F000 of the CMS2567 document. Resident's identified with a (*) were included in the Immediate Jeopardy situation. *1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Pain: Review of resident #3's Progress Notes, with the following dates and times, showed the resident had been in pain: -[DATE] at 1:10 and 3:37 p.m., showed resident had continued pain -[DATE] at 11:01 p.m., showed resident stated the Tylenol she had received on [DATE] had been ineffective for pain -[DATE] at 1:01 p.m., showed resident had been uncomfortable -[DATE] at 1:01 p.m., showed resident had continued to have leg pain and scheduled pain meds -[DATE] to [DATE] showed no assessment of pain level -[DATE] at 9:06 p.m., showed the resident had increased pain to the leg and heel -[DATE] at 11:42 a.m., showed the resident had facial grimacing, arching, and verbal indicators for pain, medicated with little effect -[DATE] at 9:40 a.m., showed the resident had facial grimacing, arching, and verbal indicators for pain -[DATE] at 4:08 p.m., showed the resident had uncontrolled pain, order for [MEDICATION NAME] times one dose now, had been noted -[DATE] at 6:10 p.m., showed the resident continued to have uncontrolled pain; it was noted the physician called the pharmacy and ordered [MEDICATION NAME] -[DATE] at 8:30 p.m., showed the resident's family had voiced concerns of the resident's pain, and the resident had not yet received a dose of [MEDICATION NAME] that had been ordered by the physician at 6:10 p.m. Resident's family requested she be sent the the emergency department for pain control. -[DATE] at 12:15 a.m., showed the resident had a change in condition, stated that pain began to increase in the leg wound. The resident's family expressed grave concern for the resident's pain level, and they had not wanted her to suffer. -[DATE] at 1:45 p.m., the family member noted she had felt her mother had been in pain for 48 hours over the weekend. The family member reported that she had not wanted her mother in pain. -[DATE] at 4:50 p.m., showed the resident had passed away. Review of resident #3's MAR, with the following dates and times, showed how the assessments for pain were not completed for pain medication given, how pain ratings did not correlate to medication provided, and how the pain ratings did not show the correlation to the pain assessment. Documentation included: -[DATE] resident rated pain 8 out of 10, [MEDICATION NAME] 50 milligrams administered at 4:30 p.m. -[DATE] resident rated pain at a 6 out of 10, medicated with Tylenol 325 milligrams (2 Tablets) at 12:00 p.m. and 8:00 p.m. -[DATE] at 3:00 a.m., resident had been given [MEDICATION NAME] 50 milligrams for pain 8 out of 10 -[DATE] at 10:00 p.m., resident had been given Tylenol 325 milligrams (2 Tablets), pain level not assessed -[DATE] at 10:00 p.m., resident had been given Tylenol 325 milligrams (2 Tablets), pain level not assessed -[DATE] at 10:00 p.m., resident had been given Tylenol 325 milligrams (2 Tablets), pain level assessed at 2 out of 10 -[DATE] at 12:00 p.m. and 10:00 p.m., showed resident had Tylenol 325 milligrams (2 Tablets), pain level assessed at a 0 out of 10 -[DATE] at 8:40 a.m., showed the resident had been given [MEDICATION NAME] 50 milligrams, pain level not assessed -[DATE] at 10:00 p.m., showed the resident had Tylenol 325 milligrams (2 Tablets), pain level not assessed -[DATE] at 12:10 a.m., and 9:00 a.m., showed the resident had [MEDICATION NAME] 50 milligrams, pain level not assessed -[DATE] at 10:00 p.m., resident had been given Tylenol 325 milligrams (2 Tablets), pain level not assessed -[DATE] at 1:00 a.m., and 9:00 a.m., showed the resident had [MEDICATION NAME] 50 milligrams, pain level not assessed -[DATE] at 12:00 p.m. and 10:00 p.m., showed resident had Tylenol 325 milligrams (2 Tablets), pain level assessed at a 5 out of 10 and 7 out of 10 -[DATE] at 2:00 a.m., showed the resident had [MEDICATION NAME] 50 milligrams, pain level assessed ,[DATE] out of 10 -[DATE] at 8:00 a.m., showed the resident had [MEDICATION NAME] ,[DATE] milligrams, pain level not assessed -[DATE] at 12:00 p.m., resident had Tylenol 325 milligrams (2 Tablets), pain level assessed at a 8 out of 10 -[DATE] at 8:00 a.m., showed there resident had [MEDICATION NAME] ,[DATE] milligrams, pain level assessed at a 8 out of 10 -[DATE] at 12:15 a.m., 2:15 a.m., 4:00 a.m., 6:45 a.m., and 8:50 a.m., showed the resident had [MEDICATION NAME] 4 milligrams, pain level not assessed -[DATE] at 10:15 a.m., 12:20 p.m., and 2:30 p.m.,, showed the resident had [MEDICATION NAME] 4 milligrams, pain level not assessed -[DATE] at 4:30 p.m., 7:00 p.m., and 8:15 p.m., showed the resident had [MEDICATION NAME] 0.25 milliliters, pain level not assessed -[DATE] at 3:00 p.m., showed the resident had [MEDICATION NAME] 0.25 milliliters, pain level not assessed Review of the facility's Pain Management Policy, with a revision date of [DATE], showed the following: -Patients' would be evaluated as part of the nursing assessment process for the presence of pain with a change in condition in pain status -To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain -Design a plan of care to achieve an optimal balance between pain relief and preservation of function -Complete a pain evaluation -Contact the physician to report findings and obtain revised treatment orders if indicated Antibiotic: Review of resident #3's Progress Notes, with the following dates and times, showed nursing documentation inconsistencies relating to the antibiotic medication received for a [MEDICAL CONDITION] infection. -[DATE] at 9:10 p.m., showed resident had been started on antibiotic for [MEDICAL CONDITION] infection, which continued through [DATE]. -[DATE] to [DATE] did not show the resident had continued on an antibiotic -[DATE] at 1:06 p.m., showed resident continued to be on antibiotic, and this continued to [DATE] at 11:42 a.m. -[DATE] at 2:24 p.m., showed the resident had completed her antibiotic that a.m. Review of resident #3's MAR, dated [DATE], showed that the resident had not been administered an antibiotic for a [MEDICAL CONDITION] infection. Review of resident #3's Care Plan, printed on [DATE], showed that the plan had not been updated to reflect the residents change in condition on [DATE], which included a change in pain medication type and amount to manage the resident's pain. Review of resident #3's Death Certificate, dated [DATE], showed the residents cause of death [MEDICAL CONDITION]. During an interview on [DATE] at 2:30 p.m., the resident's family member had stated the following: -My mom had never complained of pain before, until the end of her life. -She had been thrashing around in her bed, with uncontrolled pain, for a few days prior to passing away. -She stated the nurses' could not get the [MEDICATION NAME] out of the OMNICELL (medication dispensing machine) for two and a half hours while her mom was in pain. -She stated that the staff had made comments to her to get her mom out of the facility because she would never get her medication. -She stated she felt her mom suffered in pain, right up to her passing away, and she watched her mother thrash around in her bed, and cry, up until she had passed away. During an interview on [DATE] at 10:00 a.m., staff member L stated resident #3 had struggled in pain at the end of her life. During an interview on [DATE] at 2:40 p.m., staff member H stated resident #3 had suffered in pain due to nurses' that had not been able to get into the OMNICELL to get the resident [MEDICATION NAME] (pain medication). She stated it took staff member C, who had been on call, two and a half hours to get to the facility to get the medication for the resident. She stated the resident had declined, had a fever, high blood pressure, and a low pulse. During an interview on [DATE] at 12:15 p.m., staff member A stated a night shift nurse had not called the pharmacy to get a prescription, or call a physician to get an order on [DATE] for [MEDICATION NAME], and that had been the reason resident #3 had a delay in getting her pain medication. *2. Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #36's Progress Notes, dated [DATE] at 5:59 p.m., showed the resident had a change in condition for skin. The change in condition had been noted as a skin tear to the right lower, inner shin, and ankle. At 6:11 p.m., physician orders [REDACTED]. This dressing would be changed every other day, until healed. Review of resident #36's Progress Notes, dated [DATE] to [DATE], had noted no improvement in the resident's wound. Review of resident #36's Progress Notes' dated [DATE] at 8:46 p.m., showed that the resident had become febrile, with a temperature of 103.7, and also showed the resident had moaned and said owe (sic) describing that the resident had been in pain all over. The progress notes showed the resident continued to be febrile from [DATE] to [DATE]. Review of resident #36's Progress Notes, dated [DATE] at 1:38 p.m., showed the resident had started an antibiotic. At 3:00 p.m., the physician ordered a new wound dressing to the right inner ankle, to have [MEDICATION NAME] Extra Ag, and wrap with Kerlix. This was to be changed daily. Review of resident #36's Progress Notes, dated [DATE] at 10:32 a.m., showed the physician had ordered for the resident to receive intravenous fluids for possible dehydration. Review of resident #36's Physician Orders, dated [DATE] at 12:17 p.m., showed the resident had [MEDICATION NAME] 500 milligrams, intravenously, ordered for her wound infection. At 5:30 p.m., the orders also showed the resident had an order to culture the wound on the lower right leg, which came back positive for Four Plus Staphylococcus Aureaus A. Review of the facility's Wound Care Guideline, not dated, showed the treatment for [REDACTED]. It showed to change the dressing every 7 days, and as needed. During an interview on [DATE] at 2:40 p.m., staff member H stated she felt resident #36 had signs and symptoms [MEDICAL CONDITION], such as high fevers, altered mental status, and lethargy. During an interview and observation on [DATE] at 4:15 p.m., staff member D had completed a dressing change on resident #36's wound. The resident moaned, had facial grimacing, and moved around during the dressing change. Staff member D had stated the resident had been on Tylenol suppositories for fevers, and that the wound had started out as a skin tear that had deteriorated to [MEDICAL CONDITION]. The resident's pain did not appear to be managed by the resident's actions exhibited during the treatment, and the nurse continued the treatment. During an interview on [DATE] at 8:25 a.m., staff member Z stated she normally did not order wound cultures because all the cultures would come back positive. She stated the facility had a corporate wound policy for residents. Staff member Z stated the correct treatment for [REDACTED]. She also had stated that petroleum jelly could make a skin tear worse. The treatment being used on the resident, contained the petroleum. Review of resident #36's Physician order [REDACTED].#36. This was five days after the resident began to exhibit the fever and change in condition. During an interview on [DATE] at 10:10 a.m., staff member D stated the appropriate treatment for [REDACTED]. During an observation and interview on [DATE] at 10:00 a.m., staff member I had performed a dressing change on resident #36's wound. The right shin had necrotic tissue through out the wound bed. The resident had moaned, had facial grimacing, and had moved around while the nurse had completed the dressing change. Staff member I had stated before the resident's wound had become infected she had not been on any medications. Staff member I had applied [MEDICATION NAME] to the wound, which had not been ordered by a physician as the current wound orders, and the resident's pain had not been managed to ensure comfort during the treatment provided. During an observation on [DATE] at 2:40 p.m., resident #36's wound dressing had been saturated, and leaked through the gauze dressing. *3. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on [DATE] at 2:40 p.m., staff member H stated that resident #4 had been screaming, yelling, and crying please stop please stop when she witnessed staff members B, C, and D squeezing puss from resident #4's abscess on the back of her head. During an interview on [DATE] at 8:15 a.m., resident #4 had stated she had been in pain with her abscess on the back of her head. She stated that she cried in pain when nurses had squeezed her abscess on the back of her head. Resident #4 had stated her dressing changes for her abscess had been painful, but she had not been given any pain medication. During an interview on [DATE] at 9:10 a.m., staff member B stated she had been unsure if the resident had pain medication prior to her head abscess being packed. During an interview on [DATE] at 9:50 a.m., staff member D stated it would probably be painful to resident #4 to have her wound packed, and she had not been aware of the resident being medicated for pain prior to the treatment. During an interview on [DATE] at 1:25 p.m., resident #4's family stated she had pain with her abscess on the back of her head. Review of resident #4's PRN Pain Pain Management Flow Sheet, printed on [DATE] at 2:29 p.m., had not been filled out. Review of resident #4's MAR for November and [DATE], showed the resident had not had any pain medication ordered or administered. Review of resident #4's Care Plan, printed on [DATE], showed the resident had not had her pain care planned. Review of resident #4's Progress Notes between [DATE] and [DATE], showed the resident had been in pain relating to the absess on her neck, and when she was touched in the area of the absess. Review of the facility's Pain Management Policy with a revision date of [DATE], showed that the facility should maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain; design a plan of care to achieve an optimal balance between pain relief and preservation of function; complete a pain evaluation; and, contact the physician to report findings and obtain revised treatment orders if indicated. *4. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #17's Progress Notes, dated [DATE] at 1:26 p.m., showed the resident had a change in condition on an area to the second left toe. It had been noted that the resident's toe had an open area that had measured 1.8 centimeters by 1.2 centimeters, noted to be red and inflamed. It had been cleaned, hydrogel had been applied, and the toe covered with [MEDICATION NAME] gauze. It showed the resident had a pain level of 8 out of 10. Review of resident #17's Progress Notes, from [DATE] to [DATE], showed that the resident's left toe had deteriorated. The notes had not shown that the resident's toe had been assessed per the facility policy and wound care guidelines during those time frames. It had been noted on [DATE], that the resident had been placed on an antibiotic for an infection of the toe. Review of resident #17's Progress Notes, from [DATE] to [DATE], showed that the resident had remained on an antibiotic for a toe infection. The notes had continued to show the wound had been red, swollen, moderate amounts of purulent drainage, maceration to the periwound, and that the resident had experienced pain from this. It had been noted that an order had been obtained on [DATE], to place a foam wedge in between the resident's toes to keep a toe nail from rubbing on the resident's wound. No new orders had been obtained in this time period. Review of resident #17's MAR, dated [DATE], had shown the following: -The resident missed a dose of her antibiotic on [DATE] at 10:00 p.m. -The resident missed a dose of [MEDICATION NAME] 5 milligrams on [DATE] at 10:00 p.m. -The resident's pain had not been monitored on [DATE] between 2:00 p.m., and 10:00 p.m. -The resident missed a dose of Tylenol 500 milligrams on [DATE] at 10:00 p.m. Review of resident #17's Care Plan showed that the resident's left second toe wound had not been added to the care plan until [DATE]. Review of the facility's Skin Integrity Management Policy, with a revision date of [DATE], showed the facility should have implemented and followed the would care guidelines, reviewed and revised the care plan, and monitored the status of the dressing. Review of the facility's Wound Care Guideline showed that a pressure ulcer, that had moderate to heavy drainage, should have a [MEDICATION NAME] extra dressing applied and changed every 3 days, and as needed. The document showed that sureprep, no sting skin prep, should have been applied to the peri wound, and covered with [MEDICATION NAME]. Review of resident #17's Skin Integrity Report, dated [DATE] to [DATE], showed the following: -[DATE] The resident had pain, the wound had been intact and deep purple, the length of the wound had measured 1.8 centimeters by 1.2 centimeters and .1 centimeter deep. It had noted the drainage as purulent, surrounding tissue inflamed and indurated, wound edges macerated. -[DATE] The resident had pain, the wound had been intact and deep purple, the length of the wound had measured 3.4 centimeters by 1.3 centimeters and the depth had not been noted. The drainage had been noted to be purulent, surrounding tissue inflamed and indurated, wound edges macerated. During an observation and interview on [DATE] at 8:20 a.m., staff member F had given resident #17 an [MEDICATION NAME] 5 milligrams. The staff member had not asked the resident what her pain level had been prior to the administration of the medication. The staff member stated she had not asked the resident what her pain level was because she is always an 8. The MAR indicated [REDACTED]. During an observation and interview on [DATE] at 4:05 p.m., staff member D stated that resident #17's Skin Integrity Report, dated [DATE] and [DATE], had been coded incorrectly. Staff member D stated the appearance and drainage on the report had not been correct. The resident's wound had a black scab on it, had been red around the scab, and the wound had slight drainage on the separator sponge. *5. Review of resident #7's Progress Notes, dated [DATE], showed resident #7 fell out of his wheelchair. The right foot was on the foot pedal, and the left foot caught under the right foot pedal. The resident was experiencing pain, and was sent to the ER for a laceration to his right eye. Review of a Progress Note, dated [DATE] at 4:41 p.m., showed resident #7 was back from the ER with four sutures to the right eyebrow. Review of the Progress Note, dated [DATE] at 8:23 p.m., showed resident #7 had a moderate amount of coffee ground emesis. Review of the Progress Notes showed no assessment or follow-up regarding the coffee gound emesis. Review of the Progress Noted, dated [DATE], showed resident #7 had a temperature of 101.3 degrees. The resident was unable to swallow applesauce with Tylenol in it. Review of the Progress Notes showed no interventions or follow-up regarding resident #7's fever. Review of the Progress Note, dated [DATE], showed the resident's suture site had purulent drainage, Site swollen and fluid into eyelid. [MEDICATION NAME] antibiotic drops were started. Review of a Progress Note, dated [DATE] at 12:07 a.m., showed resident #7 had emesis at dinner time/mucus and respiration more difficult since 2300 when this RN made rounds, found resident in respiratory distress; Call PCP and family - new orders. Level of consciousness is lethargic, a change from previous state. (Resident #7) is experiencing pain related to excessive respiratory effort.Report from evening shift that resident maybe aspirated. MS started at 3:00 a.m., for respiratory distress. This process took from 12:15 a.m. to 3:00 a.m. before the resident was able to receive the MS for his respiratory distress. Review of the written complaint dated [DATE] showed Agressive hostility on the part of (staff member D) severely impacted my ability to appropriately provide nursing care to (resident #7) and severely affected the health and well-being of (resident #7) - leading to advserse processes and outcome for (resident #7), and unnecessary angst and emotional suffering for the family. Review of a Progress Note, dated [DATE], showed resident #7 was very lethargic and pale, with oxygen saturation levels at 86 percent on 5 liters of oxygen. Coughed and brought up white thick phlegm, oral suctioned small amount out. Review of a Progress Note, dated [DATE], showed resident #7 had new ulcers on the left and right buttocks. Review of the Progress Note, dated [DATE], showed the resident had passed away. During an interview on [DATE] at 10:20 a.m., staff member H stated resident #7 had lost the will to live. *6. Review of a Progress Note dated [DATE] for resident #6, showed the resident had a change in condition. Upon awakening this am, resident has a very large swelling on the left side of her neck. Area is firm, tender, and warm to touch. Some gurgling noted in throat when resident talks. Right leg with 3+ [MEDICAL CONDITION]. The concerns with the infection to the neck and [MEDICAL CONDITION] in the right leg had not been noted prior to this date by the facility staff. Review of the hospital admission notes date [DATE] showed the swelling was a 4 X 4 area with Neck and swelling to left submandibular area with [DIAGNOSES REDACTED] and tenderness to palpitation extending down left side of neck. Review of a Progress Note, dated [DATE], showed resident #6 was admitted to the hospital with [REDACTED]. The facility had not identified the pneumonia or [MEDICAL CONDITION]. Review of the hospital admission notes showed [MEDICAL CONDITION], neck infection and pneumonia of both lungs. Review of a Progress Note dated [DATE] showed resident #6 was readmitted to the facility on [DATE], with 2 days left of IV antibiotics, and 5 days of 2 oral antibiotics. Review of the Progress Notes dated [DATE] through [DATE] showed the facility had completed a skin check, noting bruises, but not the neck [MEDICAL CONDITION]. The notes showed the facility completed a Lift-Transfer-Reposition Evaluation, a Urinary Incontinence Evaluation, and a Bowel Retraining Evaluation. A follow-up note dated [DATE] showed the bruise was fading. The neck [MEDICAL CONDITION] was not assessed. Review of the progress notes from [DATE] to [DATE] showed no lung assessments, although the resident had the pneumonia. The nursing staff had not monitored her status for the illness. Review of a progress note dated [DATE] showed resident #6 was awake and alert, but confused. Lungs CTA with fair exchanges to bases. Denies chest pain. [MEDICAL CONDITION] in all 4 extremities. Review of a late entry note, dated [DATE], showed resident #6 had an unplanned discharge to the hospital. During an interview on [DATE] at 3:25 p.m., staff member G stated she did not remember why resident #6 went to the hospital, and was surprised to find out she was the nurse who sent her out. She stated resident #6 had come back from the hospital with pneumonia, and a knot on the side on her neck. She declined, [MEDICAL CONDITION] and died . Review of the emergency room documentation, dated [DATE], showed resident #6 was found minimally responsive at the nursing home, and arrived with oxygen saturation levels in the mid 40's. During an interview on [DATE] at 9:10 a.m., resident #6's guardian stated she did pass away in the hospital. *7. Review of resident #22's Progress Notes, from [DATE]-[DATE], showed the facility did not follow-up for several changes in condition including; skin, falls, temperatures, neurological checks, and low blood sugars. Resident #22 had a BIMs score of 0, with a score of 15 being the most cognitively intact. The following examples showed a lack of evidence for timely assessments and follow up by the facility: [DATE] at 5:07 p.m. -Resident noted with lethargy, blood sugar taken with results of 54. Resident unable to swallow any juice and refused to open mouth for glucose gel. Glycogen 1 mg given IM per standing order. MD aware. -The next progress note that addressed the resident's blood sugar is at 6:30 p.m., approximately 90 minutes after the treatment of [REDACTED]. The facility did not ensure the resident's blood sugar was in a safe range in a timely manner. [DATE] at 9:34 p.m. -(Resident) has a new onset/change in skin integrity as evidenced by abrasion. Location 1cm x 1cm area noted to left elbow. Experiencing pain, ,[DATE] there has been no medication change in the past week. Clean area to left elbow with wound cleanser, apply hydrogel and cover with boarder gauze change every day. -The skin tear was not mentioned in the resident's fall assessment, which happened earlier in the day. The pain was not addressed. The skin tear was addressed for three more days, and then the assessments stopped. On [DATE] the area was 1.8 cm x .8 cm with no indication of how the skin was treated. [DATE] at 10:26 a.m. -Resident has elevated temp today. 101.2 temporal. -There was no follow-up about the resident's temperature or assessment to show the cause of the resident's evaluated temperature. The evening progress note showed resident has had no nausea, vomiting, or diarrhea on this shift. However, there was no mention of nausea, vomiting, and diarrhea in previous notes. [DATE] at 2:00 p.m. -Resident had two falls last week. ,[DATE] and ,[DATE]. No injuries noted and range of motion in all extremities. Family and provider aware. Care plan reviewed and updated as necessary. -The note did not document how the care plan was addressed. The note stated no injuries, but the resident did have a skin tear that needed daily dressings. [DATE] at 03:30 a.m. -Neuro check-left grip weaker, but no following instructions. Left arm appears somewhat swollen. Response: no response necessary/no intervention. -No assessment was completed to address the swollen left arm, temperature was not taken, and no future follow-up assessment of his swollen arm. [DATE] at 1:00 p.m. A care plan meeting was held and the resident did not attend. There was no indication of change at the care plan meeting. The family was called to address the resident's POLST. At 2:42 pm., the resident is charted as having pale skin, lethargic, confused, and a change from previous state. He had a temperature of 102.4. The MD was notified. The skin was not assessed. The resident was sent to the ER the next morning at 9:00 a.m., when the nurse noted his left arm was swollen, reddened, and hot to touch, and tender and painful. Redness started at the elbow and went up almost the upper arm to the outside of the arm. The facility did not assess the patient prior to holding a care plan meeting, or documenting that the resident's condition remained the same. [DATE] at 11:20 a.m. -Resident returned from the ER per facility van and CNA assist. Resident is awake and responsive, but a little drowsy. To table for lunch. Fluids encouraged. New orders received for antibiotics. -There was not an assessment completed upon return from the hospital and no documentation of [DIAGNOSES REDACTED]. On [DATE] at 8:54 p.m., the resident stated he was on antibiotics from [MEDICAL CONDITION]. There was no documentation about the exact orderes from the hospital relating to [MEDICAL CONDITION] and antibiotics on this day. The note stated his arm was painful to touch, but there was nothing noted that addressed his pain. A review of the facility's Fall Log from [DATE] to [DATE], showed resident #22 had 11 falls in the past year, and was never transferred to the hospital. He had 9 falls since [DATE], and the care plan was updated one time in [DATE], and then not again until January. The interventions were not appropriate, timely, or discussed with direct staff. This showed that the facility had not comprehensively looked at the resident's medical status relating to his behvioral, pain, falls, and infection need. During an interview on [DATE] at 3:15 p.m., staff member G stated the resident has become combative in the past. She stated she feels it is all about the approach with the resident. The staff member felt she had a good rapport with the resident, and does not have a problem with completing his cares. She stated the resident became frustrated when he did not have his hearing aids. The resident's Progress Notes did not show if the resident had his hearing aids during times of frustration. During an interview on [DATE] at 9:15 a.m., staff member P stated she used to provide input to the management team on intervention ideas, but did not do this anymore. She was unsure what to do about resident #22's falls. She was unaware of any specific interventions to use for the residents. During an interview on [DATE] at 9:25 a.m., staff member S stated she does not give feedback to management about interventions. She stated that resident #22 liked to laugh and will not get aggressive if you make him laugh or smile before doing his cares. She was not taught any specific interventions for the residents. The staff member went by her gut feeling when she took care of the residents. During an observation and interview on [DATE] at 2:30 p.m., resident #22 was seated in his wheel chair at the nurses' station. Two aides talked with the resident and tried to get him to shower. One aide held her hand out for him, and the other aide sto

Based on interviews and record review, the facility failed to prevent abuse, neglect, and psychological harm for the resident's at the facility, and by the facility staff, to include: restricting, and threatening to eliminate smoking, which was used to assist with controlling a resident's behaviors, who had a history of [REDACTED]. to smoke. The resident experienced a neglected compromised respiratory status, and resulted in the resident being sent out the hospital, for 1 (#8); failed to provide necessary care for the resident's skin, and nursing staff provided treatment's which were not authorized by the physician, and resulted in pain for the resident, for 1 (#4); failed to prevent, report, and investigate an allegation of abuse for 1 (#13); failed to prevent, and intervene in an abusive event that was witnessed, where a resident was being forced to take medications, for 1 (#10) out of 38 sampled residents. Findings include: IMMEDIATE JEOPARDY - Abuse and Neglect On 1/31/17 at 4:20 p.m., staff members A and B were notified that an Immediate Jeopardy situation was identified, in the area of Abuse and Neglect, and was at the severity level of K. Upon removal of the immediacy for the quality of care concerns identified, the severity and scope would be a H. Those resident's identified with a (*) were included in the Immediate Jeopardy situation. *1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had been diagnosed with [REDACTED]. Review of resident #4's Progress Notes, dated 11/17/16 at 9:29 p.m., showed the resident had a change in condition with her skin. The progress notes showed the resident's back of her neck, and base of her scalp, had a rash. The change in condition showed that the physician had ordered [MEDICATION NAME] cream to the affected area, three times a day, until the rash had resolved. Review of resident #4's Progress Notes showed the following: -11/17/16 at 9:30 p.m. - The resident had been itching the rash area on the back of her neck and base of scalp. -11/18/16 at 11:41 a.m. - No change was documented for the resident's rash; the nurse noted the back of the resident's neck was red, and [MEDICATION NAME] cream had been applied. -11/18/16 at 7:41 p.m. - No change in the resident's rash, noted back of her neck was red, and treatment had been applied per physician orders. -11/19/16 at 10:30 a.m. - No change in the resident's rash, noted ointment had been applied as ordered. -11/20/16 at 10:30 a.m. - No change in the resident's rash -11/21/16 at 10:30 a.m., 11/22/16 at 3:12 p.m., 11/23/16 at 12:05 a.m., all noted the resident's rash had improved Review of resident #4's Progress Notes, dated 11/25/16 at 11:29 a.m., showed the resident had live head lice and nits on her hair. The progress note showed the resident had physician orders [REDACTED]. Although the nursing staff had been following the skin rash on the resident's neck, the lice had not been identified until days later. Review of resident #4's Progress Notes, dated 11/25/16 at 3:55 p.m., showed the resident had a large lump on the left back of her head that measured 4 centimeters by 4 centimeters, that had been noted to be bright red. The progress notes had also showed the lump on the resident's head had slight drainage, and it had been painful to touch the resident on the lump. Review of resident #4's Progress Notes, dated 11/26/16 at 11:00 p.m., showed the resident had a change in condition. It had been noted that a nurse reportedly attempted to express purulent drainage from the residents wound on the back of her head. It had been noted that the wound was swollen, red, hot to the touch, had drainage, and the resident had experienced pain. The physician had not ordered the treatment to express the drainage. Review of resident #4's Progress Notes, dated 11/27/16 at 7:30 p.m., showed the resident's back of her neck and head, had deteriorated. It showed the resident had scabbed areas on the back of the left scalp, the size of a golf ball, that had spread across to the right side of the scalp. The resident had complained of severe pain to the site, which was red and hot to the touch. The resident had been placed on Bactrim (an antibiotic) two times a day, for 10 days, for a skin infection. Review of resident #4's Progress Notes, dated 11/27/16 at 10:30 p.m., showed the resident had complained of significant pain, related to the abscess on her posterior head. It showed the abscess was red, hot, swollen, 10 centimeters across the base of the skull, and 5 centimeters wide. The physician had ordered for the resident to be seen in the emergency department. The resident had been transferred to the emergency department by ambulance on 11/28/16 at 12:10 a.m. to have her abscess on the back of her head evaluated. Review of resident #4's After Visit Summary from (Hospital Name), dated 11/28/16, showed the resident had an incision to her abscess. The abscess had been drained and packed with a gauze dressing. The resident had been prescribed [MEDICATION NAME], 500 milligrams, four times daily, for seven days for the abscess. Review of resident #4's Physician order [REDACTED]. Review of resident #4's Progress Notes, dated 12/2/16 at 2:19 p.m., showed the resident had no packing, in the wound, and the wound had to be repacked. The nursing staff had not treated the wound as ordered. Review of resident #4's Progress Notes. dated 12/3/16 at 1:39 p.m., showed the resident had no packing in the wound, and the wound had to be repacked. The nursing staff had not treated the wound as ordered. Review of resident #4's Care Plan, printed on 1/24/17, showed a lack of evidence for the abscess to the resident's head. Review of resident #4's MAR, dated November 2016, showed the resident's scalp and base of her skull should have been checked every six hours for wound care, and a gauze dressing treatment to the back of head. The resident had not had her scalp checked on 11/29/16 and 11/30/16 at 2:00 a.m. Review of the facility's Abuse policy, with a revised date of 11/28/16, showed that neglect was defined as the failure of the center, its employees, or service providers, to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility had not identified the lack of care for the abscess was potential neglect. During an interview on 1/24/17 at 2:40 p.m., staff member H stated that resident #4's dressings to the back of her head had not been being done on a consistent basis. She stated that the infected area had closed over and had filled back up with puss. Staff member H stated that she was at the start of her shift when she had heard a loud screaming sound coming from the fish bowl which was a room that had a door closed, and the blinds pulled down. The staff member stated she had entered the room where she had heard screaming coming from. She stated that resident #4 had been sitting in her wheelchair while staff members B, C, and D squeezed puss out of the abscess, and then repacked the wound with gauze. Staff member H stated resident #4 had been screaming, yelling, crying, and had asked staff members B, C, and D to please stop. Facility nursing staff had treated the resident's abscess without an order, which caused the resident pain, and failed to stop the treatment to ensure the resident was comfortable. During an interview on 1/25/17 at 8:15 a.m., resident #4 stated she had a lot of pain when she had her abscess packed. She stated she had felt sad and uncomfortable when she had been brought into the room by nurses and had her head and abscess squeezed. Resident #4 stated she had asked the nurses to stop. During an interview on 1/25/17 at 9:10 a.m., staff member B stated she had not brought resident #4 into the fish bowl to squeeze her abscess. She stated she had changed the resident's wound dressing one time in the resident's room, and she had not been aware that the resident had received pain medication for the dressing change. During an interview on 1/25/17 at 9:50 a.m., staff member C and D stated resident #4 had been brought into the fish bowl room where her wound had been packed and redressed. Staff member D stated it had probably been painful to the resident, and she had not been aware of pain medications administered to the resident prior to the treatment. Staff member D failed to ensure the resident's comfort, and stop the treatment when the resident had pain. During an interview on 1/25/17 at 11:00 a.m. staff member Z stated she had not been aware that the nursing staff had squeezed puss from resident #4's abscess. She stated that the nursing staff should not have made that judgement, and she should have been notified so she could have assessed the resident's abscess. During an interview on 1/25/17 at 1:25 p.m., resident #4's family member had stated he had not been notified about the nurses squeezing puss from the resident's abscess. He had stated that resident #4 had complained about pain that she had experienced from the abscess. During an interview on 1/26/17 at 1:00 p.m., staff member A stated he had not been aware of the abscess on resident #4's head until the surveyors had entered the building. He stated he had not been aware of the resident's abscess being squeezed by staff members. *2. Review of a State Agency Reporting form showed an allegation was made by resident #13 that a staff member of the facility had gotten mad at her because she was incontinent of bowel several times. Review of the 5 day Investigation Results Report for the event showed the facility did not address the allegation of the staff member being mad at the resident, but rather the facility addressed alternate factors. The document showed: Outcome of your investigation: (Resident) was being assisted by aide when aide was cleaning her up after she had an accident, and noticed that she did not have any clean pants. (Resident) stated that at times all her pants are in the laundry, also stated that she has had several accidents with her clothes. Staff cleaned her up and (resident) stated that she wanted to go to bed, staff offered her dinner but she declined, staff assisted (resident) into bed. Care plan reviewed and updated as needed, family and physician notified. During an interview on 2/1/17 at 3:00 p.m., staff member B stated she did counsel the staff member on how to treat residents, but did not document it. *3. During an interview on 1/28/17 at 5:50 p.m., staff member H stated there had been an episode of abuse involving resident #10, in the facility. She stated she had observed a nurse (who is no longer employed at the facility) hold down resident #10, and forced the resident to take his medication. Staff member H stated she did not intervene in the situation because the nurse was really scary, and she was in shock. She did say she told management the next day. During an interview on 1/31/17 at 4:30 p.m., staff member B stated the facility had no knowledge of this alleged abuse. The facility staff member had failed to report the allegation, and ensure the safety of the resident. *4. a. Review of a Progress Note for resident #8, dated 12/24/16, showed the resident was fidgety, putting coats on the floor and picking them up, to sink for water, to water container next to the nursing station. Resident noted to have 'cotton mouth' and white sticky substance in mouth. Stated it was Polygrip. Notified on-call (nurse) of erratic behavior, on-call to come in, resident refused to sit by nursing station without cell phone and tablet. (sic) Review of a Progress Note for resident #8, dated 12/24/16, showed On call nurse called patient again was slurring her speech, acting erratically after visit from friend, as previously noted will obtain UA for toxicology this PM. (sic) During an interview on 1/30/17 at 1:20 p.m., resident #8 stated the nurse made her sit on the toilet (when the urine was being obtained), and she could not void. The staff would not let her get off the toilet to smoke, and made her drink a lot of water. The resident said she finally told the nurse to get the urine with a catheter. Resident #8 stated obtaining the urine with the catheter was an awful experience, and it hurt. It was so painful and abusive. (Staff member C) is so mean to me. All the staff were mean when they thought I was doing meth. Resident #8 stated she had an audience of two nurses and two CNAs, and they used a flashlight. Resident #39, her roommate, stated she had to listen to resident #8's screams, saying, It just wasn't right. During an interview on 1/26/17 at 9:50 a.m., staff member C stated she came to the facility that night to get a urine sample. She stated, I put her on the potty, gave her a lot of water. She could not go, and we took her to the bed, and tried to keep her awake while we got the urine sample. We did use a flashlight. The urine sample was obtained in the morning by another nurse. b. Review of the Progress Note for residents #8 dated 11/23/16, resident showed the resident stated she was having respiratory issues and stated she needed [MEDICATION NAME] and 3 nebulizer treatments back to back. This nurse stated she was not allowed to have more than one nebulizer treatment every 4 hours, per MD orders. This nurse stated if she felt this bad, than she should not be going out to smoke knowing her lung condition was poor. The resident later came to this nurse with a typed message on her tablet showing she needed the nurse to understand what was wrong with her, and that she needed 3 nebulizer treatments. The nurse gave her tablet back and restated that she can only have 1 every 4 hours, no exceptions. Review of the Progress Note for resident #8, dated 12/1/16, showed a new order; If O2 sats less than 88 %, the resident is not to go out for that smoke break under any circumstance. The saturation levels were to be checked before resident #8 smoked. Review of the Progress Note for resident #8, dated 12/4/16, showed Resident argued with this nurse about when her oxygen saturation was supposed to be taken. This nurse stated it would be checked before her smoke break and resident stated 'you are so ridiculous and this is getting annoying, you guys are getting me upset and that's making my oxygen low.' This nurse stated all nurses were following the doctors orders. Review of the Progress Note, dated 12/7/16, showed the resident was very upset about canceled smoke breaks. The nurse stated it was not safe for residents or staff to go outside in below freezing weather. This nurse explained that if a resident or staff member got frost bite from the weather then it could mean no smoking at this facility. Resident stated 'This is unfair, I've only had 2 cigarettes today.' This nurse explained that due to the weather there are no exceptions. Review of resident #8's Progress Note, dated 12/26/16 at 3:00 p.m., showed the resident was observed having significantly labored breathing. Upon auscultation lung sounds absent in both upper lobes with crackles and wheezing in both lower lobes. Resident could not maintain an oxygen saturation level above 84% on 7 liters oxygen at any time this shift (sic). When this nurse went into residents room to answer her call light at 7:45 p.m., resident screamed in fright as I entered the room. Resident then mumbled hospital and nodded off. This nurse shook resident asking if she was ok and stated 'what yeah I'm fine don't call anyone.' This nurse stated that I had not planned to call anyone and she stated 'you cant call anyone promise you wont call anyone.' This nurse became weary of her behavior and did not feel comfortable keeping her in the facility. The resident was sent to (hospital) for evaluation. (sic) Review of the Progress Note dated 12/26/16, showed resident #8 returned from the hospital after being treated for [REDACTED]. During an interview on 1/24/17 at 1:40 p.m., staff member A stated that the facility should absolutely not be using smoking as a punishment. During an interview on 1/26/17 at 8:05 a.m., staff member K stated resident #8 would get very upset about the saturation checks, and followed the nurses around. During an interview on 1/27/16 at 2:10 p.m., resident #40 stated the residents were not treated as humans, and the staff were disrespectful. I disrespect them right back. When staff member C works the floor, she tries to push people around.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest well-being for 1 (#5) of 7 sampled and supplemental residents. Specifically, the facility did not ensure the resident had optimal improvement or did not deteriorate within the limits of a resident's right to refuse treatment. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with 2nd [MEDICAL CONDITION] the head, neck & face, and [MEDICAL CONDITION]. A review of the resident's admission progress note on 1/13/16, documented the resident arrived by wheelchair van and was ambulating. The reason for admission was documented as post trauma and/or accident rehabilitation. A review of an admission progress note, not dated, documented a skin assessment which showed several scabs and redness to both lower extremities below the knees. It also documented large purple/ discolored areas to the right buttock with one pinpoint open area. The resident's gluteal fold showed a thick lump. The resident stated that all the areas on legs and buttock were from his surgery after a car accident three years ago. A review of the admission MDS, with an ARD date of 1/20/16, reflected a BIMS score of 13. The resident was independent with ADLs, except needed supervision with eating and bathing. There were no pressure ulcers or venous ulcers coded. In section M 1040, letter F was checked which reflected resident's burns. A review of a progress note, dated 1/27/16, showed the resident was seen by the physician who ordered labs and a nicotine patch. A review of a progress note, dated 1/30/16, documented [MEDICAL CONDITION] to his legs were cleansed with normal saline and dried. A thin layer of medication was applied. A review of a progress note, dated 1/31/16, showed the resident was in the facility for rehab and skilled nursing. There were numerous [MEDICAL CONDITION] documented to both lower extremities and buttocks which were draining milky white and bloody drainage. Resident #5 was educated on infection control. A review of a progress note, dated 2/15/16, documented the resident had a change of condition and was complaining of right ear pain which radiated to his head. The pain was rated an 8 on a pain scale of 1-10. The physician was notified at 3:50 p.m. and ordered an antibiotic. A review of a progress note, dated 2/15/16 at 9:40 p.m., showed the resident was independent with all ADLs and ambulated without assistance. A review of a progress note, dated 2/16/16, reflected an order for [REDACTED]. The resident was observed grimacing in his face when the area around the left ankle was cleaned. A review of a progress note, dated 2/17/16 at 3:47 p.m., documented the resident refused therapies due to not feeling well. The resident also refused to attend meals in the dining room. It was documented he had a productive cough of thick yellowish/greenish sputum. It also reflected that the physician had been informed of his agitation and not feeling well. A review of a progress note, also dated 2/17/16 at 8:28 p.m., reflected the resident was transferred to the hospital for an evaluation of chest pain, shortness of breath and a bad headache. This was an unplanned transfer and the physician was notified. A review of cultures done at the hospital laboratory on 2/17/16 were positive for streptococcus pneumoniae and staphylococcus aureus in his leg wound. A review of a progress note, dated 2/18/16, showed the resident returned from the hospital. The resident's lower extremities were wrapped with wet to dry dressings. The resident was unsteady on his feet and needed stand by assistance to his room. The resident was started on an oral antibiotic. A review of a progress note, dated 2/20/16, documented the resident complained of pain to outer left ankle wound and the pain was rated a 10 on a pain scale of 1-10. Tylenol was given for the pain with little relief and the physician was notified. The physician ordered [MEDICATION NAME] and it was given as ordered. The nursing staff were to follow up with the physician the next morning to obtain an order for [REDACTED].>A review of a progress note, dated 2/23/16, showed the resident continued to be independent with ADLs. A review of a progress note, dated 3/4/16, showed that all areas to both lower extremities were improving without signs or symptoms of infection. A review of a progress note, dated 3/8/16, showed the resident had reported drainage from his lower left leg. The nurse observed copious amounts of frank blood saturating the dressing. A review of a progress note, dated 3/11/16, showed a social service assessment completed resulting in a BIMS of 14. A review of a progress note, dated 3/20/16, showed resident #5 stated he bumped his left leg when he went out. An assessment revealed copious amounts of frank blood saturating the dressing. A review of a progress note, dated 4/4/16, documented 2+ pedal non-[MEDICAL CONDITION] to both lower extremities (BLE). Pedal pulses were weak and (thread) in lower extremities (LEs). A review of a progress note, dated 4/6/16, showed Unna boots to both lower extremities were changed and there was a copious amount of thick pale green colored drainage on the old dressings and a sour odor was documented. A review of a progress note, dated 4/16/16, showed when the Unna boots were changed, there were copious amounts of thick tan and pale green drainage on the old dressing. The larger wounds to the left lower extremity (LLE) appeared deep and the surrounding skin was macerated. A very strong sour odor was noted. A review of a progress note, dated 4/17/16, documented when the dressing was changed to BLEs there was a foul odor and moderate green/tan drainage on old dressing. Wounds to the left lower leg were deep and skin around the area was macerated. A review of a progress note, dated 4/28/16, showed resident was taken to a doctor's appointment. No new orders were received. A review of a progress note, dated 4/29/16, showed resident having more complaints of pain especially to the right lower leg. An order was clarified by the physician to continue with the Unna boots. A review of a progress note, dated 5/7/16, documented Unna boots were changed with a moderate amount of purulent drainage noted to both lower extremities. Resident #5 refused to elevate his feet. A review of a progress note, dated 5/17/16 at 2:38 p.m., documented that the resident had been staying in his room more lately. Resident #5 was asking for pain medications more frequently and earlier than his usual times. His complaints of his left leg hurting worsened. At 11:04 p.m., it was documented that the left leg showed slough to open areas with moderate amounts of thick greenish/bloody drainage to the old dressing and a foul odor continued. A review of a progress note, dated 5/18/16 at 2:38 p.m., showed resident #5 had [MEDICAL CONDITION] to the thighs. At 9:12 p.m., the resident continued to isolate in his room and his hands were thick and shaky. The resident refused to elevate his extremities. A review of a progress note, dated 5/19/16, showed a new order to discontinue the Unna boot on the left leg only and to start wet to dry dressings twice a day (BID). A review of a progress note, dated 5/20/16, showed staff member J looked at the wounds and ordered new dressings for the left leg. This was to start when the new dressings arrived. A review of the wound care sheet with an assessment date of 5/23/16, showed staff member J documented mottling below the knee and toes were purple. A review of a progress note, dated 5/29/16, documented dressing changes to BLE. The left leg had many open areas with green exudates in the middle with one open area that showed muscle and possibly bone. The bottom of the toes on the left foot were blue in color. Some mottling was noted at his knees on both legs. A review of a progress note, dated 6/1/16, documented the resident needed two staff to assist with transfer out of wheel chair into the recliner. A review of a progress note, dated 6/3/16, documented a change of condition and an order received to send resident #5 out to the hospital. Staff notified the nurse and advised of the resident bleeding while on the toilet. Bright red blood was observed on the toilet seat and in the toilet. Both buttocks showed multiple open areas, at least 2 of these areas appeared to be tunneling and very deep. The resident was discharged to the hospital on [DATE] and did not return to the facility because the resident passed away on 6/6/16 at the hospital. During an interview on 6/9/16 at 2:48 p.m., staff member B stated resident #5 was diagnosed with [REDACTED]. A review of the MARs for May 2016 showed no antibiotic being taken during this time. At the time of exit from the facility, no recent culture of wounds were produced.

Based on staff and family interviews, and record review, the facility failed to provide necessary pain management for 1 (#3) of 5 sampled residents. Findings include: Resident #3 was admitted on [DATE] at 4:10 p.m., with [DIAGNOSES REDACTED]. Upon admit, the resident had physician's orders [REDACTED]. The facility had completed a pain evaluation dated 9/15/10. The document verified the resident reported constant pain in the lower back since arrival at the facility. His reported pain was documented at varying levels from "mod (moderate) - severe" to "excruciating". The physical therapist documented on an evaluation dated 9/16/10, that the resident's "lower back pain and spasm must be addressed". On 9/22/10 at 3:30 p.m., staff member H, a nurse, was interviewed. She stated the facility had not received the resident's medications from the pharmacy on 9/15/10 at the time of admission. During a shift report on the evening of 9/15/10, she had been told by the day shift nurse that the resident's wife had been asked to bring the medications the resident had been taking at home. When the wife arrived at the facility on the evening of 9/15/10, staff member H and the resident's wife reviewed the resident's admission orders [REDACTED]. Discrepancies were found during the review. Staff member H stated she exited the resident's room and "did not administer any of the resident's meds that night". The MAR indicated [REDACTED]. On 9/16/10 at 4:55 p.m., the resident's physician ordered [MEDICATION NAME] 400-600 mg every 6 hours prn for pain and at 3:00 p.m. the same day, [MEDICATION NAME] 10 mg 3 times a day for back spasms. Staff member B was interviewed on 9/23/10 at 12:15 p.m. She reported during interview that while waiting for the arrival of ordered medications, facility staff had been administering the medications brought into the facility by the resident's wife. Staff member B stated the facility had ordered the resident's medication the afternoon of 9/17/10 as the bottles of medications the wife had brought from their home were the wrong amounts and not all medications matched the physician's current orders. Staff member B stated that the facility had to request the medications "two more times" from the pharmacy in order to receive all the medications ordered by the physician. Per the pharmacy delivery receipt dated 9/17/10, the facility received some of the resident's medications at 4:15 p.m. The [MEDICATION NAME] sulfate was not included. The MAR indicated [REDACTED]. The resident had missed 6 doses since 9/15/10 at 4:10 p.m. The scheduled [MEDICATION NAME] was not administered at 8:00 p.m. on 9/17/10. There was no documentation of the administration of the prn [MEDICATION NAME] for breakthrough pain or the Tylenol prn ordered for mild pain. The Interdisciplinary Progress Notes dated 9/19/10 at 8:30 a.m., contained a nurse's entry that the resident was found to be unresponsive by a CNA. The physician ordered the facility to send the resident to the emergency room . The Powell County Medical Center history and physical examination [REDACTED]. The physician documented that the "back pain that this patient is experiencing is such that it is causing this patient a lot of undue stress", " ...he probably is not able to sleep all that well. Any movement seems to aggravate his back ..." History of the present illness contained per the facility staff that the patient had not had pain medication since 8:00 p.m. the night before and the last [MEDICATION NAME] dose was 4:00 p.m. the day before. The physical examination portion revealed that the resident was complaining of "excruciating back pain" and he appeared to be in some pain and distress.